The diagnostic criteria for attention-deficit hyperactivity disorder (ADHD) require both symptoms and impairment to be present. Impairment in functioning is commonly the primary reason for referral, and is also a better predictor of long-term outcomes than ADHD symptoms. And yet, only recently has research begun to examine the impact of ADHD treatments on functional impairment using efficient and psychometrically sound outcome measures. In this article, we identify several noteworthy multidimensional measures of functional impairment (ADHD FX, Barkley Functional Impairment Scale [BFIS], Impairment Rating Scale [IRS], Weiss Functional Impairment Rating Scale [WFIRS]) utilized in recent clinical trials for ADHD, and describe their psychometric properties and clinical utility. We also review existing evidence on the impact of pharmacological and behavioral treatments on different domains of functional impairment in ADHD youth as measured by these specific measures. Further research is needed to evaluate longitudinal effects of ADHD treatments on functional impairment, and the use of these measures in adaptive treatment designs.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163:716–23.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C.: American Psychiatric Association; 2013.
World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992.
Pelham WE Jr, Fabiano GA, Massetti GM. Evidence-based assessment of attention deficit hyperactivity disorder in children and adolescents. J Clin Child Adolesc. 2005;34:449–76.
Becker KD, Chorpita BF, Daleiden EL. Improvement in symptoms versus functioning: how do our best treatments measure up? Adm Policy Ment Health. 2011;38:440–58.
Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Psychiatry. 2007;46:894–921.
Faraone SV, Buitelaar J. Comparing the efficacy of stimulants for ADHD in children and adolescents using meta-analysis. Eur Child Adolesc Psychiatry. 2010;19:353–64.
Epstein JN, Langberg JM, Lichtenstein PK, Altaye MB, Brinkman WN, House K, Stark LJ. Attention-deficit/hyperactivity disorder outcomes for children treated in community-based pediatric settings. Pediatrics. 2010;164:160–5.
Karpenko V, Owens JS, Evangelista NM, Dodds C. Clinically significant symptom change in children with attention-deficit/hyperactivity disorder: does it correspond with reliable improvement in functioning? J Clin Psychol. 2009;65:76–93.
O’Connor BC, Garner AA, Peugh JL, Simon J, Epstein JN. Improved but still impaired: symptom-impairment correspondence among youth with attention-deficit hyperactivity disorder receiving community-based care. J Dev Behav Pediatr. 2015;36:106–14.
Owens JS, Johannes LM, Karpenko V. The relation between change in symptoms and functioning in children with ADHD receiving school-based mental health services. School Ment Health. 2009;1:183–95.
Barkley RA, Cunningham CE, Gordon M, Faraone SV, Lewandowski L, Murphy KR. ADHD symptoms vs. impairment: revisited. ADHD Rep. 2006;14:1–9.
Dupaul GJ. School-based interventions for students with attention-deficit hyperactivity disorder: current status and future directions. School Psychol Rev. 2007;36:183–94.
Hoza B. Peer functioning in children with ADHD. Ambul Pediatr. 2007;7:101–6.
Johnston C, Mash EJ. Families of children with attentiondeficit/hyperactivity disorder: review and recommendations for future research. Clin Child Fam Psychol. 2001;4:183–207.
Gathje RA, Lewandowski LJ, Gordon M. The role of impairment in the diagnosis of ADHD. J Atten Disord. 2008;11:529–37.
Gordon M, Antshel K, Faraone S, Barkley R, Lewandowski L, Hudziak JJ. Cunningham C. symptoms versus impairment the case for respecting DSM-IV’s criterion D. J Atten Disord. 2006;9:465–75.
Lewandowski LJ, Lovett BJ, Gordon M. Measurement of symptom severity and impairment. In: Goldstein S, Naglieri J, editors. Assessing impairment: from theory to practice. Springer: USA; 2009. p. 5–14.
Willcutt EG, Nigg JT, Pennington BF, Solanto MV, Rohde LA, Tannock R, Loo SK, Carlson CL, McBurnett K, Lahey BB. Validity of DSM-IV attention deficit/hyperactivity disorder symptom dimensions and subtypes. J Abnorm Psychol. 2012;121:991–1010.
Willcutt EG. The prevalence of DSM-IV attention deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics. 2012;9:490–9.
Barkley RA. Psychological assessment of children with ADHD. In: Barkley RA, editor. Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment. 4th ed. Ney York: Guilford Press; 2014. p. 455–74.
Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. J Am Acad Child Psychiatry. 2000;39:28–38.
Bird HR. The assessment of functional impairment. In: Shaffer D, Lucas CP, Richters JE, editors. Diagnostic assessment in child and adolescent psychopathology. New York: Guilford; 1999. p. 209–29.
Bird HR, Andrews H, Schwab-Stone M, Goodman S, Dulcan M, Richters J, et al. Global measures of impairment for epidemiological and clinical use with children and adolescents. Int J Methods Psychiatr Res. 1996;6:295–307.
Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, Aluwahlia S. A children’s global assessment scale (CGAS). Arch Gen Psychiatry. 1983;40:1228–31.
Bird HR, Canino G, Rubio-Stipec M, Ribera J. Further measures of the psychometric properties of the Children’s Global Assessment Scale (CGAS). Arch Gen Psychiatry. 1987;44:821–4.
Hodges K, Wong MM, Latessa M. Use of the Child and Adolescent Functional Assessment Scale (CAFAS) as an outcome measure in clinical settings. J Behav Health Services Res. 1998;25:325–36.
Jensen PS, Arnold LE, Swanson JM, Vitiello B, Abikoff HB, Greenhill LL, et al. 3-year follow-up of the NIMH MTA study. J Am Acad Child Psychiatry. 2007;46:989–1002.
Vitiello B, Abikoff HB, Chuang SZ, Kollins SH, McCracken JT, Riddle MA, et al. Effectiveness of methylphenidate in the 10-month continuation phase of the Preschoolers with ADHD Treatment Study (PATS). J Child Adol Psychopharmacol. 2007;17:593–603.
Gresham FM, Elliott SN. Social skills rating system manual. Circle Pines: American Guidance Service; 1990.
DiPerna JC, Elliott SN. Development and validation of the academic competence evaluation scales. J Psychoeduc Assess. 1999;17:207–25.
Conners CK. Conners 3rd edition: manual. Toronto: Multi-Health Systems Inc; 2008.
Haack LM, Gerdes AC, Lawton KE, Schneider BW. Understanding and measuring functional impairment in diverse children with ADHD development of the ADHD-FX Scale with an at-risk, community sample. J Atten Disord. 2016;20:487–500.
Haack LM, Gerdes AC. Culturally appropriate assessment of functional impairment in diverse children validation of the ADHD-FX Scale with an at-risk community sample. J Atten Disord. 2014. doi:10.1177/1087054714553021.
Haack LM, Gonring K, Harris M, Gerdes A, Pfiffner L. Assessing impairment in childhood ADHD validation of the parent and teacher ADHD-FX Rating Scale in a dual-site clinical sample. J Atten Disord. 2016. doi:10.1177/1087054716659360.
Gerdes AC, Kapke TL, Lawton KE, Grace M, Dieguez Hurtado G. Culturally adapting parent training for Latino youth with ADHD: development and pilot. J Latina/o Psychol. 2015;3:71–87.
Barkley RA. Barkley functional impairment scale: children and adolescents (BFIS-CA). New York: Guilford; 2012.
Barkley RA. Hyperactive children: a handbook for diagnosis and treatment. New York: Guilford; 1981.
Barkley RA. Distinguishing sluggish cognitive tempo from ADHD in children and adolescents: executive functioning, impairment, and comorbidity. J Clin Child Adolesc. 2013;42:161–73.
Fabiano GA, Pelham WE. Measuring impairment in children with attention-deficit hyperactivity disorder. ADHD Rep. 2002;10:6–10.
Fabiano GA, Pelham WE, Waschbusch DA, Gnagy EM, Lahey BB, Chronis AM, Onyango AN, et al. A practical measure of impairment: psychometric properties of the impairment rating scale in samples of children with attention deficit hyperactivity disorder and two school-based samples. J Clin Child Adolesc. 2006;35:369–85.
Evans SW, Allen J, Moore S, Strauss V. Measuring symptoms and functioning of youth with ADHD in middle schools. J Abnorm Child Psychol. 2005;33:695–706.
Fabiano GA, Pelham WE. Impairment in children. In: Goldstein S, Naglieri JA, editors. Assessing impairment: from theory to practice. New York: Springer; 2009. p. 105–20.
Fabiano GA, Pelham WE, Gnagy EM, Burrows-MacLean L, Coles EK, Chacko A, Wymbs BT, et al. The single and combined effects of multiple intensities of behavior modification and methylphenidate for children with attention deficit hyperactivity disorder in a classroom setting. School Psychol Rev. 2007;36:195–216.
Gajria K, Kosinski M, Sikirica V, Huss M, Livote E, Reilly K, et al. Psychometric validation of the Weiss Functional Impairment Rating Scale-Parent Report Form in children and adolescents with attention-deficit/hyperactivity disorder. Health Qual Life Out. 2015;13:1.
Vidal R, Castells J, Richarte V, Palomar G, García M, Nicolau R, et al. Group therapy for adolescents with attention-deficit/hyperactivity disorder: a randomized controlled trial. J Am Acad Child Psychiatry. 2015;54:275–82.
Dose C, Hautmann C, Doepfner M. Functional impairment in children with externalizing behavior disorders psychometric properties of the Weiss Functional Impairment Rating Scale–parent report in a german clinical sample. J Atten Disord. 2016. doi:10.1177/1087054716661234.
Multimodal Treatment of Children with ADHD Study [MTA] Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56:1073–86.
Stein MA, Waldman ID, Charney E, Aryal S, Sable C, Gruber R, Newcorn JH. Dose effects and comparative effectiveness of extended release dexmethylphenidate and mixed amphetamine salts. J Child Adol Psychopharmacol. 2011;21:581–8.
Coghill D, Banaschewski T, Lecendreux M, Soutullo C, Johnson M, Zuddas A, et al. European, randomized, phase 3 study of lisdexamfetamine dimesylate in children and adolescents with attention-deficit/hyperactivity disorder. Eur Neuropsychopharmacol. 2013;23:1208–18.
Banaschewski T, Soutullo C, Lecendreux M, Johnson M, Zuddas A, Hodgkins P, et al. Health-related quality of life and functional outcomes from a randomized, controlled study of lisdexamfetamine dimesylate in children and adolescents with attention deficit hyperactivity disorder. CNS Drugs. 2013;27:829–40.
Banaschewski T, Johnson M, Lecendreux M, Zuddas A, Adeyi B, Hodgkins P, et al. Health-related quality of life and functional outcomes from a randomized-withdrawal study of long-term lisdexamfetamine dimesylate treatment in children and adolescents with attention-deficit/hyperactivity disorder. CNS Drugs. 2014;28:1191–203.
Stein MA, Sikirica V, Weiss MD, Robertson B, Lyne A, Newcorn JH. Does guanfacine extended release impact functional impairment in children with attention-deficit/hyperactivity disorder? Results from a randomized controlled trial. CNS Drugs. 2015;29:953–62.
Hervas A, Huss M, Johnson M, McNicholas F, van Stralen J, Sreckovic S, et al. Efficacy and safety of extended-release guanfacine hydrochloride in children and adolescents with attention-deficit/hyperactivity disorder: a randomized, controlled, phase III trial. Eur Neuropsychopharmacol. 2014;24:1861–72.
Newcorn JH, Harpin V, Huss M, Lyne A, Sikirica V, Johnson M, et al. Extended‐release guanfacine hydrochloride in 6–17‐year olds with ADHD: a randomised‐withdrawal maintenance of efficacy study. J Child Psychol Psychiatry. 2016;57:717–28.
Wilens TE, Robertson B, Sikirica V, Harper L, Young JL, Bloomfield R, et al. A randomized, placebo-controlled trial of guanfacine extended release in adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Psychiatry. 2015;54:916–25.
Dittmann RW, Cardo E, Nagy P, Anderson CS, Bloomfield R, Caballero B, et al. Efficacy and safety of lisdexamfetamine dimesylate and atomoxetine in the treatment of attention-deficit/hyperactivity disorder: a head-to-head, randomized, double-blind, phase IIIb study. CNS Drugs. 2013;27:1081–92.
Nagy P, Hage A, Coghill DR, Caballero B, Adeyi B, Anderson CS, et al. Functional outcomes from a head-to-head, randomized, double-blind trial of lisdexamfetamine dimesylate and atomoxetine in children and adolescents with attention-deficit/hyperactivity disorder and an inadequate response to methylphenidate. Eur Child Adolesc Psychiatry. 2016;25:141–9.
Fuentes J, Danckaerts M, Cardo E, Puvanendran K, Berquin P, De Bruyckere K, Montoya A, Quail D, Escobar R. Long-term quality-of-life and functioning comparison of atomoxetine versus other standard treatment in pediatric attention-deficit/hyperactivity disorder. J Clin Psychopharmacol. 2013;33:766–74.
Evans SW, Owens JS, Bunford N. Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. J Clin Child Adolesc. 2014;43:527–51.
Hinshaw SP, Owens EB, Wells KC, Kraemer HC, Abikoff HB, Arnold LE, et al. Family processes and treatment outcome in the MTA: negative/ineffective parenting practices in relation to multimodal treatment. J Abnorm Child Psychol. 2000;28:555–68.
Pelham WE, Fabiano GA. Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. J Clin Child Adolesc. 2008;37:184–214.
Sonuga-Barke EJ, Daley D, Thompson M, Laver-Bradbury C, Weeks A. Parent-based therapies for preschool attention-deficit/hyperactivity disorder: a randomized, controlled trial with a community sample. J Am Acad Child Psychiatry. 2001;40:402–8.
Webster-Stratton CH, Reid MJ, Beauchaine T. Combining parent and child training for young children with ADHD. J Clin Child Adolesc. 2011;40:191–203.
Barkley RA, Shelton TL, Crosswait C, Moorehouse M, Fletcher K, Barrett S, Jenkins L, Metevia L. Multi-method psycho-educational intervention for preschool children with disruptive behavior: preliminary results at post-treatment. J Child Psychol Psychiatry. 2000;41:319–32.
Pelham WE Jr, Gnagy EM, Greiner AR, Hoza B, Hinshaw SP, Swanson JM, et al. Behavioral versus behavioral and pharmacological treatment in ADHD children attending a summer treatment program. J Abnorm Child Psychiatry. 2000;28:507–25.
Evans SW, Schultz BK, DeMars CE, Davis H. Effectiveness of the challenging horizons after-school program for young adolescents with ADHD. Behav Ther. 2011;42:462–74.
Sibley MH, Pelham WE Jr, Derefinko KJ, Kuriyan AB, Sanchez F, Graziano PA. A pilot trial of supporting teens’ academic needs daily (STAND): a parent-adolescent collaborative intervention for ADHD. J Psychopathol Behav. 2013;35:436–49.
Fabiano GA, Chacko A, Pelham WE, Robb J, Walker KS, Wymbs F, et al. A comparison of behavioral parent training programs for fathers of children with attention-deficit/hyperactivity disorder. Behav Ther. 2009;40:190–204.
Evans SW, Langberg JM, Schultz BK, Vaughn A, Altaye M, Marshall SA, Zoromski AK. Evaluation of a school-based treatment program for young adolescents with ADHD. J Consult Clin Psychol. 2016;84:15.
Langberg JM, Evans SW, Schultz BK, Becker SP, Altaye M, Girio-Herrera E. Trajectories and predictors of response to the challenging horizons program for adolescents with ADHD. Behav Ther. 2016;47:339–54.
Hantson J, Wang PP, Grizenko-Vida M, Ter-Stepanian M, Harvey W, Joober R, Grizenko N. Effectiveness of a therapeutic summer camp for children with ADHD phase I clinical intervention trial. J Atten Disord. 2012;16:610–7.
Fischer M, Barkley RA, Edelbrock CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria: II. Academic, attentional, and neuropsychological status. J Consult Clin Psychol. 1990;58:580–8.
Pfiffner LJ, McBurnett K, Lahey BB, Loeber R, Green S, Frick PJ, Rathouz PJ. Association of parental psychopathology to the comorbid disorders of boys with attention-deficit hyperactivity disorder. J Consult Clin Psychol. 1999;67:881–93.
Pelham WE, Fabiano GA, Waxmonsky JG, Greiner AR, Gnagy EM, Pelham WE, Coxe S, Verley J, Bhatia I, Hart K, Karch K. Treatment sequencing for childhood ADHD: a multiple-randomization study of adaptive medication and behavioral interventions. J Clin Child Adolesc. 2016;11:1–20.
Pelham WE, Lahey BB, Gnagy EM, Kipp HL, Roy A. Predictive validity of ADHD symptoms vs. impairment on functional outcomes. In: Poster presented at the 12th scientific meeting of the International Society for Research on Child and Adolescent Psychiatry, New York, 2005.
Hodgkins P, Lloyd A, Erder MH, Setyawan J, Weiss MD, Sasané R, Nafees B. Estimating minimal important differences for several scales assessing function and quality of life in patients with attention-deficit/hyperactivity disorder. CNS Spectr. 2016:1. doi:10.1017/S1092852916000353.
No funding support was used to complete this article.
Conflict of interest
Drs. Sasser and Schoenfelder have no conflicts of interest to report. Dr. Stein receives research support from Ironshore, Pfizer, and Shire, and is an advisor to Alcobra, Medicie, and Shire.
Rights and permissions
About this article
Cite this article
Sasser, T., Schoenfelder, E.N. & Stein, M.A. Targeting Functional Impairments in the Treatment of Children and Adolescents with ADHD. CNS Drugs 31, 97–107 (2017). https://doi.org/10.1007/s40263-016-0400-1
- ADHD Symptom
- Minimal Important Difference
- Behavioral Parent Training
- Academic Impairment