Overview of Content

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• Response Style Analysis
• Critical & Indicator Items
• Content Scales
• Impairment & Functional Outcome Scales
• DSM Symptom Scales
• Conners 4–ADHD Index
• Additional Questions

The following section provides an overview of the content included in the Conners 4 and highlights key content changes from the Conners 3. For more information on the development of this content, see chapter 6 (Development), chapter 11 (Conners 4–Short), and chapter 12 (Conners 4–ADHD Index). For details on how to interpret scores from each content area, see chapter 4 (Interpretation).

Response Style Analysis

Concerns regarding individuals feigning ADHD, and the ease with which this can be achieved, have led to calls for the creation of symptom validity indicators in the assessment of ADHD (e.g., Harrison et al., 2019; Musso & Gouvier, 2014; Sollman et al., 2010; Suhr et al., 2017; Sullivan et al., 2007). To address this need, the Conners 4 includes the Negative Impression Index that measures potential symptom exaggeration. The Inconsistency Index is included to help detect possible random or careless responding, which can also affect the accuracy of results. Scores from these validity scales help assessors ascertain the integrity of the information reported in the rating scale. Together with the validity scales, an analysis of Omitted Items and Pace (i.e., unusual administration speed) completes the picture of how a rater approached the Conners 4.

Critical & Indicator Items

The Conners 4 includes two sets of critical items—Severe Conduct and Self-Harm—as well as a Sleep Problems Indicator.

• Severe Conduct Critical Items ask about behaviors that may present danger or cause harm towards others (e.g., setting fires to cause damage, cruelty to animals, using a weapon). These behaviors are of signficant concern at any age. If any of these critical items are endorsed, they warrant immediate investigation and/or intervention.
• Self-Harm Critical Items ask about past thoughts and behaviors that intentionally cause injury or harm to one’s self. These behaviors are of significant concern at any age. If any of these items are endorsed, immediate investigation and/or intervention is merited.
• The Sleep Problems Indicator consists of items that reflect behaviors or feelings that may suggest difficulties with sleep. If this indicator is flagged, follow-up is recommended to obtain additional information. Given that sleep problems often co-occur with ADHD (e.g., Becker et al., 2019; Becker et al., 2019; Gregory et al., 2017; Ruiz-Herrera et al., 2020; Virring et al., 2017) and can mirror symptoms of ADHD, exacerbate existing symptoms, or be a side effect of medication treatment, it is critical that these problems are considered and explored further so that appropriate differential diagnosis or intervention can be provided. When sleep problems are indicated, users may choose to follow up using the PROMIS® Sleep Related Disturbance–Short Form 8a and/or the PROMIS® Sleep Related Impairment–Short Form 8a (Yu et al., 2011), which are available for free to Conners 4 users on the MHS Online Assessment Center+, in order to ensure that sleep problems are fully assessed in this population (see Additional Sleep Problems Tools Available Free of Charge in this chapter).

Content Scales

The Content Scales include items that capture key clinical constructs related to ADHD, including Inattention/Executive Dysfunction, Hyperactivity, Impulsivity, and Emotional Dysregulation. Additionally, the Depressed Mood and Anxious Thoughts scales incorporate content associated with two common co-occurring internalizing spectrum disorders of depression and anxiety, respectively.

Impairment & Functional Outcome Scales

Both the Diagnostic and Statistical Manual of Mental Disorders¹ (DSM) 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. The Conners 4 includes three scales—Schoolwork, Peer Interactions, and Family Life—that evaluate the level of impairment present in these key functional domains (note that the Family Life scale is not included on the Conners 4 Teacher). Moreover, an additional open-ended question was created to allow the raters to provide extra information on the pervasiveness of the problems reported and their impact on the youth’s functioning.

DSM Symptom Scales

The DSM Symptom Scales include items that map directly onto symptom criteria outlined in the DSM. The DSM Symptom Scales include the ADHD Inattentive Symptoms, ADHD Hyperactive/Impulsive Symptoms,Oppositional Defiant Disorder Symptoms, and Conduct Disorder Symptoms scales. A DSM Total ADHD Symptoms scale is also available. It consists of all the DSM items from the ADHD Inattentive Symptoms and ADHD Hyperactive/Impulsive Symptom scales and provides a dimensional representation of ADHD symptoms.

Conners 4–ADHD Index

Developed using advanced statistical techniques, the Conners 4–ADHD Index contains 12 items from the Conners 4 that best distinguish youth with a clinical diagnosis of ADHD from youth in the general population. See chapter 12, Conners 4–ADHD Index, for more information about the development and validation of this index.

Additional Questions

There are three additional questions at the end of the rating scale. These questions are open-ended and allow the rater an opportunity to provide extra information that may not have been captured by the Conners 4 items. The first question asks about the pervasiveness of the problems reported in the different domains of functioning. The second question asks about any other current issues or problems. Finally, the third question asks the rater to describe the youth’s strengths and skills.

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Table 1.1. Structure and Content of Conners 4 Parent, Teacher, and Self-Report Forms

		Conners 4	Conners 4–Short	Conners 4–ADHD Index
Administration Time (minutes)	Parent	10–25 (15 average)	5–10 (7 average)	1–3 (1.5 average)
	Teacher	10–20 (12 average)	5–10 (5 average)	1–3 (1 average)
	Self-Report	10–25 (15 average)	5–10 (6 average)	1–3 (1.5 average)
Number of Items	Parent	117	53	12
	Teacher	109	49	12
	Self-Report	118	51	12
Response Style Analysis	Negative Impression Index	ü	ü
	Inconsistency Index	ü
	Omitted Items	ü	ü
	Pace (online administration only)	ü	ü
Critical & Indicator Items	Severe Conduct Critical Items	ü
	Self-Harm Critical Items	ü
	Sleep Problems Indicator	ü
Content Scales	Inattention/Executive Dysfunction	ü	ü
	Hyperactivity	ü	ü
	Impulsivity	ü	ü
	Emotional Dysregulation	ü	ü
	Depressed Mood	ü
	Anxious Thoughts	ü
Impairment & Functional Outcome Scales	Schoolwork	ü	ü
	Peer Interactions	ü	ü
	Family Life (Parent and Self-Report only)	ü	ü
DSM Symptom Scales	ADHD Inattentive Symptoms	ü
	ADHD Hyperactive/Impulsive Symptoms	ü
	Total ADHD Symptoms	ü
	Oppositional Defiant Disorder Symptoms	ü
	Conduct Disorder Symptoms	ü
Conners 4–ADHD Index	Conners 4–ADHD Index	ü	ü	ü
Additional Questions	Impact of Symptoms in Functional Domains	ü	ü
	Other Concerns	ü	ü
	Strengths/Skills	ü	ü

Note. Administration time is based on the average number of items completed per minute in both the Normative and ADHD Reference Samples (see chapter 6, Development, for details).

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