Diagnosis in ADHD: Problems and Solutions

 C. Keith Conners, Ph.D.
Presentation to the Ontario Psychiatric Society Toronto, Ontario, Canada April 16, 2011  

Diagnosis in ADHD has had a rocky history. One only has to recall the events occurring at the NIMH Consensus Conference on ADHD in 1998. When asked his opinion about diagnosis, Mark Vonnegut, one of the experts on the panel, commented that “Diagnosis in ADHD is a mess.” This answer was reprinted in headlines the next day in newspapers around the world. When asked how you make the diagnosis, Dr. Vonnegut, threw up his hands, then took a line from Supreme Court justice Potter Stuart. The United States Supreme Court was in the midst of a controversy on how to define pornography. When asked for his definition , Justice Stuart replied, “I don’t know how to define it, but I recognize it when I see it.”

Dr. Vonnegut was probably correct in assuming that a fly-by- the-seat-of-your-pants recognition-of-ADHD-when-you-see-it, is the approach of most medical practitioners. Surveys of diagnosis in practice have repeatedly shown that many practitioners fail to follow the explicit guidelines for diagnosis,(1)such as those proposed by the American Academy of Pediatrics(2). This has led to repeated findings of over-diagnosis, based on the actual figures of ADHD from epidemiologic studies. (3) The late Atilla Turgay had developed similar guidelines for the Canadian Psychiatric Association, so we can assume that this audience will surely be familiar with those guidelines.

But there are other problems in making the diagnosis than simply ignoring or being unfamiliar with the guidelines. One major problem has to do with the criterion requiring impairment in at least two different settings. In early trials of DSM it was found that by using impairment in only one site, such as school or home, there was an excess of diagnosis, rising to as much as 40% of the normal population. Since most psychiatrists rely solely on the report of a parent about the child’s school behavior as well as their home behavior, the school setting is only indirectly being assessed. Mark Wolraich has reported that failure to get school information was one of the major limitations of diagnosis among pediatricians; and the evidence-based guidelines stress the importance of direct reports from classroom teachers.(4)

Another major challenge with diagnosis is the presence of comorbidities. Comorbidity with ADHD is not like seeing a diabetic who also has a broken leg, where the comorbid symptom is assumed to be caused independently from the diabetes. With ADHD two thirds of cases will have some associated problem with oppositional, conduct, anxiety, or depressive symptoms. These more “complicated cases” are the rule rather than the exception, so it places the burden on the diagnostician to have a good knowledge of the comorbid conditions. Factoring those comorbidities into the treatment plan is essential for knowing the type and sequence of appropriate treatments.

 Many parents will show up at their first interview ready with an internet-based diagnosis that includes a wealth of behaviors that may or may not be relevant to ADHD. Like Mark Twain, after reading a medical text book and finding that he had “every malady except housemaid’s knee,” parents and young adults who have read “Driven to Distraction,” will allege symptoms covering all of the DSM disorders. Which ones rise to the level of a true comorbid disorder, which are significant but below the diagnostic threshold, and which are simply factitious provides a diagnostic challenge.

 Finally, there is a special problem in making diagnoses for very young children. Many believe that such a practice is harmful to the child and family by providing an early stereotype that inflicts damage to self esteem, while others believe that such diagnoses are unreliable or unwarranted because of rapid developmental changes, which obscure meaningful diagnosis in preschoolers and younger children.

So, in summary, we see problems in ignoring evidence-based guidelines, problems in defining the pervasiveness of impairments, problems with the comorbid or associated conditions of ADHD, and problems in applying adult-based criteria to younger children. What resources are available to help with the problems we have identified here? Here is where my personal experience may be relevant. Permit me to recount a little of my own history in trying to deal with these problems.

When I began my first job at Johns Hopkins Medical Center in 1960, I was asked by my boss, Leon Eisenberg, to analyze the data from his just-completed randomized trial of Dexedrine and placebo in “delinquent” boys living in a cottage home run by social services.(5) The data I had to work with was a checklist of symptoms taken from Leo Kanner’s textbook of child psychiatry. The items in the checklist were simply being summed to give an overall symptom score. The data were striking in showing a dose-related improvement from the ratings done by the cottage “parents.” I became interested in the problem of monitoring drug effects with the checklist, and decided to convert it into a scale by having each of the 93 symptoms rated from 0-3, or “not at all, just a little, quite a bit, and very much.” Later I did a similar revision with a 39-item teacher report.

By factor analyzing (that is, clustering) the items according to their associations with each other, I was able to identify a small number of symptom clusters that were reliable and appeared to reflect some basic dimensions of behavior in our outpatient clientele. I began to collect normative data from children attending our clinic.

In later years, with the help of MHS here in Toronto, we were able to obtain a national database from thousands of children in North America and Canada. At that point we were able to develop normative data for separate ages and gender, along with other demographic data. So now we had a scale for measuring the position of any putative ADHD patient compared with the average child of the same age and gender in the population. Very early in the use of these scales I noticed a lot of pressure from respondents to have shorter scales, so I eventually developed a 48-item parent scale, and by taking the best items from there I was able to create a 10-item scale. We called it the “hyperactivity index” because it seemed to reflect the essential characteristics of the hyperkinetic child; it was especially favored by teachers who resisted the longer forms.

 In pursuit of even greater brevity, I once dreamed I had found a one-item scale, but when I woke up I forgot what it was. (This joke somewhat reminds me of the true story of William James when he was taking nitrous oxide, during which he felt he could discover the greatest secret of the universe. When he awoke from his drug-induced insight he finally remembered it well enough to write it down: “Higgedly hogamous, woman is monogamous; hoggedly higamous, man is polygamous.” He was disappointed, though some believe he may have hit upon an eternal truth.) But I digress.

 We still use the original 10-item index because it seems to be a very sensitive indicator of response to drugs or other treatments, particularly when trying to adjust dosage for an individual, or to track behavior over time. But needless to say such a brief scale cannot cover the scope of information required for diagnosis or initial assessments. Because of the complexity involved in ADHD diagnosis, the trend towards brevity has been reversed, as greater precision and clearer guidelines are needed for a comprehensive evaluation that includes differential diagnosis, measures of impairment, and much other relevant information. That is why our latest diagnostic aide for ADHD (the C-3), covers ADHD as well as its major comorbid conditions of ODD, CD, Anxiety, and Depression. The companion scale to the C-3 is a much more detailed scale of all the major pathologies identified by DSM in childhood, called the “CBRS”, or Comprehensive Behavior Rating Scale. Let me give you a brief overview of our reasoning and the process behind the development of these two major rating scales.

 First, we had at hand a large body of data from previous studies, such as the national survey of major rating scales carried out by Tom Achenbach, Herb Quay, and myself, funded by grants from the American Psychological Association.(6) This survey identified eleven major clusters of symptoms that cut across all socio-economic and ethnic levels. Second, we had the symptoms and impairments identified by DSM-IV for major childhood disorders.

We pooled all of this information and set about culling the data for redundancies, removing items of very low frequency, un-readability; and translations for the Spanish version carefully adjusted for the cultural meaning of the items. This pool of items was submitted to various experts in the field for suggestions, omissions, and relevance. On a test sample we performed several Exploratory Factor Analyses of the data, finally creating a “model” structure which was then verified by a Confirmatory factor analysis from a large North American national sample.

(Now I recognize that psychiatrists’ eyes tend to glaze over when psychologists start talking about factor analyses, but as in Herman Hesse’s novel, The Glass Bead Game, we have to have our own priestly mysteries, that we indulge in for our own special version of reality. This is a version of reality which sees that underlying the multiform appearances of behaviors there is a causal structure which we can identify by looking for the orthogonal relationships among groups of symptoms or behaviors).

Note that there are two parallel sets of “diagnoses” in these results: one of course is just the diagnoses representing the DSM-IV categories, albeit simplified in language and re-worked to be readable and comprehensible to parents, teachers and patients, and converted into normative scales. These are the “rational diagnostic categories,” only partly based on empirical data as well as clinical acumen acquired over several decades. The other set of content scales are those empirical factors which emerge from the factor analyses, and although they overlap with DSM, they empirically identify broad patterns.

In practice, the psychiatrist constructing the diagnoses of a patient will certainly want to use the “official” DSM categories, for medico-legal and professional communications, and the rating scales add a considerable benefit over the short paragraphs from the DSM handbook: Each diagnostic category is normed against a national sample adjusted for age and gender across a census-based representative population. So the prevalence of any given diagnosis in the population allows the clinician to know where the patient falls in the statistical distribution. While somewhat arbitrary, we set a threshold of 1.5 standard deviations above the mean as a clinically meaningful cutoff point for each score, including those from parents, teachers, and self-report of the child.

Alternatively, the scoring for the DSM categories can be done exactly as required by DSM involving the number of symptoms, rather than the statistical distribution in the general population. For the empirical or content scales, which overlap the DSM scales, we have clusters of symptoms that “appear in nature,” not just those constructed from closed-door committee meetings of the DSM working groups. We also calculated an overall statistical index of the probability that the patient has a diagnosis, based upon a comparison of a large well-identified clinical sample with matched normal controls. This allows the clinician to have an empirically derived probability estimate that the patient lies within the range of previously diagnosed patients who had a full clinical workup.

Built into the scales is also a check on the reliability of the informant, based upon overly negative or overly positive reporting biases, and consistency of response. The specifics of the scales and the steps needed to interpret them are provided in a Quick Reference handout. Speaking of one’s eyes glazing over, try to score these scales by hand, consisting of hundreds of items, validity checks, content scales, symptom scales, impairment items, and a variety of other clinical and immediate action scales, for parents, teachers and self-report by the patient. No wonder Mark Vonnegut elected to just wait until he saw it, instead of all that bother. Well, thanks to modern technology, the burden of all that work lands squarely on the parents, teachers, and patients who fill out the scales, not the psychiatrist who has to interpret them. The scales can be scored electronically on- line or a software disc, resulting in a beautiful comprehensive report, complete with graphs and interpretive results. Results from teachers and parents can be obtained directly from their computer-based input, with the scored results and interpretive reports available directly to the clinician.

Regarding early childhood diagnoses, recent epidemiological studies have shown that valid and reliable DSM diagnoses can be made in preschoolers(7) and an early childhood subcommittee of the APA has developed a modified diagnostic algorhythm for preschoolers to deal with constructs derived from older children or young adults. (4) I have provided an overview of those studies, which is available on my blog at http://adhd-world.blogspot.com/. We recently published an Early Childhood Diagnostic and Developmental Scale which seeks to identify the major symptom patterns in preschoolers and younger children, along with a parallel set of items to identify the major childhood developmental issues. The Conners Early Childhood™ (Conners EC™) aids in the early identification of behavior, social, and emotional problems in preschool-aged children 2 to 6. It also measures whether or not a child is appropriately meeting major developmental milestones. This scale, like our others, is described on the MHS website at MHS.com/Conners.

Finally, how should one use these reports in making a diagnosis? Let us stipulate that the most essential ingredient in making the diagnosis of ADHD is a wise and experienced clinician, trained broadly in the medical arts, particularly in taking a history; and one who is practiced at gathering as much information about the patient as is practical within the time limits of the particular setting, the availability of informants, and reimbursement issues. The key ingredient in all of this is the skillful history by the clinician, which then allows him or her to formulate hypotheses about the clinical status of the patient. The rating scale results are only hypotheses to assist clinicians in making the final decisions, based upon their own hypotheses gained from a careful and comprehensive history, including the family psychiatric history, medical examination (for example to rule out the rare thyroid condition), family functioning, educational history, and a host of possible environmental contributions. But we believe that the rating scales add a solid empirical basis to the entire process, addressing the issues we outlined in the beginning: following the best-practice guidelines, dealing with comorbidities, addressing areas of impairment, and assessing very young children.

In summary, we started with quite a few useful items to measure treatment outcome. Then we progressed to a smaller set of items by refining the long original list. And finally we ended up with a much more comprehensive set of rating scales in response to the obvious need to cover a very large field of pathologies and diagnoses. This approach, which started long ago, and evolved over time, represents my approach to diagnosis with ADHD. I think that the rating scale tools are extremely helpful in assisting the clinician in dealing with the diagnostic challenges we have discussed.

But of course, helpful as these tools are as aids to the practical problem of making a diagnosis according to today’s guidelines, they do not deal with the fundamental problem, that there is no patho-physiological diagnosis. Etiological diagnoses in psychiatry have largely been abandoned because of the absence of a patho-physiologic or anatomic causal basis, in favor of DSM’s strictly behavioral and clinical approach. So where do we go from here with diagnosis of ADHD? I have heard that psychiatrists like to talk about dreams, (at least they used to; but perhaps they mostly talk about pills now); but I will tell you one of mine. I call this dream, “A revised personal history of my work on diagnosis: or a Path Not Taken”.
This dream appears to be a wish-fulfillment about how I might better have spent my time. In the first part of this dream it is 1911, and a few friends of mine (Marie Curie, Henre Poincare, Albert Einstein, and Max Planck are at the Solvay Conference in Brussels, standing around endlessly discussing particle physics and such, and I am wondering why they aren’t paying attention to ADHD, since Sir George Still had only recently identified (in 1902) a group of children we now call ADHD. (Now I know you are wondering why I, who was born in 1933, could know this; but obviously in psychoanalysis we know that time travels very peculiarly in dreams.

 Later in this dream it is 1960, and I have just started work at Johns Hopkins. Two years later one of my great heroes, Rachel Carson, published Silent Spring. She tells me that “From 1945 when the use of synthetic pesticides began in the United States, to the time Silent Spring was published, pesticide use increased about sixfold. In the ten years between the publication of Silent Spring and the banning of DDT in 1972, pesticide use increased tenfold, to about one billion pounds annually”.

Since then the total quantity of pesticides in terms of pounds has not increased; however, the actual toxicity of pesticides has increased ten to twenty times. (8) Figures from today estimate that less than 0.01 percent of the pesticides that are applied reach the target pests, which means that 99.99 percent of the pesticides that are applied pollutes the environment. About 35 percent of the food that is purchased has measurable levels of pesticide residues, with 1 to 3 percent having residues that are above accepted tolerance levels.

Knowing all these facts in 1962, I began my scientific career in search of a physical pathology for ADHD (hyperkinesis, MBD, whatever) that would provide a true patho-physiologic bases for diagnosis. So what I did (in the dream) was the following: I never liked animal studies but knew it was essential to this program, so I studied the toxic effects of pesticides on animal behavior, and then showed by histo-pathological brain studies that the pesticides not only destroyed three of the dopamine receptor sites, but did so by transmission through the breast milk and amniotic fluid of the mother rats.

I also discovered that these toxic organophosphates worked to destroy acetyl cholinesterase, leaving acetylcholine nerve fibers in a constant state of excitability. It was then an easy step to human studies, where the concentrations of pesticides in different areas of the country were easily matched to prevalence levels of ADHD in pregnant mothers and in their offspring. The follow-up studies of the offspring showed conclusively that ADHD was tightly linked to levels of pesticides in the mothers and the child at birth.

Then, by analyzing organophosphate exposure in the urine of more than 1,100 children 8 to 15 years old, I found that those with highest levels of dialkyl phosphates which are the breakdown products of organophosphate pesticides also had the highest incidence of ADHD. (You might notice the suspicious similarity of my results to those of Bouchard, et al, just last year). Overall there was a 35% increase in the odds of developing ADHD with every 10-fold increase in urinary concentration of the pesticide residues. The effect was seen even at the low end of exposure: children who had any detectable, above-average level of pesticide metabolite in their urine were twice as likely as those with undetectable levels, to show symptoms of ADHD. (8)

With the aid of Russel Schachar and his group we were then able to relate particular endophenotypes of ADHD to organophosphates, accounting for the fact that there is a high rate of genetic loading in ADHD, and the fact that a certain proportion of pesticide exposures do not result in illness. The fact that about 300,000 humans are poisoned with pesticides annually in the United States, and about 26 million poisoned worldwide, leaves us with no doubt that ADHD and learning disabilities are but one of the many diseases caused by over use of pesticides.

Finally, the part of the dream which earned me the Nobel Prize for medicine came after I developed a simple blood test for recognizing critical levels of pesticides, and a chemical anti-toxin that cured patients of ADHD. Now that’s what I call a good diagnosis!

Rachel Carson taught us that pesticides “reach through the natural ecosystem, affecting not just the ‘target species,’ but humans and the animals in which we rejoice and the habitats on which our lives depend. Their effects reach not only across the land, but through time into future generations; toxins flow into eggs, through amniotic fluid and breast milk, into the tissues of developing children and the young of other species. The interdependence of life links us inextricably to the death-dealing effects of toxins.”(9)

As my mentor Leon Eisenberg once said, “Perhaps it’s time to worry less about how to describe the bodies we are trying to pull from the river, and see who is pushing them in upstream.”


1. Le Fever G, Arcona A, Antonuccio D. ADHD among American schoolchildren: Evidence of overdiagnosis and overuse of medication. Scientific reviews of mental health practice. 2003;2(1).

2. American Academy of Pediatrics: Committee on quality improvement soa-dhdCPG. Diagnosis and Evaluation of the child with ADHD. Pediatrics. 2000;105(5).

3. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. Research Support, U.S. Gov’t, P.H.S.]. 2003 Aug;60(8):837-44.

4. Carlat H, Perrin J, Stein M. The child with ADHD: Using the AAP Clinical Practice Guideline. American Family Physician. 2001 63(9):1803-11.

5. Eisenberg L, Lachman R, Molling P, Lachner A, Mizelle J, Conners CK. A psychopharmacologic experiment in a training school for delinquent boys. American Journal of Orthopsychiatry. 1963;33:431-47.

6. Achenbach TM, Howell CT, Quay HC, Conners CK. National survey of problems and competencies among four- to sixteen-year-olds: Parents’ reports for normative and clinical samples. Monographs of the Society for Research in Child Development. 1991;56(3)[225],):1991.

7. Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychol Psychiatry. [Review]. 2006 Mar-Apr;47(3-4):313-37.

8. Bouchard MF, Bellinger DC, Wright RO, Weisskopf MG. Attention-Deficit/Hyperactivity Disorder and Urinary Metabolites of Organophosphate Pesticides. Pediatrics. 2010 May 17, 2010:peds.2009-3058.

9. Sideris L, Moore K, editors. Rachel Carson: Legacy and Challenge. New York: State University of New York Press; 2008.

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NASP Talk on Assessing Preschoolers

Because of the difficulty in transferring PowerPoint slides to this location, the complete NASP presentation with slides may be viewed at my blog: adhd-world.blogspot.com. NASP participants are encouraged to ask questions and make comments, to which I will respond as quickly as possible.
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NASP Talk on Assessment in Preschoolers-Part I


Clinical Presentation, Classification, and Epidemiology1


C. Keith Conners, Ph.D.

Professor Emeritus

 Duke University Medical Center












            Once again it is a privilege to address this audience of committed professionals who work on the front lines, who bring their knowledge and skills to children who manifest the entire spectrum of mental, emotional, and behavioral handicaps. It is a particular pleasure to be able to introduce some new tools to aid in the understanding of the most vulnerable children of all, those just beginning their journey into the hazards of this world, the preschoolers.

            I am fortunate to have two experienced and brilliant young colleagues to help present our latest work–Elizabeth Sparrow and Jenny Pitkanen–who will provide you with an in-depth briefing on a somewhat ambitious and comprehensive assessment package, our Early Childhood symptom and developmental scales.

            My task in this workshop is to provide the background of research and the conceptual basis for the way the scales were constructed.  We started with the premise that mental illness is intimately related to the stages of normal development, so that assessment must establish both the features of illness as well as the developmental proficiencies and limitations of the child.

Aims of this Talk

Now I know you may be disappointed that your handouts do not contain a copy of my slides. There are two reasons for this: first, I adhere to the old maxim of “Why put off until tomorrow what you can put off today;” and second, in line with my Zen approach to workshops, I have made a vow to avoid that dread affliction known as “Death from Powerpoint.” So I will keep slides to a minimum However, a complete copy of this talk along with the slides can be found online at my website: http://ckconners.spaces.live.com.  There you may also see other talks and some of my oil paintings.


Much of what I will say is extensively reviewed in a paper by Helen Egger and Adrian Angold [1 ] with over 300 references. I am indebted to Professor Angold, head of the Child Epidemiology Program at Duke, for supplying some of the key slides from his paper.

Many years ago George Miller published one of the most famous articles in psychology, which became known as Miller’s Law: “The Magical Number Seven, Plus or Minus Two.” Most people can remember about 7 items without practice, with a confidence band of about 2 items; so 5 to 9 items are reliably retained by the average adult. But being mindful that the attention span of the average adult may be greatly exaggerated, let’s be conservative; I only want you to remember 3 things from this talk.


But these claims are not without controversy.  Imagine that you are sitting in a meeting with your fellow psychologists, or a principal, or some administrators from downtown. (I imagine you have many of those). Or perhaps you are in one of the many IEP meetings, which might include parents, teachers, lawyers or other mental health professionals. Suppose you have decided to do an assessment of the preschooler in question, but there is an outcry against you: “How can you think of doing such a thing? How dare you presume to apply psychiatric syndromes or labels to preschoolers, as if they were the same as older children or adolescents or adults?”

After all, look what happened to the last guy who claimed that preschoolers could be diagnosed:




Now, I am convinced that evidence supports those three claims I have listed above; but it is important that you become convinced, in order that you can defend your role as an expert who is assessing a preschooler, without harm to your person or reputation. It is not enough for you to say that you heard me say it at a workshop; you should become familiar with the evidence supporting those claims of preschooler psychopathology.

Generally there are only five arguments against labeling, diagnosing, classifying, “medicalizing” or alleging some mental illness in preschoolers:


(1)   Individual differences in temperament in normal development will be inappropriately    identified as psychiatric symptoms or disorders. The argument of normal variations in temperament

(2)   Preschool age involves such rapid physical, neural, behavioral, emotional and cognitive development that it is not possible to identify valid symptoms or clusters of symptoms that can be reliably measured. The argument of rapid, variable, unstable developmental changes.

(3)   That the dominant psychiatric classification system, DSM, does not take into account developmental variation. The argument that DSM is based solely on adults and older children and there is no continuity of illness from early childhood to adolescence or adulthood.

(4)   That a young child will be inappropriately ‘labeled’ with ‘diseases’ that will adversely affect self-perceptions or perceptions by others of the child. The argument that labeling creates harmful stereotypes.

(5)   That problem emotions or behavior are not located in the child but rather in the relationships between parents and children and the wider environment. The argument that mental illness is caused by the context in which the child grows.

Temperament and Symptom Cutoff Scores

Let’s examine the first claim, that problems might just be normal variations of temperament.  Over several decades now, numerous studies have used checklists and cut-points on symptom scales showing many symptoms with high prevalence (7% to 25%) in preschoolers. Evidence shows these to be stable characteristics that can be reliably measured. Many studies consistently validate a major class of ‘externalizing’ as well as ‘internalizing’ syndromes that map onto the broad and specific DSM diagnostic categories.

Twin studies demonstrate the heritability of many of these syndromes. Temperament studies do in fact reveal that certain extreme temperament types such as behavioral inhibition and behavioral disinhibition are risk factors for the later development of psychiatric disorders, as well as being associated with problem behaviors in preschoolers. For example, preschool children who respond to negative mood induction by overly-expressive or under-expressive facial response have more anxiety and depression at follow-up in the first grade [1].

Negative emotions of fear, anger, frustration, poor adaptability and high emotional intensity are predictors of later internalizing and externalizing symptoms, as well as antisocial behavior in adulthood. Some studies also link negative affectivity to later anxiety and depression [ ].

It is true, then, that temperament extremes among preschoolers are linked to significant later psychopathology. However, there are many syndromes that temperament concepts do not cover, and so cannot serve as a sufficient conceptual framework. There is no contradiction in recognizing that there are normal dimensions of behavior, such as activity level, or social withdrawal, or impulsive action, and that one can establish cut-points at which these normal behaviors shade into pathological extremes.

In the same way that we set certain extremes of blood pressure as causing pathology, we can establish a category of temperament beyond which bad things result. Thus, a category such as extreme activity level is no longer a harmless normal variation; shyness is a normal temperamental trait, but extreme social withdrawal leads to significant impairment and maps on to the DSM categories we recognize in older children and adults.

The key finding in the temperament research has been that extremes at either end of a dimension of temperament, such as activity level or social involvement, are associated with recognizable syndromes at the preschool level, and are predictive of later symptom categories and significant level of  impairment.


             A carefully developed DSM psychiatric interview showed excellent reliability in a large epidemiologic study [3].

Now the second argument against early diagnosis, that DSM included little direct mention of preschoolers is true; but the American Academy of Child and Adolescent Psychiatry formed a Task Force on preschoolers which produced a modified version of DSM. It is available to you online at: http://www.infantinstitute.org.



The modifications adhere as closely as possible to the original DSM-4 criteria but with modifications that take into account the developmental status of the child. For example, consider the category of Conduct Disorder as presented by the Task Force:

Conduct Disorder

Diagnostic Features

Conduct disorder is characterized by a repetitive and persistent pattern of behavior that violates norms and rules and the basic rights of others. The diagnosis of CD rests on the assumption that a child knowingly violates rules, a supposition that requires both knowledge of the rules and intent to break them. Most preschool children are generally able to understand the concept of

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NASP Talk on Assessment of Preschoolers-Part II

The duration requirement was shortened from 12 months to 6 months. This decision was made

because 12 months is a disproportionate amount of a child’s life span in this population relative to older children.


Because preschoolers are not skilled in verbal negotiation, they may make threats (e.g., I won’t be your friend) as a means of resolving disputes. Bullying and threatening should be endorsed positively only when threats and intimidation are persistent patterns of behavior and involve threats of aggression or cruelty (e.g., social ostracism)


Infrequent, reactive mild aggression towards peers or objects is common during this period.

Atypical aggression is more frequent and may be severe (e.g., kicking, biting, and choking). The effect of physical constraints on the manifestation of symptoms during this period must be considered. For example, most preschool children are not likely to have access to firearms or knives, but may use rocks or sticks to hurt someone.


Six of the 15 DSM-IV symptoms were modified and 5 symptoms were not. Four DSM-IV symptoms were deleted because they were inappropriate in relation to the developmental capacities of this age group (A10 “broken into someone else’s house, building, or car”; A13 “stays out at night”; A14 “run away”; and A15 “truant”). Since only 1 new symptom was added, this makes fewer possible symptoms available for children to meet the diagnosis.


In the task force document a complete table of the empirical studies supporting the categories of psychopathology in preschoolers and infants is presented, including Reliability, Face validity, Descriptive validity, Predictive validity, and Construct validity. The figures for all of the diagnostic categories are very similar to data in older children and adults. So despite the rapid developmental changes taking place in preschoolers, there is good evidence that assessment is both reliable and valid for most of the types of mental illness found in older children and adults.




There are four large scale studies documenting the reliability and validity of preschool diagnostic categories. For example, here is the method used in the Egger and Angold study, which used a DSM-based structured psychiatric interview (the PAPA, or Preschool Age Parent Assessment):

            The prevalence of disorders meeting DSM diagnostic criteria in these studies is similar to the prevalence found in older children and adults:


It is important to note that pediatricians in private practice have been shown to considerably underestimate the percentage of their patients with emotional and mental disorders [5]



The comorbidity with other disorders is also approximately the same as data from older children and adults:


     ADHD, its comorbidities, and levels of impairment were found to be highly similar in preschool and school age children by Wilens, et al. [4]

      An interesting finding in the Egger and Angold study, since replicated in other studies, is that although there appears to be associations among all of the comorbid factors, when the effects of each disorder on all other disorders are controlled for simultaneously, it turns out that the apparent associations between some pairs of disorders are mediated by another disorder. In the following slide, a preschooler with an anxiety disorder, but not ODD, is no more likely than a child without a disorder to have CD.  Notice how ODD seems to be a central mediator between the relationships of other disorders to each other.

     It almost appears that ODD is a gateway to other disorders. Of course oppositional behavior is normal to some degree in two and three-year-olders.  But the question is whether any individual child is more oppositional than expected for age and gender. Here, the use of extensive age and gender specific norms becomes crucial. By using a cutoff, say the 90th percentile, we can have some confidence that an intervention is warranted.  In this case, parent training has been shown to be an effective intervention for young ODD clients.



     A finding that a preschooler has more symptoms than expected for age and gender is not enough to demonstrate the need for intervention.  It is important that your assessment also shows that the symptoms lead to impairment (in social, educational, or developmental status such as play).










Percent Impairment of Preschoolers with Diagnoses

Data from the preschool studies show a strong relationship between a diagnosis and the number of symptoms and impairment.  However, even for many children who do not meet the threshold for diagnosis (“sub-syndromal” patterns), there may be significant impairment. This supports the notion of a continuum of impairment as a function of the number of symptoms. When you examine a child and they have many symptoms, but not enough to make a diagnosis, you still have to consider whether there is some impairment present.



          If you type that question into Google you will get literally thousands of “articles” berating the use of psychiatric labels in children. After reading a few dozen of these articles you may become impatient for any evidence or data to support the conclusions. Many of the articles come from Scientologists or people who can quote Tom Cruise, but cannot quote a single empirical fact to support their argument. A few will quote Peter Breggin or other well-known advocates against psychiatry, particularly those against the use of medications. Most however, are simple expressions of outrage based on no data whatsoever or an anecdote from personal experience. Anecdotes are not data.

          I adhere to the philosopher David Hume’s method of evaluation: “if it has no tables or data, commit it to the flames.”

But we mustn’t stop there; the next step is to use the vast resources of electronic searches in Ovid’s Medline, or other large databases. There it is equally frustrating to find that there are literally hundreds of thousands of articles on children, mental health, stereotyping, self-esteem, side-effects, diagnosis, and various combinations thereof; but not a single study that appears to demonstrate the harmful effect of psychiatric stereotyping or labeling on children.

          Am I missing something? Or have there been some acceptable empirical studies of this common attribution that simply have not been captured in my database searches? I confess that in my own experience, weighing the benefits of good assessment and treatment against the fear of labeling effects leaves little doubt that the benefits outweigh the risks.

After all, finding a correct label means there is some guide to action. There is benefit to knowing what the onset, course, and response to treatment is likely to be for a known disorder. A diagnosis is not a harmful label; it is an injunction to informed action, unless 2000 years of medical wisdom is to be ignored in the face of fear and ignorance.


Finally, let us consider the question of whether classifying or diagnosing a preschooler erroneously places an emphasis on innate, biological or genetic problems rather than environmental problems. Does this turn us away from thinking about the relationships between parents and children, or from the dangers inherent in the wider environment?

 Isn’t it true that much of the advance in our understanding of childhood mental illness comes from a long tradition of uncovering the kind of trauma, abuse, and neglect in the family environment, or the well-documented effects of poverty, poor housing, isolation, and what Emile Zola called, “The short and simple life of the poor?”

The answer of course, is that there is a false dichotomy here. We now know that the unfolding of the somatic development of the body and brain, the role of the genes, is markedly subject to the environment in which genetic expression must take place. The simple fact of the matter is this: if you hold environmental variables constant, then emotion, behavior and mental development are governed by the genes.  But if you hold the genetic variables constant, any variation of the phenotype is due to the environment. All diseases and disorders appear to fluctuate as a function of both environmental and genetic variation.

Let us abandon this false dichotomy between genes and environment, nature and nurture, and recognize that a valid clinical assessment requires a careful investigation of both sorts of influence on a particular child.  We believe that the innate genetic expression of many of the kinds of mental illness will be found in the very young child, even those blessed with an optimal environment. On the other hand, many children with normal genetic endowments may suffer from the slings and arrows of a dangerous world in which they live.

Remarkably, the little available data on the role of family relationships and parenting in preschoolers appears to show that early adverse family circumstances and parenting characteristics do not contribute to the prediction of later psychopathology once child characteristics are accounted for. In a longitudinal study of 420 two-to-three years olds followed up at 10 to 11 years, of the environmental risk factors, only stressful life events contributed independently to the prediction of later externalizing behavior problems [6].


          In summary, I argue that even though there is rapid and variable developmental changes, most of the broad patterns of illness found in older children and adults will be present in a certain percentage of preschoolers.

Extremes of temperament patterns do predict later mental illness, but temperament alone is not sufficient to explain the many types of individual disorders that will appear in preschoolers.

With all of its faults, DSM nevertheless is a helpful guide to the variety of disorders to be found in very young children. Appropriate modifications of the DSM for developmental stage in preschoolers have good supporting data from the available epidemiologic trials, and from our own normative studies.

We believe that the benefits of early classification leads to appropriate intervention strategies, and that whatever the downside might be in terms of stereotyping or labeling, the benefits are indisputable.

In all of these arguments, the presence of assessment tools for disorders and development in the preschool age relies upon careful census-based age and gender-based norms. It is only from a good foundation of normal behavior and development that we can venture into the world of the preschool child.



1.       Egger, Helen Link & Angold, Adrian (2006). Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychology & Psychiatry, 47(3), 313-337.

2.       Cole, Pamela M; Zahn-Waxler, Carolyn; Fox, Nathan A; Usher, Barbara A; Welsh, Jean D. (1996). Individual differences in emotion regulation and behavior problems in preschool children. J of Abnormal Psychology, 105(4),518-529.

3.       Egger, Helen Link, Erkanli, A., Keeler, Gordon, Potts, Edward;Walter, Barbara K. & Angold, Adrian (2006). Test-retest reliability of the preschool age psychiatric assessment (PAPA). J of the American Academy of Child & Adolescent Psychiatry, 45, 538-549.

4.       Wilens, T.E., Biederman, J., Brown, Sarah, Tanguay, Sarah, Monuteaux, M.C., Blake, Christie, B.S., & Spencer, T.J. (2002. Psychiatric comorbidity and functioning in clinically referred preschool children and school-age youths with ADHD. J American Academy of Child & Adolescent Psychiatry. 41, 262-268.

5.       Lavigne, J.V., Binns, Helen J., Christoffel, Katherine K., Rosenbaum, Diane, Arend, R., Smith, Karen, Hayford, Jennifer R., McGuire, P.A. (1993). Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians’ recognition. Pediatrics, 91, 649-655.

6.       Mesman, Judi; Koot, Hans M. (2001). Early preschool predictors of preadolescent internalizing and externalizing DSM-IV diagnoses. J of the American Academy of Child &  Adolescent Psychiatry. 40, 1029-1036.



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International Symposium in Madrid: Conners Lecture

Both the Spanish and English Versions of the ADHD Symposium Internationale held in Madrid, June 4-6, 2009 are reprinted below. Further information on the latest Conners Scales including just-released Early Childhood and Developmental Scales, may be found at MHS.Com/Conners.  Other Blogs on ADHD may be found at ADHD-World.blogspot.com.  You may email the author for further information at ckconners.live.com. 
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Spanish Language Version of Lecture





C. Keith Conners, Doctor en Medicina


Profesor emérito

Departamento de Psiquiatría y Ciencias del Comportamiento

Centro Médico de Duke University

Durham, North Carolina, EE. UU.


            Se ha comprobado que las escalas de evaluación constituyen herramientas útiles para la evaluación, supervisión del tratamiento, investigación y educación, especialmente en el TDAH y enfermedades relacionadas. Las versiones anteriores fueron elaboradas en los años 60 y han sido revisadas en varias ocasiones.  No solo contribuyeron a los aspectos prácticos de la evaluación clínica individual, sino también a la evolución de la comprensión de la nosología psiquiátrica en general.


Ahora existen dos grupos diferentes de escalas: la tercera revisión de las escalas familiares del TDAH que incluye trastornos “externalizantes” estrechamente relacionados tales como conducta agresiva y de oposición, y problemas sociales en relación con los semejantes (denominada C3); y un grupo más exhaustivo de escalas (CBRS) relacionado con un abanico más amplio que incluye estados de ánimo “internalizantes”, ansiedad y trastornos de la conducta.  En ambos tipos de escalas hay factores empíricamente derivados basados en amplias normas asociadas a la edad y el sexo, obtenidas a partir del censo, así como escalas basadas en los criterios diagnósticos exactos del DSM-IV.


Escalas de contenido C3: Las escalas empíricas C3 incluyen inatención, hiperactividad/impulsividad, problemas de aprendizaje, funcionamiento ejecutivo, agresión, relaciones con los semejantes, y relaciones familiares. Las escalas del Manual Diagnóstico y Estadístico (DSM-4) incluyen los 3 subtipos de TDAH, trastorno de la conducta, y trastorno de oposición desafiante. Existe una escala especial para detectar la conducta violenta de carácter crítico. También hay elementos para detectar ansiedad y depresión. Los elementos de efecto negativo incluyen las tareas escolares y las notas, las amistades y relaciones, y la vida en casa.


Escalas de contenido CBRS: Las escalas empíricas incluyen angustia emocional (pensamientos inquietantes, preocupaciones, problemas de tipo social), síntomas físicos, miedo a la separación, ansiedad social, conductas agresivas, problemas académicos, (lenguaje y matemáticas), violencia potencial. Los trastornos del DSM incluyen episodio depresivo mayor, episodio maníaco, episodio mixto, trastorno de ansiedad generalizado, trastorno de ansiedad por separación, fobia social, trastorno obsesivo-compulsivo, trastorno autista, enfermedad de Asperger, subtipos del TDAH, trastorno de la conducta, trastorno de oposición desafiante. Otros indicadores clínicos incluyen acoso escolar (victimización y perpetración), enuresis/encopresis, crisis de pánico, trastorno del desarrollo pervasivo, perversión del apetito, trastorno de estrés postraumático, fobia específica, uso de sustancias, tics y tricotilomanía.


            Existen versiones separadas para autoevaluación del paciente, evaluación de los padres y evaluación de los profesores. Existen tanto versiones largas como abreviadas para aquellas situaciones que requieran brevedad (como en el caso de evaluaciones reiteradas en el tiempo); o versiones más largas cuando está indicada una evaluación inicial más completa.  Se han añadido varios nuevos refinamientos: escalas de validez que detectan inconsistencia en los informes o un sesgo excesivamente positivo o negativo; medidas del deterioro así como de la gravedad de los síntomas; cálculos de índices que reflejan la probabilidad de la gravedad del diagnóstico clínico; puntuación en línea a través de una conexión a Internet; informes exhaustivos que incluyen el error estándar de la medida y que calculan los cambios estadísticamente significativos.           




































C. Keith Conners, Doctor en Medicina

Profesor emérito

Departamento de Psiquiatría y Ciencias del Comportamiento

Centro Médico de Duke University

Durham, EE. UU.


Señoras y señores:

Como diagnosticadores y observadores avezados, sin duda tienen conocimiento de una temible afección mórbida que se ha extendido rápidamente por todo el mundo en los últimos tiempos.  Y no me refiero al virus H1-N1 de la peste porcina sino a una enfermedad mental yatrogénica causada por la presentación visual de texto a gran velocidad por parte de los profesionales de la docencia que simultáneamente exponen información enormemente densa presentada a una increíble velocidad, que provoca un trastorno cerebral que llamamos “muerte por PowerPoint”. Quizás esto sirvió de inspiración a la fuerza de los cuadros de Francisco de Goya:

                                   DIAPOSITIVA N.º 1: MUERTE POR POWERPOINT

Para evitar la aparición de esta afección presentaré solo una diapositiva, de modo que puedan atender sin la complicación que supone tener que escuchar a la vez el inglés y la traducción simultánea al español y leer el texto en inglés.  En lugar de esto, he entregado a los oyentes una traducción escrita en español de la charla, y varios documentos que espero decidan examinar detenidamente ya que la necesidad de las escalas de evaluación es cada vez mayor en la actividad clínica, científica y docente. También dispondrán de un dossier que incluirá un conjunto completo de informes sobre un caso clínico, donde podrán ver con facilidad el tipo de información que tales escalas de evaluación pueden proporcionar. 

En primer lugar, permítanme decir unas palabras acerca de las ventajas y los peligros de las escalas de evaluación. Las escalas de evaluación usan sencillas frases descriptivas que conforman una imagen de la conducta, el estado de ánimo y los actos de un individuo.  Pero no constituyen un recuento riguroso de hechos mínimos ni el equivalente verbal de una fotografía o una película. Las escalas de evaluación reflejan más bien las impresiones que tiene un padre, un profesor o un observador externo sobre un sujeto.  No son lo que Henry Murray denominó “actones” –acciones precisas a nivel molecular de la observación. Ni son tampoco escalas de evaluación de impresiones globales, tales como “se ha vuelto loco” o “es cruel”. Más bien se trata de impresiones a un nivel de observación medio, y reflejan el impacto del sujeto sobre el observador en relación con diversos rasgos cognitivos, nivel de actividad, estado de ánimo y conductas que poseen significados comunes para el observador.

Puesto que estas puntuaciones son impresiones, pueden dar lugar a diversos errores por exageración, a efectos de halo positivos o negativos, o a incoherencias. Pero dichos errores pueden ser detectados y tenidos en cuenta mediante determinados procedimientos técnicos a los que ha podido recurrirse gracias a los modernos métodos de computación. 

Pero las escalas de evaluación van más allá de unas simples impresiones sobre la conducta del paciente o sobre el estado de ánimo de un cliente. Algunos elementos de una escala comparten el mismo destino común y guardan una estrecha correlación unos con otros y menos con otros grupos de elementos. Técnicamente se denominan “factores” que representan estructuras de un nivel superior que los elementos aislados. Así pues, robar, mentir, acosar, o pelear se agruparán juntos, con importantes correlaciones que revelan la conciencia que el observador tiene de que estas conductas tienden a presentarse como parte de un patrón de comportamiento.  El gran número de investigaciones realizadas al cabo de los años ha permitido identificar una serie de dichos patrones, y estos han dado forma a ciertas ideas sobre nosología psiquiátrica, y a su vez han sido influidos por los avances en el entendimiento clínico de los patrones anómalos.  Los patrones que se descubren mediante el análisis de factores están desde luego influenciados por el famoso principio de “GIGO” – Garbage in, Garbage Out (si entra basura, sale basura, o lo que aportas es lo que recibes), por lo que la selección cuidada de los elementos constituye una tarea fundamental al crear escalas de evaluación. Nosotros tomamos estos elementos a partir de las quejas que normalmente realizan los pacientes, sus padres, profesores u otros observadores.

Por último, mediante el uso de escalas derivadas de estos grupos o patrones, es posible reunir datos normativos de un gran número de sujetos, tanto normales como fuera de lo normal (definidos por los estándares clínicos o mediante límites estadísticos), y establecer umbrales para diferentes edades y sexos a lo largo del ciclo vital. Por ejemplo, en nuestras últimas escalas de evaluación para niños de 6 a 18 años usamos datos de más de once mil (11.000) sujetos obtenidos en EE. UU. y Canadá, y con ellos construimos evaluaciones que representan los patrones individuales típicos de cada edad y sexo en niños con edades de seis a dieciocho años.  Al conocer la media y las desviaciones estándar podemos saber qué pacientes caen fuera del rango de la “normalidad”, definida por un estándar estadístico, o por su similitud con casos clínicos conocidos. 

Ahora permítanme que vuelva sobre algunos puntos específicos de las nuevas escalas.  Una de las características nuevas más importantes de nuestras escalas se basa en la existencia de controles de validez para identificar impresiones excesivamente positivas o negativas o inconsistencias en los informes.  Estas escalas de validez, aunque no son infalibles, aportan una cierta garantía de poder detectar si un padre, profesor o paciente es demasiado positivo en sus descripciones, o demasiado negativo (“los que siempre dicen sí” y “los que siempre dicen no”), ampliamente conocidos tras muchas investigaciones como rasgos de personalidad dominante que influyen en las descripciones de ellos mismos o de otras personas).  Las inconsistencias que aparecen cuando un evaluador da respuestas contradictorias a elementos que guardan una correlación absoluta, pueden detectarse y llamar nuestra atención al interpretar una escala de evaluación. 

Mi interés principal en las investigaciones realizadas a lo largo de años se ha centrado en los niños que denominamos TDAH, o con trastorno de déficit de atención e hiperactividad.  Una de las primeras observaciones que hicieron los investigadores de psiquiatría y pediatría fue la de un grupo de niños con inteligencia normal que eran hiperactivos, inatentos, impulsivos, agresivos, desafiantes y de conducta indisciplinada.  Y ciertamente, se han puesto de manifiesto repetidas veces en análisis de factores de grupos de elementos derivados de quejas recibidas en centros de salud mental.   Por tanto, durante muchos años nos centramos en este tipo de niños puesto que constituían la variedad más común de quejas encontradas en los centros terapéuticos de salud mental.

Pero, a diferencia de la imagen que dibujó el pediatra que primero describió el síndrome (George Still en 1902), nosotros encontramos que existían factores separados para las quejas cognitivas como la inatención y la distractibilidad, la conducta excitable e impulsiva, hiperactividad, ineptitud social, y conducta oposicional y desafiante. Ya desde el principio nuestros análisis de factores demostraron que este grupo “externalizante” de niños podía escindirse en patrones separados de individuos agresivos, desafiantes, inatentos, inquietos y socialmente ineptos. En esta nueva versión de nuestras escalas, la tercera, seguimos incluyendo tales factores.

Además, ahora incluimos un factor que cubre los problemas de aprendizaje ya que se encuentran presentes en la mayoría de casos de TDAH, de conducta desordenada y de niños con deterioro social. Es importante que los procesos primarios de aprendizaje sean examinados siempre en niños que llaman la atención en primer lugar por su conducta negativa o por hiperactividad.  Los problemas de aprendizaje pueden constituir una comorbilidad junto al TDAH, un problema primario que simula un TDAH, o una consecuencia de dificultades conductuales.  En cualquier caso deben ser abordados como parte del programa de tratamiento.

Los investigadores y teóricos han prestado mucha atención a un nuevo concepto conocido como “funciones ejecutivas”.  Aunque no creemos que los trastornos de la función ejecutiva sean la causa primaria del TDAH, y que no son exclusivos del TDAH (puesto que aparecen en muchas otras enfermedades mentales), sí creemos que es necesario evaluarlos y abordarlos terapéuticamente cuando aparecen formando parte del cuadro general del TDAH o de otros trastornos relacionados.  Las funciones ejecutivas incluyen planificación, organización, realización de las tareas de la vida diaria, incluida la vida académica.  Muchas de estas funciones serán asumidas por los cuidadores o los profesores en los primeros años de la vida del niño, y no serán reconocidas hasta más tarde cuando el adolescente o el adulto joven debe asumir más responsabilidad para hacer las cosas a tiempo, programar, planificar,  e iniciar y completar tareas.

Nuestras últimas escalas incluyen cuestiones que miden conductas graves que merecen una atención inmediata; el tipo de conducta que podría provocar un daño severo a uno mismo o a otros niños y que requieren atención inmediata antes de cualquier otra intervención.  Todos somos conscientes de las ocasiones fatales en que un niño decide usar un arma para atacar a alguien o amenazar su propia vida.

Por último, nuestra nueva escala (la “C3”) incluye lo que llamamos dos “índices” que representan escalas muy breves para realizar escrutinios.  El “índice global” es una escala familiar de 10 elementos que durante años ha demostrado ser sumamente sensible a los efectos terapéuticos, y es un método muy rápido de detección en aquellas ocasiones en que se realicen escrutinios a gran escala para identificar posibles casos de TDAH.  Esta escala es especialmente útil cuando es necesario realizar mediciones repetidas, como en situaciones escolares en que sería difícil realizar escalas más agobiantes y extensas.  Un índice de TDAH ligeramente diferente consiste en un grupo de 12 elementos que discriminan estadísticamente a un alto nivel entre casos clínicos documentados y niños normales, mediante una gran base de datos normativa a partir de la última reestandarización. En una consulta muy ocupada donde de otra forma no se podría obtener información detallada, puede ser útil el uso de esta escala índice para identificar casos que deban ser remitidos a un especialista.

Es importante identificar disfunciones de la vida diaria, y no solo síntomas.  Para los niños, las tareas escolares y las notas, sus amigos y su vida en casa quizás representan las áreas más importantes del deterioro funcional.  Las nuevas escalas contienen elementos específicamente dirigidos a estas importantes áreas funcionales.  Conocer qué áreas se encuentran dañadas define el objetivo primario del tratamiento y de la intervención.

La escala C3 también incluye elementos que distinguen la ansiedad y la depresión, lo que alertará al clínico para que explore dichas áreas con mayor profundidad.  Esta también nos alerta ante elementos referentes a un problema fundamental en el diagnóstico de los trastornos mentales en los niños.  Los estándares actuales de diagnóstico del Manual diagnóstico y estadístico de América (DSM-4), y el ICD-10 europeo requieren que se cumpla un determinado número de criterios antes de poder realizar un diagnóstico (cinco criterios en el caso de DSM-4).  Nuestras escalas son especialmente útiles para identificar los criterios sintomáticos porque incluyen frases exactas y apropiadas para los síntomas del TDAH y de los trastornos relacionados.  La edad de inicio y la cronicidad de los síntomas constituyen otros criterios que se establecen fácilmente a partir de una entrevista, tal es la predominancia de los síntomas en el TDAH (por ejemplo, más de dos áreas de función).  El criterio para el deterioro puede establecerse a partir de los elementos de la escala de evaluación que acabamos de describir.  Sin embargo, el 5.º criterio requiere que se descarten otros trastornos como causantes de los síntomas.  Así pues, es esencial para los clínicos descartar ansiedad, depresión, trastornos del ánimo, y varios otros trastornos que pueden simular los síntomas del TDAH. 

Para cubrir muchos de estos trastornos se elaboró y tipificó junto con la C3 una segunda escala de evaluación mucho más extensa que la C3.  Esta escala, la CBRS o Escala exhaustiva de evaluación de la conducta (Comprehensive Behavior Rating Scale), incluye además síntomas clave del TDAH:

Episodio maníaco, episodio mixto, trastorno de ansiedad generalizado, trastorno de ansiedad por separación, fobia social, trastorno obsesivo-compulsivo, trastorno autista, enfermedad de Asperger, victimización y perpetración en el acoso escolar, enuresis y encopresis, crisis de pánico, trastorno del desarrollo pervasivo, perversión del apetito, trastorno de estrés postraumático, fobia específica, uso de sustancias, tics, tricotilomanía, autolesiones y conductas severas.

Al igual que la C3, la CBRS incluye escalas de autoevaluación, de evaluación de padres y profesores, versiones largas, versiones más cortas, y escalas de índice.  Debido a su longitud (más de 200 elementos) se recomienda el uso de un ordenador o realizar la evaluación en línea, aunque existen versiones para autoevaluación disponibles al igual que las escalas C3.  La estructura completa de la C3 y de la CBRS podrán encontrarla en el dossier.

Siempre resultará útil tener presente que la comprensión y el conocimiento de un ser humano complejo es un trabajo altamente intensivo y una tarea muy exigente.  Las escalas de evaluación son herramientas útiles en una pequeña parte del proceso de recolección de información.  De ninguna manera pueden completar la ingente tarea de realizar un diagnóstico firme a partir del cual pueda instaurarse un plan terapéutico razonable. Esa tarea requiere un equipo multidisciplinar y multiinformativo, pero sobre todo, un clínico sagaz con suficiente formación que pueda recurrir a su experiencia y al conocimiento empírico para reunir todas las piezas.  Las escalas de evaluación constituyen una valiosa ayuda pero nunca deberá trivializarse la tarea de definir el alcance y el significado de la enfermedad de un paciente convirtiéndola en un proceso automatizado.

Espero que al usar nuestras escalas de evaluación encuentren apoyo en sus denodados esfuerzos para ayudar a cada niño, adolescente o adulto joven a alcanzar todo su potencial como ser humano. Quizás el mero proceso de usar las escalas les resulte útil para comprender la amplitud y la profundidad de su tarea como clínicos, enseñándoles a respetar los variadísimos patrones de conducta que nuestra biología y nuestro entorno nos presentan. Como artistas dedicados a un género distinto a la pintura, la poesía o la novela, nosotros trabajamos observando las impresiones que otros crean, y usamos nuestro conocimiento científico para guiarnos en el delicado proceso de construir una vida que pretendemos mejorar.

Por último, les pido disculpas por haber leído este mensaje, pues como Goya sabía perfectamente, el hecho de leer un discurso, a menudo desconcierta al oyente.  Espero que un diálogo más personal permita corregir cualquier problema.

DIAPOSITIVA N.º 2: Lo que le sucede al oyente cuando un orador lee.

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Newest Versions of Conners Rating Scales







C. Keith Conners, Ph.D.


Professor Emeritus

Department of Psychiatry and Behavioral Sciences

Duke University Medical Center

Durham, North Carolina, USA


            Rating scales have proven to be useful tools for assessment, treatment monitoring, research, and education, particularly for ADHD and related conditions. Earlier versions were created in the 1960’s and have been revised several times.  They have contributed not only to the practical aspects of individual clinical assessment, but also to the evolving understanding of psychiatric nosology in general.


There are now two distinct sets of scales: the third revision of the familiar ADHD scales that include closely related “externalizing” disorders such as aggressive behavior, oppositional, and peer related social problems (designated as C3); and a more comprehensive set of scales (CBRS) related to a wide range of “internalizing” mood, anxiety, developmental, and behavioral disturbances.  For both types of scales there are empirically-derived factors based upon extensive census-based age and gender norms, as well as scales based upon exact DSM-IV diagnostic criteria.


C3 Content Scales: The C3 empirical scales include inattention, hyperactivity/impulsivity, Learning problems, executive functioning, aggression, peer relations, and family relations. Diagnostic and Statistical Manual (DSM-4) scales include the 3 subtypes of ADHD, conduct disorder, and oppositional-defiant disorder. There is a special scale for detecting critical violent behavior. There are also screener items for anxiety and depression. Impairment items include schoolwork and grades, friendships and relationships, and home life.


CBRS Content Scales: Empirical Scales include Emotional distress (upsetting thoughts, worrying, social problems), physical symptoms, separation fears, social anxiety, aggressive behaviors, academic difficulties, (language and math), violence potential. DSM disorders include major depressive episode, manic episode, mixed episode, generalized anxiety disorder, separation anxiety disorder, social phobia, obsessive-compulsive disorder, autistic disorder, Asperger’s disorder, ADHD subtypes, conduct disorder, oppositional defiant disorder. Other clinical indicators include Bullying (victimization and perpetration), enuresis/encopresis, panic attack, Pervasive Developmental Disorder, Pica, Posttraumatic Stress Disorder, Specific Phobia, Substance Use, Tics, and Trichotillomania.

            There are separate versions for patient self-report, parent report, and teacher report. There are both short and long versions for situations when brevity might be required (such as repeated assessments over time); or longer versions when initial more comprehensive assessment is indicated.  Several new refinements have been added: validity scales that detect inconsistent reporting or excessive positive or negative bias; measures of impairment as well as symptom severity; index scores reflecting the probability of  clinical diagnostic severity; online scoring through internet connection; comprehensive reports that include standard error of measurement and estimates of statistically significant change.    



See below for the full text of the lecture in English.  The Spanish language version will be added shortly .  Comments welcome.     










































C. Keith Conners, Ph.D.

Professor Emeritus

Department of Psychiatry and Behavioral Sciences

Duke University Medical Center

Durham, USA


Lecture presented at Symposio Internacional on ADHD, Madrid, June 4, 2009

Ladies & Gentlemen:

As keen observers and diagnosticians, you are no doubt aware of a frightening morbid condition that has swept across the world in modern times.  I do not refer to the H1-N1 Swine Flu virus, but to an iatrogenic mental condition, caused by long lines of visual text presented at high speed by a professional scholar, who simultaneously verbally delivers extremely dense information presented with astonishing rapidity, thus causing a brain condition we call, “Death by PowerPoint.” (Indeed, I see several of my colleagues in this very audience who are infected with this dread disease.)  Perhaps this condition was the inspiration for Francisco Goya’s powerful painting:

                                   SLIDE # 1: DEATH BY POWERPOINT

In order to avoid this condition, I will present only one slide, so that you may attend without the complication of trying to hear English while simultaneously receiving auditory translation in Spanish while also reading English text.  Instead, I have provided listeners with a written Spanish translation of this talk, and several documents which hopefully you may choose to peruse as the need for rating scales arises in your clinical, research, and teaching activities. You will also have a handout of a complete set of reports of a clinical case, from which you will easily see the kinds of information that these rating scales can provide. 

First, let me say a few words about the advantages and cautions regarding rating scales. Rating scales use simple descriptive phrases to form a picture of someone’s behavior, moods, or actions.  But they are not rigorous counts of minute events, or verbal equivalents of a photograph or movie. Rather, rating scales are impressions of a subject by a parent, a teacher, some outside observer, or the subject themselves.  They are not what Henry Murray referred to as “actones,”—precise actions at a molecular level of observation. Nor are rating scales global impressions, such as “He is demented,” or “She is cruel.” Rather, they are impressions at a middle level of observation, and reflect the impact of the subject on the observer regarding various cognitive features, activity level, mood and behaviors that have common meanings to the observer.

Because these ratings are impressions they are subject to various errors of exaggeration, positive or negative halo effects, or inconsistencies. But such errors can be detected and taken into account by use of some technical procedures made possible by modern computing methods. 

But rating scales go beyond simple impressions about a patient’s behavior or a client’s moods. Some items in a scale share the same common fate and are highly correlated with each other and less so with other groups of items. Technically, these are called “factors” which represent constructs at a higher level than the individual items. Thus, stealing, lying, bullying, fighting will cluster together, with high inter-correlations that reveal the observer’s awareness that these behaviors tend to occur as part of a pattern of behavior.  Much research over the years has identified a number of such patterns, and these have shaped ideas about psychiatric nosology, and been influenced in turn by advances in clinical understanding of abnormal patterns.  The patterns that are discovered by factor analysis are of course influenced by the famous “GIGO” principle,”– Garbage in, Garbage Out, so careful selection of items is a primary task in creating the rating scales. We get these items from the common complaints made by the patients, their parents, teachers or other observers.

Finally, by the use of scores derived from these clusters or patterns, it is possible to collect normative data from large numbers of subjects, both normal and abnormal (as defined by clinical standards or by statistical cutoffs), and to establish thresholds for different ages and genders across the lifespan. For example, in our most recent rating scales for children ages 6 through 18 years, we used over eleven thousand (11,000) subjects obtained throughout the USA and Canada, and so constructed scores that represent the typical individual patterns at each age and gender for children between six years and eighteen years.  With the known mean and standard deviations we can then reveal which patients fall outside the “normal” range, as defined by a statistical standard, or by their similarity to known clinical cases. 

Now let me turn to some specifics about the new scales.  One of the most important new features of our scales are built in validity checks for identifying excessive positive or negative impressions or inconsistencies in reporting.  These validity scores, though not infallible, give some assurance that one may detect the parent, teacher or patient who is overly positive in their descriptions, or overly negative (the “Yea-sayers and Nay-sayers well-recognized by much research as dominant personality traits that influence descriptions of themselves or other people).  The inconsistencies that occur when a rater gives opposite responses to items that are overwhelmingly positively correlated, can be identified and brought to one’s attention when interpreting a rating scale. 

My major research interest over the years has focused upon those children we now call ADHD, or Attention Deficit Hyperactivity Disorder.  One of the earliest observations that psychiatric and pediatric observers had was of a group of children of normal intelligence who were hyperactive, inattentive, impulsive, aggressive, defiant and unruly in their behavior.  And indeed, these have repeatedly shown up in factor analyses of pools of items derived from complaints in mental health facilities.   Over many years therefore, we focused on such children because they were the most common variety of complaint found in mental health treatment facilities.

  But unlike the picture drawn by the pediatrician who first described the syndrome (George Still in 1902), we found that there were separate factors for cognitive complaints such as inattention and distractibility, excitable and impulsive behavior, hyperactivity, social ineptitude, and oppositional and defiant behavior. From the very beginning our factor analyses showed that this “externalizing” group of children could be broken down into separate patterns of aggressive, defiant, inattentive, restless and socially inept individuals. In this new, third edition of our scales, we continue to include those factors.

In addition, we now include a factor covering learning problems since these are ubiquitous in most ADHD, conduct-disordered and socially-impaired children. It is important that primary learning processes always be examined in children first brought to attention by their disruptive behavior or hyperactivity.  Learning problems may be comorbid with ADHD, a primary problem that mimics ADHD, or the consequence of the behavior difficulties.  In any case they must be targeted as part of the treatment program.

A new concept known as “Executive Functions” has received much attention by researchers and theorists.  Though we do not believe that disorders of executive function are primary causes of ADHD, and are not exclusive to ADHD (since they appear in many other mental disorders), we do believe they need to be assessed and targeted for treatment when they appear as part of the overall picture of ADHD or its related disorders.  Executive functions include the planning, organizing, task completion functions of every day life, including academic life.  Many of these functions will be taken over by a child’s caretakers or teachers in the child’s earlier years, and not recognized until later when the adolescent or young adult must take more responsibility for being on time, scheduling, planning,  and starting and completing tasks.

Our newest scales also include a scale measuring severe conduct that deserves immediate attention; the kind of behavior that could result in severe harm to self or others and deserves immediate attention before any other intervention.  We are all aware of the deadly occasions when a school child decides to use a weapon to attack someone, or threatens their own life.

Finally, our new scale (the “C3) includes what we call two “indexes” that represent very brief screening scales.  The “Global Index” is a familiar 10-item scale that has been proven over the years to be exquisitely sensitive to treatment effects, and is a good rapid screener for large-scale screening purposes in identifying potential ADHD cases.  This scale is particularly useful when repeated measures are needed, such as in a school situation where burdensome longer scales would be difficult to obtain.  A slightly different ADHD index consists of a group of 24 items that statistically discriminate at a high level between documented clinical cases and normal children, utilizing the large normative database from the recent re-standardization. In a busy practice where more detailed information would not otherwise be available, it may be useful to use this index scale in order to identify cases that need referral to a specialist.

It is important to identify real-life dysfunctions, not just symptoms.  For children their school work and grades, their friendships and home life perhaps represent the most important areas for functional impairment.  The new scales have items specifically directed towards these important functional areas.  Knowing which areas are impaired defines the primary focus for treatment and intervention.

The C3 scale also includes screener items for anxiety and depression, which will alert the clinician to explore those areas in more depth.  This also alerts us to issues regarding  a fundamental problem in the diagnosis of mental disorders in children.  The current standards of diagnosis from the American Diagnostic and Statistical Manual (DSM-4), and the European ICD-10 require that a number of criteria be met before a diagnosis can be made (five criteria for DSM-4).  Our scales are particularly helpful in identifying the symptom criteria because they include exact but appropriate wording for the ADHD symptoms and related disorders.  The age of onset and chronicity of the symptoms is another criterion easily established from interview, as is the pervasiveness of the symptoms for ADHD (i.e. more than two areas of function).  The criterion of impairment can be established from the rating scale items just described.  However, the 5th criterion requires that other disorders be ruled out as causes for the symptoms.  Thus, it is crucial for clinicians to rule out anxiety, depression, mood disorders, and a variety of other disorders that can often mimic symptoms of ADHD. 

In order to cover many such disorders a second rating scale, much longer than the C3, was developed and normed along with the C3.  This scale, the CBRS or Comprehensive Behavior Rating Scale, includes key symptoms for ADHD as well as:

Manic episode, mixed episode, generalized anxiety disorder, separation anxiety disorder, social phobia, obsessive-compulsive disorder, autistic disorder, Asperger’s disorder, bullying vicitimization and perpetration, enuresis & encopresis, panic attack, pervasive developmental disorder pica, posttraumatic stress disorder, specific phobia, substance use, tics, trichotillomania, self-harm and severe conduct.

As with the C3, the CBRS includes scales for self-report, parent and teacher report, long versions, shorter versions, and the index scales.  Because of its length (over 200 items) computer or online scoring is highly recommended, although self-scoring versions are available as for the C3 scales.  The entire structure of the C3 and CBRS is available in the tables contained in your handouts.

It is always useful to remind ourselves that the clear understanding and knowledge of a complex human being is a highly labor intensive and demanding task.  Rating scales are helpful aids in a small part of the process of gathering information.  In no way can they complete the daunting task of making a firm diagnosis from which a reasonable treatment plan can be formulated. That task requires a multi-disciplinary and multi-informant team, and above all, a well-trained and astute clinician who can draw upon experience and empirical knowledge to put the pieces together.  Rating scales are valuable aides but should never trivialize the task of defining the scope and significance of a patient’s illness by becoming an automatic process.

It is my hope that by using our rating scales you will find support in your worthy efforts to help every child, adolescent, or young adult reach their full potential as human beings. Perhaps the very process of using the scales will be useful in alerting you to the breadth and depth of your task as clinicians, teaching you to respect the many different patterns of behavior that our biology and environment lay out before us. As artists of a different genre than the painter, poet, or novelist, we work with our observations of the impressions that others create, and use our knowledge of science to guide us in the delicate process of constructing a life that we seek to improve.

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New Drug Trials for ADHD: Who is watching?

Drug Trials for ADHD: Who is Watching?

Stimulant drugs like methylphenidate and dextro-amphetamine for ADHD are among the most well-established therapeutic drugs in all of psychiatry (see for example my article, 40 years of methylphenidate treatment of ADHD, J of Attention Disorders, 2002, Vol. 6, Supplement 1). One reason for this general acceptance is a large number of well-controlled trials repeated by many different investigators over the years. But more importantly, frequent clinical use over many years supports the conclusion of the efficacy and safety of these drugs. Though not without some controversy and certain drawbacks, on the whole it is safe to say that most reputable scientists and clinicians find these stimulants to be of substantial value in treatment of an otherwise very refractory disorder.

But as the success of these drugs has encouraged pharmaceutical companies to seek even more effective drugs, or to market drugs that provide an alternative for those patients who prove refractory to the stimulants, many novel chemical agents are appearing in new drug trials. In addition, potent new anti-psychotic drugs are being touted as safe and effective. Are the drug trials for these newer drugs adequate, or are there serious loopholes in the methodology that allow ineffective or dangerous drugs to be approved?

Here’s what often happens in the development of a new psychoactive drug for ADHD. Someone has an idea that a particular molecule, perhaps from a failed trial of some other condition like depression or Alzheimer’s or schizophrenia might work with ADHD. An "open label" trial by a proponent is found to produce some favorable response in a few patients by a welll-known clinician treating ADHD, suggesting to the pharmaceutical company that it is worth doing a more carefully controlled trial. (Of course it is financially profitable for the clinician to find positive results because further trials will potentially bring in big bucks, and the pharma company tends to trust the clinical judgments of well-known clinician experts in the field.)

Sometimes a well-meaning investigator finds that although the main experiment failed to confirm the efficacy of the drug, a few patients showed a dramatic improvement, warranting a further look. One of my favorite maxims is that "looking for a subgroup in an experiment is a sure sign of a failed experiment." Pursuing a small lead in a failed experiment is like betting on a nag that put up a good effort but lost.

But pharmaceutical companies have experts in drug trial methodology who also know that they must conform to the standards set by the FDA, and eventually must fund large trials that employ a standard double-blind design, using approved measures. Typically, this means that patients are randomly assigned to a treatment group and a placebo control group, and assessed with a symptom list of some sort representing the current diagnostic standards, such as a DSM-4 checklist. After getting measures before treatment starts ("baseline") subsequent checklists or scales are filled out based upon an interview with the patients (or in the case of children, their parents and/or teachers).

So a parent might respond to questions about hyperactivity, inattention, defiance, or social behavior for example; and the investigator will then fill out his or her own scale, or perhaps a "global" judgment of overall improvement or change. Sounds reasonable. But wait, there are some issues here!

What if the parent or teacher or the patient is able to "peek through the double blind," that is to guess which treatment they are receiving? Not that they would consciously cheat, but because it is well-known that the first thing a patient or parent wants to do is please the doctor, or to do what they think the investigator or doctor wants to find. This is called the "demand character" of an experiment, which every experimenter learns to expect and tries to avoid.

But how can the patient or parent peek through and know which treatment is being used? Easy. Every drug produces some subjective effect, perhaps a side effect like stomach pain or nausea, or a racing heart, or a thousand other subtle or obvious bodily changes. When the patient experiences one of these effects, they will often respond in the way their brain expects. This is called the "cognitive potentiation of a bodily feeling." Let me illustrate from a very early experiment carried out by Stanley Schacter.

Subjects in a drug experiment were told they would receive a drug that would cause some changes in their mood. One group was told that the drug (epinephrine) would make them feel euphoric, and another group was told that the drug would cause them to feel depressed. Now epinephrine is a stimulant that typically will increase heart rate, but the behavioral effect that occurred in this experiment depended upon which expectation the subjects had about the drug, and they acted accordingly. Even though epinephrine produces a number of peripheral signs of stimulation, patients interpreted those signs as if they got a depressant, not a stimulant.

Another favorite experiment was with medical students who were asked to drink coffee and then have measures of heart rate, respiration, and skin temperature taken. One group saw the experimenter brew the coffee from a brand coffee jar (Folger’s as I recall), and the other group saw that the jar was labeled as decaf. In fact, both groups got only decaf. But the supposedly "loaded" coffee group had increases in heart rate, respiration and finger temperature, while the "decaf" group showed no changes. This study illustrates how the subjects’ expectations can manipulate their own bodily responses.

Returning to ADHD, we now see that when an investigator uses the report by a patient, a parent, or a teacher, there is the possibility that "improvement" will simply be the desire to please the investigator as informed by their own knowledge of the "active" treatment condition. Thus, the double-blind is leaking all over the place.

But there is an even more deadly threat to the integrity of these experiments. In many cases it is the most senior member of the investigating team, the accredited specialist or doctor, who records the signs of improvement. This is so because there is always the possibility of significant "adverse events" or AEs caused by the drug, and the senior investigator must be vigilant in detecting and reporting these AEs for the safety of the patient as well as for eventual calculation of the risk and benefit of the drug. So in these trials, the dose of the drug will usually be adjusted to get a good response without undue side effects or AEs. But if the doc is knowledgeable about the side effects, isn’t he or she also then apprised of which drug the patient is receiving? Obviously. Well then, even the honest doc might unconsciously want to please their sponsor by finding positive results. And of course if it is an openly greedy doc, what would you expect?

Funny, though, when I raise these objections in pharmaceutical meetings about the drug results, nobody seems to care. The drug companies persist in believing that the investigator is objectively recording their observations as far as improvement is concerned, while nevertheless being apprised of the side effects. And the investigators themselves never question their own objectivity despite the clear knowledge of who is being treated with what.

These problems might not matter much with the proven stimulants because the efficacy is often so dramatic; but when a more subtle drug effect occurs, who knows what might happen? In fact, I know of more than one such drug that got approved but began to falter after a longer period of clinical use showed the true lack of efficacy. The old maxim in psychopharmacology is worth remembering: "Use a new drug quickly, while it still works."

This is not to allege conscious impropriety. Investigators may truly believe they are objective and drug companies are simply following the models set up as appropriate by the FDA. But there are some simple solutions to these dilemmas, but not without cost. One solution is to use an "active placebo," where a dummy drug is used as a control, producing some bodily effects without much behavioral effect. But this solution has its own problems and is seldom used.

Another solution, and the most logical one, is to have one well-trained physician recording and judging the side effects (and therefore changing the dosages during the adjustment phases of the experiment), and a different experimenter/physician recording the improvement. This requires careful scripting of the protocol for inquiring about improvement, and careful shielding of one investigator from the other colleague.

I often wonder how much subterranean motives influence the investigator, who stands to profit from a successful trial, and the drug company which seeks FDA approval and a rich reward for their investiment. In general I choose to believe in the honesty and integrity of both the docs and the companies. But I also believe in the deeper effects of "demand qualities of the experiment," and the power of placebo when potentiated by cognitions, therefore that we must employ the most rigorous protections possible in our experiments on behalf of our trusting and troubled patients.


C. Keith Conners, Ph.D.

Professor Emeritus, Duke University

About Me

Keith Conners

Durham, North Carolina, United States

Founder of Duke ADHD program. Ph.D. in clinical psychology from Harvard. Graduate of U. of Chicago and Oxford.

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