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     

Transition planning and recidivism among mentally ill juvenile offenders

OBJECTIVES: To determine the extent to which transition planning and community service would predict lower levels of recidivism among mentally ill juvenile offenders. DESIGN: Review of legal, medical and social service records including examination of 3-month period following community release. PARTICIPANTS: Juvenile offenders incarcerated for 6 months or more (N = 44) transitioning to community. MEASURES: Child and Adolescent Functional Assessment Scale (CAFAS), sum of different documented pre- and post-release discharge planning contacts, documented community service contacts. OUTCOMES: Re-offense during the first year post-release. RESULTS: 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. CONCLUSIONS: 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.     

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.     

Assessment of Functional Impairment in Spanish Children

Le pressent travaux vérifie l’applicabilité et la validité du CAFAS, un instrument pour évaluer l’incapacité fonctionnel dans une population espagnole. L’échantillon est formé par 441 malades ambulatoires psychiatriques d’entre 8 et 17 années et leurs parents, et aussi par un échantillon de 74 malades ambulatoires pédiatriques. On a applique différents instruments pour évaluer l’incapacité fonctionnel, la psychopathologie, et autres variables psychologiques. La fiabilité intra observateur varie entre modérée et bonne. L’accord entre les ponctuations obtenues avec l’information des parents et des infants varie entre faible et modérée. Les corrélations avec autres mesures d’incapacité et du fonctionnement sont significatives mais modérée. Les ponctuations CAFAS différencient significativement les enfants avec et sans psychopathologie. Les résultats obtenus avalisent l’utilisation du CAFAS pour les études en psychopathologie, en incapacité fonctionnel et pour planifier interventions et services de santé mental. The present work tests the applicability and validity of the CAFAS, an instrument for assessing functional impairment, in the Spanish population. The sample included 441 psychiatric outpatients from 8 to 17 years old and their parents, and a pediatric group of 74 outpatients. Different instruments for assessing functional impairment, psychopathology, and other related variables were used. Interrater reliability ranged from moderate to very good. Weak‐to‐moderate agreement between CAFAS scores based on information from parents and children was obtained. Correlations with other measures of impairment and functioning were moderate. CAFAS scores differentiated significantly between children with and without psychopathology. These results permit the use of the instrument for studies on psychopathology and functional impairment, and for planning intervention and mental health services.     

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.     

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.     

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.     

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.     

Pornography use and sexual aggression: the impact of frequency and type of pornography use on recidivism among sexual offenders

In this study, we examined the unique contribution of pornography consumption to the longitudinal prediction of criminal recidivism in a sample of 341 child molesters. We specifically tested the hypothesis, based on predictions informed by the confluence model of sexual aggression that pornography will be a risk factor for recidivism only for those individuals classified as relatively high risk for re-offending. Pornography use (frequency and type) was assessed through self-report and recidivism was measured using data from a national database from the Royal Canadian Mounted Police. Indices of recidivism, which were assessed up to 15 years after release, included an overall criminal recidivism index, as well as subcategories focusing on violent (including sexual) recidivism and sexual recidivism alone. Results for both frequency and type of pornography use were generally consistent with our predictions. Most importantly, after controlling for general and specific risk factors for sexual aggression, pornography added significantly to the prediction of recidivism. Statistical interactions indicated that frequency of pornography use was primarily a risk factor for higher-risk offenders, when compared with lower-risk offenders, and that content of pornography (i.e., pornography containing deviant content) was a risk factor for all groups. The importance of conceptualizing particular risk factors (e.g., pornography), within the context of other individual characteristics is discussed.     

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.     

Training and Maintaining System-Wide Reliability in Outcome Management

The Child and Adolescent Functional Assessment Scale (CAFAS) is widely used for outcome management, for providing real time client and program level data, and the monitoring of evidence-based practices. Methods of reliability training and the assessment of rater drift are critical for service decision-making within organizations and systems of care. We assessed two approaches for CAFAS training: external technical assistance and internal technical assistance. To this end, we sampled 315 practitioners trained by external technical assistance approach from 2,344 Ontario practitioners who had achieved reliability on the CAFAS. To assess the internal technical assistance approach as a reliable alternative training method, 140 practitioners trained internally were selected from the same pool of certified raters. Reliabilities were high for both practitioners trained by external technical assistance and internal technical assistance approaches (.909–.995, .915–.997, respectively). 1 and 3-year estimates showed some drift on several scales. High and consistent reliabilities over time and training method has implications for CAFAS training of behavioral health care practitioners, and the maintenance of CAFAS as a global outcome management tool in systems of care.     

Validity of Treatment Target Progress Ratings as Indicators of Youth Improvement

We examined whether clinical progress ratings on the Monthly Treatment and Progress Summary form (MTPS), an idiographic treatment progress measure, were meaningfully related to changes measured by two separate standardized instruments; the Child and Adolescent Functional Assessment Scale (CAFAS) and the Child and Adolescent Level of Care Utilization System (CALOCUS). Validity coefficients were examined at intake and three-, six-, and nine-month follow-up periods. Samples were selected for each measure and follow-up period from the population of youth receiving services through the Hawaii Child and Adolescent Mental Health Division’s (CAMHD) system of care. Significant youth improvement was evident on all three measures across all follow-up intervals. The type of changes measured by the MTPS and CAFAS were more alike over longer follow-up intervals than changes measured by the CALOCUS. The MTPS captures distinct aspects of client change that overlaps somewhat with CAFAS and CALOCUS measures. The MTPS is a brief client-tailored measure that seems to provide valid, sensitive, and nonredundant client specific treatment outcome information that can be collected on a frequent basis within a complex system of care.     

Actuarial Criminology: Meeting Current Challenges in Southern Africa

South African prisons were overcrowded by more than sixty-three percent in 2005. Overcrowding and poor prison conditions have enormous implications for rehabilitation efforts made by the South African Department of Correctional Services. The South African White Paper on Corrections (2005) commits the Department of Correctional Services to provide needs-based rehabilitation processes and a framework of continuous evaluation to measure the impact and success of such processes. It also acknowledges that monitoring the rates of recidivism is a critical indicator of the success, the effectiveness of needs-based rehabilitation, and improved service. A reliable system for monitoring recidivism will have to be developed and put in place. In this respect, actuarial criminology can make a vital contribution. This article poses a strategic alternative to the correctional industry in Southern Africa that can be used for the realization of correctional ideals, especially where retribution and overcrowding are still the main features of correctional institutions.     

From multimodal programs to a new cognitive–interpersonal approach in the rehabilitation of offenders

A considerable amount of meta-analytic research supports the effectiveness of cognitive–behavioral psychoeducational programs in reducing recidivism rates, in youths and adults with antisocial behavior. These same studies suggest that programs including a cognitive component are as twice as more effective in reducing recidivism rates. This paper reviews outcome studies sustaining the use of structured interventions in forensic settings. It introduces a new program, Growing Pro-Social (GPS), currently in use in several Portuguese youth rehabilitation centers and prisons. GPS is a multimodal structured group program designed for the rehabilitation of individuals with antisocial behavior. It includes 40 weekly sessions, organized into 5 sequential modules. Based on a cognitive–interpersonal theoretical framework, GPS focuses on cognitive, emotional, and behavioral change, assuming as an ultimate goal the modification of dysfunctional core beliefs underlying antisocial behavior.     

Will They Do It Again? Predicting Sex-Offense Recidivism

This article reviews the empirical research on the prediction of reoffending among sexual offenders. The major predictors of sexual-offense recidivism are factors related to sexual deviance (e.g., deviant sexual preferences, previous sex crimes) and, to a lesser extent, criminal lifestyle (e.g., antisocial personality disorder, total number of prior offenses). The factors that predict general recidivism among sex offenders are the same as the factors that predict general recidivism among nonsexual criminals (e.g., juvenile delinquency, prior violent offenses). Given that there are special predictors of sexual recidivism, evaluators should consider separately the risk for sexual and nonsexual recidivism.     

Illuminating the dark figure of sexual recidivism

Detected or reported (“observed”) rates of sexual reoffending have long been recognized as underestimating the occurrence of actual sexual recidivism. Past attempts to bridge the gap between the two rates have been unsuccessful. Scurich and John try to reverse this course by presenting a simulation model to estimate the predicted actual sexual recidivism rates among individuals convicted of sexual offenses based on three parameters; they also apply these data to calibrate the sexual recidivism rates from four sexual recidivism studies. The accuracy of the predicted actual sexual recidivism rates is wholly dependent upon the reliability of the inputs to the model. This analysis relies upon scientific studies and literature to delve into the precision of the parameters of Scurich and John in relation to the accuracy of their predicted actual sexual recidivism rates and the validity of the calibration process. The results reveal that some of the assumptions by Scurich and John about the parameters are supported empirically, while others are not. Overall, the simulation model parameters suffer from significant deficiencies that likely produce inaccurate predicted actual sexual recidivism rates. Moreover, the methodologies of the comparison studies used in the calibration process do not actually meet the requirements of the analytic strategy of Scurich and John, which effectively invalidates their findings. Until computational strategies are employed that account for linear and nonlinear effects of model parameters, closing the gap between observed and actual sexual recidivism rates will remain elusive.     

Does intra-individual change predict offender recidivism? Searching for the Holy Grail in assessing offender change

Offender rehabilitation effectively reduces recidivism for treatment groups compared to control groups, but there is less evidence demonstrating that intra-individual changes are related to reductions in risk. We review and critique academic and government literature linking individual change scores to recidivism, focusing on three key treatment domains: cognition, violence, and substance misuse. Database searches identified 378 studies measuring change, but only 53 studies yielding 49 explicit tests of the relationship between intra-individual change scores and recidivism outcome. Of the 49 available tests, 26 effect sizes (53.1%) were significant, ranging from small (d = 0.06) to large (d = 1.48). Across all domains, change variables significantly related to recidivism included known dynamic risk factors: antisocial attitudes, antisocial beliefs, antisocial associates, antisocial personality, social support, and substance misuse. Two additional findings centered on changes in negative emotion and successful treatment process. This review further suggests there is a need to utilize better measurement strategies and more sophisticated constructs. Additional practical, theoretical, and methodological implications are discussed.     

An Exploration of Factors Reducing Recidivism Rates of Formerly Incarcerated Youth with Disabilities Participating in a Re-Entry Intervention

Juvenile offenders are costly to our society in terms of the monetary and social expenditures from the legal system, victims’ person costs, and incarceration. The re-entry and community reintegration outcomes for formerly incarcerated youth with a disabling condition are bleak compared to peers without disabilities. In this study, we examined the factors––both static and intervention-related––that reduce recidivism rates for project participants possessing a mental health and/or special education diagnosis and were served by a facility-to-community re-entry intervention. Our sample was comprised of a total of 320 youth formerly incarcerated who received project services between August of 1999 through June of 2004. Project services include a transition specialist whose role is service coordination to youth from the facility to the community. Kaplan–Meier survival functions were calculated for participants on the outcome measure of the rates of recidivism. Additionally, Cox regression modeling was used to identify factors for the prediction of time to recidivate. Our findings indicate that the intervention may contribute to reduced recidivism rates but that a set of static demographic and pre-incarceration risks contribute more to the prediction of recidivism than community adjustment factors (e.g., employment or enrollment). With these findings, the intervention seems promising yet it remains unclear about which programmatic features contribute to reduced recidivism rates. Implications for research and practice are shared.     

The multifactor offender readiness model

There has been a resurgence of interest in the rehabilitation of offenders. Research has consistently shown that rehabilitation programs for offenders, when they adhere to general principles of program design and delivery, will achieve significant reductions in recidivism. In this paper, we suggest that even greater reductions in recidivism can be achieved when readiness is addressed at the level of the individual offender, the program, and the context. A comprehensive understanding of readiness allows for fuller engagement in treatment, thus increasing probability of good treatment outcomes. We describe person, program, and context factors in a model of offender treatment readiness and discuss implications of the model for both assessment of offenders and for modification of low readiness.     

What works for serious juvenile offenders? A systematic review

This study examines the outcomes of best available empirical research regarding the effectiveness of treatment programs implemented in secure corrections to prevent the recidivism of serious (violent and chronic) juvenile offenders (from 12 to 21 years old). In this review 30 experimental and quasi-experimental studies are analyzed, comparing 2831 juveniles in the treatment groups and 3002 youths for the control groups. The global effect size of these 30 studies in terms of standardized mean difference was d = 0.14 in favour of the treatment groups. This size effect, in terms of "r" coefficient reached the value of 0.07, of low magnitude. The cognitive-behavioral methods of treatment were the most effective in decreasing recidivism. These results report that the rehabilitation programs for serious offenders achieve to reduce the general recidivism in comparison with the control juveniles in approximately seven percent.