Manual

Conners 4 Manual

Chapter 6: Conceptualization, Initial Planning, and Item Development

Conceptualization, Initial Planning, and Item Development

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Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with hallmark features that include a persistent pattern of inattention, hyperactivity, and impulsivity. It is often associated with other cognitive, social, and emotional impairments, including difficulties in executive functioning, problems with emotion regulation, disruptive and aggressive behavior, impairments in school, and adverse family and peer relationships. It is one of the most common childhood mental health disorders, affecting approximately 5.0% to 7.1% of children (Emser et al., 2018; Thomas et al., 2015). Diagnostic guidelines require that ADHD be assessed and diagnosed using information obtained from multiple sources (e.g., parents, teachers, clinicians, youth themselves; De Los Reyes et al., 2015; Izzo, Donati, & Primi, 2019), and that the evaluation process must not rely solely on one method, but rather on a variety of methods that include clinical interviews, observations, performance tests, and rating scales (Emser et al., 2018; Krieger & Amador-Campos, 2018; Wolraich et al, 2019).

The Conners’ Rating Scales have been in use for over 50 years, with the first scales created by Dr. C. Keith Conners in the 1960s. As documented in Conners (2008), the wealth of research conducted on these scales has established them as one of the most well-validated tools for evaluation of symptoms of ADHD. The latest version, the Conners 4, builds upon the years of research with its predecessors. The previous version, the Conners 3rd Edition™ (Conners 3®; Conners, 2008), was developed to provide a thorough and focused rating scale for school-aged youth (6- to 18-years-old) that assesses ADHD, along with the behaviors and symptoms of disorders most likely to co-occur with ADHD in childhood and adolescence. The Conners 3 consists of Validity Scales, Content Scales, DSM Symptom Scales, the Conners 3 ADHD Index™ (Conners 3 AI™), the Conners 3 Global Index™ (Conners 3 GI™), Screener Items for Anxiety and Depression, Severe Conduct Critical Items, Impairment Items, and additional questions that ask raters to describe their concerns about, and strengths of, the youth being rated. A multi-informant perspective is provided with Parent, Teacher, and Self-Report forms. The Conners 3 was developed as a companion tool to the Conners Comprehensive Behavior Rating Scales™ (Conners CBRS®; Conners, 2008), which is a broadband measure for a wide range of behavioral, emotional, social, and academic concerns and disorders for school-aged youth. Shortly after the release of the Conners 3 and the Conners CBRS , the Conners Early Childhood™ (Conners EC™; Conners, 2009) was released. The Conners EC is used to assess the concerns of parents, teachers, and childcare providers about preschool-aged children. This instrument aids in the early identification of behavioral, social, and emotional problems. The Conners EC also assists in measuring whether or not a child is appropriately meeting major developmental milestones. Together, the Conners EC, Conners CBRS, and Conners 3 offer a comprehensive suite of tools that help assess psychopathology across childhood and adolescence. The Conners’ Adult ADHD Rating Scale (CAARS; Conners et al., 1999), and the soon-to-be-released Conners Adult ADHD Rating Scale 2nd Edition (CAARS 2™; Conners et al., 2022) rounds out the comprehensive suite of Conners rating scales.

The Conners 3 has been used in both clinical and research contexts and has consistently demonstrated strong psychometric properties (e.g., Izzo et al., 2018, 2019; Izzo, Donati et al., 2019; Morales-Hidalgo et al., 2017; Roigé-Castellví et al., 2020). However, since its publication, knowledge of, and research on, ADHD has expanded, and thus, a revision of the tool was in order.

The initial phase of the development of the Conners 4—conceptualization, initial planning, and item development—was guided by three sources of information. First, a comprehensive and systematic literature review on ADHD was conducted on material published since the Conners 3 was released in 2008 and on research that examined the Conners 3 as a tool for evaluating ADHD in children and adolescents. This review highlighted gaps in the assessment of ADHD in youth with current measures. Second, market research with, and customer feedback from current users of the Conners 3 provided insight into what components of the tool they valued most and changes they wanted to see to further improve the utility of the test. Finally, the development team worked closely with internal and external subject-matter experts, including the author of the test, Dr. Conners. Although Dr. Conners passed away during the development of the Conners 4, his command of the science of ADHD, deep understanding of the disorder, and vision for how rating scales could best be applied to its assessment were all influential in the conceptualization and initial development phases of this revision.

All three sources of information shaped the following goals for the development of the Conners 4:

  • Retain the strengths and key components of the Conners 3 as a comprehensive assessment of ADHD in children and adolescents.

  • Create greater alignment with the adult measure of ADHD—the Conners Adult ADHD Rating Scales 2nd Edition (CAARS 2; Conners et al., 2022).

  • Meet standards of fairness and cultural sensitivity through more representative Normative Samples, along with careful and inclusive choices about language employed in the test.

  • Update the Normative Samples, add ADHD Reference Samples, and provide a revised and broadened array of clinically relevant scores.

  • Create greater alignment of content across all three rater forms (Parent, Teacher, and Self-Report).

  • Modify existing metrics and create new metrics to capture possible invalid symptom reporting and other invalid responding.

  • Develop new items to flag concerns frequently related with ADHD (e.g., self-harm behavior, sleep problems).

  • Modify and update scale- and item-level content, including

    • core symptoms of ADHD and its associated features,

    • symptoms that typically co-occur with ADHD (i.e., externalizing and internalizing disorders), and

    • assessment of impairment and functional outcomes typically experienced by youth with ADHD symptoms.

Conceptualization and Initial Planning

Comprehensive ADHD Assessment Tool for Youth

The Conners 4 was designed to build upon the core strengths of the Conners 3, which offers a comprehensive assessment of ADHD and common co-occurring behaviors and disorders in children and adolescents. The revision intended to improve the tool by addressing needs identified in the literature review and user feedback. Both comprehensiveness and brevity were identified as important and desirable features by current customers; therefore, a goal of the revision was to find a balance between providing extensive content coverage while maintaining the much-appreciated brevity of the Conners 3.

Greater Alignment with the CAARS 2

It is well documented that ADHD symptoms persist into adulthood for many individuals who have been diagnosed with ADHD in childhood. Williamson and Johnston (2015) found a persistence rate of approximately 36% to 55%, as reflected in children followed into adulthood who retained a full diagnosis. Additionally, about 30% to 70% of individuals diagnosed in childhood continue to demonstrate significant impairment into adulthood (Barkley, 2015; Barkley et al., 2008; Gordon & Hinshaw, 2020; Kessler et al., 2010). Having a means for a lifespan approach to the evaluation of ADHD is extremely beneficial for clinicians and researchers alike because it allows for an examination of how reported problems in core functional areas of inattention, hyperactivity, and impulsivity change over time. In addition, it allows for the tracking of changes in other areas that are closely related to ADHD (e.g., executive functioning, emotion regulation). Thus, greater alignment with an adult measure of ADHD, the CAARS 2, was a priority. The Conners 4 and CAARS 2 were co-developed with the intention that in all phases of development, the content for youth and adults alike would be comparable, whenever possible. Note: to obtain a full lifespan evaluation, the Conners EC can be used for pre-school aged children.

Fairness and Cultural Sensitivity

According to the Standards for Educational and Psychological Testing (American Educational Research Association [AERA], American Psychological Association [APA], & National Council on Measurement in Education [NCME], 2014), fairness is a fundamental validity issue in test development and must be addressed throughout all stages of a test’s development and use. Fairness is defined as the“responsiveness of a test to individual characteristics and testing contexts so that the test scores will yield valid interpretations for intended uses” (AERA, APA, & NCME, 2014, p. 50). A fair test not only provides impartial treatment of all test-takers during testing, but also provides unbiased measurement as reflected by: (a) the absence of measurement bias based on subgroup differences, (b) accessibility to constructs being measured and universal design in terms of accessibility of the test components, and (c) validity of individual test score interpretations for the test’s intended use(s). In other words, a fair test does not put some individuals at an advantage or a disadvantage because of characteristics that are irrelevant to the intended construct being measured.

The goal of the revision was to ensure that these standards were upheld throughout the different phases of test development. For example, item content was guided by findings in the literature and a review by experts in cross-cultural research. These considerations helped to ensure the accessibility of test content (e.g., absence of colloquial words and phrases, selection of language that would be familiar to and comparably interpreted by raters from varying cultural backgrounds).

In addition, the development of the Conners 4 followed best-practice recommendations with respect to gender inclusivity and sensitivity (The Market Research Society, 2016). For instance, the test items on the Parent and Teacher forms use the gender-inclusive singular they/them pronouns, rather than using he/she/him/her (the Self-Report does not include gendered pronouns). Additionally, on all Conners 4 forms, there is an optional “Gender” field (as opposed to sex at birth) provided as part of the basic demographics, along with a response option of “Other” with a “Please specify” textbox. This response option was added to ensure inclusion of individuals who indicate that their gender is other than male or female. Finally, reports use only the pronouns they/them to offer a more gender-inclusive approach to report content (American Psychological Association, 2021).

During later phases of development (i.e., pilot and standardization phases), the Normative Samples were selected to match recent census proportions for the U.S. and Canada based on race/ethnicity, region, and parental education level. This representation ensured that current demographic compositions of these populations were reflected within these samples, making the samples appropriately diverse and inclusive. A portion of the Normative Samples also include youth with clinical diagnoses, with a rate that matches recent prevalence rates (see chapter 7, Standardization, for more details). Detailed demographic data were captured so that the Conners 4 could be evaluated for measurement invariance, differential item and test functioning, and mean differences with regard to gender, race/ethnicity, country of residence, and parental education level (for more information about the investigations into measurement bias, see chapter 10, Fairness).

Finally, after the creation of the final forms, U.S. Spanish and French-Canadian versions of all the Conners 4 forms were created. These versions were linguistically and culturally sensitive adaptations of the English versions. These versions also took into account the gender inclusivity and sensitivity considerations made throughout the item development process.

Updated Normative Samples and Addition of ADHD Reference Samples

Normative Sample Updates

The Conners 3 normative samples required updating to ensure they were reflective of today’s youth, as the original norms were published in 2008. The demographic composition of the population they represented has changed considerably since that time. For example, comparing the 2000 U.S. Census (used in the creation of the normative sample for Conners 3) and the 2018 U.S. Census (used for Conners 4), 12.5% and 18.3% of youth, respectively, reported being of Hispanic, Spanish, or Latin origin (U.S. Census Bureau, 2000; 2018). Therefore, to achieve representativeness, new norms were obtained to provide a closer match to current U.S. and Canadian census proportions.

ADHD Reference Samples

In addition to providing updated normative samples as a reference group, it was decided that the inclusion of a clinical reference sample would be a valuable addition to the Conners 4. By providing an ADHD Reference Sample (stratified by age and gender; for more details on the composition of these samples, see chapter 7, Standardization), clinicians are given greater flexibility. They can determine whether the youth’s scores compare to youth from the Normative Sample, as well as to youth diagnosed with ADHD. This additional reference group can facilitate a greater understanding of the severity of the profile compared to youth with an ADHD diagnosis.

Greater Alignment of Item Content Across Rater Forms

Multiple perspectives are needed to get a comprehensive characterization of a youth’s emotional, behavioral, and social difficulties. This variety of perspectives provides a more informed evaluation of the youth’s clinical profile that in turn can guide diagnosis, treatment planning, and treatment monitoring. Several studies have shown that the use of multiple informants improves the validity of assessments of psychopathology in general (e.g., De Los Reyes et al., 2015; Izzo, Donati, & Primi, 2019) and ADHD in particular (Wolraich et al., 2019) in children and adolescents. There are inherent differences in what a rater can and cannot report regarding the youth (e.g., youth can describe feelings and thoughts that may not be easily observable by other raters). However, having consistent content across forms facilitates the comparison of raters’ perspectives, which may help identify and highlight any differences.

The Conners 3 Parent, Teacher, and Self-Report forms have overlapping content, but there are substantial differences across items and scales, making it challenging, at times, to compare results across raters. For instance, the Peer Relations scale is only included on the Parent and Teacher forms, whereas the Family Relations scale is only found on the Self-Report. Although there are certain questions regarding specific behaviors that may not be suitable to ask all raters (e.g., asking teachers to rate a student’s behavior at home), a goal of the Conners 4 was to improve the consistency of item and scale content across forms to make content more parallel across raters, wherever possible.

New and Improved Metrics to Capture Invalid Responding

Obtaining an accurate assessment of symptoms and impairment is affected by how raters respond to test questions. There are various reasons why the validity of rater responses could be called into question. One reason is that raters may engage in invalid or biased responding. For example, raters may not be attending appropriately to item content or may be randomly responding. Alternatively, raters, whether intentionally or unintentionally, may provide an overly negative or overly positive characterization of symptoms and problems. For instance, parents reporting on a youth being evaluated may fail to admit even minimal faults that most people would admit or may create a more negative clinical picture than is warranted. The Conners 3 includes the Inconsistency Index, Positive Impression Scale, and Negative Impression Scale embedded within the test to identify invalid or biased responding.

During the initial conceptualization phase, it was determined that the Conners 4 would continue to include these embedded validity scales in order to continue to provide a means of determining the validity of responses. Specifically, the Conners 4 would contain a new set of Inconsistency Index items that, similar to the Conners 3 Inconsistency Index, would be designed to flag response inconsistency as a result of random or careless responding.

At the initial conceptualization phase, it was determined that the Conners 4 would include new items for the Positive Impression Scale that describe the youth in an overly positive manner (e.g.,“Likes everyone they meet”), as well as items for the Negative Impression Scale that describe general problems not necessarily related to ADHD (e.g., “Is impossible to please”). Customer feedback revealed some challenges with the Conners 3 Positive Impression Scale. Raters (without realizing the items are meant for identifying positive impression management) find items such as “Is perfect in every way” or“Behaves like an angel” objectionable and have expressed concern about their inclusion on the test. User input is an essential component in creating tests and evaluations (e.g., Govindarajan & Kopalle, 2005; Griffin & Hauser, 1993); therefore, it was important to create a new set of items that would capture positively biased responding, without causing issues with face validity for raters.

Invalid symptom reporting can also call the validity of results into question. Invalid symptom reporting can occur for several reasons, including a cry for help or the possibility of obtaining secondary gains. Of the various reasons for invalid symptom reporting, the one that has received the greatest attention in the literature and popular media is the presence of secondary gains (e.g., school or work accommodations, access to stimulant medications, avoidance of harsh sentencing in justice settings). For example, access to special academic accommodations, such as more time on tests or a private testing room, is seen as a desirable result for youth receiving an ADHD diagnosis. Gaining access to these accommodations can motivate a rater to endorse items in such a way as to lead the clinician to believe that the youth experiences symptoms of ADHD. In fact, research has demonstrated that self-reported ADHD symptoms can be easy to feign (e.g., Harrison et al., 2007; Quinn, 2003; Suhr et al., 2011; Tucha et al.; 2015). A growing body of research has also demonstrated that feigning symptoms of ADHD is prominent in school settings (e.g., Conti, 2004; Harrison & Edwards, 2010; Harrison et al., 2007; Musso & Gouvier, 2014; Sullivan et al., 2007). Although this research has generally been conducted with college student samples, one can argue that children and adolescents can engage in the same invalid reporting themselves or may be instructed to misrepresent symptoms or problems by their parents or caregivers to obtain secondary gains. Invalid reports can also be produced by informants who are highly motivated to secure help for the youth being evaluated (Harrison & Suhr, 2021). For example, Norfolk and Floyd (2016) documented how parents may be motivated to report more problems than actually observed in order to have their child receive extra services. Hence, it was decided that the Conners 4 would also aim to include a new measure that could flag potential invalid symptom reporting.

Work with analog samples in simulated designs (in which participants are asked to respond to a test while pretending to have a disorder to differentiate between feigning and honest responding; e.g., Harrison et al., 2007; Sollman et al., 2010; Suhr et al., 2011) have found that embedding test items into the inventory that reflect unlikely presentations or improbable symptoms has been successful. These items, on the surface, describe problems that may be relevant for someone who has ADHD or sound ADHD-related, but are actually not associated with having the disorder (e.g., “It’s impossible for me to pay attention to things”) by individuals with bona fide symptoms. It has been demonstrated that individuals motivated to feign ADHD symptoms erroneously endorse these exaggerated items, believing this would increase their ADHD scores, when in fact, endorsement of these items will flag invalid symptom reporting (Harrison & Armstrong, 2016).

Based on this research at the initial conceptualization phase, it was determined that the Conners 4 would aim to include items that are exaggerated versions of true ADHD symptoms or sound ADHD-related but are not actually true symptoms. The goals of embedding ADHD Symptom Validity Test (ADHD SVT) items are to provide sufficient face validity to test-takers while aiding in the differentiation between those who may be exaggerating symptoms from those who are engaging in honest symptom reporting.

Overall, the goal of the revision was to embed new and improved validity metrics in the rating scale. It was expected that the inclusion of different types of validity indices would enhance the ability to identify various forms of invalid responding and invalid symptom reporting. These embedded validity metrics do not replace independent symptom validity assessments. In clinical settings, it is still best practice to use an independent validity assessment tool, in addition to embedded validity measures, to obtain a more comprehensive evaluation of the validity of responses.

Critical & Indicator Items

Intentional Harm to Self and Others

Because of the high co-occurrence of ADHD with externalizing disorders, the Conners 3 includes a set of Severe Conduct Critical items. These items describe behaviors regarding aggression to people and animals, destruction of property, and theft. Although these items are included in the DSM Conduct Disorder Symptom scale, the Severe Conduct Critical items, as a set, alert the clinician to behaviors that, if endorsed, are of significant concern at any age and would warrant immediate investigation and/or intervention.

ADHD has also been found to be associated with self-injurious behaviors (Simioni et al., 2018). These behaviors include non-suicidal self-injury (i.e., self-directed, deliberate harm of self in the absence of suicidal intent, such as cutting or burning), as well suicidal ideation, suicide attempts, and completed suicide (i.e., direct, self-injurious behavior with the intent to end one’s life, such as hanging, or jumping from extreme heights; Nock, 2010). In their meta-analysis, Septier et al. (2019) found a significant association of ADHD with suicidal spectrum behaviors (i.e., behaviors that encompass suicidal ideations, attempts, plans, and completed suicides). Additionally, self-harm behavior has been found to be exacerbated by other risk factors, such as anxiety and depression, emotional and behavioral problems, low self-esteem, and strained social relationships, all of which are often a part of the clinical picture for ADHD (Hu et al., 2016; Moran et al., 2012). Balázs et al. (2018) found that among adolescents, ADHD symptoms were associated with an increased risk of non-suicidal self-injury. This increased risk was found to be especially true for youth with co-occurring externalizing and internalizing disorders.

Self-harm behavior can complicate treatment (Singer, 2006), is debilitating, could be fatal, and may need more immediate intervention than other areas measured by the Conners 4. Septier et al. (2019) recommended that screening for suicidal spectrum behaviors should be standard for ADHD evaluations in youth, yet most scales commonly used to screen or assess ADHD symptoms fail to include suicide related items. A comprehensive ADHD rating scale should include such items because, when left undetected, self-harm behaviors can have serious consequences; however, with detection, severity can be mitigated.

During initial conceptualization, it was determined that the Conners 4 would continue to include a subset of items from the DSM Conduct Disorder Symptoms scale identified as Severe Conduct Critical Items and would also incorporate Self-Harm Critical Items to assess this additional set of thoughts and behaviors. If any of these items are flagged, a more in-depth assessment using disorder specific measures is recommended to examine the extent of the problems and the relationship between these problems and other problems reported on the Conners 4.

Sleep Problems

Sleep problems are prevalent among youth with ADHD (Ricketts et al., 2018; Virring et al., 2017). Rates of youth with ADHD reporting significant sleep disturbance range from 45% to 73% (Craig et al., 2017; Shur-Fen, 2006; Sung et al., 2008). These problems can include daytime sleepiness, bedtime resistance, difficulty falling asleep, waking up during the night, and sleep talking (Cortese et al., 2009; Kirov & Brand, 2014). Sleep problems can induce, mimic, or aggravate symptoms of ADHD (Moreau et al., 2013; Owens, 2005; Peralta et al., 2018; Smith et al., 2018; Stein et al., 2012; Um et al., 2017) and have been identified as an important area of focus for ADHD interventions and treatments (e.g., Baglioni et al., 2016; Becker et al., 2019). For these reasons, it was determined that the Conners 4 would incorporate Sleep Problems Indicator items. Similar to the Critical Items, if any of these items are flagged, a further evaluation of sleep problems and how they may relate to the symptoms reported is merited.

New and Modified Scales

The revision retained the key content from the Conners 3 (see chapter 1, Introduction, Table 1.2 for a full list of Conners 3 scales). However, some scales were reconceptualized or expanded, and new scales were developed to cover other important content areas.

Content Scales Updates

New items were drafted to update the Content Scales from the Conners 3. As one of the hallmarks of ADHD, a wide range of deficits in inattention and executive function was determined to be important to include for the Conners 4. The Conners 3 includes the scales of Inattention and Executive Functioning for the Parent form, but Executive Functioning is only a subscale on the Teacher form and does not exist in the Self-Report form. The revision aimed to cover these two areas more thoroughly across all raters, and thus new items were needed to produce corresponding scales across all three rater forms.

Content was expanded to separate the Conners 3 Hyperactivity/Impulsivity scale, with the intention of creating two discrete scales. Although highly related and often measured as one factor in rating scales, research has questioned whether impulsivity and hyperactivity may be better conceptualized as distinct but related domains (Kofler et al., 2020; McKee, 2012; Parke et al., 2015). While these two core features of ADHD are interrelated, they appear to stem from unique aspects of behavioral inhibition with distinct behavioral profiles, symptom trajectories, neuropsychological correlates, and behavioral outcomes (Barkley et al., 2008; McKee, 2012; Parke et al., 2015; Raiker et al., 2012). For example, it has been found that impulsivity (and not hyperactivity) is related to increased academic difficulties (Palili et al., 2011), poor social functioning (Moeller et al., 2001), and occupational, financial, and relational difficulties in adulthood (Barkley et al., 2006). There is also research suggesting that although impulsivity is often a predictor of aggressive behavior and delinquency (Barkley et al., 2008; McKee, 2012; Raiker et al., 2012) and is highly related to substance abuse (Moffitt et al., 2011), hyperactivity is not. Moreover, research has demonstrated that hyperactivity and impulsivity have different symptom trajectories, with symptoms of hyperactivity often remitting in adolescence, whereas symptoms of impulsivity often persist into adulthood (Larsson et al., 2006; Moyá et al., 2014). While further research is needed, evidence seems to support that hyperactivity and impulsivity represent distinct symptom dimensions on ADHD rating scales, and it would therefore be informative to measure these symptoms separately to provide information about the course and likelihood of poor outcomes, as well as to better guide assessment and treatment practices.

An underrepresented yet integral aspect of ADHD is problems with emotion regulation (e.g., Johnstone et al., 2020; Nigg et al., 2020; Shaw et al., 2014; Thorell et al., 2016), which can manifest as affective lability, emotional over-reactivity, and the inability to inhibit emotional expression (Adler et al., 2017). These aspects of emotional dysregulation are assessed to some extent by items that measure poor control of anger and temper on the Conners 3 Defiance/Aggression scale. The revision aimed to bring greater focus to this construct by including more items that describe not just difficulties regulating anger, but also difficulties with managing emotions in general.

Additionally, an individual with ADHD often presents with multiple co-occurring disorders, including internalizing disorders such as depression and anxiety (Becker et al., 2015; Chang et al., 2016; Clemow et al., 2017; Di Trani et al., 2014; Elkins et al., 2014; Jarrett & Ollendick, 2008; Jarrett et al., 2012; Oh et al., 2018). Willcutt et al. (2012) reported that children with ADHD are 3.5 to 6.5 times more likely to meet criteria for Generalized Anxiety Disorder. Rates of depression are also higher in youth with ADHD, ranging from 12% to 50% (Angold et al., 1999; Blackman et al., 2005; Daviss, 2008; Hassan et al., 2013). These disorders by themselves can cause significant functional impairment, and the prognosis can be worse when they co-occur with other diagnoses (e.g., Becker et al., 2012; Becker et al., 2015; Hummer et al., 2011; Matthys et al., 1998). The Conners 3 includes Screener Items for anxiety and depression, but the Conners 4 bolsters these sets of items to full scales to facilitate the evaluation for co-occurring internalizing disorders. New items were required for each set: one set focusing on anxious thoughts and excessive worrying, and the other set focusing on general feelings of sadness and depressed mood.

Inclusion of Scales to Assess Impairment and Functional Outcomes

Both the DSM1 diagnostic criteria and the determination of educational eligibility under Individuals with Disabilities Education Improvement Act (IDEA 2004) require that reported problems be associated with clinically significant impairment in the youth’s functioning. For example, one of the diagnostic criteria outlined in the DSM for ADHD is to have “clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning” (American Psychiatric Association, 2013, p. 60). As a result, to aid clinicians in their diagnosis of ADHD or to help determine educational eligibility, an assessment should provide a means to evaluate symptom criteria and operationalize and measure impairment in a standardized way. Examining both symptoms and impairment are important because these two areas, although related, provide distinct information (e.g., Gathje et al., 2008; Gordon et al., 2008; Johnstone et al., 2020). Coghill et al. (2017) examined the effects of symptoms and impairment on children and adolescents with ADHD during treatment and found that although symptoms were informative for tracking improvements and changes, the reported symptoms did not provide a complete profile of treatment response. Capturing functional impairment was needed to understand the continued problems experienced by the youth in order to provide the additional support needed. The measurement of impairment is central to Dr. Conners’ conceptualization of how a proper ADHD diagnosis is made (Siekowski, 2017). The inclusion of items that evaluate functional impairment and associated outcomes would allow for a standardized measure of the areas of impairment most commonly connected to ADHD symptoms in youth.

The Conners 3 has up to three items (varying by the rater form) that ask about functional impairment due to symptoms experienced at school, in interpersonal relationships, and at home. The items are broad single-item indicators of problems in each particular functional area. The Conners 3 also includes Content Scales that evaluate Peer Relations (Parent & Teacher form only), Family Relations (Self-Report form only) and Learning Problems (all forms).

A goal of the Conners 4 revision was to strengthen the assessment of impairment by creating scales that specifically ask about problems in functioning or outcomes that are commonly reported alongside symptoms of ADHD. These problems manifest in different functional domains, including home, school, and interpersonal interactions. It was therefore determined that the Conners 3 Family Relations, Peer Relations, and Learning Problems scales would be updated to represent impairment typically reported by youth with ADHD (or observed in youth with ADHD, in the case of the Parent and Teacher forms). Also, it was important that these areas be represented in the tool across all raters (where possible) to gauge how much impairment the youth is experiencing in order to better inform diagnosis and treatment planning.

Thus, the Conners 3 Family Relations scale, which is largely an assessment of the youth’s impression of parenting style and punishment and is only found on the Self-Report form, needed new items that would be able to be rated by the parent as well as the youth. Moreover, content needed to be adjusted to measure impairments at home, including how the youth interacts with the family, rather than focusing on the youth’s perception of parenting style and punishment. Updates were also made to the Conners 3 Peer Relations scale, which was previously only on the Parent and Teacher forms. Because the youth is a reasonable source of information for this domain, a corresponding scale was added to the Conners 4 Self-Report. Finally, the Learning Problems scale on the Conners 3 included items that were a proxy for a learning disorder, such as having difficulties with spelling, reading, and math. This scale needed to be updated with new items that describe problems in a school setting with respect to functional outcomes.

DSM Symptom Scales Updates

During this phase of conceptualization, it was determined that the items in the DSM Symptom Scales (i.e., DSM ADHD Inattentive Symptoms, DSM ADHD Hyperactive/Impulsive Symptoms, DSM Oppositional Defiant Disorder Symptoms, and DSM Conduct Disorder Symptoms) needed to be updated, wherever possible, to remove colloquial terms and idiomatic expressions. Items that contained compound sentences must be split into multiple items to offer clarity.

Indices Updates

A goal of the Conners 4 revision was to retain an ADHD Index with a set of items that best distinguished between youth with ADHD and youth in the general population. Because a new item pool was created for Conners 4, a new ADHD index needed to be developed as well to ensure the Index represents the best set of items available in the Conners 4 item pool. The purpose of the ADHD Index remained unchanged, with the goal of facilitating a determination as to whether the scores of the individual being evaluated are more similar to scores from a sample of youth diagnosed with ADHD or scores from a general population sample. The new ADHD Index was developed using modern best practices (see chapter 12, Conners 4–ADHD Index, for details on its development). The ADHD Index is still offered as a component of the full-length and shortened forms, as well as a quick stand-alone screener.

The Conners 4, however, does not include a Global Index. The Global Index was designed to identify youth whose ratings are more aligned with youth with some form of psychopathology compared to youth in the general population. However, when developing a focused assessment of ADHD, there was greater interest in highlighting the probability that a given youth has a diagnosis of ADHD instead of the probability of a broadly defined psychopathology.

Item Development

The Conners 4 development team drafted a large bank of potential test items in response to the goals delineated in the conceptualization phase. This item pool was reviewed by the author , along with external subject-matter and multicultural experts (named in the Acknowledgments section of this manual). This review process ensured not only that the critical ADHD content areas were represented and adequately covered, but also that the item bank reflected cultural fairness and sensitivity. Items identified as containing colloquial phrases or terms or that were otherwise deemed to be potentially inaccessible or unfair to diverse or marginalized populations were either dropped or revised to be culturally appropriate.

At the end of the Conceptualization, Initial Planning, and Item Development phase, the item pool consisted of 327 items for the Conners 4 Parent, 304 items for the Conners 4 Teacher, and 318 items for the Conners 4 Self-Report.


1 Throughout this manual, DSM refers to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR, 2022).


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