Child And Adolescent Functional Assessment Scale Research Articles

A feasibility study to assess service providers' perspectives regarding the use of the child and adolescent functional assessment scale in ontario

This brief report describes a feasibility study conducted to assess the level of satisfaction with the Child and Adolescent Functional Assessment Scale (CAFAS) rater reliability training, the ease of achieving interrater reliability in rating CAFAS, and the clinical utility of CAFAS as an outcome measurement tool for the province of Ontario, from the perspective of service providers. This study has been instrumental in the development of a 4-year province-wide measurement initiative. The study proved useful to government policy and decision-makers, mental health administrators, clinicians, and mental health service researchers interested in the implementation of outcome measurement tools. It highlighted the fact that at least 85% of respondents were satisfied with CAFAS training and the ease of achieving interrater reliability. The majority identified the usefulness of the tool in case formulation and the value in tracking changes over time.

Use of the CAFAS to Evaluate Outcome for Youths with Severe Emotional Disturbance Served by Public Mental Health

Outcomes are reported for youths with serious emotional disturbance receiving customary services from community mental health service providers who receive state mental health funds. Various outcome indicators for the Child and Adolescent Functional Assessment Scale (CAFAS) are described, as well as a procedure for categorizing youths into client types based on the CAFAS subscale scores. The youth's intake assessment was compared to the last CAFAS evaluation that the youth received. A statistically significant reduction in mean CAFAS total score was observed for the entire sample and for each client type. In addition, the mean number of subscales on which the youth was rated as severely impaired significantly decreased for the total sample and for each client type. The proportion of youths who experienced a clinically meaningful improvement in functioning was 58.6%. For the subset of youths who were rated as severely impaired on one or more subscales at intake, 53.1% left services without any severe impairments. The pattern of outcome results differed for subgroups based on type and extent of impairment. Implications of these findings and suggestions for using outcome monitoring to improve services in the public mental health sector are discussed.

Transition planning and recidivism among mentally ill juvenile offenders.

To determine the extent to which transition planning and community service would predict lower levels of recidivism among mentally ill juvenile offenders. Review of legal, medical and social service records including examination of 3-month period following community release. Juvenile offenders incarcerated for 6 months or more (N = 44) transitioning to community. Child and Adolescent Functional Assessment Scale (CAFAS), sum of different documented pre- and post-release discharge planning contacts, documented community service contacts. Re-offense during the first year post-release. Documented community service contacts in the 3 months following discharge were rare for mental health (20.5%), substance abuse (38.6%), financial assistance (29.5%), and school placement (34.1%). The average number of different pre-release and post-release discharge planning contacts was also low, M(SD)=1.86(1.68) and M(SD)= 2.34(1.71) respectively. Post-release discharge planning and the receipt of financial assistance and mental health services were all associated with lower levels of reoffending. Community transition planning, including the coordination and provision of community services, is an essential component of community reintegration for juvenile offenders and is associated with lower rates of recidivism during the first year post-discharge.

Innovative Treatment for Children With Serious Emotional Disturbance: Preliminary Outcomes for a School-Based Intensive Mental Health Program

This article describes the development, implementation, and preliminary evaluation of a school-based Intensive Mental Health Program (IMHP) for 50 children (42 boys, 8 girls) with severe, early-onset, serious emotional disturbances (SED). Eighty-four percent of the children showed clinically significant improvement in overall functioning as measured by the Child and Adolescent Functional Assessment Scale (CAFAS). Child functioning at home and school, behavior toward others, regulation of moods and emotions, self-harm, and problems in thinking improved significantly. Results provide initial support for the IMHP as a promising approach to serving the needs of children with SED.

Outcomes for Children with Problematic Behavior in School and at Home Served By Public Mental Health

The authors report outcomes for 4,777 youth served by the public mental health system in Michigan who had problems in school, at home, in interpersonal relationships, or in modulating their mood. Cluster analysis identified five subgroups: Pervasive Problems with Mood Disturbance (i.e., severe or moderate impairment in school, at home, in behavior toward others, and in mood); School Problems with Mood Disturbance; Home Problems with Mood Disturbance; School and Home Problems; and Mild Behavior/Mood Problems. Outcome was defined as the proportion of youth whose functioning changed from severe or moderate impairment to mild impairment or no impairment on each of the relevant subscales of the Child and Adolescent Functional Assessment Scale (CAFAS).The results indicated that youth with pervasive impairment across domains (i.e.,the Pervasive Problems with Mood cluster) had the poorest outcomes.The authors present recommendations for research protocols that match evidence-based treatments to type and extent of impairment, as reflected by cluster membership, which in turn corresponded to differential profiles of scores on the CAFAS.

The role of monitoring outcomes in initiating implementation of evidence-based treatments at the state level.

This article describes a six-year statewide initiative to help mental health service providers in continuously monitoring the outcomes of youths with serious emotional disturbances who are treated in the public-sector managed behavioral health care system. Participating providers submit outcome data to a state-sponsored evaluator, using the Child and Adolescent Functional Assessment Scale (CAFAS), and receive monthly feedback that identifies youths who are making poor progress in treatment. Additional reports are used to ensure record compliance, monitor at-risk youths, and assist in reviewing the adequacy of treatment plans. In addition, outcome data for closed cases are generated for various types of clients. The consistently poor outcomes for some types of clients have generated a genuine interest among clinical staff in learning and implementing evidence-based treatments. The data for all participating providers were pooled to generate state averages for various indicators so that each provider can compare their site to these benchmarks. State administrators consider the data in generating policy and identifying systemwide needs. The processes that shaped this initiative and that created the providers' investment in continuous quality improvement activities are described.

Clinical and forensic outcomes from the Illinois mental health juvenile justice initiative.

To address the mental health needs of youths who are arrested and detained in Illinois, an initiative was designed and implemented that identified youths with psychotic or affective disorders, linked them to community services, and monitored their cases. This study assessed whether such linkage is possible and whether it improves clinical and forensic outcomes. S: Under the initiative, court staff refer youths who may have a mental illness to a clinical liaison. If the youth is eligible for the program, the liaison works with the family to develop a community-based action plan. For the analysis presented here, the Child and Adolescent Needs and Strengths-Mental Health Scale (CANS-MH) and the Child and Adolescent Functional Assessment Scale (CAFAS) were used to assess outcomes among 314 youths who had completed the program at the time of the study. School and forensic outcomes were also monitored. Seventy-five percent of the youths were successfully linked to at least one mental health or community service. A comparison of average CANS-MH dimension scores at enrollment and program completion indicated that youths' emotional problems decreased considerably within three months of referral. CAFAS scores six months after enrollment improved across nearly all dimensions. Home, community, and school functioning were significantly improved from baseline. Only 42 percent of the youths were rearrested, compared with a statewide rate of 72 percent of detained youths. S: By linking youths with significant mental health needs to existing community-based services, it appears possible both to ameliorate psychopathology and to reduce delinquency.

Assessing the effectiveness of care for youth with severe emotional disturbances: is there agreement between popular outcome measures?

Limited information exists regarding how some popular measures for assessing the effectiveness of services to children with severe emotional disturbance interrelate when used as part of ongoing outcome accountability systems. This article examines the interrelationships--at intake and over time--between the Child Behavior Checklist (CBCL), the Youth Self Report (YSR), the Child and Adolescent Functional Assessment Scale (CAFAS), and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) clinical diagnoses across six California care systems. At intake, there were mild to moderate relationships between the clinical diagnosis, the CAFAS, the CBCL, and the YSR. These relationships were not as strong as those found in other studies conducted in more controlled research environments. There was limited agreement among the CAFAS, the CBCL, and the YSR regarding the outcomes of the youths served. These findings raise questions regarding translating measures from research settings to clinical environments and reconciling differences between outcome measures.

The Target Symptom Rating: A Brief Clinical Measure of Acute Psychiatric Symptoms in Children and Adolescents

Describes the development and psychometric properties of the Target Symptom Rating (TSR), a brief, multi-informant measure of commonly observed symptoms in child and adolescent clinical work. In a large sample of children and adolescents in inpatient and residential treatment, the 13 TSR items fell into 2 subscales: Emotional Problems and Behavior Problems, which were associated in expected ways with the Internalizing and Externalizing factors of the Achenbach scales and the Child and Adolescent Functional Assessment Scale (CAFAS). The measure was sensitive to change in brief and extended treatment, as rated by parents, patients, primary clinicians, and family therapists, and shows promise as a tool for outcome research in applied settings.

The Target Symptom Rating: A Brief Clinical Measure of Acute Psychiatric Symptoms in Children and Adolescents

Describes the development and psychometric properties of the Target Symptom Rating (TSR), a brief, multi-informant measure of commonly observed symptoms in child and adolescent clinical work. In a large sample of children and adolescents in inpatient and residential treatment, the 13 TSR items fell into 2 subscales: Emotional Problems and Behavior Problems, which were associated in expected ways with the Internalizing and Externalizing factors of the Achenbach scales and the Child and Adolescent Functional Assessment Scale (CAFAS). The measure was sensitive to change in brief and extended treatment, as rated by parents, patients, primary clinicians, and family therapists, and shows promise as a tool for outcome research in applied settings.

The Child and Adolescent Functional Assessment Scale (CAFAS): review and current status.

Measures of impairment in psychological and behavioral functioning have a long history in the field of children's mental health, and appear particularly useful in eligibility determination, treatment planning, and outcome evaluation of services for children and adolescents with serious emotional disturbance (SED). One recently developed multidimensional measure of functional impairment-the Child and Adolescent Functional Assessment Scale (CAFAS; K. Hodges, 1989, 1997)-has enjoyed widespread use nationwide. It has been adopted as a tool for making treatment eligibility decisions and documenting outcomes on a statewide level in more than 20 states and on a local level in dozens of research and demonstration projects. In this paper, the technical merits of the CAFAS are closely examined, with the conclusion that empirical evidence is lacking to support its valid use in making the types of treatment decisions for which it is currently being employed across the nation. Furthermore, there appears to be little concern among mental health researchers, practitioners, administrators, and state legislators about these apparent limitations of the CAFAS. The potential benefits of establishing objective and valid level-of-need criteria, using the CAFAS are numerous and the interest in doing so is clear; however, the psychometric limitations of the scale identified in this review need to be addressed before its full potential can be realized.

A Longitudinal Analysis of Family Empowerment and Client Outcomes

We examined the relationship between family empowerment, parent satisfaction, and mental health outcome across time. Based on the Vanderbilt Family Empowerment Project Model, increased empowerment should lead to positive changes in client outcomes. Data consisted of the Family Empowerment Scale (FES), which was used to assess the caregiver's perception of empowerment, Child and Adolescent Functional Assessment Scale (CAFAS), which measures the degree of disruption in the youth's current functioning, Client Satisfaction Questionnaire (CSQ), and demographic information gathered from families receiving services from a county mental health service system at intake and discharge. The results showed that the CAFAS and CSQ were related to empowerment at intake and discharge. Results also indicated significant increases in the knowledge subscale of the FES and the CAFAS and moderate increases in the advocacy subscale of the FES and the CSQ. We discuss the implications of these findings for systems of care, such as stronger parent-professional relationships.

Client typology based on functioning across domains using the CAFAS: implications for service planning.

Cluster analysis was used to develop a five-group typology based on the eight subscales of the Child and Adolescent Functional Assessment Scale (CAFAS) using data on 4,758 youths referred to Community Mental Health Service Providers in Michigan. The groups are described in terms of clinical diagnoses, overall impairment in functioning, past and current use of services from other agencies (i.e., juvenile justice, social services), and caregiver resourcefulness. From most to least impaired, the clusters were the following: Substance Users/Externalizers, Comorbid/Self-Harmful, Delinquents, Marked/School Problems, and Adjustment Problems with Impairment/Secondary Prevention. The results are being used to help identify the most impaired youths with serious emotional disturbance (SED) youths, develop specific programs and services for the different types of youths being served, determine staff training needs, and foster clinical practice in which the youth's progress is continually monitored.

Predicting service utilization with the Child and Adolescent Functional Assessment Scale in a sample of youths with serious emotional disturbance served by center for mental health services-funded demonstrations.

This study investigated level of restrictiveness of living arrangements and number of days in out-of-family care at six months postintake, based on the Child and Adolescent Functional Assessment Scale (CAFAS), the Child Behavior Checklist (CBCL), gender, age, and level of family income at intake. It was composed of youths who met the criteria for serious emotional disturbance (SED) and were for the most part living in families that are described as socioeconomically disadvantaged. A multinomial logit model was used in the analysis of level of restrictiveness of living arrangements, and an ordinary least squares (OLS) regression model was conducted on number of days in out-of-family care. The CAFAS score at intake was found to be a significant predictor of service utilization between intake and six months and was a more consistent predictor than the CBCL. Results suggest that the CAFAS can be used to match service needs with resource allocation and to monitor performance-based outcome indicators.

Psychometric study of the Child and Adolescent Functional Assessment Scale: prediction of contact with the law and poor school attendance.

The predictive validity of the Child and Adolescent Functional Assessment Scale (CAFAS) is investigated using the data set generated by the national evaluation of the demonstration service grants funded by the Center for Mental Health Services. Logistic regressions were performed separately for contact with the law and poor school attendance, which were both assessed at 6 months postintake. Other variables included in the model besides the CAFAS total score at intake were age, gender, and family risk factors. The results show that the CAFAS total score at intake was a positive predictor of the likelihood of contact with the law and poor school attendance, even after controlling for age, gender, and risk factors. Furthermore, the CAFAS total score was predictive even after excluding scores on CAFAS subscales, which may have been influenced by absenteeism or delinquency. These findings are consistent with recent research indicating that the CAFAS predicts recidivism in juvenile delinquents.

Identification of Elementary School Children at Risk for Disruptive Behavioral Disturbance: Validation of a Combined Screening Method

To examine the validity of the teacher-rated Inattention/Overactivity With Aggression (IOWA Conners) questionnaire followed by the Conners Abbreviated Symptom Questionnaire (CASQ) as a feasible, combined screening method to identify children at high risk for externalizing behavioral disturbance in a school setting. The IOWA Conners and CASQ were administered to the entire population of children, grades K through 6, in a single elementary school. Using a whole-number IOWA Conners threshold score of 18 (1.5 SD), coupled with a CASQ score of 18 (1.0 SD), a high-risk group and an age-, sex-, and classroom-matched low-risk control group were selected for comparison on the Child Behavior Checklist (CBCL), Teacher's Report Form (TRF), Child and Adolescent Functional Assessment Scale (CAFAS), and Diagnostic Interview for Children and Adolescents-Revised diagnoses. The data showed significant intergroup differences in CBCL (p < .0002), TRF (p < .0006), and CAFAS (p < .0002) scores and higher numbers of DSM diagnoses (1.7 +/- 0.3 versus 0.1 +/- 0.3, p < .0007) between the high- and low-risk group. The positive predictive value for externalizing diagnoses for the IOWA Conners plus CASQ was 100% and negative predictive value was 70%. The IOWA Conners combined with the CASQ is a useful initial screening strategy in the school setting for identification of children with disruptive behavioral difficulties.

The Relationship Between the Child and Adolescent Functional Assessment Scale (CAFAS) and Indicators of Functioning

We investigated the relationship between scores on the Child and Adolescent Functional Assessment Scale (CAFAS) and several indicators of functioning assessed in the national evaluation of the demonstration grants funded by the Center for Mental Health Services System of Care Initiative. The sample included 3187 youths, ranging in age from 4 to 23, with serious emotional disturbance (SED) who were evaluated at intake. At 6 month post-intake, 873 of these youths were re-evaluated. As predicted, higher CAFAS scores were associated with previous psychiatric hospitalization, more serious psychiatric diagnoses, and more restrictive living arrangements. Youths in residential inpatient settings were significantly more impaired than youths living in their own home or in regular foster care. Below average school performance, poor attendance, and contact with law enforcement personnel were also associated with greater impairment. Youth's total CAFAS scores decreased significantly from intake to 6 months. These results indicate that the CAFAS is a measure of functioning which has both statistical and clinical significance.

Use of the Child and Adolescent Functional Assessment Scale (CAFAS) as an outcome measure in clinical settings.

This article discusses how the Child and Adolescent Functional Assessment Scale (CAFAS) can be used as an outcome measure in clinical settings. Outcome data from two clinical samples are provided: a small community mental health center located in Michigan and a large referred sample from the Fort Bragg Evaluation Project. Outcome indicators for assessing change over time included overall level of dysfunction, percentage of respondents with severe impairment, mean total score, mean scores for individual CAFAS subscales, and change in total score at the client level. Implications of the findings were discussed from several perspectives: improving services to individual clients, developing databases at the local level that can be used for the agency's continuing self-scrutiny, and pooling databases across sites that can be used to study broader issues within a managed care environment.

Use of the Child and Adolescent Functional Assessment Scale to predict service utilization and cost.

The Child and Adolescent Functional Assessment Scale (CAFAS) is a multidimensional measure of impairment that assesses the extent of interference in day-to-day functioning secondary to emotional, behavioral, or substance use problems. Respondents were 984 youths, aged 5 to 17, who were referred for mental health services. They were assessed at intake and at 6 and 12 months postintake with a battery of measures administered by evaluation staff who were independent of treatment. Utilization indicators included restrictiveness of care, total cost, number of bed days, and total number of days of service received. The CAFAS total score at intake was a significant predictor of service utilization and cost determined at 6 and 12 months postintake. The CAFAS score was also the best predictor when compared with other measures of psychopathology. Only the CAFAS and presence of conduct disorder contributed to the prediction of service utilization and cost at 12 months.

Psychometric characteristics of a multidimensional measure to assess impairment: The Child and Adolescent Functional Assessment Scale

The Child and Adolescent Functional Assessment Scale (CAFAS) is a multidimensional measure of degree of impairment in functioning. Interrater reliability data are presented for lay raters, graduate students, and frontline staff. Reliability was high for the total score and behaviorally-oriented scales. Construct, concurrent, and discriminant validity were assessed with the sample of children and adolescents evaluated at the Fort Bragg Demonstration Evaluation Project. Youth and their caregivers were evaluated via interview and selfcompleted instruments at four time points. Significant correlations were found between the CAFAS and other related constructs. Concurrent validity was demonstrated by logistic regression analyses examining the relationship between CAFAS ratings and problematic behaviors endorsed on measures completed by parents, teachers, or the youth. Youth with higher CAFAS total scores were much more likely to have poor social relationships, difficulties in school, and problems with the law. Discriminant validity was assessed with a repeated measures analysis of variance with intensity of care at intake and time as factors. Youth who were inpatients or in residential treatment centers at intake had higher CAFAS scores than those who were outpatients. These findings provide strong evidence for the reliability and validity of the CAFAS.