Childhood hyperactivity: An overview of rating scales and their applications

Clinical Psychology Review, Vol. 5, pp. 429-445, Printed in the USA. All rights reserved.

1985 Copyright

0272-7358185 $3.00 + .OO 0 1985 Pergamon Press Ltd.

CHILDHOOD HYPERACTIVIN: AN OVERVIEW OF RATING SCALES AND THEIR APPLICATIONS Craig Edelbrock University of Massachusetts Medical School and

Michael D. Rdncurel/o University of Pimburgh School of Medicine

ABSTRACT. Rating scales for assessing childhood hyperactivity, including those designed for parents and teachers, are reviewed. Both omnibus measures covering a broad range of children’s behavior and more circumscribed hyperactivity scales are &scribed. Applications of these rating scales clinically and in research are disczcssed and illustrated.

Behavior checklists and ratings scales have played a central role in clinical and research efforts pertaining to childhood hyperactivity. There are many reasons for their widespread use. In practical terms, behavior rating scales are simple and efficient in terms of time, cost, equipment, and personnel-particularly as compared to laboratory performance measures, psychological testing, and behavioral observations. More important, the nature of child hyperactivity itself makes rating scales indispensable. Hyperactivity is defined by quantitative deviations in fairly common childhood behaviors which occur at least sometimes or to some degree in all children. Moreover, behaviors related to hyperactivity are almost always manifest in natural settings such as home and school, but might not be evident in laboratory or clinical environs. Parents’ and teachers’ judgments regarding the frequency, severity, and appropriateness of children’s behavior are therefore essential for accurate detection and diagnosis of the disorder. Adults’ perceptions are not necessarily valid, but they are usually instrumental in determining what is done for .disturbed children. Changes in reported behavior can also provide “social validaReprint requests University

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Edelbrock,

Ph.D.,

55 Lake Avenue 429

Department

North,

Worcester,

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Craig Edelbrock and Michael D. Rancurello

tion” of interventions aimed at reducing problem behavior and fostering positive adjustment. Behavior checklists and rating scales have several other assets. Standardized rating scales reduce the subjectivity involved in adults’ judgments of hyperactive behavior. They force the informant to rate specific component behaviors, rather than making a global, all-encompassing judgment that a child is “hyperactive.” Rating scales with age-graded norms also provide a basis for determining whether reported behaviors are age appropriate or are deviant relative to normal agemates. This is crucial because the prevalence and severity of many behaviors related to hyperactivity decline with age (Achenbach & Edelbrock, 1981), and operational definitions of behavioral deviance must be developmentally attuned (Edelbrock, 1984; Werry, 1968). Finally, rating scales yield quantitative indices of behavior which are useful for plotting changes in behavior over time and in response to interventions. Numerous ratings scales have been developed for tapping parents’, teachers’, and mental health workers’ perceptions of child psychopathology. Many assess behavior problems syndromes identified empirically via factor analysis, rather than tapping prespecified syndromes or diagnostic criteria. Factor analyses of parent and teacher ratings, however, have often identified a “hyperactive” syndrome (Achenbach & Edelbrock, 1978). The summary labels applied to such factors vary from study to study, but there is consistency in identifying a factor encompassing the core symptoms of hyperactivity including inattention, impulsivity, distractibility, restlessness, overactivity, and fidgety behavior. More focused rating scales have also been developed for assessing hyperactivity defined a priori. These definitions also vary, so “hyperactivity” scales may differ drastically in terms of behavioral coverage and target phenomena. Some are narrowly focused on excess motor behavior or attention deficits, whereas others address a broader syndrome of inattention, distractibility, impulsivity, restlessness, and overactivity. Still others encompass a wide range of behaviors including anxiety, tension, irritability, oppositionalism, explosiveness, and aggression, in addition to hyperactive symptoms. The goal of this article is to review rating scales relevant to childhood hyperactivity and to illustrate their clinical and research applications. This review is selective. Of the numerous rating scales relevant to childhood hyperactivity, only a few have acceptable reliability, validity, and norms. Not surprisingly, the more psychometrically sound instruments, and those with age-graded norms, have been more widely used. These instruments will be the focus of our review. RATING SCALES The following measures differ in many ways, including stage of development, psychometric quality, availability of norms, and suitability to different applications. They also differ in terms of the underlying definition of hyperactivity. Nevertheless, each measure taps hyperactivity-broadly construed-and all have been used in clinical and research efforts involving disturbed children.

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Conner-s’ Rating Scales Without a doubt, the rating scales developed by Conners (1969, 1970, 1973) have been the most widely used assessment tools in research on child hyperactivity. His original teacher rating scale (Conners, 1969) comprised 39 items (e.g., excitable, inattentive, defiant, stubborn). Each item was rated on a four-step scale reflecting not at all present, just a little present, quite a bit present, and very much present. Factor analysis on a sample of 103 clinically referred children yielded five factors, which were labeled Aggressive Conduct Disorder, Daydreaming-Inattentive, Anxious-Fearful, Hyperactivity, and Sociable-Cooperative. The latter factor comprised only negatively loading items and was interpreted as reflecting positive adjustment. One-month test-retest reliabilities averaged r = 82 for the untreated (placebo) group in Conners’ 1969 study. Scores on all five factors showed significant improvements in response to d-amphetamine treatment. Conners’ original Parent Rating scale (Conners, 1970) comprised 73 items which were grouped into 24 categories (e.g., fears and worries, restless, problems in school). Each item is rated on the same four-step scale as the teacher measure. Factor analysis of parent ratings on 316 clinically referred children yielded five factors, which were labeled Aggressive Conduct Disorder, Anxious-Znhibited, Antisocial Reaction, Enuresis, and Psychosomatic Problems. Scores on five factor-based scales were found to discriminate significantly between clinically referred and non-referred samples. Moreover, referred children classified as “hyperkinetic” obtained higher scores on the Aggressive Conduct Disorder scale, whereas children classified as “neurotic” obtained higher scores on the Anxious-Inhibited scale. This suggests good discriminative power with respect to psychiatric diagnoses. Conners (1973) has also developed an Abbreviated Parent-Teacher Questionnaire comprising the 10 most often endorsed items common to both the parent and teacher rating scales. This scale is brief and easy to complete, so it represents little response burden and can be administered repeatedly to plot changes in reported behavior over time and in response to interventions. Conners’ Parent and Teacher Rating scales have undergone more recent revisions and normative standardization (Goyette, Conners, & Ulrich, 1978). The parent and teacher versions were shortened to 48 and 28 items, respectively, by eliminating items not scored on any scales and by combining similarly worded items. Some items were also reworded for clarity. Separate factor analyses of mothers’ and fathers’ ratings on large samples of non-referred children revealed six factors that were similar enough to warrant the same summary labels: Conduct Problem I, Learning Problem, Psychosomatic, Impulsive-Hyperactive, Conduct Problem II, and Anxiety. The first Conduct Problem factor comprised behavior problems such as destructive, quarrelsome, bullies, and fighting, whereas the latter Conduct Problem factor included disobedience, talking back, and moodiness. Factor analyses of the Revised Teacher Rating scale revealed three factors, dubbed Conduct Problem, Hyperactivity, and Inattentive-Passive. Both revised instruments are storable in terms of a lo-item Hyperkinesis Index, which is similar to the Abbreviated Parent-Teacher Questionnaire described previously. Norms, in the form of means and standard deviations, have been computed for boys and girls of different ages (range: 3- 17 years). Evidence in support of the validity of Conners’ measures is widespread. Concurrent validity is supported by significant correlations with numerous other rating scales and criterion measures (discussed in’ a subsequent section). Conners’ scales

have repeatedly been shown to discriminate significantly between normal and hyperactive samples (e.g., Copeland & Weissbrod, 1978; Klein & Young, 1979; Werry, Sprague, & Cohen, 1975; Zentall & Barack, 1979). They have also been widely used as dependent measures in drug trials and are sensitive to drug effects (for reviews, see Barkley, 1977; Conners 8c Werry, 1979). The rating scales developed by Conners have also been translated into several languages and used in research in many countries. In addition to the United States, comparative data are available from Great Britain (Thorley, 1983), West Germany (Sprague, Cohen, & Eichlseder, 1977), Canada (Trites, Dugas, Lynch, & Ferguson, 1979), Australia (Glow, 1981), and New Zealand (Werry & Hawthorne, 1976). Finally, Conners’ measures have been subjected to various modifications and refinements by other investigators. Factor analyses on diverse samples have been performed (e.g., Werry, et al., 1975; Trites, Blouin, & Laprade, 19821, resulting in slight psychometric refinements but few practical gains. One modification that may have a practical advantage is the development of the Iowa version of Conners’ Teacher Rating scale (Loney 8c Milich, 1981). Using chart ratings of clinically referred children as a criterion, items were selected that correlated with either aggression or hyperactivity ratings, but not both. A lo-item scale was developed, with five items tapping Inattention-Overactivity and five items tapping Aggression. The measure can be used to identify three diagnostic subtypes: pure hyperactivity, pure aggressive, and mixed hyperactivity and aggressive. This tripartite distinction has been useful in differentiating among clinically referred children (Langhorne & Loney, 1979; Loney, Langhorne, & Paternite, 1978). Why-Weiss-f

ekrs Ac tidy

Scale

The Werry-Weiss-Peters Activity scale, also called the “Motor Activity Checklist” (Shaffer, McNamara, & Pincus, 1974), is based on a structured interview (Werry, 1968) and is focused on restless and fidgety behavior in a variety of situations (e.g., during meals, at play, watching television). Routh, Schroeder, and O’Tuama (1974) converted the interview into a rating scale format for use in a study of age differences in activity level. The rating scale version has been widely used in research, but in different ways. Some investigators have employed the entire 3 1-item version (e.g., Salkind, 1981), whereas others have omitted the nine items pertaining to homework and school (see Barkley, 1981). Shaffer et al. (1974) took a novel approach and had teachers complete the section on behavior at school and parents complete the remaining sections. Parents’ and teachers’ responses were then combined to yield a total activity score for each child. Although the rating scale version of the Werry-Weiss-Peters has been used in numerous research studies, it has been criticized by several authorities, including one originator (see Ross Xc Ross, 1982; Werry, 1978). Reliability data are lacking, but the interview version yielded an interrater (mother-father) reliability of .90 (Werry, Weiss, Douglas, & Martin, 1966). Outside of mean values for 140 children has not been ages 3 to 9 years (Routh et al., 1974), normative standardization undertaken. Additional problems have been identified. For one, the scale does not appear to tap a uniform dimension of activity level in children. The items are not highly intercorrelated with one another and when subjected to factor analysis, the scale yields seven factors reflecting behavior during meals, while watching television, at bedtime, and so on (Routh et al., 1974). Second, the scale fails to correlate

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with objective measures of activity in free play and testing situations (Barkley & Ullman, 1975). Nevertheless, it has been repeatedly shown to be sensitive to drug and psychosocial interventions with hyperactive children (see Barkley, 1981), and it correlates highly with other hyperactivity measures such as Conners’ lo-item questionnaire (Broad, 1982). Davids Hy~er~nes~

bdex

This seven-item rating scale is designed for either parents or teachers (Davids, 1971). Although the scale is very brief, it covers school performance and six hyperactivity symptoms including overactivity, short attention span, behavioral variability, impulsiveness, irritability, and explosiveness. Each item is rated on a six-step scale ranging from much less than most children to much more than most children. One disadvantage is that the scales lack a midpoint corresponding to “about the same as most children.” Respondents must rate items as being either “slightly less” or “slightly more” characteristic of the target child as compared to most children. Responses to each of the six hyperkinesis items are assigned points from 1 to 6, which are summed to produce a total score ranging from 6, to 36. Davids (1971) has recommended a cutoff score of 24 for identifying hyperactive children. Reliability, validity, and normative data for the Davids measure are meager. Some studies suggest the index may be sensitive to drug effects (Denhoff, Davids, & Hawkins, 1971, Schnackenberg, 1973), but the evidence is weak. Concurrent validity is supported by significant correlations with other measures of hyperactivity, including Conners’ Abbreviated Teacher scale (Zentall & Barack, 1979) and the rating system developed in 1972 by Bell, Waldrop, and Weller (Saxon, Dorman, & Starnes, 1976). More recently, the index has been found to be sensitive to the effects of relaxation training with hyperactive boys (Dunn & Howell, 1982). Reliability studies are lacking, but some evidence suggests high interteacher reliability and moderately high test-retest stability (Zentall & Barack, 1979). Spring’s Hy~erac~~i~

Rating Scale

Spring and his colleagues have developed the 33-item Hyperactivity Rating scale for obtaining teachers’ ratings of children’s behavior (Spring, Blunden, Greenberg, & Yellin, 1977). The items are organized into 11 categories (e.g., restlessness, distractibility, impulsivity) of three items each. Teachers rate each item on a 1 to 5 scale corresponding to sever observed to always obserued. Category scores thus range from 3 to 15. Normative data, in the form of means and standard deviations for each category, have been produced for boys and girls in Grades kindergarten through 4 (Spring et al., 1977). Factor analysis suggests the scale taps a homogeneous dimension of behavior. All 11 categories load positively on the first factor, which accounts for 51% of the variance. The second factor contains few high loadings and accounts for only 15% of the remaining variance. Validity is supported by the finding that hyperactive children obtain high scores on the categories reflecting restlessness, distractibility, and impulsivity. An earlier version of the scale, called the Classroom Behavior Inventory, has also been partially validated against observational ratings of children’s classroom behavior (Blunden, Spring, & Greenberg, 1974). Reliability data are unfortunately lacking.

Craig Edelbrock and Michael D. Rancurello

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Child Behavior

Checklist

and Profile

The Child Behavior Checklist and Profile tap a broad range of children’s behavioral (see Achenbach 8c Edelbrock, 1983). Parallel are being developed for different informants,

are omnibus instruments problems and adaptive

designed to competencies

versions of the checklist and profile including parents, teachers, trained

observers, and the children themselves. To account for age and sex differences the prevalence and patterning of behaviors, separate editions of each measure

in are

being developed for boys and girls aged 4 to 5, 6 to 11, and 12 to 16 years. Norms for each measure are being constructed based on large, representative samples of non-referred children. Parent Checklist and Profile. The parent version of the checklist comprises 20 social competence items reflecting social relations, amount and quality of participation in activities, sports, hobbies, and school performance, as well as 118 items covering a broad range of behavior problems. Behavior problem items are rated on a Ol-2 scale corresponding to not true, somewhat or sometimes true, and very or often true. The checklist is storable in terms of the Child Behavior Profile, which includes three a priori social competence scales named Activities, Social, and School, and behavior problem scales derived via factor analysis of checklists completed on large samples of clinically referred children. Except for boys aged 4 to 5 years, all editions of the profile scored from parent reports include a Hyperactive scale encompassing behaviors such as can’t concentrate, impulsive, and overactive. The version for girls aged 12 to 16 years included items such as acts too young, clings to adults, and thumbsucking, and was therefore labeled Immature-Hyperactive. The reliability and validity of the profile is supported by numerous lines of evidence (see Achenbach & Edelbrock, 1983). For the scales reflecting hyperactivity, l-week test-retest reliabilities averaged r = .96, whereas 6-and l&month stabilities averaged .73 and .64, respectively. Interparent agreement has averaged r = 65. Concurrent validity is supported by significant correlations with the ImpulsiveHyperactive scale of Conners’ Parent Questionnaire and the Attention ProblemsImmaturity scale of the Revised Behavior Problem Checklist developed by Quay and Peterson (1983). Scores on the Hyperactive scale have also been found to correlate significantly with symptom scores for Attention Deficit Disorder with Hyperactivity derived from a semi-structured interview (Hodges, Kline, Stern, Cytryn, & McKnew, 1982). Criterion-related validity is supported by highly significant differences between matched samples of clinically referred and non-referred children (Achenbach, 1978; Achenbach & Edelbrock, 1979) and by significant differences between normal, outpatient, and inpatient populations (Hodges et al., 1982). The Hyperactive scale has also been found to discriminate significantly between boys diagnosed Attention Deficit Disorder and other types of disturbed boys (Edelbrock, in press). A profile pattern typical of boys diagnosed hyperactive obtained high scores on the Hyperactive, Obsessive-Compulsive, Aggressive, and Delinquent scales of the profile. Teacher ChecWist and Profile. The teacher versions of the checklist and profile have been recently completed for boys aged 6 to 11 years (Edelbrock & Achenbach, 1984). The teacher checklist parallels the checklist designed for parents and is

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storable in terms of scales reflecting school performance, adaptive functioning, and behavior problem syndromes. Eight factor-based behavior problem scales have been developed: Anxious, Social Withdrawal, Unpopular, Self-Destructive, ObsessiveCompulsive, Inattentive, NeroomX3veractive, and Aggressive. The Inattentive and Nervous-Overactive scales comprise items related to hyperactivity and, on the surface at least, appear to correspond to the DSM distinction between Attention Deficit Disorder with- and without-Hyperactivity (Edelbrock, Costello, & Kessler, 1984). One-week test-retest reliabilities for behavior problems scales have averaged .89, whereas 2- and 4- month stabilities have averaged .77 and .64, respectively. Validity of the teacher profile is supported by highly significant differences between clinically referred and non-referred children (Edelbrock 8c Achenbach, 1984). In terms of concurrent validity, teacher ratings on the Inattentive and NervousOveractive scales have been found to correlate significantly with observational assessments of children’s classroom behavior (Edelbrock & Reed, 1984b). Scores on these two profile scales have also been found to correlate significantly with scores on the Inattentive-Passive and Hyperactivity scales of Conners’ Revised Teacher Rating scale (Edelbrock & Reed, 1984a). Hyperactivity scores derived from the teacher checklist have also been found to correlate significantly with teachers’ and observers’ ratings of disruptive and off-task behavior (Kazdin, Esveldt-Dawson, & Loar, 1983). Recent studies of diagnostic subgroups have also supported the validity of the teacher checklist and profile. Boys meeting DSM criteria for Attention Deficit Disorder (ADD) obtained high scores on the Inattentive scale (Edelbrock et al., 1984). Additionally, boys diagnosed ADD with Hyperactivity have been found to score high on the Nervous-Overactive scale (Edelbrock et al., 1984). Kazdin et al. (1983) have also found that psychiatric inpatients diagnosed ADD with Hyperactivity were described by their teachers as more hyperactive and inattentive than other inpatient children.

Additional Measures Several other checklists and rating scales tap hyperactive behavior. Although these measures have not been as widely used in research on hyperactivity, many are suitable for such applications and some have unique assets. Personality Inventory for Children. The Personality Inventory for Children (PIC) is a 600-item measure designed to be completed by parents. The development, standardization, and validation of the PIC parallels that of the MMPI. Separate PIC Profiles are available for boys and girls aged 4 to 5 and 6 to 16 years (see Wirt, Lachar, Klinedinst, Jc Seat, 1977). The 36-item Hyperactivity scale seems most relevant here and has been shown to discriminate very well between hyperactive and non-hyperactive children referred for mental health services. This scale has moderately high test-retest reliability (r = .78 to .85), but mediocre interrater (mother-father) reliability (r = .47 to .49). Recent results suggest the PIC may have utility in predicting response to methylphenidate treatment (Voelker, Lachar, Jc Gdowski, 1983). However, several disadvantages have been noted, including the facts that the inventory taps personality domains rather than overt behaviors and is quite long (see Achenbach, 1981; Barkley, 1981 for commentaries). Despite these

criticisms, the PIC is appropriate when a comprehensive personality assessment called for. Shorter, more practical versions are also being developed.

is

Behavior Questionnaire. The Preschool Behavior Questionnaire (PBQ) (Behar, 1977) is one of the few behavior rating scales designed for children aged 3 through 6 years. The PBQ comprises 30 items and is designed for teachers or teacher aides in preschool settings. Items are scored on a 0- l-2 scale corresponding to doesn’t upply, applies sometimes, and certainly applies. In addition to a total behavior problem score, the PBQ is storable in terms of three factor-based scales labeled hostile-Ag~e.~sive, Actor, and Hyperactive-~zstmctible. The latter factor encompasses inattentiot~, short attention span, restlessness, and fidgety behavior and is clearly relevant to child hyperactivity. Preschool Behavior Questionnaire scores have been found to discriminate significantly between normal and disturbed samples and to have adequate reliability. Recent analyses also suggest that the Hyperactive-Distractible scale may be useful for identifying hyperactive toddlers (Campbell, Szumowski, Ewing, Cluck, & Breaux, 1982). Preschool Behavior Questionnaire scores have also been shown to correlate significantly with the Werry-Weiss-Peters Activity Rating scale (Campbell & Breaux, 1983). Preschool

Ozawa’s Behavior Rating Scale. Ozawa and Michael (1983) have recently developed a scale for assessing Attention Deficit Disorder as defined in the DSM-III (American Psychiatric Association, 1980). The scale includes 15 items, which teachers rate on a 1 to 5 continuum corresponding to n.e-cierto al-ruuys.It is storable in terms of a nine-item Impulsivity scale and a six-item Distractibility scale, as well as total Composite score. Internal consistency is high (CX= .95). Scores on Ozawa’s measure have been found to correlate significantly with the WISC and the Matching Familiar Figures test. The scale also discriminates significantly between normal children and learning disabled children receiving special school services. Home and School Situations Questionnaires. Barkley (1981) has developed two questionnaires: the Home Situations Questionnaire (HSQ) for parents, and the School Situations Questionnaire (SSQ) for teachers. These measures are unique in several respects. Rather than focusing in specific problem behaviors which occur across various situations, they concern specific situations in which any problem behaviors may occur. The HSQ, for example, lists 16 situations (e.g., when playing alone, watching TV, going to bed) and asks whether any behavior problems occur during these times. The response scaling is also novel. Parents respond either yes or no, and if yes is indicated, they rate severity on a 1 to 9 scale indicating mild to severe. The SSQ has a parallel format, but school situations are delineated (e.g., during lectures, during recess, while arriving at school). Preliminary analyses suggest that these measures may be useful in clinical and research endeavors involving hyperactive children (Barkley, 1981, pp. 132- 134). Both measures are in an early stage of development, but they may be valuable when situational contingencies of problem behavior are of interest. Other Scales. Several other rating scales are relevant to childhood hyperactivity, but can only be briefly mentioned here. The Bristol Social Adjustment Guides, for example, is a teacher report measure developed primarily on British and Canadian samples. The Over-reaction score, which reflects impulsivity and over-reaction, has

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recently been used to assess effects of stimulant medication, and it correlates significantly with other hyperactivity measures (Broad, 1982). The Devereaux Child Behavior Rating scale (Spivack & Spotts, 1965) is a 9’7-item measure designed for parents. It is storable in terms of 17 behavioral dimensions, many of which discriminate between hyperactive and nonhyperactive samples (Forbes, 1978; Proger, Mann, Green, Bayuk, & Burger, 1975). The Peterson-Quay Behavior Problem Checklist (BPC) is one of the most widely used behavioral rating scales, but it does not encompass a hyperactivity factor. Many factor analyses, however, have yielded an “Immaturity” factor reflecting inattention, daydreaming, short attention span, and distractibility (see Quay, 1979 for a review). The Revised BPC (Quay & Peterson, 1983) is storable in terms of six subscales, two of which-Attention Problems/ Immaturity and Motor Excess-seem directly relevant to hyperactivity. Finally, the Behavior and Temperament Survey is a 32-item teacher rating scale similar in content to Conners’ (Sandoval, 1981). RFAATIONS AMONG MEASURES We have described what may appear to be a heterogeneous grab bag of rating scales. Although they all address one facet or another of child hyperactivity, these measures differ in many ways. Do these instruments tap the same or even similar aspects of behavior? Subjective comparisons among these measures reveal as many differences as similarities in their behavioral coverage and item content. Results of factor analytic studies also obscure the issue because even identical factors can be given different summary labels. Objective statistical comparisons among these measures, however, have revealed a surprisingly high correspondence. Several investigators have reported correlations between two or more of the measures reviewed previously. Research on Conners’ scales illustrates these findings. Conners’ Abbreviated Rating Scale, for example, has been found to correlate .91 with the Over-reaction score of the Bristol Social Adjustment Guides and .69 with the Werry-Weiss-Peters scale (Broad, 1982). Sandoval (198 1) also found that the abbreviated Conners form correlated .89 with the Behavior and Temperament Survey and .76 with the School Behavior Survey. It also correlates .85 with the Externalizing scale of the teacher version of the Child Behavior Profile (Edelbrock & Reed, 1984a) and .84 with Davids’ Hyperkinesis Index (Zentall & Barack, 1979). The more extensive parent and teacher rating scales developed by Conners have also been shown to correlate highly with the Behavior Problem Checklist (Arnold, Barnebey, 8c Smeltzer, 1981; Campbell & Steinert, 1978; von Isser, Quay, & Love, 1980); Davids’ Hyperkinesis Index (Arnold et al, 198 1); the Devereaux Scales (von Isser et al., 1980); and the parent and teacher versions of the Child Behavior Profile (Achenbach & Edelbrock, 1983; Edelbrock & Reed, 1984a; Weissman, Orvaschel, & Padian, 1980). Some studies also support the convergent and discriminant validity of scales identified via factor analysis. Edelbrock and Reed (1984a), for example, recently compared Conners’ Revised Teacher Rating scale with the teacher version of the Child Behavior Profile. Scores on Conners’ scales labeled Inattentive-Passive, HJperactivity, and Conduct Problem correlated very highly with the profile scales labeled Inattentive, Nemous-Overactive, and Aggressive, respectively. Moreover, scores on Conners’ scales did not correlate significantly with any other behavior problem scales on the teacher profile. This suggests a one-to-one correspondence between

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Craig Ede~~~ck and Michael i3. Ra?l~~r~~l~

scales identified by separate factor analyses of the two instruments. These findings also corroborate the existence of three distinct behavior problem syndromes: one involving aggressive and oppositional behavior, another reflecting inattention and distractibility, and a third comprising restlessness and overactivity. Two additional lines of evidence support the correspondence between different assessment instruments. First, there appears to be good agreement between some measures on identifying children as deviant. Zentall and Barack (1979), for instance, compared Conners’ lo-item scale and Davids’ Hyperkinesis Index in terms of the decision to label children “hyperactive.” Although Conners’ measure identified fewer children as hyperactive, agreement between the two measures was very high. Second, different measures agree in terms of the direction and magnitude of change in hyperactive behavior during treatment. Broad (1982), for example, found that three measures--Canners’ Abbreviated Teacher Rating scale, the Werry-WeissPeters Activity scale, and the Over-Reaction scale of the Bristol Social Adjustment Guides-showed similar treatment effects in a recent double-blind, placebo controlled methylphenidate trial. Overall, the evidence suggests that very different rating scales tap a similar domain of child behavior. This is not to say that all measures are equally good or useful, or that they are interchangeable. There are some immutable aspects of each measure, not the least of which involve target phenomena (e.g., excess motor activity vs. inattention), informant (e.g., parent vs. teacher), age range (e.g., preschool vs. school age), and the availability of norms. Nevertheless, there appears to be enough common ground among measures to assure the contribution of each to a cumulative body of knowledge about the hyperactive child. WHAT GOOD ARE RATINGSCAIB? The rating scales we have described are simply assessment tools which can be applied to numerous questions, problems, issues, and tasks facing the clinician or researcher concerned with children. In the following sections, we illustrate their diverse clinical and research applications. C~ini~i Appkca t/offs Behavior checklists and rating scales have numerous clinical applications assessment, diagnosis, treatment, and clinical training.

involving

initial Assessment. Rating scales can play a key role in the intake and evaluation of children referred for mental health services. Omnibus rating scales that tap a broad range of behaviors are more appropriate for general mental health referrals. With a minimum of time and professional resources, such rating scales can yield a wealth of information regarding the child’s behavior and emotional functioning as seen by the parent. They also provide a mechanism for linking the parent’s perception to that of other informants, such as spouse or teacher. Additionally, standardized rating scales permit comparisons of a parent’s report with age-graded norms based on other parents’ perceptions of their own children. C~i~i~~prajsa/. In addition to providing descriptive information, behavior rating scales provide a means of identifying salient problems and concerns about indi-

An Overview of Rating Scales

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vidual children. Parent reports, for example, can be used to identify areas of greatest parental concern and, when compared to norms, they can pinpoint areas of behavioral deviance. Checklist responses also provide a springboard for clinical interviewing. The history and context of specific problems can be discussed and differences between informants (e.g., husband and wife) can be addressed. Diagnosis. Rating scales also have diagnostic applications, even though few tap specific diagnostic criteria. One exception is the scale recently developed by Ozawa and Michael (1983) which operationalizes DSM criteria for Attention Deficit Disorder. Nevertheless, most rating scales tap diagnostically relevant behaviors. Moreover, several measures have been shown to discriminate well between various diagnostic groups. Omnibus rating scales, such as the Child Behavior Profile, can be used heuristically to identify areas of deviance requiring further diagnostic investigation. Rating scales can also be used in a confmatoly manner to verify or reject a diagnostic hunch. The DSM-III (APA, 1980), for example, suggests that reports and ratings by teachers are often crucial in formulating a diagnosis of Attention Deficit Disorder. Unfortunately, it does not specify how such information should be obtained. Rating scales are one solution to this dilemma. Treatment Selection. Behavioral measures also provide a means of making treatment decisions. Standardized descriptions assist the clinician in determining whether the child’s behavior is deviant and/or in need of treatment. They can also indicate degree of deviance in various areas and facilitate the selection and prioritization of treatment goals. Instruments that tap both parent and teacher perceptions, such as Conners’ scales, can help identify global situational differences that may be crucial in designing interventions. More finely tuned situational measures, such as Barkley’s Home and School Situations Questionnaires, can pinpoint situational contingencies more precisely for more focused interventions. Treatment Monitoring and Evaluation. Repeated administration of checklists and rating scales can be used to document changes in the child’s behavior and to determine if treatment goals are being met. Brief measures, such as Conners’ IO-item questionnaire and Davids’ Hyperkinesis Index, can be administered on a daily basis to plot changes in behavior and monitor treatment effects. Modifications of the treatment plan may be called for if changes are not seen or are seen only in one setting. Iatrogenic or other unanticipated effects might also be revealed that have implications regarding further treatment. Clinical Training. Standardized rating scales provide a common data-language for communication and training in child mental health. They provide a more objective common ground for discussing salient features of individual cases and for linking clinical experiences with different cases. They can also provide trainees with guidance in assessment, clinical interviewing, problem identification, treatment selection, and treatment monitoring and evaluation. Research Applications Our review has focused on the most widely used assessment tools in research on child hyperactivity. In the following section, diverse research applications are outlined and illustrated by recent studies.

Epidemiology Prevalence estimates based on epidemiological surveys suggest that many children suffering from psychopathological disorders such as hyperactivity are not referred for mental health services (see Graham, 1979). How common is hyperactivity? How is the disorder distributed in the population? What risk fact.ors are associated with different childhood disorders? What determines referral for services? Behavior checklists and rating scales are well suited to answering these questions. They represent a simple, efficient, and reliable means of surveying large samples and they do not depend upon complex clinical inferences by highly trained personnel. They also represent a standard, operational, and replicable way of which cannot be said of clinical judgments. defining disordersSome of the most important applications of rating scales are therefore epidemiological. An excellent example is the recent study by Trites et al. (1979). Conners’ 39-item Teacher Rating scale was completed on a randomly selected sample of more than 14,000 Canadian school children. Using various cutoff scores for defining hyperactivity, the prevalence of the disorder, as well as its distribution by age and sex, was determined. Because other epidemiological studies have also used Conners’ measure, comparisons of prevalence rates cross-nationally were also possible. Selection Criteria. Checklists and rating scales are also useful for identifying groups of children for research purposes. They provide a more objective and reliable way of categorizing children into comparison groups and they yield groups that are more behaviorally homogeneous than alternative methods such as clinical judgment or psychiatric diagnosis. Conners’ rating scales have been widely used as selection criteria for studies of child hyperactivity. A variety of procedures have been employed. Tant and Douglas (1982), for example, employed a cutoff score of 1.5 on the Hyperactivity scale of Conners’ (1969) Teacher Rating scale. Children scoring 1.5 or higher were considered “hyperactive,” whereas children scoring below 1.5 were considered non-hyperactive. A score of 1.5 on Conners’ Abbreviated Questionnaire has also been commonly used as a selection criterion (Barkley, 1981). As an alternative procedure, a score 2 standard deviations above the mean for the child’s age and sex group has been recommended as a screening and selection criterion (Barkley, 1981). Although various selection procedures exist, they provide a consistent operational rules for subject selection and they provide a basis for standardizing subject sampies across studies. ftio/os There are many ways in which rating scales can be used to investigate etiological factors associated with child hyperactivity. Numerous biomedical factors have been explored. Family, twin, and adoption studies have suggested possible polyfactorial genetic linkages in hyperactivity. Environmental exposure to lead is considered a major public health hazard (Lin-Fu, 1979) and has been implicated with child hyperactivity. Needleman et al. (1979), for example, found that very low levels of dentine lead showed a dose-response relationship with teachers’ ratings of hyperactivity and impulsivity. The idea that hyperactivity may be a “radiation stress” condition resulting from exposure to fluorescent lighting and television emissions has been proposed (Ott, 1968, 1976). However, O’Leary, Rosenbaum, and Hughes (1978) found no such effects in a carefully designed study using the Peterson-Quay Behavior Problem Checklist. The notion that salicylates and preservatives in food could produce irritability

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and hyperactivity in children was popularized by Feingold (1975). He later emphasized the deleterious effects of antioxidant preservatives such as BHA and BHT and developed a diet free of such “forbidden” substances. Evaluations of such dietary manipulations, most of which were dependent upon parent and teacher ratings, have largely ruled out such agents as etiological factors-at least for most hyperactive children. Several other etiological contributors, such as prenatal alcohol exposure, perinatal stress, neurological dysfunctions, and minor physical anomalies, have also been explored using rating scales. Treatment Resea&. By far the most common use of rating scales has been the evaluation of treatment effects. In fact, one could argue this is their ration &e&e. Conners’ original instrument, for example, was dubbed “a teacher rating scale for use in drug studies with children” (Conners, 1969). Numerous rating scales, including those developed by Conners and other investigators, have proven useful in identifying hyperactive children who are candidates for drug treatment and in documenting drug mediated behavioral changes (see Barkley, 1976). Behavioral ratings have been less powerful predictors of drug response than more direct measures of attention span. High ratings of hyperactivity are weakly associated with positive drug response, and ratings by teachers are somewhat better predictors than those by parents. Anxiety in hyperactive children, as reported by parents and teachers, is associated with poor drug response. Rating scales have also substantiated a U-shaped dose-response curve for shortacting stimulants such as methylphenidate and ~-amphetamine. Sprague and Sleator (1977), for example, found that scores on Conners’ Teacher Rating scale improved more with a high daily dose of methylphenidate (1 mgikg) than low dose (0.3 mg/kg). Brief rating instruments, such as Conners’ lo-item scale and Davids’ Hyperkinesis Index, can be administered periodically to monitor treatment effects. Overall, rating scales have proven their worth in detecting drug mediated behavioral change and monitoring treatment progress (see Kavale, 1982). Feingold’s hypothesis prompted a flurry of intervention studies in the late 1970s. Several uncontrolled studies reported positive results of dietary manipulations, but as Werry (1976) pointed out, the improvements could be best explained on the basis of spontaneous remission, placebo effects, statistical regression, and measurement error. Controlled dietary crossover studies, with raters blind as to dietary status of the children, have yielded negative or equivocal results (Harley et al., 1978). Challenge studies, where “forbidden” substances are introduced or withdrawn at a specific time, have also failed to document diet related changes in behavior (Kavale & Forness, 1983). Developmental Research. Finally, rating scales can be used to elucidate age and developmental differences in hyperactive behavior. Cross-sectional studies have revealed age contingencies in children’s behavior problems associated with the hyperactive syndrome. Routh et al. (1974), for example, used the rating scale version of the Werry-Weiss-Peters scale to investigate age differences in activity level. Parent ratings of inappropriate motor activity showed a sharp decline over the age range from 3 to 9 years. Achenbach and Edelbrock (198 1) used the parent version of the Child Behavior Checklist to assess problem behavior in 2,600 normal and disturbed children aged 4 to 16 years. They found that the prevalence of many of the behaviors associated with hyperactivity declined with age. Longitudinal stud-

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ies have also been conducted to examine stability and change in hyperactive behaviors over time. Glow, Glow, and Rump (1982), for example, used the parent and teacher versions of Conners’ scales in a l-year fallow-up of non-referred children aged 5 to 12 years. Ratings were moderately stable over the i-year interval, but were lower for preschool aged children rated by their teachers. Kating scales have also proven useful in revealing the course, prognosis, and adult outcome of hyperactivity in children (see Ross & Ross, 1982). SUMMARY AND CONCLUSIONS Numerous rating scales are available for clinical and research applications with hyperactive children. These instruments differ in many ways, but the empirical evidence suggests they are tapping a similar domain of child behavior. The research literature on hyperactivity is dominated by a few rating scales, particularly those developed by Conners. Several other measures have been shown to have acceptable reliability and validity, and some have age-graded norms. Omnibus measures, such as the Child Behavior Checklist and Profile, can be recommended when the goal is to assess a broad range of behaviors, including hyperactivity. The instruments we have reviewed are not equally well suited to all applications. Some key considerations in choosing a rating scale are (a) the underlying definition of “hyperactivity,” (b) the specific target phenomena the measure taps, (c) the informant, (d) the response burden the measure represents, (e) the age range of the subjects, (f) the setting (e.g., home or school), (g) the purpose of the assessment, and (h) psychometric quality (reliability, validity, and norms). Overall, there is a sufficiently diverse armementarium of rating scales to meet almost all possible clinical and research needs, but further work on the descriptive assessment and classification of child hyperactivity and other disorders is clearly needed.

Acknowledgement-Preparation of this article was supported by an NIMH Research Scientist Development Award (MH00403) to the first author and by NIMH grant number MH37372. The support of the William T. Grant Foundation is gratefully acknowledged.

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