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.     

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.     

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.     

Validation of the Preschool and Early Childhood Functional Assessment Scale (PECFAS)

Efforts to determine the prevalence of serious emotional disturbance in preschool-aged children have been hampered by the lack of a validated measure. The Preschool and Early Childhood Functional Assessment Scale (PECFAS) is a multi-dimensional measure that assesses the psychosocial functioning of children aged 3–7 years. The concurrent validity and reliability of the PECFAS were assessed in a sample of 30 preschool-aged children in a large Head Start program in Ventura, California. PECFAS ratings based on in-depth interviews were significantly related to parental ratings that the children had mental health problems, psychiatric diagnoses, teacher ratings of the child's need for mental health evaluations, teacher ratings of behavior problems on a standardized screening inventory (DIAL-R), and actual referrals for mental health evaluations. Interrater reliability for the total PECFAS score was high (r = .90) as was internal consistency of the five subscales (alpha = .86). Using the PECFAS scores as a standard, the weighted prevalence of serious emotional disturbance in this West Coast Head Start program was 17%, at the lower end of the current estimated rate of SED for older children in low income samples (18–26%).     

Measuring Treatment Outcome for Children with Serious Emotional Disturbances: Discriminant Validity and Clinical Significance of the Child and Adolescent Functioning Assessment Scale

We investigated the use of a popular measure, the Children and Adolescent Functional Assessment Scale (CAFAS), in treatment outcome research. The sample included 70 children who had been discharged from an elementary therapeutic classroom (Intensive Mental Health Program). Significant relationships were found between decreases in CAFAS scores and optimal educational placement, contributing to evidence of the scale’s discriminant validity. Clinically significant change in CAFAS scores was also investigated, with a 30 point change in score most accurately discriminating between placements after discharge. Further investigations of real world outcomes versus changes in score on this measure are warranted.     

Mentalization in children and mothers in the context of trauma: An initial study of the validity of the Child Reflective Functioning Scale

This study examined the validity of the Child Reflective Functioning Scale (CRFS: Ensink, Target, & Oandason, 2013, Child reflective functioning scale scoring manual: for application to the Child Attachment Interview. London, UK: Anna Freud Centre – University College London), a measure designed to assess reflective functioning (RF) or mentalization during middle childhood. Participants were 94 mother–child dyads divided into two subgroups; 46 dyads where children had histories of intrafamilial (n = 22 dyads) or extrafamilial (n = 24 dyads) sexual abuse, and a community control group composed of 48 mother–child dyads. RF of children and their mothers was assessed using videotaped and transcribed data gathered using the Child Attachment Interview and the Parent Development Interview (PDI: Slade, Aber, Bresi, Berger, & Kaplan, 2004, The parent development interview‐Revised. New York, NY: The City University of New York). The findings indicate that the CRFS proved reliable, with excellent intraclass correlation coefficients for general RF, as well as RF regarding self and others. Significant differences in RF were found between sexually abused children and the control group, and also between children who had experienced intrafamilial and extrafamilial sexual abuse. This provides support for the discriminant validity of the CRFS. Furthermore, maternal RF was associated with child RF. Both abuse and maternal RF made significant contributions to predicting children's RF regarding themselves, but child sexual abuse was the only variable that made a significant contribution to explaining variance in children's RF regarding others.     

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.This research was conducted while the author was a Research Associate at the Population Studies Center, University of Michigan, Ann Arbor, MI     

Reliability of the Child and Adolescent Needs and Strengths-Mental Health (CANS-MH) Scale

We examined the interrater reliability of the Child and Adolescent Needs and Strengths-Mental Health (CANS-MH) scale among researchers and between researchers and clinicians. All children presenting to a treatment facility for either protective or mental health needs were eligible to be included in the study. As part of standard assessment procedure, all children entering the facility were described by caseworkers using the CANS-MH. A random sample of 60 cases was selected and researchers made retrospective assessments using the CANS-MH based on chart review. Results of the interrater reliability support previous findings that the CANS-MH is a reliable measure of clinical and psychosocial needs and strengths. Results also suggest that ratings on the CANS-MH based on medical record abstraction by researchers relate to ratings performed by clinical staff, demonstrating the clinical and research utility of the CANS-MH. The CANS-MH can be used reliably to assess the type and severity of problem presentation, risk behaviors, functioning, care intensity and organization, caregiver capacity and strengths among children with protective and mental health needs. In addition, items of the CANS-MH appear to be reliable supporting the use of these items individually. Findings are relevant to the ongoing delivery of clinical services, monitoring of quality assurance, and outcomes.     

家庭功能与青少年问题行为关系的追踪研究

选取北京市三所中学620名初一和初二的学生为被试,采用追踪调查的方式,先后两次(间隔为九个月)让被试报告其家庭功能和问题行为,以探讨青少年家庭功能和问题行为的发展变化情况,以及家庭功能与青少年问题行为的因果关系。研究发现:(1)青少年的家庭功能和问题行为均存在一定的稳定性,但在任务完成、沟通和卷入方面存在变化,均为后测功能不如前测功能;而危害健康行为随着年龄的增长呈显著下降趋势。(2)家庭功能的每个方面均与青少年问题行为呈显著相关,即家庭功能发挥越好,青少年的问题行为也相应越少。(3)交叉滞后回归分析的结果表明,在更大程度上是家庭功能影响着少年的问题行为,进一步回归分析表明,家庭功能中的卷入维度对青少年问题行为具有显著的预测作用。     

Child Psychosocial Functioning and Parent Quality of Life Among Clinically Referred Children

We examined factors that account for quality of life among parents of clinically referred children. Families (N = 201) of children (ages 3-14) referred for oppositional, aggressive, and antisocial behavior participated. Parent and family contextual factors and child psychosocial functioning (symptoms and impairment) were predicted to influence parents' quality of life. As predicted, socioeconomic disadvantage, parent stress and psychopathology, poor interpersonal relations, and limited social support were related to lower levels of quality of life. Once these factors were controlled, child psychosocial functioning also contributed positively to quality of life. Further research on quality of life in the family can have important implications for understanding the context of both child and parent functioning.     

Associations Among Aspects of Interpersonal Power and Relationship Functioning in Adolescent Romantic Couples

This study used a multidimensional assessment of interpersonal power to examine associations between indices of relationship power and relationship functioning in 92 adolescent romantic couples recruited from rural communities in the Rocky Mountain region of the USA. Significant differences emerged between girlfriends and boyfriends in their reports of decision making authority, perceptions of humiliating behaviors by the partner, and ratings of themselves giving-in to their partners in a videotaped interaction task. In addition, indices of interpersonal power were associated with dating aggression and relationship satisfaction for both girlfriends and boyfriends, although gender differences emerged in the patterns of association between power and outcomes. Results are discussed in light of current developmental, feminist, and social psychological theories of interpersonal power in romantic relationships.     

家庭功能与青少年消极冒险行为的关系:一个有调节的中介模型

为探讨家庭功能影响青少年消极冒险行为的作用机制及条件,采用青少年冒险行为问卷、家庭功能问卷、自尊问卷、同伴群体特征问卷对山东省日照市940名初高中学生进行调查。结果发现:(1)家庭功能不良不仅可直接预测青少年更多的消极冒险行为,而且也可通过使青少年交往更多不良同伴进而使其冒险行为进一步增多;(2)不良同伴交往对青少年消极冒险行为的预测受到个体自尊的调节。低自尊个体更容易受到不良同伴交往的影响而发生更多的消极冒险行为,表现出两风险因素的叠加效应。研究结果提示,家庭是青少年健康成长的基础,家庭功能不良可使青少年适应不良,塑造良好的同伴环境、培养良好的自我素质或可降低这一风险。     

青少年家庭功能与心理复原力的关系：一个有调节的中介模型

为探讨家庭功能、自我控制与青少年心理复原力的关系及其作用机制,采用家庭功能评定量表、自我控制量表、心理复原力量表对浙江省、山东省、河北省957名中学生进行调查。结果发现：（1）家庭功能对青少年心理复原力具有显著正向预测作用。（2）自我控制在家庭功能和青少年心理复原力之间起到部分中介作用。（3）家庭功能对青少年心理复原力中介过程的前半段路径受到性别调节,相比于女生,男生群体的家庭功能对自我控制的影响更为显著。     

家庭功能：理论、影响因素及其与青少年社会适应的关系

该文综述了中西方近20年有关家庭功能的定义、理论、影响因素及家庭功能与青少年社会适应关系的研究进展。有关家庭功能的理论可以分为两大类：以家庭发展结果为取向和以家庭发展过程为取向的家庭功能理论。现有研究主要探讨了家庭结构、社会经济地位、家庭关系、发展阶段、生活事件等对家庭功能的影响,并发现家庭功能与青少年的社会适应有着非常密切的关系。文章最后分析了已有家庭功能理论及相关研究的不足,并指出了未来家庭功能领域的研究方向。     

The Effect of Maltreatment Type on Adolescent Executive Functioning and Inner Speech

There are indications that different types of maltreatment can lead to different cognitive and behavioural outcomes. This study investigated whether maltreatment type was related to executive functioning (EF) abilities and the use of inner speech. Forty maltreated adolescents and a comparison group of 40 non‐maltreated typically developing adolescents completed a battery of tasks designed to assess both their EF abilities and their vulnerability to disruptions to inner speech. They also completed an IQ test. Multivariate analysis of covariance (MANCOVA) and ANCOVA analyses were carried out to examine potential effects of maltreatment type (abuse alone; neglect alone; abuse/neglect combined and no maltreatment) on EF and use of inner speech. Maltreatment type was related to EF abilities. In particular, abuse only and abuse/neglect combined had a greater negative impact on EF than neglect only. However, the neglect alone group was more vulnerable to disruptions to inner speech than the other two maltreatment groups, suggesting that they may be more reliant on the use of inner speech. These findings provide new insights into the differential impact of maltreatment type on EF and the use of inner speech in adolescence and could be used to improve the educational outcomes of these vulnerable young people. Copyright © 2015 John Wiley & Sons, Ltd.     

Parent-Adolescent Relationship and Adolescent Psychological Functioning among African-American Female Adolescents: Self-Esteem as a Mediator

African-American female adolescents living in urban areas are at increased risk for adverse adjustment outcomes. The present study accomplished two goals. First, the quality of the parent-adolescent relationship across age groups was examined for differences among younger (i.e., 12'14) versus mid-range (i.e., 15'16) versus older (i.e., 17'18) adolescents. Second, self-esteem was examined as a possible mediator of the relationship between the quality of the parent-adolescent relationship and adolescent psychological functioning in a sample of 608 African-American urban adolescent females. With regard to developmental shifts in the quality of the parent-adolescent relationship, midrange adolescents reported a significantly poorer relationship with their mother than older adolescents. Results also indicated that self-esteem partially mediated the relationship between parent-child relationship and adolescent psychological functioning. Mental health professionals can broaden their interventions that aim to improve adolescent psychological functioning by either focusing on the quality of the parent-adolescent relationship or adolescent self-esteem.     

Validation of the Norwegian version of the Social Functioning Scale (SFS) for schizophrenia and bipolar disorder

Hellvin, T., Sundet, K.,Vaskinn, A., Simonsen, C.,Ueland, T., Andreassen, O.A. & Melle, I. (2010). Validation of the Norwegian version of the Social Functioning Scale (SFS) for schizophrenia and bipolar disorder. Scandinavian Journal of Psychology 51, 525–533. Studies of social functioning in severe mental disorders are disadvantaged by the multitude of different assessment instruments in use. The present study aims to establish reliability and validity of the Norwegian version of the Social Functioning Scale (SFS) and to examine social functioning in bipolar disorder (BD) compared to schizophrenia (SZ) and healthy controls (HC). SFS, a 76 item questionnaire divided into seven subscales measuring various aspects of daily life functioning, was administered to samples diagnosed with BD (n = 100) or SZ (n = 100) and to HC (n = 100), recruited from the ongoing Tematic Organized Psychosis (TOP) study. Reliability analyses prove adequate psychometric properties both for the composite full scale score (α: 0.81) as well as for the seven subscale scores (α: 0.60–0.88). Principal component analysis of the subscales confirms a one‐component structure, explaining 59% of the variance. Although significantly correlated with the Global Assessment of Functioning, our results indicate that the SFS measures different aspects of social functioning, is less influenced by demographic and clinical characteristics, but differentiates at the same time significantly BD from SZ. Thus, SFS adds valuable information as a supplement to standard clinician‐rated assessment tools of social functioning, suited both for research and clinical work.     

Reliability of self-reported service use: Test-retest consistency of children's responses to the Child and Adolescent Services Assessment (CASA)

This paper reports on the reliability of children's responses on the Child and Adolescent Services Assessment (CASA) — a self-report instrument for use with 8– to 18-year-olds that gathers information about services used to address mental health problems. Findings were based on interviews completed by 77 children at a one week test-retest interval. Results showed that reports of lifetime service use were as reliable as were reports of service use in the preceding three months. Children reported restrictive and intrusive services more reliably than services that were provided in their natural environment. Reliability appeared to be associated more strongly with characteristics of the type of service than with characteristics of the child. Children also could report reliably on some details about their encounters with service providers (e.g., length of stay, number of visits, and onset of service use).     

亲子间家庭功能的知觉差异及其与青少年孤独感的关系

采用家庭功能评价量表（FAI）,青少年孤独感问卷,对北京和两安的1325名初高中生及其父母进行调查。结果发现：（1）在家庭功能问卷的所有维度,亲子间知觉差异显著,青少年的知觉更消极;（2）在家庭功能的所有维度,男孩与父母的知觉差异均大于女孩与父母的差异;沟通维度父子间的差异大于母予差异,冲突与和谐维度母女间的差异大于父女间的差异;（3）不同知觉差异纽青少年的孤独感差异显著,知觉差异水平与孤独感间呈线性关系;亲子阃在冲突与和谐及父母关注维度的知觉差异可以显著预测青少年的孤独感。