Journal of Abnormal ChildPsychology, VoL 3, No. 3, 1975
Conners' Teacher Rating Scale for Use in Drug Studies with Children -- An Empirical Study 1 John S. Werry 2 University of Auckland
Robert L. Sprague and Miye N. Cohen University o f Illinois
Their classroom teachers rated 291 schoolchildren, grades kindergarten through 6, on Conners' Teacher Rating Scale, developed for and used widely in drug studies in children. Scores were found to be significantly lower than those reported for a similar group of 92 New York children and considerably less than those of a group o f 64 children receiving medication for deviant behavior. Boys generally had higher scores for acting-out-type behavior while girls scored higher on neuroticism. The factor structure in this sample showed some differences from that in Conners' original analysis but they are insufficient for any change in the widely accepted scoring system, except perhaps to add a fifth factor o f sociability. An area of abnormal child psychology which has escaped the attention o f most child psychologists is psychopharmacotogy, or the study o f behavior-modifying drugs. The heritage of this neglect was revealed recently in the public furor of the Omaha incident and the subsequent Congressional hearings (Gallagher, 1970). Since physicians alone can prescribe medication, child psychologists and other behavioral scientists who have the knowledge necessary to bring some order and sophistication into this area have been reluctant to enter into a collaborative effort. F o r some reason, this has been less so of psychopharmacology in adults, where a large number of psychologists have been and are active. Manuscript received in final form May 7, 1975. This study was supported in part by USPHS grant MH18909 from the National Institute of Mental Health to Dr. R. L. Sprague and by a grant from the Medical Research Council of New Zealand to Professor J. S. Werry. 2Requests for reprints should be sent to J. S. Werry, Department of Psychiatry, University of Auckland, School of Medicine, P. B., Auckland, New Zealand. 217 @ 1 9 7 6 Plenum Publishing C o r p o r a t i o n , 2 2 7 West 1 7 t h Street, N e w Y o r k , N . Y . 1 0 0 1 1 . No part o f this p u b l i c a t i o n m a y be reproduced~ stored in a retrieval system, or t r a n s m i t t e d , in a n y f o r m or by any means, e~ectronic, m e c h a n i c a l , p h o t o c o p y } n g , m i c r o f [ } m i n g , recording, or o t h e r w i s e , w i t h o u t w r i t t e r , F3errnission o f the publisher~
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Werry, Sprague, and Cohen Table I. Items and Factor Composition of the Conners' Teacher Rating Scale (Current NIMH ECDEU version except where noted) Items Classroom behavior 1.a Fidgeting [Sits fiddling with small objects] 2. Hums and makes other odd noises 3. Demands must be met immediately, gets frustrated [Falls apart under stress of examination] 4. Coordination poor 5. Restless (overactive) 6. Excitable, impulsive 7. Inattentive, distractible 8. a Fails to finish things he starts (short attention span) [Difficulty in concening] 9. Sensitive to criticism 10. Serious or sad 11. Daydreams 12. Sullen or sulky 13. a Cries [Selfish] 14. Disturbs other children 15. Quarrelsome 16. a Mood changes quickly [Tattles] 17. Acts "smart" 18. Destructive 19. Steals 20. Lies 21. Temper outbursts (explosive and unpredictable behavior) 22. Isolates himself from other children 23. Appears to be unaccepted by group 24. Appears to be easily led 25. No sense of fair play 26. Appears to lack leadership 27. Does not get along with the opposite sex 28. Does not get along with the same sex 29. Teases other children or interferes with their activities Attitude toward authority 30. Submissive 31. Defiant 32. Impudent 33. Shy 34. Fearful 35. Excessive demands for teacher's attention 36. Stubborn 37. Anxious to please 38. Uncooperative 39. Attendance problem 40. Considering your total teaching experience with children of this age, how much of a problem is the child at this time (none, minor, moderate, or severe)? 41. What changes have you observed in this child since the start of this study (much improved, minimally improved, no change, minimally worse, or much worse)? (Omit this item at the initial rating). (a) Academic achievement (b) Overall behavior (c) Group participation (d) Attitude toward authority
Conners' Teacher Rating Scale-An Empirical Study
219
Table I. C o n t i n u e d Factor composition Factor I (Conduct Problem) Item: 12 13 (changed) a, b 14 b 15 16 (changed)a,b 17 18 19 20 21 25 29 b -30 31 32 36 38 Factor II (Inattentive-Passive) Item: 4 7 8 (changed) a 11 24 26
Factor III ( T e n s i o n - A n x i e t y ) Item:
3 (ehanged)a,b 9 10 30 33 34 37 b -39 Factor IV (Hyperactivity) Item: 1 (changed) a 2 5 6 14 29 35 b 37 b Factor V (Sociability) Item: -22 -23 -27 -28
a T h e s e items are n o w different; old version in brackets. bNot scored n o w on this factor.
We have consistently argued (Sprague & Werry, 1974; Werry & Sprague, 1972) that pediatric psychopharmacology is a challenging area of research, theoretically and clinically, and one with important social implications (now made painfully obvious), and that the best results will come from the active collaboration of experimental and clinical child psychologists and physicians trained in either pediatrics or child psychiatry. One exception to the neglect of this area of research by child psychologists is the work of Conners who, in a series of papers (see Conners, 1969, 1970, 1972, 1973), has developed measures in a wide range of areas of function. One of these is his 39-item behavior symptom checkfist for teachers (Conners, 1969) which has five orthogonal factors: Conduct Problem, Inattentive-Passive, Tension-Axtxiety, Hyperactivity, and Sociability, though, inexplicably, Conners did not include the last in scoring. There are a number of other such factored behavior symptom scales which nearly all reveal the two factors of Conduct Problem and Tension-Anxiety (or Neurotic Problem), and often a factor of Hyperactivity and one of Immaturity, the latter probably approximating to the Inattentive-Passive factor (Quay,
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Werry, Sprague, and Cohen
1972). One scale which has received a significant amount of psychometric study is that by Peterson and Quay (Quay, 1972), but it is designed to serve as a stable personality measure rather than as a dependent variable measure. On the other hand, Conners developed his scale in the course of drag studies and has honed it to suit that purpose. It is not surprising, therefore, that it has repeatedly proved to be drag sensitive (Conners, 1972; Eisenberg & Conners, 1971; Werry & Sprague, 1974), so that a partially reworded version of it has been adopted by the National Institute of Mental Health Early Clinical Drug Evaluation Unit (ECDEU) as part of a children's psychopharmacological battery (Psychopharmacology Bulletin, 1973) (see Table I). It is thus important for other investigators not only to confirm its usefulness as a dependent variable measure, but also to examine its psychometric characteristics, such as the replicability of its factor structure and the creation of norms (Sprague, Christensen, & Werry, 1974). These norms are badly needed to meet the charge that drags are being given to normal, eccentric, or even creative children (Gallagher, 1970). Conners subsequently changed 5 items: (1) "sits fiddling with small objects" to "fidgeting," (3) "falls apart under stress of examination" to "demands must be met immediately - gets frustrated," (8) "difficulty in concentrating" to "fails to finish things he starts - short attention span," (13) "selfish" to "cries," and (16) "tattles" to "mood changes quickly." Conners changed these items to yield 10 items in common with his 93-item Parent Questionnaire (Conners, 1970) but did not resubmit his data to factor analysis. METHOD
Subjects These were 291 children (143 boys and 148 girls) who were classmates of some 48 hyperactive/attention-disordered children participating in an ongoing' program of clinical and laboratory psychopharmacological research (Sprague & Werry, 1971; Sprague, Christensen, & Werry, 1974; Werry, Sprague, Weiss, & Minde, 1970; Werry & Sprague, 1974). They came from 13 classes (1 kindergarten and 2 each of grades 1-6) from 7 of the 26 elementary schools in a midwestern university town, population 100,000. All children in the classes except the hyperactive subjects were rated simultaneously by their class teachers in the winter of 1971-1972. Data from 16 hyperactive New Zealand children were pooled with those of the 48 U.S. children to form a deviant group.
Raters These were 13 class teachers, all of whom had known the children in their class for at least 3 months and all of whom had previously familiarized them-
Conners' Teacher Rating Scale-An Empirical Study
221
selves with the rating scale by rating the hyperactive children. However, none of the teachers knew the factor structure, but thought of the scale in terms of individual items of problem behavior. Participation on the part of raters was voluntary and unremunerated. Scoring
The scale has 4 points: Not at all (scored 1); just a little (2); Pretty much (3); and Very much (4). The same 4 points are scored 0 - 3 by ECDEU and by the junior authors for the U.S. data. These data have been transformed to the 1 - 4 scale for purposes of discussion in this article. These raw scores formed the data for factor analysis. In clinical use, and hence in calculating norms, scores are summed within a given factor and then divided by the number of items loading to yield a mean score. When factor scores are discussed, the first set of numbers are derived from the 1 - 4 scoring whereas the numbers in parentheses are derived from the 0 - 3 scoring. Factor Analysis
Conners (1969) in his factor analysis used the principal components solution with unity in the diagonal and the varirnax criterion for rotation to simple structure. In this study, in addition to the above methods, factoring was stopped when any one of three possible criteria was reached: (1) 100% of the variance (actually 99.9996%) removed from the correlation matrix, (2) eigen values less than unity, or (3) 10 factors extracted.
RESULTS Normative Data
The means and standard deviations of the four factors for both the normal and the hyperactive children and the z scores of the hyperactive children are presented in Table II. It is apparent that the hyperactive group is quite deviant from Table II. Means and Standard Deviations of Normal and Hyperactive Children on the Conners' Teacher Rating Scale Normal Factor I. II. III. IV.
Conduct Problem Inattentive-Passive. Tension-Anxiety Hyperactivity
Hyperactive
Meana
SD
1.14 (.14) 1.51 (.51) 1.32 (.32) 1.40 (.40)
.35 .57 .39 .55
Meana 2.03(1.03) 2.74(1.74) 1.66 (.66) 3.17 (2.17)
a Numbers in parentheses reflect 0-3 scoringof items.
SD
z Score
.63 .55 .54 .72
2.54 2.16 .87 3.22
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Fig. 1. The Conners' Abbreviated Teacher Rating Scale.
Conners' Teacher Rating Scale-An Empirical Study
223
the normal group. For example, the hyperactive group is 3.22 standard deviations above the normal group on Factor IV, Hyperactivity. This pattern of results strongly supports the teachers' ability to rate the children correctly in that they had no knowledge of the factor composition, yet they rated the samples as quite different on the factor which probably most clearly differentiated the two groups, namely hyperactivity. Conners' Abbreviated Teacher Rating Scale (Psychopharrnacology Bulletin, 1973, p. 222) consists of I0 items from the longer 39-item scale and the Conners' 93-item Parent Questionnaire (Conners, 1970). The 10 items on the abbreviated scale (see Figure 1) were among those most often checked by teachers and parents, and Conners (1972) found them to be sensitive to drug change. This finding has been repeatedly replicated (Sprague & Sleator, 1973). The mean rating for the normative sample on the 10 items was 1.43 (.43) with a standard deviation of .52. If one accepts 1.96 standard deviations above the mean as an acceptable cutting score (p < .05) for classifying a child on the basis of these data, then a mean of 2.5 (1.5) per item or 25 (15) for the total score would be required. The mean item rating for boys was 1.54 (.54) with a standard deviation of .58, and the mean item rating for girls was 1.32 (.32) with a standard deviation of .43. The correlation between the abbreviated and complete scales seems quite acceptable as can be ascertained from Table III.
Factor Analysis This extracted eight factors accounting for 99.9996% of the variance. Table IV shows the communalities, the percentage of variance accounted for by each factor, and the rotated factor matrix. Since Conners used .40 or greater as defining a loading, the same criterion was used here. In addition, only one loading per item was permitted. The loadings are in italics and the item structure of each of the eight factors indicated. Names given to the factors are: I. Conduct Problem; II. Hyperactivity-Inattentiveness; III. Unsociability; IV. Tension-Anxiety; V. Shyness; VI. Lying-Stealing; VII. Helpfulness; VIII. Absence from school. The comparison between Conners' factors and ours is shown in Table V, with Conners' original structure as criterion. Table III. Correlations Between Conners' Teacher Rating Scale and Its Abbreviated Form
I
II III IV Mean
Mean of factors Abbreviated
II
III
IV
.43
.11 .49
.77
.74
.78
.63 .13
.88 .54 .86
.74 .28 .94 .92
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Table IV. Communalifies, Variances, and Matrix Syruptom No.
Cornmunality
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
68 66 69 51 71 69 76 71 70 74 68 64 58 81 79 84 70 68 79 72 73 74 82 64 64 77 72 77 64 74 81 66 65 69 74 73 67 71 77
Percent of variance
Factor I
II
III
IV
V
VI
39 48 43 -01 49 59 31 21 24 20 19 65 09 65 83 81 79 64 17 36 80 09 11 23 67 12 32 34 68 05 84 77 -24 08 55 79 -09 76 01
67 58 54 47 62 49 76 74 22 05 65 01 07 58 19 21 22 24 05 05 14 03 19 49 27 42 27 21 31 -01 12 06 07 12 33 18 -08 30 04
11 10 20 42 03 06 21 17 13 50 17 22 05 10 21 24 01 -09 04 17 07 77 86 33 23 56 69 72 10 06 12 08 14 31 19 17 02 06 09
05 05 20 01 -04 08 09 22 73 62 21 35 71 -09 01 19 -06 O1 02 12 16 29 15 07 10 13 09 08 -09 -07 15 -01 49 68 18 15 39 07 17
-12 -04 -11 18 10 -12 14 06 02 09 20 -09 -17 08 -06 -06 04 01 -02 01 -08 07 05 45 -04 47 02 02 -01 85 08 20 56 31 -04 01 42 13 07
34.5
18.3
10.6
7.3
13.9
VII
VIII
02 24 02 04 07 06 01 -05 06 06 12 12 07 04 03 14 01 44 87 71 07 05 07 14 22 01 10 0 08 -02 17 06 -04 -02 15 13 -05 0 08
20 07 35 -01 24 26 -06 -13 21 -18 -28 -09 09 11 13 15 14 -01 0 02 13 -20 02 13 -02 11 16 24 09 03 -13 -07 -10 05 49 -10 56 -13 -01
-07 -11 04 -27 -11 -10 13 12 04 11 12 12 13 08 06 01 01 -11 -03 21 -08 -07 -02 0 06 14 15 16 23 07 07 -08 -08 02 05 04 -02 -01 85
6.3
4.8
4.2
F a c t o r I ( C o n d u c t Problem). This shows a g o o d c o n c o r d a n c e w i t h our Factor I (Conduct Problem) and our 2-item Factor VI (Lying-Stealing) combined. This a c c o u n t s for 14 o f t h e 17 i t e m s ( n o w 13) in C o n n e r s ' F a c t o r I. O n e remaining i t e m , " s u b m i s s i v e , " w i t h a negative l o a d i n g o n his F a c t o r I, loads o n o u r F a c t o r V ( S h y n e s s ) , a 2-item factor. I t e m s 13 a n d 16 were c h a n g e d b y C o n n e r s a f t e r t h e original analysis. This leaves 2 i t e m s c o n t r i b u t i n g to o u r F a c t o r I n o t in
Conners' Teacher Rating Scale-An Empirical Study
225
Conners' Factor I. These 2 items appear in his Factor IV (Hyperactivity). One item, "excitable," has a substantial secondary loading on our Hyperactivity factor within .10 of the primary loading, and thus may be considered as interchangeable between factors without undue loss of validity. The second item, "demands attention," quite clearly belongs more properly to Factor I (Conduct Problem) in our study. Face validity would suggest that it probably belongs more properly in Conduct Problem than Hyperactivity. In summary, it may be said that the basic structure of the principal factor (accounting for 34.5% of the variance in this study) is the typical principal factor not only of Conners' study but also of practically all such studies (Quay, 1972). A small subsidiary factor (VI) appears here suggesting that lying and stealing may be regarded more benignly, or at least differently, in this community, but the items are inconsequential in terms of contributing to Conners' Factor I. Another minor difference is that teachers in this community tend to perceive disturbing and excitable/impulsive behavior as more a sign of Conduct Problem than of Hyperactivity, but this difference is relative, not absolute. Factors II (Inattentive-Passive) and IV (Hyperactivity). It is necessary to discuss these together since it is clear that in this study there is a substantial difference in factor structure. Of the 14 items (now 12) comprising Conners' Factors II and IV, 6 appear in our Factor II. Items 1 and 8 appear in Conners' Factor IV and Factor II and in our Factor II but represent differently worded items. Our Factor II has an additional item, "gets frustrated," which is 1 of the 5 changed by Conners after his original analysis. In summary then, Conners' Factors II (Inattentive-Passive) and IV (Hyperactivity) appear here as a single factor. There is no objection to continuing to treat them as separate factors except they would be expected to behave similarly if used as a dependent variable. This has been true of most drag studies in which they have been used (Conners, 1969; Eisenberg & Conners, 1971; Werry & Sprague, 1974). Weak effects, however, might be obscured by splitting them across two separate measures. Factor III (Tension-Anxiety). Of the 8 items (now 6) loading, 3 are common to our Factor IV, which has 4 items. Of the remaining 5, 4 emerge in three discrete factors near the tail of the analysis: 2 items, "shy" and "submissive," comprising our Factor V (Shyness); 1 item, "anxious to please," our Factor VII (Helpfulness); and 1 item, "attendance problem," our Factor VIII (Absence from school). The last difference is that one of the altered items, "cries," loads on our Factor IV. Thus, while the replication of Factor III (Tension-Anxiety) is poor, it is only because it emerges as 4 factors rather than 1. Factor V (Sociability). Conners' Factor V is almost exactly replicated in our Factor III (including the amount of variance at 13.9), except that it emerges here as a deviant one or polar opposite which we have called "Unsociability." Our Factor III has 1 extra item loading, "lacks leadership," which appeared in his Factor II (Inattentive-Passive). It may be noted, however, that this item also has a secondary significant loading (.42) on our comparable Factor II.
226
Werry, Sprague, and Cohen Table V. Comparison Between Factor Structures Item
Factor I (Conduct Problem) 19. Steals 20. Lies 30. Submissive 12. Sullen 15. Quarrelsome 17. A c t s " s m a r t " 18. Destructive 21. Temper 25. Unfair 31. Defiant 32. Impudent 36. Stubborn 38. Uncooperative 16. Mood changes 14. Disturbs 29. Teases 13. Cries Factor IV (Hyperactivity) 35. Demands attention 14. Disturbs 6. Excitable 29. Teases 1. Fidgeting 2. Hums, etc. 5. Restless 37. Anxious to please Factor II (Inattentive-Passive) 7. Inattentive 8. Short attention 11. Daydreams 4. Coordination poor 24. Easily led 26. Lacks leadership 3. Gets frustrated Factor III (Tension-anxiety) 33. Shy 30. Submissive 39. Attendance problem
9. 10. 34. 13.
Sensitive Serious Fearful Cries
3. Gets frustrated 37. Anxious to please
Conners I I (-) I I I I I I I I I I I New a Ia Ia New a
IV a IV IV IV New IV IV IV a
II New II II II II New a (no loading) III III (-)III
III III III Newa (no loading) Newa III a
Werry et al. 17 36 04 I I I I I I I I I I I I I 09
I I I I II II II -08
II II II II II 42 II
49 -07 17
(55) (65) (59) (68)
VI VI V
(87) Entire factor (71) Lying-stealing (85)
IV
(71)
II II II II
(33) (58) (49) (31)
VII
(56) Entire factor (Helpfulness)
III
(56)
V V VIII
(56) Entire factor (85) Shyness (85) Entire factor (Absence from school)
II VII
(54) (56) Entire factor (Helpfulness)
IV IV IV IV 20 39
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227
Table V. Continued Item Factor V (Sociability) 22. Isolate 23. Unaccepted 27. Doesn't get along with opposite sex 28. Doesn't get along with same sex 26. Lacks leadership
Conners
Werry et al.
(-) V (-) V (-) V
III III III
(-) V
III
II
III
II
(42)
aNot scored on this factor currently. Table VI. New Zealand and U.S. Norms Compared to Present Studya N.Z. (N = 418) (Werry & Hawthorne)
Present study b (N = 291)
U.S. c ( N = 92) (Kupietz et al.)
Mean SD
Mean
SD
Mean SD
I. Conduct Problem Boys Girls Total
1.60 1.42 1.51
.53 .47 .51
1.21 (.21) 1.08 (.08) 1.14 (.14)
.39 .30 .35
1.36
.69
F=50.81 d
II. Inattentive-Passive Boys Girls Total
1.96 1.71 1.83
.60 .58 .60
1.60 (.60) 1.43 (.43) 1.51 (.51)
.58 .55 .57
1.82
.75
F=25.17 d
III. Tension-Anxiety Boys Girls Total
1.61 1.73 1.67
.46 .56 .53
1.29 (.29) 1.35 (.35) 1.32 (.32)
.33 .44 .39
1.86
.62
F = 60.88 d
IV. Hyperactivity Boys Girls Total
2.07 1.58 1.82
.73 .65 .78
1.56 (.56) 1.25 (.25) 1.40 (.40)
.65 .39 .55
1.75
.71
F = 34.70 d
Factor
F
adf for all analyses = 2,-795. All three groups differ significantly from each other except N.Z. and U.S. on Factors II and IV. bNumbers in parentheses reflect 0 - 3 scoring of items. Cltems and scoring slightly different from current version of the scale. dp < .001.
Comparison o f Norms with Other Studies C o m p a r i s o n w i t h the n o r m s o f K u p i e t z , Bialer, a n d Winsberg ( 1 9 7 2 ) for 92 N e w Y o r k c h i l d r e n and t h o s e accruing f r o m a r a n d o m sample o f 418 N e w Z e a l a n d s c h o o l c h i l d r e n (Werry & H a w t h o r n e , 1975) are set o u t in Table VI. It can be seen t h a t , n o t only are t h e r e d i f f e r e n c e s b e t w e e n n o r m a l s a n d h y p e r a c t i v e s , b u t t h e r e are also d i f f e r e n c e s in n o r m s f r o m the t h r e e locales,
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Werry, Sprague, and Cohen
though the New York and New Zealand scores are in some respects rather comparable. The implication is that norms from one region must be interpreted with caution in another region. The cause of this variation could lie in eitt/er genuine cultural differences in children's behavior or, more probably, differences in raters' hypothetical internal standards. The fact that teachers in this sample were thoroughly familiar with the rating scale may have militated to produce low scores, since the scale is susceptible to quite a marked practice effect between first and subsequent administrations (Werry & Sprague, 1974). Hitherto this has been assumed to lie in the reliability vis-a-vis the subject, whereas it could well lie in the rater, appearing once per rater rather than once per child. As with other studies, this attempt to replicate Conners' factor structure has revealed that differences do occur, but to a modest degree. Factor II (Inattentive-Passive) and Factor IV (Hyperactivity) are not discrete, but form a single factor. There is no compelling reason to combine these two factors, but rather to see if they behave similarly in subsequent investigations as suggested by previous drug studies (Conners, 1972; Eisenberg & Conners, 1971; Werry & Sprague, 1974). Factor III (Tension-Anxiety) is the most unstable, appearing here as four discrete factors each really too small to be useful. It would be better to retain it as a single factor in spite of its lack of replication, since from the point of view of face validity it reflects a combination of behaviors of a single class, namely escape/avoidance. Also, other studies have generally revealed a factor of this type (Quay, 1972). Several new but small factors have emerged from this study. The first of these reflects lying and stealing and, consisting of only two items, should continue to be included in Factor I (Conduct Problem). The others are so small they hardly merit consideration. Thus, the replication is sufficien.tly satisfactory to suggest no change in Conners' scoring system, particularly now that it has been adopted by NIMH. A fifth factor, Unsociability, comprised of items 22, 23, 27, and 28 could be added to test its usefulness on an empirical basis. Investigators and clinicians wishing to use the rating scale would be well advised to consult the Psyehopharmaeology Bulletin (1973, p. 219) to make sure they are using the current version.
REFERENCES Conners, C. K. A teacher rating scale for use in drug studies with children. American Journal of Psychiatry, 1969, 126, 884-888. Conners, C. K. Symptom patterns in hyperkinetic, neurotic, and normal children. Child Development, 1970, 41, 667-682. Conners, C. K. Pharmacotherapy of psychopathology in children. In H. C. Quay & J. S. Werry (Eds.), Psychopathological disorders of childhood. New York: Wiley, 1972.
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Conners, C. K. Rating scales for use in drug studies with children. Psychopharmacology Bulletin (Special Issue -- Pharmacotherapy with children), 1973, 24-84. Eisenberg, L., & Conners, C. K. Psychopharmacology in childhood. In N. B. Talbot, J. Kagen, & L. Eisenberg (Eds.), Behavioral science and pediatric medicine. Philadelphia: Saunders, 1971. Gallagher, C. E. Federal involvement in the use o f behavior modification drugs on grammar school children o f the right to privacy inquiry. Washington, D. C.: U. S. Government Printing Office, 1970. Kupietz, S., Bialer, I., & Winsberg, B. A behavior rating scale for assessing improvement in behaviorally deviant children: A preliminary investigation. American Journal o f Psychiatry, 1972, 128, 1432-1436. Psychopharmacology Bulletin (Special Issue -- Pharmacotherapy with children), 1973. Quay, H. C. Patterns of aggression, withdrawal and immaturity. In H. C. Quay & J. S. Werry (Eds.), Psychopathological disorders o f childhood. New York: Wiley, 1972. Sprague, R. L., Christensen, D. E., & Werry, J. S. Experimental psychology and stimulant drugs. In C. K. Conners (Ed.), Clinical use o f stimulant drugs in children. The Hague: Excerpta Medica, 1974. Sprague, R. L., & Sleator, E. K. Effects of psychopharmacological agents on learning disorders. Pediatric Clinics o f North America, 1973, 20, 719-735. Sprague, R. L., & Werry, J. S. Methodology of psychopharmacological studies with the retarded. In N. R. Ellis (Ed.), International review o f research in mental retardation (Vol. 5). New York: Academic Press, 1971. Sprague, R. L., & Werry, J. S. Psychotropic drugs and handicapped children. In L. Mann & D. A. Sabatino (Eds.), The second review o f special education. Philadelphia: JSE Press, 1974. Werry, J. S. & Hawthorne, D. Conners' Teacher Questionnaire Norms and factor structure. Unpublished manuscript, 1975. Werry, J. S., & Sprague, R. L. Psychopharmacology. In J. Wortis (Ed.), Mental retardation (Vol. 4). New York: Grune & Stratton, 1972. Werry, J. S., & Sprague, R. L. Methylphenidate in children -- effect of dosage. Australia and New Zealand Journal o f Psychiatry, 1974, 8, 9-19. Werry, J. S., Sprague, R. L., Weiss, G., & Minde, K. Some clinical and laboratory studies of psychotropic drugs in children: An overview. In W. L. Smith (Ed.), Drugs and cerebral]unction. Springfield, Illinois: Charles C. Thomas, 1970.
Conners' Teacher Rating Scale for Use in Drug Studies with Children -- An Empirical Study 1 John S. Werry 2 University of Auckland
Robert L. Sprague and Miye N. Cohen University o f Illinois
Their classroom teachers rated 291 schoolchildren, grades kindergarten through 6, on Conners' Teacher Rating Scale, developed for and used widely in drug studies in children. Scores were found to be significantly lower than those reported for a similar group of 92 New York children and considerably less than those of a group o f 64 children receiving medication for deviant behavior. Boys generally had higher scores for acting-out-type behavior while girls scored higher on neuroticism. The factor structure in this sample showed some differences from that in Conners' original analysis but they are insufficient for any change in the widely accepted scoring system, except perhaps to add a fifth factor o f sociability. An area of abnormal child psychology which has escaped the attention o f most child psychologists is psychopharmacotogy, or the study o f behavior-modifying drugs. The heritage of this neglect was revealed recently in the public furor of the Omaha incident and the subsequent Congressional hearings (Gallagher, 1970). Since physicians alone can prescribe medication, child psychologists and other behavioral scientists who have the knowledge necessary to bring some order and sophistication into this area have been reluctant to enter into a collaborative effort. F o r some reason, this has been less so of psychopharmacology in adults, where a large number of psychologists have been and are active. Manuscript received in final form May 7, 1975. This study was supported in part by USPHS grant MH18909 from the National Institute of Mental Health to Dr. R. L. Sprague and by a grant from the Medical Research Council of New Zealand to Professor J. S. Werry. 2Requests for reprints should be sent to J. S. Werry, Department of Psychiatry, University of Auckland, School of Medicine, P. B., Auckland, New Zealand. 217 @ 1 9 7 6 Plenum Publishing C o r p o r a t i o n , 2 2 7 West 1 7 t h Street, N e w Y o r k , N . Y . 1 0 0 1 1 . No part o f this p u b l i c a t i o n m a y be reproduced~ stored in a retrieval system, or t r a n s m i t t e d , in a n y f o r m or by any means, e~ectronic, m e c h a n i c a l , p h o t o c o p y } n g , m i c r o f [ } m i n g , recording, or o t h e r w i s e , w i t h o u t w r i t t e r , F3errnission o f the publisher~
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Werry, Sprague, and Cohen Table I. Items and Factor Composition of the Conners' Teacher Rating Scale (Current NIMH ECDEU version except where noted) Items Classroom behavior 1.a Fidgeting [Sits fiddling with small objects] 2. Hums and makes other odd noises 3. Demands must be met immediately, gets frustrated [Falls apart under stress of examination] 4. Coordination poor 5. Restless (overactive) 6. Excitable, impulsive 7. Inattentive, distractible 8. a Fails to finish things he starts (short attention span) [Difficulty in concening] 9. Sensitive to criticism 10. Serious or sad 11. Daydreams 12. Sullen or sulky 13. a Cries [Selfish] 14. Disturbs other children 15. Quarrelsome 16. a Mood changes quickly [Tattles] 17. Acts "smart" 18. Destructive 19. Steals 20. Lies 21. Temper outbursts (explosive and unpredictable behavior) 22. Isolates himself from other children 23. Appears to be unaccepted by group 24. Appears to be easily led 25. No sense of fair play 26. Appears to lack leadership 27. Does not get along with the opposite sex 28. Does not get along with the same sex 29. Teases other children or interferes with their activities Attitude toward authority 30. Submissive 31. Defiant 32. Impudent 33. Shy 34. Fearful 35. Excessive demands for teacher's attention 36. Stubborn 37. Anxious to please 38. Uncooperative 39. Attendance problem 40. Considering your total teaching experience with children of this age, how much of a problem is the child at this time (none, minor, moderate, or severe)? 41. What changes have you observed in this child since the start of this study (much improved, minimally improved, no change, minimally worse, or much worse)? (Omit this item at the initial rating). (a) Academic achievement (b) Overall behavior (c) Group participation (d) Attitude toward authority
Conners' Teacher Rating Scale-An Empirical Study
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Table I. C o n t i n u e d Factor composition Factor I (Conduct Problem) Item: 12 13 (changed) a, b 14 b 15 16 (changed)a,b 17 18 19 20 21 25 29 b -30 31 32 36 38 Factor II (Inattentive-Passive) Item: 4 7 8 (changed) a 11 24 26
Factor III ( T e n s i o n - A n x i e t y ) Item:
3 (ehanged)a,b 9 10 30 33 34 37 b -39 Factor IV (Hyperactivity) Item: 1 (changed) a 2 5 6 14 29 35 b 37 b Factor V (Sociability) Item: -22 -23 -27 -28
a T h e s e items are n o w different; old version in brackets. bNot scored n o w on this factor.
We have consistently argued (Sprague & Werry, 1974; Werry & Sprague, 1972) that pediatric psychopharmacology is a challenging area of research, theoretically and clinically, and one with important social implications (now made painfully obvious), and that the best results will come from the active collaboration of experimental and clinical child psychologists and physicians trained in either pediatrics or child psychiatry. One exception to the neglect of this area of research by child psychologists is the work of Conners who, in a series of papers (see Conners, 1969, 1970, 1972, 1973), has developed measures in a wide range of areas of function. One of these is his 39-item behavior symptom checkfist for teachers (Conners, 1969) which has five orthogonal factors: Conduct Problem, Inattentive-Passive, Tension-Axtxiety, Hyperactivity, and Sociability, though, inexplicably, Conners did not include the last in scoring. There are a number of other such factored behavior symptom scales which nearly all reveal the two factors of Conduct Problem and Tension-Anxiety (or Neurotic Problem), and often a factor of Hyperactivity and one of Immaturity, the latter probably approximating to the Inattentive-Passive factor (Quay,
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Werry, Sprague, and Cohen
1972). One scale which has received a significant amount of psychometric study is that by Peterson and Quay (Quay, 1972), but it is designed to serve as a stable personality measure rather than as a dependent variable measure. On the other hand, Conners developed his scale in the course of drag studies and has honed it to suit that purpose. It is not surprising, therefore, that it has repeatedly proved to be drag sensitive (Conners, 1972; Eisenberg & Conners, 1971; Werry & Sprague, 1974), so that a partially reworded version of it has been adopted by the National Institute of Mental Health Early Clinical Drug Evaluation Unit (ECDEU) as part of a children's psychopharmacological battery (Psychopharmacology Bulletin, 1973) (see Table I). It is thus important for other investigators not only to confirm its usefulness as a dependent variable measure, but also to examine its psychometric characteristics, such as the replicability of its factor structure and the creation of norms (Sprague, Christensen, & Werry, 1974). These norms are badly needed to meet the charge that drags are being given to normal, eccentric, or even creative children (Gallagher, 1970). Conners subsequently changed 5 items: (1) "sits fiddling with small objects" to "fidgeting," (3) "falls apart under stress of examination" to "demands must be met immediately - gets frustrated," (8) "difficulty in concentrating" to "fails to finish things he starts - short attention span," (13) "selfish" to "cries," and (16) "tattles" to "mood changes quickly." Conners changed these items to yield 10 items in common with his 93-item Parent Questionnaire (Conners, 1970) but did not resubmit his data to factor analysis. METHOD
Subjects These were 291 children (143 boys and 148 girls) who were classmates of some 48 hyperactive/attention-disordered children participating in an ongoing' program of clinical and laboratory psychopharmacological research (Sprague & Werry, 1971; Sprague, Christensen, & Werry, 1974; Werry, Sprague, Weiss, & Minde, 1970; Werry & Sprague, 1974). They came from 13 classes (1 kindergarten and 2 each of grades 1-6) from 7 of the 26 elementary schools in a midwestern university town, population 100,000. All children in the classes except the hyperactive subjects were rated simultaneously by their class teachers in the winter of 1971-1972. Data from 16 hyperactive New Zealand children were pooled with those of the 48 U.S. children to form a deviant group.
Raters These were 13 class teachers, all of whom had known the children in their class for at least 3 months and all of whom had previously familiarized them-
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221
selves with the rating scale by rating the hyperactive children. However, none of the teachers knew the factor structure, but thought of the scale in terms of individual items of problem behavior. Participation on the part of raters was voluntary and unremunerated. Scoring
The scale has 4 points: Not at all (scored 1); just a little (2); Pretty much (3); and Very much (4). The same 4 points are scored 0 - 3 by ECDEU and by the junior authors for the U.S. data. These data have been transformed to the 1 - 4 scale for purposes of discussion in this article. These raw scores formed the data for factor analysis. In clinical use, and hence in calculating norms, scores are summed within a given factor and then divided by the number of items loading to yield a mean score. When factor scores are discussed, the first set of numbers are derived from the 1 - 4 scoring whereas the numbers in parentheses are derived from the 0 - 3 scoring. Factor Analysis
Conners (1969) in his factor analysis used the principal components solution with unity in the diagonal and the varirnax criterion for rotation to simple structure. In this study, in addition to the above methods, factoring was stopped when any one of three possible criteria was reached: (1) 100% of the variance (actually 99.9996%) removed from the correlation matrix, (2) eigen values less than unity, or (3) 10 factors extracted.
RESULTS Normative Data
The means and standard deviations of the four factors for both the normal and the hyperactive children and the z scores of the hyperactive children are presented in Table II. It is apparent that the hyperactive group is quite deviant from Table II. Means and Standard Deviations of Normal and Hyperactive Children on the Conners' Teacher Rating Scale Normal Factor I. II. III. IV.
Conduct Problem Inattentive-Passive. Tension-Anxiety Hyperactivity
Hyperactive
Meana
SD
1.14 (.14) 1.51 (.51) 1.32 (.32) 1.40 (.40)
.35 .57 .39 .55
Meana 2.03(1.03) 2.74(1.74) 1.66 (.66) 3.17 (2.17)
a Numbers in parentheses reflect 0-3 scoringof items.
SD
z Score
.63 .55 .54 .72
2.54 2.16 .87 3.22
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Fig. 1. The Conners' Abbreviated Teacher Rating Scale.
Conners' Teacher Rating Scale-An Empirical Study
223
the normal group. For example, the hyperactive group is 3.22 standard deviations above the normal group on Factor IV, Hyperactivity. This pattern of results strongly supports the teachers' ability to rate the children correctly in that they had no knowledge of the factor composition, yet they rated the samples as quite different on the factor which probably most clearly differentiated the two groups, namely hyperactivity. Conners' Abbreviated Teacher Rating Scale (Psychopharrnacology Bulletin, 1973, p. 222) consists of I0 items from the longer 39-item scale and the Conners' 93-item Parent Questionnaire (Conners, 1970). The 10 items on the abbreviated scale (see Figure 1) were among those most often checked by teachers and parents, and Conners (1972) found them to be sensitive to drug change. This finding has been repeatedly replicated (Sprague & Sleator, 1973). The mean rating for the normative sample on the 10 items was 1.43 (.43) with a standard deviation of .52. If one accepts 1.96 standard deviations above the mean as an acceptable cutting score (p < .05) for classifying a child on the basis of these data, then a mean of 2.5 (1.5) per item or 25 (15) for the total score would be required. The mean item rating for boys was 1.54 (.54) with a standard deviation of .58, and the mean item rating for girls was 1.32 (.32) with a standard deviation of .43. The correlation between the abbreviated and complete scales seems quite acceptable as can be ascertained from Table III.
Factor Analysis This extracted eight factors accounting for 99.9996% of the variance. Table IV shows the communalities, the percentage of variance accounted for by each factor, and the rotated factor matrix. Since Conners used .40 or greater as defining a loading, the same criterion was used here. In addition, only one loading per item was permitted. The loadings are in italics and the item structure of each of the eight factors indicated. Names given to the factors are: I. Conduct Problem; II. Hyperactivity-Inattentiveness; III. Unsociability; IV. Tension-Anxiety; V. Shyness; VI. Lying-Stealing; VII. Helpfulness; VIII. Absence from school. The comparison between Conners' factors and ours is shown in Table V, with Conners' original structure as criterion. Table III. Correlations Between Conners' Teacher Rating Scale and Its Abbreviated Form
I
II III IV Mean
Mean of factors Abbreviated
II
III
IV
.43
.11 .49
.77
.74
.78
.63 .13
.88 .54 .86
.74 .28 .94 .92
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Table IV. Communalifies, Variances, and Matrix Syruptom No.
Cornmunality
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39
68 66 69 51 71 69 76 71 70 74 68 64 58 81 79 84 70 68 79 72 73 74 82 64 64 77 72 77 64 74 81 66 65 69 74 73 67 71 77
Percent of variance
Factor I
II
III
IV
V
VI
39 48 43 -01 49 59 31 21 24 20 19 65 09 65 83 81 79 64 17 36 80 09 11 23 67 12 32 34 68 05 84 77 -24 08 55 79 -09 76 01
67 58 54 47 62 49 76 74 22 05 65 01 07 58 19 21 22 24 05 05 14 03 19 49 27 42 27 21 31 -01 12 06 07 12 33 18 -08 30 04
11 10 20 42 03 06 21 17 13 50 17 22 05 10 21 24 01 -09 04 17 07 77 86 33 23 56 69 72 10 06 12 08 14 31 19 17 02 06 09
05 05 20 01 -04 08 09 22 73 62 21 35 71 -09 01 19 -06 O1 02 12 16 29 15 07 10 13 09 08 -09 -07 15 -01 49 68 18 15 39 07 17
-12 -04 -11 18 10 -12 14 06 02 09 20 -09 -17 08 -06 -06 04 01 -02 01 -08 07 05 45 -04 47 02 02 -01 85 08 20 56 31 -04 01 42 13 07
34.5
18.3
10.6
7.3
13.9
VII
VIII
02 24 02 04 07 06 01 -05 06 06 12 12 07 04 03 14 01 44 87 71 07 05 07 14 22 01 10 0 08 -02 17 06 -04 -02 15 13 -05 0 08
20 07 35 -01 24 26 -06 -13 21 -18 -28 -09 09 11 13 15 14 -01 0 02 13 -20 02 13 -02 11 16 24 09 03 -13 -07 -10 05 49 -10 56 -13 -01
-07 -11 04 -27 -11 -10 13 12 04 11 12 12 13 08 06 01 01 -11 -03 21 -08 -07 -02 0 06 14 15 16 23 07 07 -08 -08 02 05 04 -02 -01 85
6.3
4.8
4.2
F a c t o r I ( C o n d u c t Problem). This shows a g o o d c o n c o r d a n c e w i t h our Factor I (Conduct Problem) and our 2-item Factor VI (Lying-Stealing) combined. This a c c o u n t s for 14 o f t h e 17 i t e m s ( n o w 13) in C o n n e r s ' F a c t o r I. O n e remaining i t e m , " s u b m i s s i v e , " w i t h a negative l o a d i n g o n his F a c t o r I, loads o n o u r F a c t o r V ( S h y n e s s ) , a 2-item factor. I t e m s 13 a n d 16 were c h a n g e d b y C o n n e r s a f t e r t h e original analysis. This leaves 2 i t e m s c o n t r i b u t i n g to o u r F a c t o r I n o t in
Conners' Teacher Rating Scale-An Empirical Study
225
Conners' Factor I. These 2 items appear in his Factor IV (Hyperactivity). One item, "excitable," has a substantial secondary loading on our Hyperactivity factor within .10 of the primary loading, and thus may be considered as interchangeable between factors without undue loss of validity. The second item, "demands attention," quite clearly belongs more properly to Factor I (Conduct Problem) in our study. Face validity would suggest that it probably belongs more properly in Conduct Problem than Hyperactivity. In summary, it may be said that the basic structure of the principal factor (accounting for 34.5% of the variance in this study) is the typical principal factor not only of Conners' study but also of practically all such studies (Quay, 1972). A small subsidiary factor (VI) appears here suggesting that lying and stealing may be regarded more benignly, or at least differently, in this community, but the items are inconsequential in terms of contributing to Conners' Factor I. Another minor difference is that teachers in this community tend to perceive disturbing and excitable/impulsive behavior as more a sign of Conduct Problem than of Hyperactivity, but this difference is relative, not absolute. Factors II (Inattentive-Passive) and IV (Hyperactivity). It is necessary to discuss these together since it is clear that in this study there is a substantial difference in factor structure. Of the 14 items (now 12) comprising Conners' Factors II and IV, 6 appear in our Factor II. Items 1 and 8 appear in Conners' Factor IV and Factor II and in our Factor II but represent differently worded items. Our Factor II has an additional item, "gets frustrated," which is 1 of the 5 changed by Conners after his original analysis. In summary then, Conners' Factors II (Inattentive-Passive) and IV (Hyperactivity) appear here as a single factor. There is no objection to continuing to treat them as separate factors except they would be expected to behave similarly if used as a dependent variable. This has been true of most drag studies in which they have been used (Conners, 1969; Eisenberg & Conners, 1971; Werry & Sprague, 1974). Weak effects, however, might be obscured by splitting them across two separate measures. Factor III (Tension-Anxiety). Of the 8 items (now 6) loading, 3 are common to our Factor IV, which has 4 items. Of the remaining 5, 4 emerge in three discrete factors near the tail of the analysis: 2 items, "shy" and "submissive," comprising our Factor V (Shyness); 1 item, "anxious to please," our Factor VII (Helpfulness); and 1 item, "attendance problem," our Factor VIII (Absence from school). The last difference is that one of the altered items, "cries," loads on our Factor IV. Thus, while the replication of Factor III (Tension-Anxiety) is poor, it is only because it emerges as 4 factors rather than 1. Factor V (Sociability). Conners' Factor V is almost exactly replicated in our Factor III (including the amount of variance at 13.9), except that it emerges here as a deviant one or polar opposite which we have called "Unsociability." Our Factor III has 1 extra item loading, "lacks leadership," which appeared in his Factor II (Inattentive-Passive). It may be noted, however, that this item also has a secondary significant loading (.42) on our comparable Factor II.
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Werry, Sprague, and Cohen Table V. Comparison Between Factor Structures Item
Factor I (Conduct Problem) 19. Steals 20. Lies 30. Submissive 12. Sullen 15. Quarrelsome 17. A c t s " s m a r t " 18. Destructive 21. Temper 25. Unfair 31. Defiant 32. Impudent 36. Stubborn 38. Uncooperative 16. Mood changes 14. Disturbs 29. Teases 13. Cries Factor IV (Hyperactivity) 35. Demands attention 14. Disturbs 6. Excitable 29. Teases 1. Fidgeting 2. Hums, etc. 5. Restless 37. Anxious to please Factor II (Inattentive-Passive) 7. Inattentive 8. Short attention 11. Daydreams 4. Coordination poor 24. Easily led 26. Lacks leadership 3. Gets frustrated Factor III (Tension-anxiety) 33. Shy 30. Submissive 39. Attendance problem
9. 10. 34. 13.
Sensitive Serious Fearful Cries
3. Gets frustrated 37. Anxious to please
Conners I I (-) I I I I I I I I I I I New a Ia Ia New a
IV a IV IV IV New IV IV IV a
II New II II II II New a (no loading) III III (-)III
III III III Newa (no loading) Newa III a
Werry et al. 17 36 04 I I I I I I I I I I I I I 09
I I I I II II II -08
II II II II II 42 II
49 -07 17
(55) (65) (59) (68)
VI VI V
(87) Entire factor (71) Lying-stealing (85)
IV
(71)
II II II II
(33) (58) (49) (31)
VII
(56) Entire factor (Helpfulness)
III
(56)
V V VIII
(56) Entire factor (85) Shyness (85) Entire factor (Absence from school)
II VII
(54) (56) Entire factor (Helpfulness)
IV IV IV IV 20 39
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227
Table V. Continued Item Factor V (Sociability) 22. Isolate 23. Unaccepted 27. Doesn't get along with opposite sex 28. Doesn't get along with same sex 26. Lacks leadership
Conners
Werry et al.
(-) V (-) V (-) V
III III III
(-) V
III
II
III
II
(42)
aNot scored on this factor currently. Table VI. New Zealand and U.S. Norms Compared to Present Studya N.Z. (N = 418) (Werry & Hawthorne)
Present study b (N = 291)
U.S. c ( N = 92) (Kupietz et al.)
Mean SD
Mean
SD
Mean SD
I. Conduct Problem Boys Girls Total
1.60 1.42 1.51
.53 .47 .51
1.21 (.21) 1.08 (.08) 1.14 (.14)
.39 .30 .35
1.36
.69
F=50.81 d
II. Inattentive-Passive Boys Girls Total
1.96 1.71 1.83
.60 .58 .60
1.60 (.60) 1.43 (.43) 1.51 (.51)
.58 .55 .57
1.82
.75
F=25.17 d
III. Tension-Anxiety Boys Girls Total
1.61 1.73 1.67
.46 .56 .53
1.29 (.29) 1.35 (.35) 1.32 (.32)
.33 .44 .39
1.86
.62
F = 60.88 d
IV. Hyperactivity Boys Girls Total
2.07 1.58 1.82
.73 .65 .78
1.56 (.56) 1.25 (.25) 1.40 (.40)
.65 .39 .55
1.75
.71
F = 34.70 d
Factor
F
adf for all analyses = 2,-795. All three groups differ significantly from each other except N.Z. and U.S. on Factors II and IV. bNumbers in parentheses reflect 0 - 3 scoring of items. Cltems and scoring slightly different from current version of the scale. dp < .001.
Comparison o f Norms with Other Studies C o m p a r i s o n w i t h the n o r m s o f K u p i e t z , Bialer, a n d Winsberg ( 1 9 7 2 ) for 92 N e w Y o r k c h i l d r e n and t h o s e accruing f r o m a r a n d o m sample o f 418 N e w Z e a l a n d s c h o o l c h i l d r e n (Werry & H a w t h o r n e , 1975) are set o u t in Table VI. It can be seen t h a t , n o t only are t h e r e d i f f e r e n c e s b e t w e e n n o r m a l s a n d h y p e r a c t i v e s , b u t t h e r e are also d i f f e r e n c e s in n o r m s f r o m the t h r e e locales,
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Werry, Sprague, and Cohen
though the New York and New Zealand scores are in some respects rather comparable. The implication is that norms from one region must be interpreted with caution in another region. The cause of this variation could lie in eitt/er genuine cultural differences in children's behavior or, more probably, differences in raters' hypothetical internal standards. The fact that teachers in this sample were thoroughly familiar with the rating scale may have militated to produce low scores, since the scale is susceptible to quite a marked practice effect between first and subsequent administrations (Werry & Sprague, 1974). Hitherto this has been assumed to lie in the reliability vis-a-vis the subject, whereas it could well lie in the rater, appearing once per rater rather than once per child. As with other studies, this attempt to replicate Conners' factor structure has revealed that differences do occur, but to a modest degree. Factor II (Inattentive-Passive) and Factor IV (Hyperactivity) are not discrete, but form a single factor. There is no compelling reason to combine these two factors, but rather to see if they behave similarly in subsequent investigations as suggested by previous drug studies (Conners, 1972; Eisenberg & Conners, 1971; Werry & Sprague, 1974). Factor III (Tension-Anxiety) is the most unstable, appearing here as four discrete factors each really too small to be useful. It would be better to retain it as a single factor in spite of its lack of replication, since from the point of view of face validity it reflects a combination of behaviors of a single class, namely escape/avoidance. Also, other studies have generally revealed a factor of this type (Quay, 1972). Several new but small factors have emerged from this study. The first of these reflects lying and stealing and, consisting of only two items, should continue to be included in Factor I (Conduct Problem). The others are so small they hardly merit consideration. Thus, the replication is sufficien.tly satisfactory to suggest no change in Conners' scoring system, particularly now that it has been adopted by NIMH. A fifth factor, Unsociability, comprised of items 22, 23, 27, and 28 could be added to test its usefulness on an empirical basis. Investigators and clinicians wishing to use the rating scale would be well advised to consult the Psyehopharmaeology Bulletin (1973, p. 219) to make sure they are using the current version.
REFERENCES Conners, C. K. A teacher rating scale for use in drug studies with children. American Journal of Psychiatry, 1969, 126, 884-888. Conners, C. K. Symptom patterns in hyperkinetic, neurotic, and normal children. Child Development, 1970, 41, 667-682. Conners, C. K. Pharmacotherapy of psychopathology in children. In H. C. Quay & J. S. Werry (Eds.), Psychopathological disorders of childhood. New York: Wiley, 1972.
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Conners, C. K. Rating scales for use in drug studies with children. Psychopharmacology Bulletin (Special Issue -- Pharmacotherapy with children), 1973, 24-84. Eisenberg, L., & Conners, C. K. Psychopharmacology in childhood. In N. B. Talbot, J. Kagen, & L. Eisenberg (Eds.), Behavioral science and pediatric medicine. Philadelphia: Saunders, 1971. Gallagher, C. E. Federal involvement in the use o f behavior modification drugs on grammar school children o f the right to privacy inquiry. Washington, D. C.: U. S. Government Printing Office, 1970. Kupietz, S., Bialer, I., & Winsberg, B. A behavior rating scale for assessing improvement in behaviorally deviant children: A preliminary investigation. American Journal o f Psychiatry, 1972, 128, 1432-1436. Psychopharmacology Bulletin (Special Issue -- Pharmacotherapy with children), 1973. Quay, H. C. Patterns of aggression, withdrawal and immaturity. In H. C. Quay & J. S. Werry (Eds.), Psychopathological disorders o f childhood. New York: Wiley, 1972. Sprague, R. L., Christensen, D. E., & Werry, J. S. Experimental psychology and stimulant drugs. In C. K. Conners (Ed.), Clinical use o f stimulant drugs in children. The Hague: Excerpta Medica, 1974. Sprague, R. L., & Sleator, E. K. Effects of psychopharmacological agents on learning disorders. Pediatric Clinics o f North America, 1973, 20, 719-735. Sprague, R. L., & Werry, J. S. Methodology of psychopharmacological studies with the retarded. In N. R. Ellis (Ed.), International review o f research in mental retardation (Vol. 5). New York: Academic Press, 1971. Sprague, R. L., & Werry, J. S. Psychotropic drugs and handicapped children. In L. Mann & D. A. Sabatino (Eds.), The second review o f special education. Philadelphia: JSE Press, 1974. Werry, J. S. & Hawthorne, D. Conners' Teacher Questionnaire Norms and factor structure. Unpublished manuscript, 1975. Werry, J. S., & Sprague, R. L. Psychopharmacology. In J. Wortis (Ed.), Mental retardation (Vol. 4). New York: Grune & Stratton, 1972. Werry, J. S., & Sprague, R. L. Methylphenidate in children -- effect of dosage. Australia and New Zealand Journal o f Psychiatry, 1974, 8, 9-19. Werry, J. S., Sprague, R. L., Weiss, G., & Minde, K. Some clinical and laboratory studies of psychotropic drugs in children: An overview. In W. L. Smith (Ed.), Drugs and cerebral]unction. Springfield, Illinois: Charles C. Thomas, 1970.
