Archives of Clinical Neuropsychology

18 (2003) 431–437

Book review
Conners’ Adult ADHD Rating Scales (CAARS).
By C.K. Conners, D. Erhardt, M.A. Sparrow. New York: Multihealth Systems, Inc., 1999

1. Test description

In previous years, Attention Deficit Hyperactivity Disorder (ADHD) was thought to be a

disorder that primarily affected children. Current research has shown that ADHD is a problem
that also affects adults. Although the age of onset for this disorder is in childhood, the problems
continue throughout adulthood and is not something an individual will overcome through the
mere maturation process. Individuals with ADHD, in addition to having difficulties with sus-
taining attention, impulsivity, and hyperactivity, also are at risk for other difficulties throughout
their lifetime. With the emphasis traditionally on assessment of ADHD in children, there has
been a paucity of measures for use in the assessment of ADHD in adults. In addition, while
assessment of children often relies on teacher(s) and parent(s) serving as informants, with
adults the use of others as informants becomes more problematic. As a result, adult diagnosis
is often based on self-report.
The Conners’ Adult ADHD Rating Scales (CAARS) were designed to assess ADHD in
adults. The CAARS utilizes short, long, and screening self-report and observer rating scale
forms. The instrument is designed for individuals aged 18 through 50 years and older. The
scales address ADHD symptoms as described in the Diagnostic and Statistical Manual Fourth
Edition (American Psychiatric Association, 1994). Separate T-scores are provided for men
and women.
The various scales (short, long, screening) provide differing scores and vary in reliability
and validity. The long version rating scales include measures of Inattention/Memory problems,
Hyperactivity/Restlessness, Impulsivity/Emotional Lability, Problems with Self-Concept,
DSM-IV Inattentive Symptoms, DSM-IV Hyperactive-Impulsive Symptoms, DSM-IV ADHD
Symptoms Total, and ADHD Index. The short version rating scales only include DSM-IV Inat-
tentive Symptoms, DSM-IV Hyperactive-Impulsive Symptoms, DSM-IV ADHD Symptoms
Total, and ADHD Index. The CAARS also utilizes an Inconsistency Index. This score is made
up of paired items that can be used to determine whether or not an individual completing the
scale may be unmotivated, noncompliant, or may be answering in a haphazard fashion. It may
also be used as an indicator of whether or not the respondent was able to understand wording
of the test items. Test development, normative data, reliability, and validity of the scales will
be discussed.

0887-6177/03/$ – see front matter © 2003 National Academy of Neuropsychology.

doi:10.1016/S0887-6177(03)00021-0
432 Book review / Archives of Clinical Neuropsychology 18 (2003) 431–437

2. Test construction

Using the DSM-IV symptom criteria, the Conners’ Rating Scales revised for Children and
Adolescents (Conners, 1997), and current conceptualizations of adult ADHD (Wender, 1995)
an item pool was developed for the scale, which resulted in the 4 factor-derived scales. The
CAARS are available in three forms in both self-report and observer report. The long form
(CAARS-S:L; CAARS-O:L) consists of 66 items with 9 subscales. The subscales include 4
factor-derived scales—Inattention/Memory Problems (12 items), Hyperactivity/Restlessness
(12 items), Impulsivity/Emotional Lability (12 items), and Problems with Self-Concept (6
items), three DSM-IV ADHD Symptoms subscales which correspond with the criteria estab-
lished by the DSM-IV—Inattentive Symptoms (9 items), Hyperactive-Impulsive Symptoms
(9 items), Total ADHD Symptoms subscale, an ADHD Index which contains the set of items
which will distinguish ADHD adults form nonclinical adults, and an Inconsistency Index which
can be used to identify haphazard responses or difficulty in understanding the measure. These
scales represent current conceptualizations of adult ADHD from the previously mentioned
sources.
From an item pool of 93 items, subjects were asked to respond to statements using a 4-point
scale (0 for “not at all, never” and 3 for “very much, frequently”). Factor analysis was used
to determine which items should be retained. Items were included based on the following
criteria. First, the item had to have conceptual coherence with the factor. Second, factors were
determined if items loaded significantly on a given factor, greater than 0.30 and less than 0.30
on other factors. No other information was provided for how item loadings were determined.
The ADHD Index “provides a method of identifying those adults who are likely to be
diagnosed with ADHD” (Conners, Erhardt, & Sparrow, 1999, p. 51). The items for this scale
were selected based on whether or not they appeared to differentiate between ADHD and
non-ADHD adults. The Inconsistency Index was designed to determine whether or not an
individual was responding randomly to scales items. Items were paired and then correlated.
Correlation values range from r = .65 to r = .42 for the eight pairs included on this subscale.
Scores of 8 or higher may be considered an indication of an inconsistent response pattern.
The cutoff of 8 or higher on the Inconsistency Index was established based how successful the
score is at differentiating 100 respondents from 100 sets of random numbers.
The DSM-IV Symptoms scale is derived from the Conners (1997) self-report measure for
adolescents that adapts the ADHD criteria of the DSM-IV. Wording was modified for use
with adult clients. The short and screening forms were designed with fewer items than the
long version using confirmatory factor analysis testing a one-dimensional model to select five
items for each subscale (Conners et al., 1999). Items were selected only if they had high
loadings with the latent variable (Conners et al., 1999).
The short form (CAARS-S:S; CAARS-O:S) contains 26 items and 6 subscales. An ab-
breviated version of the 4 factor-derived scales included—Inattention/Memory Problems (5
items), Hyperactivity/Restlessness (5 items), Impulsivity/Emotional Lability (5 items), and
Problems with Self-Concept (5 items) which are subsets from the long form. The short form
also includes the 12-item ADHD Index and the Inconsistency Index.
The screening form (CAARS-S:SV; CAARS-O:SV) contains 30 items and the 3 DSM-IV
ADHD symptoms measures. The DSM-IV ADHD symptom subscales include—Inattentive
 Book review / Archives of Clinical Neuropsychology 18 (2003) 431–437 433

Symptoms (9 items), Hyperactive-Impulsive Symptoms (9 items), Total ADHD Symptoms

subscale, and the ADHD Index (12 items).

3. Standardization

The CAARS self-report forms norms were developed on 1,026 adults aged 18 through
50 years and higher. The observer norms were developed on 943 individuals. Individuals
who participated were from the United States and Canada. No other specific information is
provided for the sample. Age and gender differences were found in the data analysis resulting
in separate norms for age and gender. The manual provides detailed tables containing means
and standard deviations for both self-report and observer forms as well as results of ANOVA
for each subscale.

4. Administration

Administration of the CAARS requires a protocol and a pencil or a ballpoint pen. The long
form can be completed in approximately 30 min while the short and screening versions can be
completed in approximately 10 min. Nine administration steps are provided. Examiners should
tell the individual that the scale will provide information about feelings and behaviors. The
4-level Likert scale should also be explained—0 for “not at all or never,” 1 for “just a little, once
in a while,” 2 for “pretty much often,” and 3 for “very much, very frequently”. Individuals
are to be instructed to select the “best” answer if they are unsure how to respond. A post
administration debriefing also is recommended in the manual. According to the Dale–Chall
formula (1948), that establishes reading level of an instrument, the CAARS, overall, requires a
fourth grade reading level in order to be completed. The manual provides a complete readability
analysis of all of the forms.
The CAARS manual indicates that the rating scales can be used for routine screening of
individuals in clinics, treatment centers, private practice, prisons, and psychiatric hospitals.
When determining which form to use with individuals, the manual briefly contrasts each
measure. The long form should be administered whenever possible since it encompasses all
symptoms of ADHD and will provide the most information. The short form may be more suited
when individuals repeatedly will complete the scale over a period of time (e.g., treatment
or research study). In selecting the short form over the screening version, practitioners or
researchers should consider their own needs. These two versions are approximately the same in
length. The short version addresses core symptoms of ADHD through the ADHD Index, related
problem areas, and contains the Inconsistency Index. The screening version only included the
DSM-IV subscales and the ADHD Index.

5. Scoring and interpretation

The CAARS manual provides detailed steps to score protocols, which includes procedures
specific to the form being scored. Hand scoring requires a minimal amount of time, which
434 Book review / Archives of Clinical Neuropsychology 18 (2003) 431–437

includes transferring scores to columns, adding up each column, and completing the Inconsis-
tency Index. If items were not completed a “0” can be transferred to the column for that item.
One should note that if two or more items are missing for a subscale, the subscale should be
considered invalid. If three or more items are missing from the short or screening form or five
or more items are missing from the long form, the entire protocol is considered invalid.
When profiling results, raw scores are converted to T-scores. Profiles are specific to the
gender and age group of the individual. Separate norms are available for men and women.
When scoring, the correct gender must be selected first, and then the correct age category
column is selected. Raw scores from the scoring sheet are circled in the columns. The circles
are then connected by a line to obtain the “shape of the profile” (Conners et al., 1999, p. 9). In
addition to the detailed scoring and profiling instructions, the manual also includes examples
of this process with copies of protocols to guide users.
The manual recommends interpreting the CAARS by examining item responses, subscale
scores, and profile patterns. Symptoms indicated at the item level provide information for
making recommendations. Subscale scores can be interpreted using T-scores or percentile.
Scores depending on range fall into qualitative categories, though the manual cautions against
using these categories as absolutes. In profile interpretation, the examiner should look at the
number of subscales that fall above a T-score of 65. The number of scales with clinically
relevant elevations the greater the chance that scores indicate a significant problem.
The manual also provides a step-by-step approach to interpreting the CAARS. First, Does
the CAARS provide valid information about ADHD symptoms? The examiner should examine
the Inconsistency Index to determine if responses are consistent and a valid representation of
the individual’s symptoms. Second, Which item responses are elevated? Third, examine the
subscale scores and the overall level of symptomatology. The manual points out that the ADHD
Index “represents a measure of the overall level of ADHD-related symptoms. This is the best
screen for identifying those ‘at-risk’ for ADHD (Conners et al., 1999, p. 23).” The T-scores
above 65 are clinically significant. Fourth, the examiner must integrate information from the
self-report and observer report forms. Fifth, integrate information from other sources. Sixth,
consider the diagnosis and make recommendations. The manual also provides six case studies
and CAARS results to provide concrete examples when the scale can be used and they present
problems that commonly are presented in clinical practice.

6. Technical adequacy

6.1. Reliability

Four types of reliability tests were completed on the CAARS. First, internal consistency
reliability was calculated. Internal consistency reliability indicates whether or not items on
a scale consistently measure the same construct. Cronbach’s alpha across age, subscales and
forms men ranged from 0.64 to 0.91 and for women ranged from 0.49 to 0.90.
Second, mean inter-item correlations were calculated. This reliability measure indicates the
degree to which items on a particular scale consistently measure the same construct. According
to Hogan and Nicholson (1988) the higher the mean inter-item correlations the greater chance
 Book review / Archives of Clinical Neuropsychology 18 (2003) 431–437 435

the scale is one-dimensional. Across age, subscales and forms Cronbach’s alpha for men
ranged from 0.31 to 0.68 and for women ranged from 0.26 to 0.63.
Third, test–retest reliability measures the stability of the scale given multiple administra-
tions. Test–retest reliability was calculated based on 33 men and 28 women who were seen
at an adult ADHD clinic. The CAARS-S:L was completed twice, 1 month apart. Correlation
values range from .88 to .91. The CAARS-O:L was examined in a sample of nonclinical indi-
viduals (24 men and 26 women) who were rated by their spouses. Correlation values ranged
from .85 to .95.
Finally, standard error of measurement (SEM) and standard error of prediction (SEP) were
calculated. The SEM was calculated for all age groups and for self-report and observer forms.
The manual provides a complete table with all of the SEM values. The SEP was calculated
based on the test–retest reliability estimates, which may provide evidence of the degree to
which scores will vary between original scores (Conners et al., 1999). The SEP values are
calculated for all age groups and forms and the manual provides complete tables with all of
the values.

6.2. Validity

Confirmatory factor analysis was conducted on the short and long self-report and observer
forms. Goodness of Fit Index (GFI), Adjusted Goodness of Fit Index (AGFI), Non-normed
Fit Index (NNFI), and Confirmatory Fit Index were conducted. Guidelines for acceptable
values follow the recommendations of Cole (1987) and Marsh, Balla, and McDonald (1988):
GFI > 0.850 , AGFI > 0.800, NNFI > 0.900, CFI > 0.900.
The four factor structure of the CAARS-S:L, CAARS-S:S, CAARS-O:L, and CAARS-O:S
(Inattention/Memory Problems, Hyperactivity, Impulsivity/Emotional Lability, and Problems
with Self-Concept) met the criteria for good fit. Intercorrelations of the self-report and observer
scales (short and long forms) were completed. The manual provides four tables that detail the
information.
Discriminant validity studies, which examines whether or not an instrument is able to
differentiate between clinical and nonclinical groups, also are reported in the manual. One
study (Erhardt, Conners, Epstein, Parker, & Sitarenios, 1999) found that the CAARS produced
an overall correct classification rate of 85%. The ADHD Index also was cross-validated on a
sample (N = 192) of ADHD and non-ADHD adults (Conners et al., 1999). Sensitivity was
71%, specificity was 75%, positive predictive power was 74%, negative predictive value was
72%, false positive rate was 25%, false negative rate was 29%, kappa coefficient was 0.458,
and overall classification rate was 73%. These results indicate the ADHD Index may be used
to identify adults who would benefit from a full assessment (Conners et al., 1999).
Construct validity is reported regarding current ADHD symptoms and retrospective reports
of symptoms from childhood or adolescence and the relationship between self-report and ob-
server ratings of symptoms (Conners et al., 1999). Erhardt et al. (1999) studied the relationship
between adult and childhood ADHD symptoms. The CAARS-S:L and Wender Utah Rating
Scale (WURS; Ward, Wender, & Reimherr, 1993) were completed by 101 clinical individuals.
The two scales correlate as follows: Inattention/Memory Problems, r = .37; Hyperactivity,
r = .48; Impulsivity/Emotional Lability, r = .67; and Problems with Self-Concept, r = .37
436 Book review / Archives of Clinical Neuropsychology 18 (2003) 431–437

(P < .01) (Conners, 1997). The relationship between self-report and observer forms were
examined based on a sample of 188 adults who completed the CAARS-S:L and also were
rated by a significant other. Moderate to high correlations were found (.12–.61).

7. Summary

Research provides evidence that ADHD is not only a disorder of childhood and that symp-
toms and the disorder can continue during adolescence and into adulthood. A need for a rating
scale measure for adults exists and Conners et al. (1999) have developed such a measure. This
rating scale system provides measures in three versions (long, short, and screening) for two
informants (self and observer reports). In terms of normative data, the manual provides very
limited information on the sample of individuals. Information about ethnicity, region of the
United States, and Canada, and socioeconomic status is important for generalization of test
scores and to determine for which individuals the test is appropriate. Reliability of the CAARS
ranged from moderate to high for internal consistency and low to moderate for mean inter-item
correlations. The CAARS was found to correlate moderately with one other measure of adult
ADHD and discriminate between clinical and nonclinical groups. Further study of the CAARS
is needed as part of the standardization process. Since no information is provided on the ethnic
representation of the normative sample, and no studies address issues of ethnic differences or
bias, caution should be exercised when using the CAARS with individuals of minority status.
Research is needed in this area.

Acknowledgments

The author would like to acknowledge and express appreciation to Dr. Cynthia A. Ric-
cio, Department of Educational Psychology, Texas A & M University for all of her time,
encouragement, and assistance with this manuscript.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Wash-
ington, DC: Author.
Cole, D. A. (1987). Utility of confirmatory factor analysis in test validation research. Journal of Consulting and
Clinical Psychology, 55, 584–594.
Conners, C. K. (1997). Conners’ Rating Scales–Revised. New York: Multihealth Systems.
Conners, C. K., Erhardt, D., & Sparrow, M. A. (1999) Conners Adult ADHD Rating Scales (CAARS). New York:
Multihealth Systems, Inc.
Dale, E., & Chall, J. S. (1948). A formula for predicting readability. Coumbus, OH: Ohio State University Bureau
of Educational Research. (Reprinted from Educational Research Bulletin, 27, 11–20, 37–54).
Erhardt, D., Conners, C. K., Epstein, J. N., Parker, J. D. A., & Sitarenios, G. (1999). Self-ratings of ADHD symptoms
in adults II: Reliability, validity, and diagnostic sensitivity. Manuscripts submitted for publication.
Hogan, R., & Nicholson, R. A. (1988). The meaning of personality test scores. American Psychologist, 43,
621–626.
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Marsh, H. W., Balla, J. R., & McDonald, R. P. (1988). Goodness-of-Fit Indexes in confirmatory factor analysis:
The effect of sample size. Psychological Bulletin, 103, 391–410.
Ward, M. F., Wender, P. H., & Reimherr, F. W. (1993). The Wender Utah Rating Scale: An aid in the retrospective
diagnosis of child hood attention deficit hyperactivity disorder. American Journal of Psychiatry, 150, 885–890.
Wender, P. H. (1995). Attention-Deficit Hyperactivity Disorder in adults. Oxford, UK: Oxford University Press.

Katherine DeGeorge Macey

Department of Educational Psychology 4225
Texas A & M University, College of Education
College Station, TX 77843-4225, USA
E-mail address: kldegeorge@tamu.edu