Canadian Psychiatric Association

Original Research

Validation of the French Version of Conners’ Parent Rating Scale Revised, Short Version: Factorial Structure and Reliability

Association des psychiatres du Canada

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2016, Vol. 61(4) 236-242 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716635549 TheCJP.ca | LaRCP.ca

Validation de la version franc¸aise de la version re´vise´e et abre´ge´e de l’e´chelle parents de Conners; structure factorielle et fiabilite´

Pierre Fumeaux, MD1,2,3, Catherine Mercier, PhD4,5,6,7, Sylvain Roche, MSc4,5,6,7, Jean Iwaz, PhD4,5,6,7, Michel Bader, MD2,3, Philippe Ste´phan, MD2,3, Rene´ Ecochard, MD, PhD4,5,6,7, and Olivier Revol, MD1

Abstract Objective: Attention-deficit hyperactivity disorder is one of the most frequent neurodevelopmental disorders. Its diagnosis requires reference questionnaires such as the Conners’ Parent Rating Scale (CPRS). Presently, in French-speaking countries, a few translations of the revised short CPRS have been put to use without previous formal validation. We sought here for the validation of a French version (Lausanne, Switzerland) of the revised short CPRS regarding construct validity, internal consistency, and item reliability in a sample of French schoolchildren. Method: The study involved 795 children and adolescents aged 9 to 19 years from a single school. The factorial structure and item reliability were assessed with a confirmatory factor analysis for ordered categorical variables. The dimension internal consistency was assessed with Guttman’s lambda 6 coefficient. Results: The results confirmed the original and strong 3-dimensional factorial structure (Oppositional, Cognitive Problems/ Inattention, and Hyperactivity), showed satisfactory item reliability, and indicated a good dimension internal consistency (Guttman’s lambda 6 coefficient: 0.87, 0.90, and 0.82, respectively, to the 3 dimensions). Conclusions: Thus, the Lausanne French version of the revised short CPRS may be considered validated regarding construct validity and item and dimension reliability; it can be now more confidently used in clinical practice. Abre´ge´ Objectif : Le trouble de de´ficit de l’attention avec hyperactivite´ (TDAH) est l’un des troubles neurode´veloppementaux les plus fre´quents. Son diagnostic ne´cessite des questionnaires de re´fe´rence comme le Conners’ Parent Rating Scale (CPRS). Un certain nombre de traductions en franc¸ais du CPRS re´vise´, version courte, sont utilise´s dans les pays francophones sans avoir

1 2

3 4 5 6 7

Service de Neuropsychopathologie de l’enfant et de l’adolescent, Hoˆpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Bron, France Service Universitaire de Psychiatrie de l’enfant et de l’adolescent (SUPEA), De´partement de Psychiatrie (DP), Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland Universite´ de Lausanne (UNIL), Lausanne, Switzerland Hospices Civils de Lyon, Service de Biostatistique, Lyon, France Universite´ de Lyon, Lyon, France Universite´ Lyon 1, Villeurbanne, France CNRS, UMR5558, Laboratoire de Biome´trie et Biologie Evolutive, Equipe Biostatistique-Sante´, Villeurbanne, France

Corresponding Author: Pierre Fumeaux, MD, Cabinet de Pe´dopsychiatrie et Neuropsychologie enfants et adolescents, Rue Mauborget 12, CH-1003 Lausanne, Switzerland. Email: [email protected]

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e´te´ valide´s. L’objectif de ce travail consiste a` valider une version franc¸aise (Lausanne, Suisse) de ce questionnaire, sur un e´chantillon d’enfants en aˆge scolaire, en France. Me´thode : L’e´tude incluait 795 enfants et adolescents de 9 a` 19 ans d’une meˆme e´cole. La structure factorielle et la fiabilite´ des items ont e´te´ e´value´es a` l’aide d’une analyse factorielle confirmatoire pour les variables cate´goriques ordonne´es. La dimension de cohe´sion interne a e´te´ e´value´e par le coefficient lambda 6 de Guttman. Re´sultats : Le construit en 3 dimensions (Opposition, Probl e` mes cognitifs/Inattention, et Hyperactivite´) de la version originale est retrouve´ dans la version franc¸aise, avec une bonne fiabilite´ des items et une bonne cohe´rence interne pour les 3 dimensions (coefficient lambda 6 de Guttman: 0,87; 0,90; et 0,82, respectivement pour les 3 dimensions). Conclusions : Ainsi, la version francophone du CPRS re´vise´, version courte, est valide´e en termes de validite´ du construit, de cohe´rence interne et de fiabilite´ des items. Elle peut de´sormais eˆtre utilise´e en pratique clinique. Keywords attention-deficit hyperactivity disorder, child, adolescent, validation studies, confirmatory factor analysis, validity, reliability, questionnaire Attention-deficit hyperactivity disorder (ADHD) is one of the most frequent neurodevelopmental disorders. It affects 1% to 20% of school-aged children, and its global prevalence is 5.3% (95% CI, 5.0 to 5.6).1 The current knowledge is orienting the understanding of this disorder toward a multifactorial cause: genetic, biological, environmental, and psychosocial.2 The main clinical presentations are difficulties with concentration, organization, and planning; impulsivity; and, very often, motor hyperactivity.3-5 For ADHD diagnosis, the international guidelines recommend first a clinical examination, then the use of reference questionnaires4,5 (Conners’ Parent Rating Scale [CPRS]6 or ADHD Rating Scale7). These questionnaires have been scientifically validated and investigate the overall functioning of a given subject in various environments (school, family, etc.). The long form of the revised CPRS (CPRS-R: L) includes 48 items divided into 7 dimensions. The short form of the CPRS-R (the CPRS-R: S) includes 27 items, of which 18 quantify 3 dimensions: Oppositional, Cognitive Problems/ Inattention, and Hyperactivity. The 9 remaining items and 3 items from the Cognitive Problems/Inattention dimension provide an ADHD index. A number of studies have demonstrated the relevance of the various CPRSs and underlined the advantages of the CPRS-R in investigating ADHD.8 Some Conners’ scales have been already translated and validated in various languages (Turkish, 9 Swedish, 10 Spanish, 11 or rural Bengali12). A few French versions of the CPRS-R: S are also available; however, to our knowledge, although widely used, none has been validated yet. In 2006, the American CPRS-R: S6 was translated into French and then backtranslated in Lausanne, Switzerland13 (Table 1) in collaboration with Multi-Health Systems (New York, NY, and Toronto, Canada). The present article reports the validation of this French version regarding its construct validity, internal consistency of the dimensions, and reliability of the items.

Methods Study Population By the end of 2011, the study team solicited the parents of 1218 schoolchildren (40 mid-level classes of a private school in Lyon, France) via the school principal and then the head teachers. The approach included an explanatory note and a whole questionnaire (see the 27-item form in Table 1) to fill out freely and anonymously. Among the 901 returned questionnaires (74% of those sent), 106 were left blank; thus, the response rate was 65% (795 of 1218). The responses corresponded to 366 boys and 374 girls; the sex was not mentioned in 55 forms. The mean + SD age of the children was 12.7 + 1.3 years (range: 9-19). Data on all 795 children/adolescents were kept for statistical analysis. The parents of the children under study belonged to the rather well-educated French middle class. In other words, 79% of the children had at least one parent with higher education (nearly 70% of the mothers and 60% of the fathers), and 87% of the mothers and 97% of the fathers were in paid full-time or part-time employment.

Data The data were the responses to the 18 items that quantify the 3 dimensions of the American version of the CPRS-R: S.6,14,15 These dimensions were 1) Oppositional (items 2, 6, 11, 16, 20, and 24), 2) Cognitive Problems/Inattention (items 3, 8, 12, 17, 21, and 25), and 3) Hyperactivity (items 4, 9, 14, 18, 22, and 26). Each item is rated on a 4-point Likert scale (0 ¼ not true at all/Pas du tout vrai to 3 ¼ very ` vrai; see Table 1). much true/Tres

Statistical Methods Confirmatory factor analysis. A confirmatory factor analysis (CFA)16 checked the 4 hypotheses of the baseline CFA model (or model 1) applied to the French CPRS-R: S: 1)

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Table 1. French Version of the Conners’ Parent Rating Scale,a Short Form (CPRS-R: S) Used for the Study (Lausanne Translation). Questions concernant l’enfant Vous trouverez ci-dessous une liste des comportements que les enfants peuvent pre´senter. Basez-vous sur les attitudes de votre enfant durant le mois e´coule´. Pour re´pondre a` chaque question, entourez d’un cercle la meilleure re´ponse. Pour des raisons de lisibilite´, nous utilisons le masculin ge´ne´ralement. ` vrai Tres Assez vrai Pas du tout (Tr`es souvent, tr`es (souvent, vrai (jamais, Un peu vrai fre´quem ment) rare) (occasion nel) passable ment) 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.

Inattentif, facilement distrait Cole´rique et rancunier Difficulte´ a` faire ou a` terminer ses devoirs a` la maison Bouge sans arreˆt, ne tient pas en place A une dure´e d’attention re´duite Se dispute avec les adultes Bouge sans arreˆt ses mains ou ses pieds, se tortille sur son si`ege N’arrive pas a` finir ses devoirs Difficile a` controˆler dans un magasin De´sordonne´ a` la maison ou a` l’e´cole Perd facilement son calme A besoin d’eˆtre tr`es encadre´ pour faire ses devoirs S’implique dans quelque chose seulement si c¸a l’inte´resse beaucoup Court ou grimpe partout quant il ne devrait pas Facilement distrait ou n’arrive pas a` se concentrer longtemps Irritable Evite, est re´ticent, ou a des difficulte´s a` s’engager dans les activite´s demandant une attention soutenue (p. ex. devoirs scolaires) Se tortille tout le temps Vite distrait quand on lui explique quelque chose a` faire De´fie les adultes ou refuse de leur obe´ir A de la peine a` se concentrer en classe A de la peine a` rester dans une file ou a` attendre son tour dans les jeux ou en groupe Quitte sa place dans la classe ou dans d’autres situations ou` il devrait rester assis Fait expr`es des choses qui agacent les autres Ne suit pas jusqu’au bout les instructions et n’arrive pas a` terminer ses devoirs ou ce qui lui est demande´ (non provoque´ par un probl`eme de compre´hension) A de la peine a` rester tranquille pendant les jeux et les loisirs Facilement frustre´ quand il doit faire un effort

0 0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3

0 0 0 0

1 1 1 1

2 2 2 2

3 3 3 3

0 0 0 0 0

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

0

1

2

3

0 0

1 1

2 2

3 3

0 0

1 1

2 2

3 3

a

Based on Conners CK 1997. Translation: Michel Bader, Blaise Pierrehumbert, Raphae¨le Miljkovitch et Olivier Halfon.

ADHD responses can be explained by 3 factors (also called latent variables, or dimensions): Oppositional, Cognitive Problems/Inattention, and Hyperactivity; 2) each item has a nonnull coefficient of regression on the dimension it was designed to measure (loading factor) and null loading factors on the 2 other dimensions; 3) the 3 factors are correlated; and 4) the residual errors associated with each item are uncorrelated (Figure 1). As the items are ordinal variables, the parameters of the CFA models were estimated from polychoric correlation matrices,17 using mean- and variance-adjusted weighted least squares (WLSMV). Items and latent variables were standardized leading to standardized parameters, thus standardized loading factors.

This enables interpreting and comparing these loading factors as correlations. Several indexes (with their distinct rules for good fit) were used to assess the fit of the CFA models: 1) the comparative fit index (CFI)18,19 and the Tucker-Lewis index (TLI),20 with ‘‘good fit’’ if >0.95; 2) the root mean square error of approximation (RMSEA) and its 90% confidence interval (CI) with ‘‘close fit’’ if 0.80. The loading factors, the correlation coefficients between the 3 dimensions, and the residual correlations were all statistically significant. In addition, the correlations between the latent variables were not too high: 0.70 between Hyperactivity and Oppositional, 0.56 between Cognitive Problems/Inattention and Oppositional, and 0.71 between Cognitive Problems/Inattention and Hyperactivity. This indicates that the model with 3 dimensions is relevant.

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Table 2. Model Fit on the Basis of the Statistical Indexes. RMSEA Model Number and Characteristics Model 1: baseline model

w2

df

CFI

TLI

Value (90% CI)

Model Improvement P Value WRMR Parameter to Add

495.932 132 0.972 0.968 0.059 (0.053 to 0.064)

0.004

1.321

398.790 131 0.980 0.976 0.051 (0.045 to 0.056) Model 2: model 1 þ residual correlation between items 4 and 18

0.409

1.155

342.287 130 0.984 0.981 0.045 (0.040 to 0.051) Model 3: model 2 þ residual correlation between items 6 and 20

0.903

1.054

Model 4: model 3 þ item 24 reflecting hyperactivity

0.993

0.972

302.595 129 0.987 0.984 0.041 (0.035 to 0.047)

MI

CS-EPC

106.085 Residual correlation between items 4 and 18 58.984 Residual correlation between items 6 and 20 Item 24 reflecting 44.231 hyperactivity

1.148

Item 25 reflecting hyperactivity

0.267

35.167

0.618

0.327

CFI, comparative fit index; CI, confidence interval; CS-EPC, completely standardized expected parameter change; MI, modification index; RMSEA, root mean square error of approximation; TLI, Tucker-Lewis index; WRMR, weighted root mean square residual.

Item Reliability Table 3 shows the estimated reliabilities of all items in decreasing order within each dimension. These values ranged between 0.487 and 0.841 and were all, statistically speaking, significantly different from 0 (P < 0.0001). The lowest values belonged to items 18, 4, and 6 that had residual correlations.

Table 3. Reliability of the Items per Dimension. Dimensions and Items

Figure 2. Final model for the French version of Conners’ Parent Rating Scale, Short Form (CPRS-R: S). Standardized parameter estimates and their standard errors.

Oppositional Item 11 Item 16 Item 24 Item 20 Item 2 Item 6 Cognitive Problems/ Inattention Item 17 Item 3 Item 8 Item 25 Item 21 Item 12 Hyperactivity Item 14 Item 26 Item 9 Item 22 Item 18 Item 4

Estimated Reliability

Standard Error

Residual Variance

0.770 0.755 0.677 0.667 0.600 0.487

0.029 0.029 0.040 0.036 0.037 0.043

0.230 0.245 0.323 0.333 0.400 0.513

0.841 0.837 0.825 0.778 0.739 0.646

0.021 0.021 0.027 0.030 0.034 0.029

0.159 0.163 0.175 0.222 0.261 0.354

0.685 0.675 0.617 0.594 0.553 0.552

0.057 0.055 0.067 0.058 0.053 0.046

0.315 0.325 0.383 0.406 0.447 0.448

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Internal Consistency

Conclusions

The coefficient of internal consistency was 0.87 for Oppositional, 0.90 for Cognitive Problems/Inattention, and 0.82 for Hyperactivity. The 3 dimensions are thus internally consistent.

To our knowledge, this is the first validation study on the French version of the CPRS-R: S. The next validation study will investigate the scale invariance, first by sex and age classes, then by clinical status (cases vs. controls). In case of invariance, scores by sex and age will be proposed that will allow reliable comparisons between same sex and age classes in similar populations. Other investigations such as test-retest reliability, interrater reliability, external validity, and, especially, sensitivity to change would be necessary. If these properties prove satisfactory, this French version of the CPRS-R: S will represent more than a complementary diagnostic tool; it will allow following children’s progress and using the version in international clinical trials.

Discussion The existence of ADHD and its diagnosis and management are still the objects of lively debates. The tools recommended for the diagnostic approach are already widely used but sometimes inadequately or suboptimally. In testing the factorial validity of the Lausanne French version of the CPRS-R: S and in estimating item and dimension reliability, we wanted to provide French-speaking physicians and researchers a valid, reliable, and recognized tool. The present results confirmed the 3 assumptions checked by the study: 1) a strong 3-dimensional factorial structure identical to that of the 1997 American version, 2) a satisfactory dimension internal consistency, and 3) a good item reliability. These properties make this rating scale a fairly objective behaviour assessment tool in ADHD. One strength of the present study is that it takes into account the ordered categorical items into the CFAs. In a previous study, Kumar and Steer29 did not use a robust categorical least squares estimator and thus could not confirm the 3-dimensional factorial structure stated by Conners et al.6,14,15 Other explanations is that Kumar and Steer observed American psychiatric outpatients, whereas Conners et al. observed American and Canadian schoolchildren. This emphasizes the need for a study of the invariance of the scale between different populations using multigroup CFA for categorical data. The present results showed that allowing for 2 residual correlations, one between items 6 and 20 and another between items 4 and 18, led to a better-fitted model but violated the fourth hypothesis of the baseline CFA model. This was not surprising because, in French, as in English, items 6 and 20 on one hand and items 4 and 18 on the other hand have very close meanings; however, to our knowledge, no residual correlations were considered in the models used with the American version. These residual correlations may stem from the specific feature of our sample (a single French school); they should be confirmed in other independent samples. Anyway, because each residual correlation belongs to items of the same dimension, this does not question the use of CFA models or the strong 3-dimensional factorial structure of the French version. The suggested modification to model 3 (item 24 may reflect Oppositional as well as Hyperactivity) did not meet the pragmatic criteria (no evidence in French that item 24 does not suggest the Hyperactivity dimension). However, this suggestion was already present in childhood cancer survivors30; this item should thus be carefully examined in further analyses.

Acknowledgments Special thanks to Charles de Foucauld School Director for providing help and its students for their participation. Study conducted with financial support from Fonds de Perfectionnement du Centre Hospitalier Universitaire Vaudois, Socie´te´ Acade´mique Vaudoise, Fondation d’Entreprise Laboratoire Urgo, and Shire Pharmaceuticals Group.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Study carried out with agreements from 1) Comite´ de Protection des Personnes Lyon Sud Est II (France), obtained on January 5, 2012; 2) Comite´ Consultatif sur le Traitement de l’Information en mati`ere de Recherche dans le domaine de la Sante´ (France), Agreement Nr. 12.185bis, issued on September 6, 2012; and 3) Commission Nationale de l’Informatique et des Liberte´ s (France), Agreement Nr. DR-2012-524, issued on November 7, 2012.

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Validation of the French Version of Conners' Parent Rating Scale Revised, Short Version: Factorial Structure and Reliability.

Attention-deficit hyperactivity disorder is one of the most frequent neurodevelopmental disorders. Its diagnosis requires reference questionnaires suc...
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