• Administration Time
• Time Frame
• Administration Settings
• Modified Administration of the CAARS 2
• Repeated Administrations of the CAARS 2
• Administration Procedure
  • Preparing for the Administration
  • During the Administration

Administration Time

Typical Self- and Observer-report completion times along with associated ranges for all CAARS 2 forms are presented in Table 3.1. These figures are based on the data collection times for the Normative and ADHD Reference Samples (see chapter 7, Standardization, for a description of the samples). The average number of items completed per minute was calculated and then multiplied by the total number of items. Although raters will typically complete the full-length CAARS 2 in less than 15 minutes (and the other forms in considerably less time), various factors may lead to longer administrations (e.g., external interruptions, frequent breaks, reading limitations, and completing a form in one’s non-native language). Administration times may also be longer for older adults or people who require the CAARS 2 items to be read aloud. Although there are no time limits for completing the CAARS 2, online administrations must be completed in one sitting. Note that unusually fast or slow completion times for online assessments will be flagged under Pace in the Response Style Analysis section of the report (see chapter 4, Interpretation, for more information on this metric).

Time Frame

The CAARS 2 instructions guide raters to consider the person’s life in general when completing their ratings. This wording was chosen to elicit ratings based on the individual’s typical functioning across time and situations.

There are two exceptions to the “life in general” timeframe. Given the clinical importance of identifying any instance of suicide attempts/ideation or self-injurious behavior (as opposed to whether these are “typical” of a person’s functioning), the instructions for the items assessing those concerns guide the rater to “Think about your entire life” (Self-Report) and “Think about this person’s entire life” (Observer) when responding.

Administration Settings

The CAARS 2 should always be completed in a quiet setting with minimal distractions. It can be administered by any individual who is properly trained by a qualified CAARS 2 user (see Users and User Qualifications in chapter 1, Introduction). The rater can respond either locally (e.g., in a clinic) or remotely (e.g., at home).

• Local. Online CAARS 2 forms can be completed in a quiet, distraction-free consultation or waiting room via an internet-enabled device (e.g., desktop or laptop computer, tablet, smartphone). CAARS 2 paper forms can easily be completed in these same settings.
  
  
• Remote. The online format is convenient for remote administration, as the examiner can e-mail a link to each rater. (A paper form can also be provided to the rater for remote administration upon request.)
  

With advancements in technology, remote testing has become more prevalent, including through digital platforms. The CAARS 2 can easily be administered through remote online administration. Each rater receives a unique link that allows them to enter responses directly in the online portal, either on their own time or during a scheduled appointment with the clinician (e.g., via video conference). When the CAARS 2 is administered remotely, it is recommended that the examiner make contact with the rater in advance to ensure instructions are communicated and understood. Establishing a timeline for completion is recommended. Provide an estimate of how long the form should take to complete and encourage the rater to complete the CAARS 2 in one sitting, to complete it independently without the aid of others, and, in the case of a paper administration, to return the form promptly. For online administrations, the form is submitted automatically upon completion, and a notification is sent to the examiner. Reminder emails to complete the form can be sent from the online portal to the rater as needed. For paper remote administrations, it is often helpful to provide a pre-addressed, stamped envelope for the return of the completed form or instructions for returning it electronically that consider privacy and data security issues (i.e., sending a digital version through encrypted, secure means, as opposed to scanning and emailing files for example).

Remote administration has several advantages for both raters and examiners. For examiners, time and money are not wasted on sending out paper forms and reminding raters to mail in the completed forms. With remote administration, it is simple to send email reminders from the online portal. Raters find remote administration convenient because they can complete the form at their convenience and there are no issues with losing the paper form or making a trip to the mailbox/post office.

Despite the many advantages of remote administration, it is not a good fit for all situations. Completion of an online rating scale requires the rater to have access to an internet connection and a device (e.g., computer, tablet, smartphone). Examiners should be aware that technology and connection requirements may be barriers for some individuals (e.g., limited income, unstable housing, older adults). Although less convenient, in these contexts, a paper form can also be provided to the rater for remote administration.

Test security is another concern for remote administration. MHS has a clear set of guidelines (see https://mhs.com/info/remote-admin-collection/#MHSGuidelines) with respect to online testing, to ensure that items are not copied or duplicated in any way. Examinees are to be told that they should not take screenshots of the test items or share them with anyone and that doing so is a violation of copyright law (see Ethical and Legal Guidelines in this chapter for more information). In situations where others may unduly influence a rater, consider asking the rater to complete the CAARS 2 during a telehealth session or while in your office. For returning completed forms, examinees should be asked to adhere to the procedure outlined to them by the administrator. For more information regarding remote testing using MHS products, please see https://mhs.com/info/remote-admin-collection/.

Typically, the CAARS 2 is administered on a one-on-one basis, but there are times when it is administered in a group setting.

• One-on-one. When a rater completes the CAARS 2 in a private setting with the examiner nearby, they can ask questions or seek clarifications as needed. Although the examiner is discouraged from rephrasing items (see During the Administration in the Administration Procedure section), they can make note of which items were confusing to the rater; these notes may help with interpretation (e.g., tendency to be concrete, easily confused by longer items). The examiner can also capture tangential comments which may be forgotten by the time the rater completes the form.
  
  
• Group. When administering the CAARS 2 in a group setting, make sure each rater has sufficient physical space to ensure privacy while responding. Instruct the raters to complete the form to the best of their ability and to save questions until the end (as allowing questions and/or comments during the response period may bias all the raters in the room). It may be helpful to provide pen and paper for raters to note questions and comments that arise while they complete the CAARS 2.
  

Modified Administration of the CAARS 2

In some instances, accessibility issues may require modifications to standard administration forms or procedures. These might include enlarging the text through adjusted screen settings, having the examiner read items aloud and/or record responses, and allowing for breaks during the administration of the CAARS 2. Considerations associated with such accommodations are discussed below. Examiners providing accommodations should otherwise adhere to standard administration procedures and clearly document the modifications made when reporting and interpreting CAARS 2 results.

• Enlarged text through adjusted screen settings. The font size used for the online administration is suitable for most readers. If a larger print is required, internet browser settings can be adjusted as needed.
  
  
• Visual guide. When using a paper form, it may be appropriate to offer a ruler or straight-edge to help the reader align item text with response options. This accommodation can be helpful for people with visual tracking issues as well as for some with attentional deficits. Note that online administration may be better suited for people with these challenges, as only one item is presented per screen.
  
  
• Verbal administration. If a rater cannot read the CAARS 2 instructions and items (e.g., poor eyesight, low reading-level), the examiner can read the instructions and items aloud. The rater can then be given a separate device or form, so they can follow along with what is being read and mark their responses privately. If a rater cannot record their own responses (e.g., due to limited motor skills), the examiner can mark the rater’s responses on the electronic or paper form. Read-aloud accommodations can be provided in-person or remotely via telephone or virtual session; however, given the confidential nature of CAARS 2 responses, a secure telehealth platform that adheres to local privacy laws for the protection of information should be used. When providing verbal administration, the examiner should read the items word-for-word, serving as a text-to-voice translator while avoiding interpreting or rephrasing the CAARS 2 items. Examples should not be provided, particular items should not be emphasized in any way, and certain responses should not be differentially reinforced (e.g., followed by the examiner saying “good”). Efforts should be made to ensure that items are completed independently, without input from others. Nonetheless, examiners need to recognize that verbal administration can impact self-disclosure (Clark-Gordon et al., 2019; Gryscynski et al. 2019). They may, for example, amplify social desirability responding (i.e., adjusting responses in order to look good and avoid looking bad; Burger, 2008).
  
  
• Allowing breaks. Ideally, the CAARS 2 is completed in one sitting. In rare instances, some individuals may require breaks. If necessary, the CAARS 2 administration can be divided into shorter time blocks (e.g., take a stretch break after 10 minutes) or fewer items (e.g., take a break after 20 to 25 responses). When using a paper form, examiners are encouraged to fold the paper or use self-stick notes to mask upcoming items while the rater is taking a break. The CAARS 2 should be completed within the same hour so that the rater’s frame of reference does not shift due to intervening events.
  

Repeated Administrations of the CAARS 2

The CAARS 2 can be re-administered to assess for changes in symptoms over time, such as when evaluating treatment effects and response to intervention (i.e., “progress monitoring;” see also Comparing Results Across Different Points in Time in chapter 4, Interpretation). The CAARS 2–Short and CAARS 2–ADHD Index are particularly well-suited to repeated administrations because they take little time to complete; however, it is prudent to ensure treatment targets are covered by the reduced item content.

When a person engages in a treatment plan, the goal is to effect meaningful change. The CAARS 2 can be given before the intervention (i.e., the baseline) and repeated at intervals during and after the intervention to determine if they are responding to the plan. If change is not evident, new treatment goals, strategies, and/or ways to increase compliance could be appropriate. This practice can be helpful whether initiating new treatment or adding/changing interventions. Some providers may wish to assess functioning six months or a year after discontinuing an intervention to determine if therapeutic gains have been maintained or whether a booster session could be helpful. Follow-up administration of the CAARS 2 after a change in life circumstances (e.g., new job, new living situation, divorce, death in the support system, marriage) can help identify areas that have benefited or suffered from the change.

Administration Procedure

CAARS 2 users are encouraged to follow the administration procedure outlined in this section to increase compliance from raters, obtain reliable information, and ensure that ethical and legal guidelines are followed. The guidelines below apply to both online and paper administration, as well as to both in-person and remote administration, except where stated otherwise.

Preparing for the Administration

• Ensure that you have met ethical and legal requirements, particularly informed consent, release of information (for Observer reports), and clarification of confidentiality (see Ethical and Legal Guidelines in this chapter).
  
  
• Choose which form (full-length, short, or ADHD Index), format (online or paper administration), and setting (local or remote) is appropriate to use. Confirm that the person being described is 18 years or older, or document your rationale for testing outside the normative range (see Age Ranges in chapter 1, Introduction). Consider whether any modifications are needed (see Reading Levels in chapter 1, as well as Modified Administration of the CAARS 2 earlier in this chapter).
  
  
• Advise the rater that copying of test items (e.g., manually, via screen capture, by photo) that can compromise test security is prohibited; this warning may be included in the consent documents.
  
  
• Provide the rater with the appropriate tools:
  
  
  • If administering the online version locally, confirm connectivity and provide the rater with an appropriate device (e.g., computer, tablet, or another internet-enabled device).
    
    
  • If planning to administer the online version remotely, verify that the rater has internet access and a valid email address.
    
    
  • If administering a paper form in a clinic, give the rater the appropriate form, a pen or pencil, and a comfortable place to work. If no table is available, provide a clipboard.
    
  
  
• Explain task instructions to the rater:
  
  
  • Inform the rater that the CAARS 2 is a rating scale that asks about various thoughts, feelings, and behaviors that adults may experience; avoid specific references to ADHD.
    
    
  • Explain why you are asking the rater to complete the CAARS 2 and how you plan to use the results (e.g., “The assessment will give me information about how this person functions in the home setting, which will help us answer their questions and make suggestions.”). An understanding of why they are being asked to complete the form may motivate the rater to respond openly and honestly.
    
    
  • Instruct the rater that they are being asked to describe themselves (for the Self-Report form) or the person being evaluated (for the Observer form).
    
    
  • Explain that the CAARS 2 must be completed independently (e.g., two informants should not collaborate to complete the same form or either of their forms).
    
    
  • Encourage the rater to read each item carefully and to decide about each item separately. Their answer for one item should not affect answers for the other items. Responses should be based on personal observations (or self-perceptions, in the case of the Self-Report).
    
    
  • Let the rater know that while they may go back and change answers, it is recommended that they move through the rating scale without second-guessing their responses
    
    
  • Inform the rater that they can modify their responses if they change their mind or make a mistake. When completing an online form, they can use the “Back” option to return to a prior item and change their selection.
    
    
  • If completing the paper form:
    
    
    • Explain that the rater must clearly mark their responses so the responses can be accurately entered into the scoring system. If they need to erase a response, the rater must ensure it is fully erased (or crossed out if using a pen) and the new response is clearly marked.
      
      
    • Ask the rater to choose only one response for each item. Even though it may be hard to decide, the rater should select the one response that they think best describes the person being evaluated (for the Observer form) or themself (for the Self-Report form).
      
    
    
• Prepare the test environment:
  
  
  • The test should be completed in one sitting. Although some factors may lead to longer administrations (e.g., frequent breaks, interruptions, reading limitations, getting distracted), most raters will typically complete the test within the time listed in the Administration Time section earlier in this chapter. Examiners should ensure that enough time is available for the rater to complete the chosen form.
    
    
    • For in-person administrations, ensure that the appointment time is long enough to allow completion of the test in one sitting.
      
      
    • If sending a link by email for remote administration, recommend that the rater should set aside enough uninterrupted time to complete the test in one sitting (see Administration Time for completion times).
      
    
    
  • Ideally, the testing environment should have reduced distractions and the test should be completed in a setting that is conducive to focus, whether online or paper administration.
    
  
  
• Explain limits to confidentiality. Inform the rater if the answers and scores will be shared with anyone. Doing so increases the chances of honest responding and complies with the ethical and legal requirements of administration (see Ethical and Legal Guidelines in this chapter).
  

During the Administration

The CAARS 2 can be administered either remotely (e.g., a paper form given to a rater to be completed at another time, a link sent via email for online completion) or locally (i.e., in person).

Online Remote Administration. Each rater will receive an email containing a unique link to complete the assessment. Upon clicking the link, raters are taken to the CAARS 2 assessment in their web browser. There, raters will:

1. Read and accept the Terms and Conditions of Use.
   
   
2. Enter/verify demographic information for the person being described, including their name or ID (the examiner may prefer to use a participant identification code rather than a name), gender, birth date, and age. The CAARS 2 Observer also requests the rater’s name or ID, the relationship of the rater to the person being evaluated (e.g., spouse/domestic partner/romantic partner, friend), and the length of time the rater has known the person. Other than the name/ID and age of the person being evaluated, demographic fields are optional.
   
   
3. Read instructions for completing the CAARS 2
   
   
4. Complete the CAARS 2 items.
   
   
5. After the last item has been completed, a Thank You page confirms that the responses are received and submitted automatically to the administrator. Close the browser to exit the site.
   

In-Person Administration. In-person administration can be completed either locally (e.g., in the clinician’s office) or virtually (e.g., via video conference, telehealth).

• If necessary, help the rater complete the demographic information (see Online Remote Administration).
  
  
• Ensure that the rater reads and understands the test instructions.
  
  
• If the rater expresses indecision about an item, the examiner can say, “I know that it may be hard to know how to answer some of the questions, but please try your best and be sure to respond to each question.”
  
  
• Avoid influencing the rater’s response to any item. Refrain from any interpretation or explanation of the items. However, if a rater indicates they do not understand a word, make a note and provide the necessary definitions to ensure the item can be rated.
  
  
• Once the CAARS 2 is completed:
  
  
  • For paper administrations completed in person, quickly review the form, including the demographic information. If any of the required demographic information is missing, it will not be possible to score the form. Check that all items have been completed and ask the rater if they can correct any missing or unclear information (see Omitted Responses in this chapter and appendix B for information on how missing responses are addressed).
    
    
  • Thank the rater for taking the time to complete the form and tell them that the information they provided is appreciated and helpful (see also Ethical and Legal Guidelines in this chapter).
    
    
  • Ask the rater if they have any additional comments or questions. This post-administration moment is a good opportunity to obtain additional information that the rater thought about while filling out the CAARS 2.
    
    
  • Record any behavior observations from the administration, such as requests for explanation, restlessness, indecision, and off-task remarks/behaviors.