Acta Pdiatrica ISSN 08035253

REGULAR ARTICLE

The Conners 10-item scale: findings in a total population of Swedish

1011-year-old children
1
Joakim Westerlund (jwd@psychology.su.se)1 , Ulla Ek1 , Kirsten Holmberg2 , Katharina Naswall
, Elisabeth Fernell3

1.Department of Psychology, Stockholm University, Stockholm, Sweden

2.Department of Womens and Childrens Health, Section for Paediatrics, Uppsala University, Uppsala, Sweden

3.Department of Paediatrics, Unit of Neurodevelopmental Disorders, Skaraborgs Hospital Mariestad and FoU Centre Skovde
and Autism Centre, Handicap and Habilitation and
Karolinska University Hospital, Stockholm, Sweden

Keywords
ADHD, Conners 10-item scale, Emotional lability,
Gender, Restless/impulsive behaviour
Correspondence
Joakim Westerlund, PhD, Department
of Psychology, Stockholm University, S-10691
Stockholm, Sweden.
Tel: +46 8 163856 |
Fax: +46 8 161002 |
Email: jwd@psychology.su.se
Received
11 September 2008; revised 18 November 2008;
accepted 19 December 2008.
DOI:10.1111/j.1651-2227.2008.01214.x

Abstract
Aim: To present normative data for the Swedish version of the Conners 10-item scale, to validate the
scale by comparing children with and without attention deficit/hyperactivity disorder (ADHD), to
explore the factor structure of this scale and to investigate behavioural characteristics and gender
differences among 10- to 11-year-old children, as rated by parents and teachers respectively.
Methods: Parents and teachers rated 509 10- to 11-year-old children (261 boys and 248 girls) from
a population-based cohort in a Swedish municipality.
Results: The Conners 10-item scale discriminated very well between children with and without
ADHD. Confirmatory factor analyses confirmed a two-dimensional structure of the scale with items
measuring restless/impulsive behaviour in one factor and items measuring emotional lability in
another. An ANOVA revealed that parents and teachers reported different behavioural characteristics
in boys as compared to girls.
Conclusion: The Conners 10-item scale is a valid screening instrument for identification of ADHD. The two
subscales can be used separately, in addition to the total score, to get a more detailed picture of the childs
behaviour. Parents and teachers pay attention to different aspects of problem behaviour in boys and girls. The
less disruptive behaviour of girls needs to be highlighted.

INTRODUCTION
The use of Conners behavioural rating scales has a long
tradition (1). Different scales exist and there has been a refining, reshaping and revising of the rating scales over time
(24). One of the most frequently used versions in the clinical setting is the Conners 10-item scale. This scale consists
of ten statements (Table 1) for which a parent or a teacher
rate the childs behaviour on a 4-point Likert scale, ranging from 0 not at all true to 3 very much true. The
scale is obtained from the 10 items constituting the hyperactivity index (HI) from the longer versions of the Conners
scales and is also known as the abbreviated Conners rating
scales for parents (CPRS-HI) and teachers (CTRS-HI) and
as the abbreviated symptom questionnaire-parent/teacher
(ASQ-P/T). Although the scale has a focus on hyperactivity
it is currently more accurately viewed as a global measure of
psychopathology, and not as a specific indicator of attention
deficit/hyperactivity disorder (ADHD) (5,6).
Parker and collaborators (7) found that this 10-item scale
constitutes a two-factor structure: a restless/impulsive behaviour dimension and an emotional lability dimension with
a high correlation between the two. Their study comprised
2345 and 1736 American children from mainstream education, with mean ages of about 10 years. To our knowledge
the factor structure of the scale has not been in examined in
a Swedish child population.
The Conners 10-item scale is widely used in Sweden in
assessments of children with behavioural problems. Norms
828

and cut-off scores for parental ratings of children in different

age groups has been extensively studied and discussed by
Rowe and Rowe (8). Sprague and collaborators (9) used
a cut-off score of 15 from the total possible score of 30.
Landgren and collaborators (10) used a cut-off of 10 in their
study of 6-year-old children with developmental disorders.
Few studies have addressed the diagnostic utility of the
Conners 10-item scale concerning ADHD. To the best of
our knowledge, the Swedish version of the scale has not
been validated with respect to ADHD, neither have norms
for Swedish children been presented.
The aims of the present study therefore were to: (i)
present normative data, derived from a population of 10- to
11-year olds (a common age for referral for assessment), (ii)
validate the scale by comparing children with and without
a diagnosis of ADHD according to the scale, (iii) analyze
the factor structure of the scale and (iv) explore behavioural
characteristics and gender differences as rated by parents
and teachers.
Ethical approval for the study was granted by the Ethics
Committee at Karolinska Hospital, Stockholm.
PARTICIPANTS AND METHODS
The study is part of a population-based survey aimed at
elucidating the spectrum of attention related problems in
school children. The entire study population comprised all
577 children (295 boys and 282 girls) in the fourth grade
of primary school in Sigtuna, a municipality in Stockholm


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Westerlund et al.

Table 1 The Conners 10-item scale

1. Restless or overactive
2. Excitable, impulsive
3. Disturbs other children
4. Fails to finish he/she starts short attention span
5. Constantly fidgeting
6. Inattentive, easily distracted
7. Demands be met immediately easily frustrated
8. Cries often and easily
9. Mood changes quickly and drastically
10. Temper outbursts, explosive and unpredictable behaviour
Note: Items are rated on a Likert scale with four categories: not at all (0), just
a little (1), pretty much (2) and very much (3).

County. All schools, mainstream education as well as special, in the municipality participated in the data collection
(11). In connection with the regular school health examination, the parents were invited to participate in the study
with their child. The Conners 10-item scale was part of the
screening procedure and was distributed to the parents and
teachers of all 577 children. The teachers and parents were
asked to complete the forms and return them to the school
doctor, this was done for 515 children. The 509 (261 boys
and 248 girls) children for whom complete data were obtained (all 10 items filled out by both parents and teachers)
were included in the statistical analyses. Of these 509 children, only 12 (2.4%), all boys, had had a clinical work-up
prior to the study and been given a diagnosis of ADHD according to DSM-IV (12).
Statistical analyses
MannWhitney U-tests were used to compare Conners
scores from children with and without ADHD. Dimensionality of the scale was tested by subjecting the ratings to
a series of confirmatory factor analyses. Since the ratings
were highly skewed, robust maximum likelihood was used.
Parents and teachers ratings were correlated using Pearson
product moment correlation coefficients and, finally, gender, rater and subscale differences were examined using a
2 2 2 mixed ANOVA.
RESULTS
Norms
Substantial gender differences were found. According to the
parents the 90th percentile was equivalent to a score of 8
and 14 in girls and boys, respectively and according to the
teachers, scores equivalent to the 90th percentile were 5 and
19 in girls and boys, respectively (Table 2).
Mean scores on the Conners 10-item scale in children
with and without ADHD according to parents
and teachers
For the total sample of 509 children, the mean score was 4.03
(SD = 5.33) and 3.87 (SD = 6.56) according to the parents
and teachers ratings, respectively. Of these 509 children,
12 (boys) had previously received a diagnosis of ADHD. The
mean score in that group was 20.83 (SD = 6.83) according

The Conners 10-item scale in children

Table 2 Normative data for total raw scores on the Conners 10-item scale
(n = 509)
Parents ratings

Teachers ratings

Percentile value

Girls

Boys

Girls

Boys

1
5
10
20
25
30
40
50
60
70
75
80
90
95
99

0.0
0.0
0.0
0.0
0.0
0.0
1.0
2.0
3.0
3.3
4.0
5.0
8.0
12.0
18.5

0.0
0.0
0.0
0.0
0.0
1.0
2.0
3.0
4.0
6.0
7.0
8.0
14.0
20.0
27.5

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
1.0
2.0
3.0
5.0
9.0
24.0

0.0
0.0
0.0
0.0
0.0
0.0
1.0
2.0
4.0
6.4
8.0
11.0
19.0
25.0
27.0

Mean
SD

2.99
3.95

5.03
6.22

1.77
4.08

5.86
7.75

to parents ratings and 15.75 (SD = 10.83) according to

teachers ratings. In the remaining 497 children, without a
diagnosis of ADHD, the mean score was 3.63 (SD = 4.60)
according to parents ratings and 3.58 (SD = 6.16) according
to teachers ratings.
MannWhitney U-tests revealed that parents as well as
teachers rated children who had a diagnosis of ADHD significantly higher than children without ADHD (z = 5.73,
p < 0.001, Cohens d = 3.70 and z = 3.96, p < 0.001,
Cohens d = 1.94 according to parents and teachers,
respectively).
Dimensionality of the Conners 10-item scale
in 1011-year olds
Dimensionality of the scale was tested using Lisrel 8.80 (13),
by subjecting the ratings to a series of confirmatory factor
analyses. Since the ratings were highly skewed (mean skewness = 2.11 for the parents ratings and 2.29 for the teachers
ratings), robust maximum likelihood was used. Three models were tested for both the parents and teachers rating:
(i) A unidimensional model, (ii) A two-factor model with
item 17 in factor 1 (restless/impulsive behaviour) and item
810 in factor 2 (emotional lability). This model was used
for the parents ratings in the study by Parker and collaborators (7) and (iii) A two-factor model with item 16 in factor 1 (restless/impulsive behaviour) and item 710 in factor
2 (emotional lability). This model was used for the teachers
ratings by Parker and collaborators (7).
In order to determine goodness of fit as well as comparative fit, a number of fit statistics were used in addition to the
chi-square measure. A root mean square error of approximation (RMSEA) below 0.05 was considered as very good
fit, and a value below 0.08 as good fit (14). Normed fit index (NFI) and comparative fit index (CFI) levels above 0.90
were considered indicative of good fit (15), while goodness


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Westerlund et al.

Table 3 Fit statistics for the parents and the teachers ratings of children on the Conners 10-item-scale
Model comparisons
Model

df

RMSEA

GFI

NFI

CFI

AGFI

r between factors

Model

df

 2

Parents rating
A. Unidimensional model
B. Two-factor model (item 17 vs. 810)
C. Two-factor model (item 16 vs. 710)

35
34
34

509
509
509

230.75
108.10
93.28

0.105
0.066
0.059

0.70
0.82
0.84

0.98
0.99
0.99

0.98
0.99
0.99

0.53
0.71
0.74

0.81
0.81

B vs. A
C vs. A

1
1

122.65
137.47

Teachers rating
D. Unidimensional model
E. Twofactor model (item 17 vs. 810)
F. Twofactor model (item 16 vs. 710)

35
34
34

509
509
509

366.89
169.07
150.32

0.137
0.088
0.082

0.49
0.63
0.65

0.97
0.99
0.99

0.98
0.99
0.99

0.20
0.40
0.43

0.82
0.83

E vs. D
F vs. D

1
1

197.82
216.57

Table 4 Parameter estimates from the confirmatory factor analysis of the parents ratings on the Conners 10-item-scale, model C (item 16 vs. 710, n =
509) and from the confirmatory factor analysis of the teachers ratings, model
F (item 16 vs. 710, n = 509)
Items

Parents ratings
F1

1. Restless
2. Excitable
3. Disturbs children
4. Fails to finish
5. Fidgeting
6. Inattentive
7. Demands must be met
8. Cries often
9. Mood changes
10. Temper outbursts

F2

0.86
0.80
0.87
0.83
0.91
0.81

F1

F2

0.90
0.72
0.98
0.97

of fit index (GFI) should be above 0.85 (13) and adjusted

goodness of fit index (AGFI) above 0.80 to be considered
satisfactory (13).
The parents ratings
The results of the confirmatory factor analyses of the Conners 10-item scale according to the parents ratings of all
children (n = 509) are presented in Table 3. The two factor model placing item 16 in factor 1 and item 710 in
factor 2 (model C), demonstrated the best fit to the data.
The RMSEA for this model (0.059) was close to very good.
The NFI and the CFI indices were adequate. But the GFI
and the AGFI indices were not indicative of good fit. However, Model C still demonstrated superior fit compared to
the other models and the factor loadings were significant,
indicating good local fit. Parameter estimates for this twofactor model are presented in Table 4. Cronbachs alpha was
0.87 for the restless/impulsive behaviour scale (item 16),
0.83 for the emotional lability scale (item 710) and 0.90 for
the total scale (item 110).
The teachers ratings
The two-factor model with item 16 in factor 1 and item
710 in factor 2 (model F), demonstrated the best fit to
the data (Table 3). The RMSEA, the NFI and the CFI in-

830

Teachers ratings

Teachers ratings

0.96
0.90
0.96
0.87
0.98
0.90
0.76
0.67
0.94
0.91

Table 5 Correlations between the parents and the teachers ratings (n = 509)

Teachers restl/imp
Teachers emot lab
Teachers total
Parents restl/imp
Parents emot lab
Parents total

Parents ratings

Restl/imp

Emot lab

Total

Restl/imp

Emot lab

Total

0.60
0.94
0.41
0.19
0.32

0.73

0.84
0.26
0.20
0.26

0.97
0.87

0.39
0.22
0.33

0.54
0.52
0.57

0.65
0.90

0.30
0.36
0.34
0.75

0.92

0.48
0.49
0.51
0.96
0.90

Note: Females are below the diagonal (n = 248); males are above the diagonal
(n = 261). Correlations between raters but within the same dimension are in
bold face. p < 0.01 for all correlations.

dices were good for this model. But the GFI and the AGFI
indices were not above the suggested criteria of 0.85 and
0.80, respectively, perhaps due to the highly skewed data.
Model F demonstrated superior fit compared to the other
models, and the factor loadings were significant, indicating
good local fit. Parameter estimates for this two-factor model
are presented in Table 4. Cronbachs alpha was 0.94 for the
restless/impulsive behaviour scale (item 16), 0.87 for the
emotional lability scale (item 710) and 0.94 for the total
scale (item 110).
Thus, the results of the confirmatory factor analyses supported a two-dimensional structure of the scale when used
by parents and by teachers, as demonstrated by Parker and
collaborators (7). The best fit to the data for both parents and teachers ratings was to cluster item 16 (restless/impulsive behaviour) in one factor and item 710 in
the other (emotional lability).
Relationship between the parents
and the teachers ratings
Pearson correlations between the parents and the teachers ratings are presented in Table 5. Interrater agreement
was higher for boys than for girls and higher for restlessness/impulsivity than for emotional lability. The highest correlation between parents and teachers ratings of the same
dimension was obtained for restlessness/impulsivity among
boys (r = 0.54) and the lowest correlation was obtained for
emotional lability among girls (r = 0.20).


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Westerlund et al.

The Conners 10-item scale in children

Gender and rater differences

In order to make comparisons between the subscales possible, the mean rating (instead of the sum of the ratings) on
the six items measuring restless/impulsive behaviour and the
mean rating on the four items measuring emotional lability
was computed for each child from the parents and teachers responses separately. Instead of possible maximums of
18 and 12, respectively, both subscales were now given a
possible maximum of 3.
The mean ratings were analysed with an ANOVA using
rater (parent or teacher) and subscale (restless/impulsive
behaviour or emotional lability) as within-subject factors
and gender (boys or girls) as a between-subject factor. The
main effects of subscale and gender were significant (F 1507 =
17.73, p < 0.001, 2 = 0.034 and F 1507 = 42.92, p > 0.001,
2 = 0.078), as were the interaction effect between rater and
gender (F 1507 = 13.98, p < 0.001, 2 = 0.027), the interaction effect between subscale and gender (F 1507 = 57.71,
p < 0.001, 2 = 0.102) and the interaction effect between
subscale and rater (F 1507 = 76.36, p < 0.001, 2 = 0.131).
The main effect of subscale indicated that the children
were rated higher on the restless/impulsive behaviour
than on the emotional lability subscale. However, more detailed analyses revealed that the girls were rated somewhat
higher on emotional lability than on restless/impulsive behaviour whereas the boys were rated considerably higher on
restless/impulsive behaviour than on emotional lability
(Fig. 1a). The teachers rated the children considerably higher
on restless/impulsive behaviour than on emotional lability
but parents rated the children somewhat higher on emotional lability than on restless/impulsive behaviour (Fig. 1b).
The main effect of gender indicated that boys received
higher ratings than girls. Boys were rated higher than girls
on both subscales, but the difference between boys and
girls was greater for restless/impulsive behaviour than for
emotional lability (Fig. 1a). While both parents and teachers gave higher ratings to boys than to girls, the difference was considerably greater for teachers than for parents.
Figure 1c also reveals that while parents and teachers rated
boys about equally high on the Conners 10-item scale, parents rated the girls higher than the teachers did. The behavioural problems among girls thus seem to be more salient
to the parents than to the teachers.

DISCUSSION
In this population-based study, we found that the
Conners 10-item scale discriminated very well between children with and without ADHD. Furthermore, we confirmed
that the scale is composed of two subscales (one measuring
restless/impulsive behaviour and one measuring emotional
lability). In addition, we found that parents and teachers
reported different behavioural characteristics in boys as
compared to girls.
The Conners 10-item scale reflects behavioural problems
of different kinds, strongly correlated to underlying cognitive/executive problems. In the model proposed by Brown
(16) six clusters of executive functions, impaired in attention

Figure 1 (a) The gender X subscale interaction effect, (b) The rater X subscale
interaction effect, (c) The rater X gender interaction effect.

deficit disorders, can be identified that is activating to work,

focusing, sustaining effort, managing frustration and modulating emotions, working memory and self regulating action.
The 10 items making up the short Conners scale capture the
essence of these problems.


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Westerlund et al.

The scale is easy to complete for parents and teachers and

is widely used clinically as a screening instrument. The items
cover a broad variety of symptoms related to deficits in executive functions, which means that different diagnostic entities may be captured in addition to ADHD, such as autism
spectrum disorders and other cognitive developmental disorders. Tillman and Geller (17) concluded that the Conners
Abbreviated Parent Questionnaire that is the 10-item scale,
is a promising tool to screen for prepubertal and early adolescent bipolar disorder and reported that scores for items
7, 8, 9 and 10 (i.e. the items measuring emotional lability in
our study) were all significantly higher in the bipolar disorder phenotype group than in the ADHD group. Based on
our findings of large differences between boys and girls with
respect to ratings we suggest that different norms should
be used for boys and girls respectively. The specific cut off
scores however, is beyond the scope of the present paper.
The rate of children with clinically diagnosed ADHD in
the study group was low, only 2.4%. This might illustrate
the low detection rate still prevailing during the study period (2002). However, the study revealed that the Conners
10-item scale clearly discriminated between those children
with a diagnosis of ADHD and those without. While most
children in the population under study had a very low score
on the scale (mean 3.63 according to parents and 3.58 according to teachers), children diagnosed with ADHD had,
as a group, a very high score (mean 20.83 according to parents and 15.75 according to teachers). The findings support
that the scale can be used as a valid screening instrument
for ADHD.
Normative data for total scores in boys and girls as rated
by parents and teachers are presented in Table 2. As can
be seen, Conners scores are highly skewed. Most children
received very low ratings from both parents and teachers.
For example, sixty percent of the girls and thirty percent of
the boys were given a rating of zero (not at all) on all ten
items by the teachers. For a few children, the ratings were
higher, but gender and rater differences were pronounced:
While about 10% of the boys received a total score of 20 or
higher when rated by the teachers, less than 1% of the girls
received a total score of 20 or higher when rated by the
parents. A total score of 20 is obtained if for example the
child is given a rating of 2 (pretty much) on all ten items.
Confirmatory factor analyses verified the two-dimensional
structure found by Parker and collaborators (7). The best fit
to the data in the present study were obtained by having item
16 in one factor (measuring restless/impulsive behaviour)
and item 710 in another (measuring emotional lability). In
addition to the total score, the two subscales can be evaluated independently giving a more complete picture of the
childs behavioural repertoire, including less overt manifestations.
When correlating the parents and the teachers ratings,
interrater agreement was generally quite high. For emotional
lability in girls, the agreement was less pronounced (r =
0.20). This finding is well in accordance with Parker and collaborators (7) who also obtained low interrater agreement
for emotional lability among girls (r = 0.05). Two large meta-

832

studies (18,19) found that females with ADHD were rated

higher on internalizing problems than males. Gershon (18)
reports that parent and teacher ratings generally disagree
on some of the primary symptoms (p. 150). Interestingly,
we found no girls in this population who had received a diagnosis of ADHD prior to the study. According to our findings the parents seem to perceive a more varied behavioural
repertoire and are able to identify both the restless/impulsive
behaviour and the low frustration tolerance of the girls
(Fig. 1b). The teachers, on the other hand, seem to overly attend to disruptive behaviours and overlook more inattentive
behaviours. Girls with attention spectrum disorders are less
likely to be referred for relevant assessments, presumably
because their behaviour is less disruptive and therefore has
a reduced impact on their environment compared to boys.
We speculate that the lag for diagnosing girls with ADHD
might be a consequence of their problems being more invisible in the classroom setting. Considering the developmental trajectory of the child with behavioural problems, there
is an increased risk of aggravating problems. Both ADHD
symptoms and comorbid disorders are presented differently
in boys and girls. This may be a serious disadvantage for
girls with attention spectrum disorders because preventive
measures and interventions will not be taken (19). In a clinical assessment, emotional symptoms have to be carefully
evaluated in order to detect a potential underlying attention
spectrum disorder.
Gaub and Carlson (20) called attention to the fact that
few studies report both parent and teacher ratings on the
same assessment instrument. It is essential to use more than
one rater to capture the full variation of a childs symptomatology (19). Thus, an evaluation from different settings that
is home and school, is needed.
Limitations
As noted above, data were quite skewed. The use of
Pearson correlations for correlating parents and teachers
ratings and the use of ANOVA for examining rater and gender differences could be questioned, since these are parametric methods. We used Pearson correlations (Table 5) for
easier comparison with the results obtained by Parker and
collaborators (7). We have however also computed Spearman rank-correlations and the results are very similar. The
robustness of the ANOVA was checked by making squareroot transformations of the mean ratings. This made the
data less skewed. Skewness for the parents mean rating on
the restless/impulsive behaviour items decreased from 2.13
to 0.69 and skewness for the parents mean rating on the
emotional lability items decreased from 2.05 to 0.60. For
the teachers ratings the corresponding decreases were from
1.99 to 0.99 and from 2.56 to 1.63. An ANOVA using the
square-root transformed data gave almost identical results as
the ANOVA using raw data presented above. Thus we consider our results valid even though the data were skewed.
Another limitation of this study is that the data were collected within the school health system and used in connection with health visits to the school nurses and physicians.
This means that the information may have been biased by


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Westerlund et al.

thoughts about how it would be used within the school.

This method of data collection, however, is also the greatest
strength of this study, since it explains the extraordinarily
high participation rate of parents and teachers. Yet another
limitation is that knowledge of the childs ADHD diagnose
may have influenced the parents and teachers ratings.
ACKNOWLEDGEMENTS
The authors are grateful to Majblommans Riksforbund
for

financial support. We are also grateful to the children, their

parents and teachers who made this study possible.

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