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Clinical Child and Family Psychology Review, Vol. 4, No. 1, 2001

The Child and Adolescent Functional Assessment Scale

(CAFAS): Review and Current Status1

Michael P. Bates2

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 determina-
tion, 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 legis-
lators 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.
KEY WORDS: functional impairment; measurement.

Measures of impairment in psychological and be-
havioral functioning have a long history in the field of
children’s mental health. These level-of-functioning
(LOF) scales have many promising features such as
cost and time effectiveness, clinical utility, and under-
standability to a wide audience. They also appear to be
particularly promising for use with children and ado-
lescents with serious emotional disturbance (SED).3
1 This article was adapted from portions of the author’s doctoral
dissertation.
2 Counseling, Clinical, School Psychology Program, Graduate
School of Education, University of California, Santa Barbara,
California, 93106-9490; e-mail: mbates@education.ucsb.edu.
3 The term serious emotional disturbance (SED) was replaced with
the term emotional disturbance (ED) in the 1997 reauthorization
of the Individuals with Disabilities Education Act (IDEA). Many
scholars have also used the less stigmatizing term emotional and
behavioral disorders (EBD) to refer to this population. SED is
used in this paper because this is the term used in both the IDEA
and Center for Mental Health Services (CMHS) definitions.
Whereas the earliest measures of functional impair-
ment were hailed for providing simple scores along
a single dimension of global functioning, they have
also been criticized for containing vague descriptors
and being susceptible to rater bias. Recently, multi-
dimensional measures of functional impairment have
been developed that, presumably, have greater resis-
tance to rater bias. One of these multidimensional
measures—the Child and Adolescent Functional As-
sessment Scale (CAFAS; Hodges, 1989, 1997)—has
enjoyed widespread use nationwide. For example, it
has been adopted on a statewide level in more than 20
states and on a local level in dozens of research and
demonstration projects. In fact, several states are us-
ing it as the sole determinant of placement and fund-
ing decisions for children’s behavioral health services.
Given this widespread adoption of the CAFAS, it is
timely and necessary to review this scale within the
context of LOF assessment. The purpose of this pa-
per is to describe the current status of the CAFAS in

63
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C 2001 Plenum Publishing Corporation
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64
the field of children’s mental health services, to crit-
ically examine its technical qualities, and to propose
future research activities that may enhance its validity.
BACKGROUND
Measures of functional impairment have numer-
ous uses in the diagnosis, treatment, and evaluation
of children’s mental health problems. For example,
the definitions of serious emotional disturbance (SED)
issued by the Center for Mental Health Services
(CMHS, 1999) and contained within the Individual
with Disabilities Education Act (IDEA, 1990) both
cite functional impairment as a critical component of
SED. The CMHS, which has funded more than 40 na-
tionwide sites for developing systems of care for com-
prehensive services for youths with SED, recently is-
sued the following definition of children with SED as:
. . . persons from birth up to age 18 who currently
or at any time during the past year have had a diag-
nosable mental, behavioral, or emotional disorder of
sufficient duration to meet diagnostic criteria speci-
fied within DSM-III-R (or the most recent edition of
DSM) that resulted in functional impairment which
substantially interferes with or limits the child’s role
or functioning in family, school, or community activ-
ities. (Federal Register, 1993, p. 29425)
Similarly, the IDEA definition of SED requires that
certain characteristics exist “over a long period of time
and to a marked degree that adversely affects a child’s
educational performance” [34 CRF 300.5(b)(8)]. Un-
der both of these definitions, the assessment of func-
tional impairment is a required component.
The construct of global functioning has also
become an important component of determining eli-
gibility to receive mental health services. For example,
CMHS administers a block grant program to allocate
funds to community mental health agencies for the
provision of services to youths with SED. As part of
the application for this process, states must estimate
the incidence (number of new cases) and prevalence
(total number of cases per year) of SED, using,
in part, LOF measures (Federal Register, 1993).
Similarly, many states have adopted a managed care
perspective and seek Medicaid reimbursement for
mental health services for children and adolescents
with mental health problems. Under this system,
eligibility for Medicaid-funded services is contin-
gent upon demonstration that the youth exhibits
some level of functional impairment (Anderson,
Berlant, Mauch, & Maloney, 1996; Srebnik, Uehara,
16:45 Style file version Nov. 07, 2000
Bates
& Smukler, 1998). This requirement represents a
significant change from traditional reimbursement
models, in which a diagnostic classification—such as a
diagnosis from the Diagnostic and Statistical Manual
of Mental Disorders, 4th edition (American Psychi-
atric Association, 1994)—was sufficient to establish
eligibility for any available services (Hodges & Gust,
1995; Pokorny, 1991).
In addition to these uses for LOF scales, much
has been written about their utility in outcome assess-
ment (e.g., Lambert, 1994; Newman, 1980; Pokorny,
1991). Historically, LOF measures have been widely
used in outcome assessment. For example, Lambert
and McRoberts (1993) found that LOF indicators
comprised 53% of the therapist-completed outcome
measures used in psychotherapy treatment studies
published in the Journal of Consulting and Clini-
cal Psychology between 1986 and 1991. One reason
that LOF measures appear to be especially useful in
outcome evaluation is that they provide a standard
means of comparing clients across diagnoses or set-
tings or both (Burlingame, Lambert, Reisinger, Neff,
& Mosier, 1995). Burlingame et al. (1995, p. 228) sum-
marized this point nicely:
Risk assessment establishes the pretreatment degree
of severity of the patient to the level playing field
when comparing outcomes from different providers,
clinics, or patient groups. Outcome assessment pro-
cedures used in risk assessment should ensure that
one is comparing apples with apples when it comes to
initial severity of patients’ disorders. If initial patient
severity is not accounted for, then one health care
institution may erroneously appear to exhibit poorer
outcomes due solely to treating more or less symp-
tomatically severe cases. Reliable risk assessment
is even more important in mental health outcomes
where improvement is measured in shades of gray in
contrast to the black-and-white comparisons often
possible in other areas of the health care industry.
This aspect of LOF measures appears particularly use-
ful for studies of treatment effectiveness for youths
with SED because this classification is a heteroge-
neous and complex diagnostic category encompass-
ing a variety of emotional and behavioral problems.
This definitional complexity creates a problem for re-
searchers who wish to study this population. Espe-
cially under the system of care model that typically
encourages broader service eligibility, two individu-
als with SED may exhibit vastly different symptoms
or behaviors and may require different interventions.
Thus, LOF assessment may be the best tool to provide
a common metric by which to compare these youths.
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Review and Current Status of the CAFAS
Sechrest and colleagues (Sechrest, McKnight,
& McKnight, 1996) extended this argument. They
strongly recommended that treatment outcome scales
be calibrated, not only to provide standardized nor-
mative scores, but to develop a standard measure by
which to assess meaningful change. They advocated
the use of procedures to associate changes in a scale’s
scores with actual change in behavior or functioning.
For example, they purported that “actual change in
behavior or functioning is critical for assessing treat-
ment outcome, rather than simply inferring change
from a metric of uncertain meaning” (p. 1065). A de-
crease of 10 scale units on a depression scale, for exam-
ple, might represent decrease of some degree in the
intensity or severity of specific symptoms. Yet, how
much of a change in behavior actually occurred and
what impact might such changes have on meaningful
indicators such as functional status or quality of life?
According to these authors, it is critical to establish
change in functioning as the meaningful criterion of
the effectiveness of psychotherapeutic intervention.
From this perspective, LOF measures should play a
key role in the calibration of other psychological mea-
sures and documentation of “real-life” changes in so-
cial, emotional, and behavioral status.
The uses of LOF measures for purposes of
assessment, eligibility determination, and outcome
evaluation in children’s mental health services are
numerous. Furthermore, there is a clear interest in
collecting LOF data on both the state and local levels
[Georgetown National Technical Assistance Center
(GUNTAC), 2000]. Perhaps the most widely used
LOF scale, at least on the statewide level, is the
CAFAS. The following section presents a brief sur-
vey of current CAFAS usage on both the state and
local levels.
EXTENT OF USE OF CAFAS
Statewide Implementation
Many states have adopted policies or passed
legislation mandating the use of the CAFAS on a
statewide basis. It appears that this trend has in-
creased over the past few years. For example, in a late-
1993 survey of state usage of LOF measures, Hodges
and Gust (1995) found that four states (Arizona, New
Hampshire, North Carolina, and Wisconsin) were
consistently using the CAFAS statewide. As of July
2000, there were 30 states that have implemented or
are considering implementing the CAFAS statewide
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65
(GUNTAC, 2000; Hodges, Wong, & Latessa, 1998).
Table I lists these 30 states and describes how they
are using the scale.
The primary uses of the CAFAS, at least on the
statewide level, appear to be for performance out-
come assessment and service eligibility determina-
tion. For example, in August 1995, the state of Florida
began using the CAFAS as part of its state-legislated
mandate to collect performance outcome data for
all children receiving mental health services (Massey,
et al., 1998). In Virginia, the CAFAS was selected as
one component of a statewide performance and out-
come system (POMS) to assess outcomes within the
public mental health system (Koch & Brunk, 1998).
Beginning April 1998, in California, the CAFAS is
completed for every youth receiving mental health
services through every county mental health depart-
ment (G. M. Pettigrew, personal communication, July
21, 1997). As shown in Table I, numerous other
states, including Delaware, Georgia, Maine, North
Dakota, South Carolina, and Tennessee, are currently
using the CAFAS for performance assessment pur-
poses. Additionally, Illinois and Kentucky are cur-
rently considering implementing the scale statewide
(J. Call, personal communication, January 28, 2000;
GUNTAC, 2000). Ohio recently switched from the
CAFAS to the Ohio Youth Scales (Ogles, Melendez,
Davis, & Lunnen, 1999) for their performance assess-
ment (M. Wood, personal communication, February
9, 2000).
Many states have implemented systematic col-
lection of the CAFAS to determine eligibility for ser-
vices. For example, the North Carolina Department
of Mental Health is currently using the CAFAS to
establish service eligibility for youths with mental
health needs (Behar & Stelle, 1997; S. Clark, personal
communication, November 19, 1997). The CAFAS
is also being used statewide in Virginia to deter-
mine levels of care to manage services funded by
the recent Comprehensive Services Act (Kirkman,
et al., 1999). Louisiana and Massachusetts are also
using the CAFAS to determine level of need for
Medicaid funded services (Hersch, 1998; Lemoine
& McDermott, 1998). Michigan is in the process
of developing empirical service eligibility guidelines
using the CAFAS and other data (i.e., risk fac-
tors, clinical condition) to predict type and inten-
sity of services (Hodges, Warren, & Wotring, 1998).
North Dakota uses the CAFAS and diagnostic cri-
teria to assign youths to one of four eligibility cat-
egories (J. Perry, personal communication, January
31, 2000). In addition, both Georgia and South
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66 Bates

Table I. Summary of Statewide Implementation of the CAFAS

State Purpose of CAFAS use Approx. date of implementation Source(s)
AL Using CAFAS along with a battery of other measures At least since 1999 Georgetown University
(CBCL, YSR, and Parent Questionnaire) National Technical Assistance
for outcome evaluation on a statewide basis. Center (GUNTAC), 2000
AZ Cutoff total score of 90 on CAFAS qualifies youth At least since Hodges & Gust, 1995;
for Intensive Case Management Services October, 1993 Schwartz & Perkins, 1997
funded by the Division of Behavioral
Health Services of the Arizona Department
of Health Services (considering revising
criteria to include diagnostic information).
CA Component of state-mandated performance outcome April 1, 1998 G. M. Pettigrew, personal
assessment for all youths receiving Department of communication, July 21,
Mental Health services for 2 months or longer. 1997; GUNTAC, 2000
DE Clinical service management teams using CAFAS At least since 1999 R. Ray, personal
for treatment planning and outcome evaluation communication,
with all youths receiving Medicaid or state- January 31, 2000
funded services.
FL Component of state-legislated collection of August, 1995 Massey, Kershaw, Armstrong,
performance outcome data for all children Shepard, & Wu, 1998
receiving services funded by the
Department of Children and Families.
GA All providers will be mandated to collect CAFAS March 1, 2000 GUNTAC, 2000; S. Lindsey,
as component of the Performance Measurement personal communication,
& Evaluation System (PERMES). Will become January 28, 2000
sole criterion for determining eligibility
and level-of-need.
IL Piloting the CAFAS as part of a study on the At least since 1999 GUNTAC, 2000
feasibility of implementing MHSIP Consumer
Oriented Report Card.
IN Using Miniscale version (with two added At least since 1997 J. Phillips, personal
subscales: Environment and Reliance) for communication,
performance assessment. January 28, 2000
KY Currently used in some programs. Recommended July, 1999 GUNTAC, 2000
for use by KY Managed Care Outcomes
Committee. May be integrated with statewide
evaluation protocol.
LA Sole criterion to establish level-of-need (LON) December, 1995 Lemoine, Speier, Ellzey,
to receive one of 3 Medicaid-funded service & Pine, 1997; Lemoine
packages (high, medium, and low). & McDermott, 1998
ME In process of implementing CAFAS along with At least since 1999 S. Amero, personal
other measures (CALOCUS, BERS) for communication,
performance assessment, service planning, February 1, 2000
and outcome evaluation for youths receiving
Mental Health case management services.
MD Piloting CAFAS via phone interviews with a At least since 1998 GUNTAC, 2000
sample of total youths served as evaluation
of first year of managed care reform.
MA Cut-off score of 80 using six of eight subscales, July 1, 1996 Irvin & Hersch, 1997;
in conjunction with diagnosable disorder of Hersch, 1998
1-year duration, to determine eligibility
for services funded by Department of
Mental Health.
MI Presently developing guidelines to predict No information given Hodges, et al., 1998
type and intensity of services from CAFAS
scores and diagnostic/risk information.
MN Statewide CAFAS use is encouraged but At least since 1999 GUNTAC, 2000
not mandated as component of measuring
client and family outcomes.

(Continued )
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Review and Current Status of the CAFAS 67

Table I. (Continued )
State Purpose of CAFAS use Approx. date of implementation Source(s)
MO Component of preliminary study to assess October 1, 1995 Daniels & Clements, 1997
outcomes for children and adolescents receiving
public mental health services funded by the
Department of Mental Health.
NE Collected at intake, every At least since 1999 GUNTAC, 2000
6 months, and at discharge while in
Professional Partner Program.
NH Using Miniscale Version (see IN) and diagnostic At least since GUNTAC, 2000; J. Perry,
information to determine eligibility for services. October, 1993 personal communication,
Planning to implement full version of the scale January 31, 2000
beginning July 2000.
NJ Piloting the CAFAS in Southern Region Summer, 2000 GUNTAC, 2000
with the long-term goal to use statewide.
NY Administered with other battery instruments At least since 1999 GUNTAC, 2000
at intake and every 6 months in the
F.R.I.E.N.D.S. program.
NC Primary criterion to authorize levels of care January, 1994 Behar, & Stelle, 1997;
related to six levels of intensity of services (statewide by 1997) S. Clark, personal
for children with mental health and/or communication,
substance use problems. November 19, 1997
ND Expanding use of CAFAS from 3 to all 8 At least since 1999 K. Moum, personal
state regions for outcome assessment communication,
and treatment planning. January 28, 2000
OH Component of pilot study during 1998–99. 1998 GUNTAC, 2000
Switched to Ohio Youth Scales in 2000.
OR Using the CAFAS statewide along with At least since 1999 GUNTAC, 2000
the CGAS for outcome evaluation.
SC Currently mandated for use in treatment At least since 1999 D. Mahrer, personal
planning and outcome evaluation in inpatient communication,
and outpatient child and adolescent programs. February 1, 2000
Also in process of developing criterion
scores for eligibility determination.
SD CAFAS is principal instrument used across At least since 1999 GUNTAC, 2000
inpatient and outpatient settings statewide.
TN Component of Children’s Plan Outcome Review 1994 Heflinger & Simpkins,
Team (C-PORT) used in evaluation of service 1997; O’Neal
system for all children in state custody. & Wade, 1998
VT Component of evaluation battery designed by At least since 2000 GUNTAC, 2000
University of VT Evaluation Team to create
linkages across multiple state grants.
VA Component of performance and outcome Summer, 1997 Koch & Brunk, 1998;
measurement system (POMS) being piloted Kirkman, Brunk,
statewide to assess outcomes of child/ & Cohen, 1999
adolescent public mental health services,
and used to determine Level of Care
for services funded by the Comprehensive
Services Act.
WV Component of assessment battery required for At least since 1999 GUNTAC, 2000
all children receiving Medicaid-reimbursed
behavioral health services.
Note. Information regarding current usage of evaluation instruments in children’s mental health services for each state can be found at
the Georgetown University National Technical Assistance Center (GUNTAC) website (http://www.dml.georgetown.edu/depts/pediatrics/
gucdc/eval.html).
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Carolina are in the process of developing guide-
lines for using the CAFAS in eligibility determina-
tion (S. Lindsey, personal communication, January 28,
2000; K. Moum, personal communication, January 31,
2000).
Several recent changes in the way state mental
health departments conduct business appear to have
contributed to this rise in CAFAS usage. First, the in-
clusion of the functional impairment stipulation in the
CMHS definition of SED now requires states to oper-
ationally define and measure functional impairment
to receive federal block grant funding for treatment
of youths with SED. Second, with many states adopt-
ing a managed care model of service delivery, third-
party payers such as Medicaid are requiring documen-
tation of functional impairment to justify treatment
decisions (Anderson et al., 1996; Srebnik et al., 1998).
Third, the fields of psychology and mental health have
sparked a demand for empirically justified treatment
methods, which has created the need to collect ob-
jective outcome data using instruments such as the
CAFAS (Kazdin & Weisz, 1998; Task Force, 1995).
Demonstration Projects
In addition to statewide implementation, the
CAFAS is widely used as an outcome measure on
a smaller scale in local mental health settings and
evaluation projects across the country. The CAFAS
was developed as one of the outcome measures for
the Fort Bragg Evaluation Project (FBEP; Bickman,
1996a, 1996b). This project has recently received
much public scrutiny, primarily because the evalua-
tors reported no significant differences in outcomes
between the experimental and control groups. In a
single issue, the American Psychologist (May, 1997)
devoted eight commentary articles in response to
Bickman’s findings. The interest raised was due pri-
marily to Bickman’s conclusion that the $80 million
experimental treatment—a system of care for youths
with SED—produced no better outcomes than the
traditional mental health system control. Although
many have questioned Bickman’s conclusions (e.g.,
Friedman & Burns, 1996; Pires, 1997), it is clear that
the CAFAS was an essential component of Bickman’s
arguments.
The CAFAS is also being used in other system of
care projects. The Center for Mental Health Services,
for example, has funded more than 40 sites nation-
wide to develop, implement, and evaluate systems of
care for youths with SED. The CAFAS was selected as
one of the mandatory outcome measures that evalua-
16:45 Style file version Nov. 07, 2000
Bates
tors at each site must collect. Similarly, the CAFAS
is mandated for use in all county system of care
projects funded by California State Assembly Bill
3015 (18 counties; A. Rosenblatt, Wyman, Kingdon, &
Ichinose, 1997). Table II lists these and some of the
additional research projects that have used or are cur-
rently using the CAFAS as an outcome measure.
EVALUATION OF LOF MEASURES
Given that global functioning plays an important
role in the provision and evaluation of mental health
services, and that the CAFAS in particular has been
adopted on such a widespread scale, it is prudent to
evaluate LOF measures for their technical and prac-
tical adequacy in serving these purposes. Several au-
thors have offered criteria for selecting appropriate
measures to assess treatment outcomes in studies of
service delivery in mental health settings (Green &
Newman, 1996; Newman & Ciarlo, 1994; Newman,
Hunter, & Irving, 1987; Vermillion & Pfeiffer, 1993).
Although there are differences between these sets
of criteria, they seem to converge into the follow-
ing four broad features of desirable outcome mea-
sures: (a) strong psychometric properties, (b) validity
for use with target populations, (c) ease of use, and
(d) utility. In the following sections, these guidelines
will be applied as a framework to discuss the evalua-
tion of LOF measures in general and the CAFAS in
detail.
Studies of the reliability and validity of LOF
measures have generally produced mixed results; al-
though most suggest that their psychometric qualities
are moderate to good (Bird & Gould, 1995; Hodges
& Gust, 1995), others have characterized them as un-
acceptable (Zimmerman, 1996). Perhaps where LOF
measures excel is in their ease of use. Most LOF
measures employ a simple methodology, have min-
imal cost, take little time to complete, and can usually
be completed by nonprofessionals, though perhaps
with questionable validity (B. Green, Shirk, Hanze,
& Wanstrath, 1994; Hodges & Gust, 1995). For most
LOF scales, training materials are not available; yet
because of their simple methodology they may not be
needed. LOF scales also have high utility. They usu-
ally generate a single score that is easily applied to
clinical treatment and outcome assessment, and pro-
vide a common metric by which to compare clients
with different diagnostic features.
Unidimensional scales assessing global function-
ing have a long history of use in diagnosis, treatment,
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Review and Current Status of the CAFAS 69

Table II. Summary of CAFAS Use in Research and Demonstration Projects

Project title Description of project & CAFAS use Source
Fort Bragg (NC) Evaluation Demonstration project comparing youths who Bickman, 1996a, 1996b
Project (FBEP) received continuum of care mental health
services with those who received CHAMPUS-
funded services. CAFAS was one of many
outcome measures.
California Assembly Bill 3015- Eight counties in CA funded to develop, implement, Rosenblatt, et al., 1997
Funded County Sites and evaluate systems of care for youths with SED.
CAFAS is used as one component of evaluation.
CMHS-Funded Sites More than 40 nationwide sites funded to develop, “Comprehensive community
implement, and evaluate systems of care for mental health services for
youths with SED. CAFAS is mandated component children program,” 1999
of outcome evaluation.
Mental Health Services Program Using CAFAS scores to assess client outcomes Rotto, Sokol, Matthews,
for Youth (MHSPY) Replication and track service accountability of this system of & Russell, 1998
Project (Indianapolis, IN) care for youths with SED.
Anne E. Casey Foundation’s Using CAFAS scores to assess client outcomes, Gutierrez-Mayka, 1998
Mental Health Initiative for service fidelity, and clinical impact of
Urban Children community-based services for children at-risk
of out-of-home placement in three Boston
neighborhoods.
Wraparound Milwaukee (WI) Using CAFAS scores to evaluate a pilot study Kamradt, Kostan, &
of the effectiveness of “wraparound” services Pina, 1998
for youths with SED.
MENTOR (Boston, MA) Using CAFAS scores to assess outcomes for youths Altaffer & Stelk, 1998
served by this national provider of community-
based child/adolescent mental health programs.
Cleo Wallace Center (Westminster, CO) Using CAFAS scores at intake and discharge to Jacobson & Meyer, 1997
establish need for service and monitor treatment
outcomes in this residential psychiatric facility.
Youth Alliance of Central Georgia Using CAFAS scores at intake, at 3-month intervals, Feibelman, 1998
and discharge to assess progress of youths served in
a variety of mental health treatment facilities.
School and Community Study Using CAFAS to evaluate study of four model Oliveira, Rivera,
(KY & VT) school-based programs for inclusion of children Kutash, Duchnowski,
with SED in communities with a system of care. & Calvanese, 1998
Illinois State Board of Using CAFAS to evaluate study of community- Eber & Rolf, 1998
Education Sites based supports and services for children with
emotional and behavioral disabilities and
their families.
Prime Time Project Using CAFAS scores to describe and monitor Selby, Trupin, McCauley,
(King County, WA) adolescents enrolled in community-based & Vander Stoep, 1998
intervention for youths with SED and
involvement in the juvenile justice system.

and evaluation of mental health problems. The first
generation of global level of functioning scales was the
Health-Sickness Rating Scale (HSRS) developed by
Luborsky (1962). This was a 100-point scale with eight
descriptor anchor points. Although the HSRS was
easy to use, it was criticized because its anchor points
included both behavioral descriptions and diagnostic
categories and were unevenly distributed within its
total range (Friis, 1996). Developed as an improve-
ment over the HSRS, the Global Assessment Scale
(GAS; Endicott, Spitzer, Fleiss, & Cohen, 1976) was
also a 100-point scale marked by the inclusion of 10
evenly distributed anchor points, which contained no
diagnostic categories (Friis, 1996). Both of these scales
were designed for use with adults.
The most widely accepted and utilized unidimen-
sional LOF scale for youths—the Children’s Global
Assessment Scale (CGAS, Shaffer et al., 1983)—was
developed as an adaptation of the GAS for use with a
younger population. Similar to the GAS, it contained
10 anchor points evenly distributed between 0 and
100. Much of the wording of descriptors was signif-
icantly altered, however, for use with children and
adolescents. The Global Assessment of Functioning
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(GAF) scale was first introduced in 1987 as Axis V
of the multiaxial diagnostic system of the DSM-III-R
(American Psychiatric Association, 1987). This scale
was conceptually very similar to the GAS and the
CGAS, although with a range of only 0–90. Whereas
the descriptors of the CGAS were written exclusively
for use with children, the descriptors of the GAF were
more general and designed for use with both adults
and children. With the publication of the DSM-IV
(1994), the total range of the GAF was extended to 0–
100 by adding definitions for the 91–100 range of func-
tioning. Both the GAF and CGAS anchor points con-
tain a mix of behavioral descriptions and symptoms.
There have been few published studies of the
reliability or validity of unidimensional global rating
scales (Friis, 1996). It appears that most of the studies
that do exist were conducted using the CGAS. Relat-
ing to the stability of the CGAS, test-retest reliabil-
ity coefficients have been generally positive (.74–.76,
Bird, Canino, Rubio-Stipec, & Ribera, 1987; Canino
et al., 1987; .69–.95, Shaffer et al., 1983). Relating to
interrater reliability, the evidence is more mixed. Gen-
erally, interrater reliability has been adequate in stud-
ies using professional raters when information is gath-
ered through case histories or in-person interviews. In
the original study of the CGAS, for example, Shaffer
et al. (1983) reported a high coefficient of interrater
reliability (.84). Raters in this study were five second-
year psychiatry fellows responding to case vignettes.
In a second study in which the GAF (DSM-III ver-
sion) was also completed, two child psychiatrists con-
ducted in-depth diagnostic interviews with both par-
ents of 191 children. Two additional child psychiatrists
completed ratings from observing the videotapes of
these interviews. The interrater reliability coefficients
for overall severity were .72 for the CGAS, and .74
(current) and .73 (past 6 months) for the GAF (Bird
et al., 1987).
Whereas these initial findings demonstrated
moderate support for the interrater reliability of the
CGAS and GAF, Green et al. (1994) argued that none
of these studies used raters who were actually in-
volved in the treatment of the child. Addressing this
issue, these authors found somewhat lower interrater
reliabilities for attending psychiatrist raters (.62), and
comparable reliabilities for milieu staff raters (.76),
who completed the CGAS on 95 child hospital inpa-
tients upon admission and discharge. Unsatisfactory
reliability coefficients were also reported in an earlier
applied field study conducted by Herman (1983, as
cited in Hodges & Gust, 1995). A more recent study
(Rey, Starling, Wever, Dossetor, & Plapp, 1995) docu-
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Bates
mented low coefficients of interrater reliability among
20 experienced clinicians using the GAF (DSM-III-
R version; .54 for outpatients, .66 for inpatients) and
the CGAS (.63 for outpatients, .53 for inpatients) to
rate children in inpatient and outpatient treatment
settings. Thus, the interrater reliabilities of the CGAS
and the GAF appear to be adequate only under cer-
tain conditions.
Studies of the validity of the CGAS have also
yielded mixed results. On the one hand, Bird et al.
(1987) found moderate correlations (absolute value
range = .40–.65) between CGAS ratings and scores
on the Child Behavior Checklist (CBCL; Achenbach,
1991). Using the criterion score of 70 on the CGAS to
form impaired and nonimpaired groups, these authors
also found significant group differences on CBCL to-
tal problem scores, clinical status (case–noncase), re-
ferral status (referred–nonreferred), and number of
clinical diagnoses. Green et al. (1994), on the other
hand, failed to find significant correlations between
CGAS and CBCL scores, but reported that CGAS
scores correlated significantly with indices of chil-
dren’s competence. Thus, these results provide some
evidence, but not compelling support, for the CGAS’s
valid use in making clinical treatment decisions.
Hodges and Gust (1995, p. 407) concluded that
the CGAS “has satisfactory reliability and validity
when used by professionals and when used in a sit-
uation in which there is minimal information vari-
ance (i.e., information on which the score is based is
consistent across all raters).” These authors and oth-
ers (Green et al., 1994; Rey et al., 1995) emphasized
that more research is needed to assess the adequacy
of the CGAS and similar measures for use in less-
controlled applied settings. Hodges and Gust (1995)
suggested that the CGAS and other unidimensional
global functioning measures are particularly vulnera-
ble to respondent bias when the amount of available
information about the child is low. Whereas the threat
of bias is present to some extent in all rating scales,
one goal of scale development, use, and evaluation
should be to minimize the degree to which respon-
dent bias contributes to the given score (Hodges &
Gust, 1995). Thus, to generate an estimate of level of
functioning that is less prone to respondent bias, these
authors advocated the use of multidimensional scales
that attempt to measure global functioning across a
variety of domains.
Although several multidimensional functioning
scales have appeared in the literature, descriptive or
psychometric information (or both) about them is vir-
tually nonexistent. The Colorado Client Assessment
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Record (CCAR; Ellis, Wilson, & Foster, 1984) appears
to have been the first multidimensional checklist of
client functioning. The CCAR consists of 77 checklist
items in the following nine domains: socio-legal, sub-
stance use, medical/physical illness/injury, thinking,
personal distress, personal behavior, interpersonal
behavior, interpersonal relations, role performance
(employment, academic training, and management of
personal affairs), and meeting basic needs. Item and
factor analyses were conducted to arrive at these do-
main groupings. Although the developers claim the
CCAR has an extensive research background, much
of it is unpublished. Unfortunately, no reliability data
on the CCAR are available and the only validity ev-
idence reported was that scores from a preliminary
version of the scale discriminated hospital from clinic
clients both at admission and at discharge (Ellis et al.,
1984).
The North Carolina Functional Assessment Scale
(NCFAS) is another multidimensional functioning
scale that was adapted from the CCAR. Again, very
little information about the NCFAS is available in the
literature. To date, only one study using the NCFAS
has been published (Walker, Minor-Schork, Bloch, &
Esinhart, 1996). According to these authors, the NC-
FAS is a clinician-administered rating scale designed
for use with adults. Level of functioning is rated along
six dimensions: role performance, emotional health,
ability to care for basic needs, behavior, thinking, and
substance use. These scales are combined to yield a
global score ranging from 0 to 180, with a score of
40 or above indicating significant functional disabil-
ity (Walker et al., 1996). Published reliability or other
validity data are unavailable.
Studies of the reliability and validity of unidimen-
sional LOF measures have yielded mixed results. In
particular, these scales appear to be highly vulnerable
to rater bias when used in conditions of high informa-
tion variance. Whereas multidimensional LOF mea-
sures appear on the surface to resolve this problem,
the reliability and validity evidence to support this
claim is essentially nonexistent. To date, the CAFAS
is the only multidimensional LOF measure for which
published reliability and validity studies are available.
DESCRIPTION OF THE CAFAS
Both the CCAR and NCFAS were designed
for use with adults. In order to fill the need for a
multidimensional global assessment scale for chil-
dren and adolescents, Hodges (1989, 1997) cre-
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71
ated the Child and Adolescent Functional Assess-
ment Scale (CAFAS). Adapted from the NCFAS
(Bickman, Heflinger, Pion, & Behar, 1992), the
CAFAS initially contained five domains (Role Per-
formance, Moods/Emotions, Behavior Toward Oth-
ers/Self, Thinking, and Substance Use) with possi-
ble total scores ranging from 0 to 150. In later
versions, the Role Performance subscale was divided
into School/Work, Home, and Community domains.
The instrument was originally designed as an outcome
measure in the Fort Bragg Evaluation Project (FBEP;
Bickman et al., 1992) for use with children and adoles-
cents with severe emotional and behavioral disorders
(Hodges & Wong, 1996).
Overview
The CAFAS (Hodges, 1989, 1997) is a rating scale
designed to measure functional impairment across
multiple domains in children and adolescents, and
their caregivers. Impairment is operationalized as the
degree to which the youth’s problems interfere with
his or her functioning in various life roles (e.g., stu-
dent, family member, worker, friend, citizen). To com-
plete the scale, a rater reviews a list of 165 behav-
ioral descriptions and selects those statements that
describe the child’s most severe level of function-
ing during a given time period (usually the past 1–3
months). The list of behaviors fall into the following
five domains:
1. Role Performance – effectiveness of the
youth’s ability to fulfill societal roles, includ-
ing School/Work, Home, and Community
subscales;
2. Behavior Toward Others/Self – appropriate-
ness of the youth’s daily behavior;
3. Moods/Self-Harm – modulation of the youth’s
emotional life and extent to which youth
demonstrates self-harmful behavior, including
Moods/Emotions and Self-Harmful Behavior
subscales;
4. Thinking – ability of the youth to use rational
thought processes; and
5. Substance Use – the youth’s substance use and
the extent to which it is inappropriate and dis-
ruptive.
A second portion of the scale allows the rater to
assess functional impairment in the caregiver. Be-
cause these caregiver subscales are supplementary
(Hodges, 1997) and the first five scales often are used
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exclusively, this paper will focus only on the first por-
tion of the instrument. Hodges and Wong (1996) sug-
gested that the CAFAS may be useful in (a) linking
level of care to level of need, (b) evaluating and plan-
ning programs, (c) conducting client-oriented cost
outcome studies, and (d) providing consumer “report
cards.”
Scale Development
There is currently no available information in the
published literature explaining how the CAFAS was
developed. Both Hodges (1997) and Bickman et al.
(1992) stated that the CAFAS was adapted from the
NCFAS scale as part of the FBEP. In fact, 67% of
the items on the original version of the CAFAS were
duplicate or modified NCFAS items. One source—
the Clinical Training Manual of the Children and
Youth Performance Outcome Program implemented
by the California Department of Mental Health (1997,
p. 61)—provides some information about the origins
of the CAFAS. According to this document, the au-
thor of the CAFAS
. . .made extensive modifications to the items and
scales of the NCFAS to render them more appropri-
ate for children, and subsequently sought input from
40 experts on three separate occasions after each re-
vision of the developing instrument. Colleagues were
selected who could provide input from a variety of
perspectives, including child psychopathology, nor-
mal development, and the special needs of Hispanic
and Afro-American children. Suggestions were also
obtained from spokespersons for parent advocate
groups.
No further information is available about the specific
methods used in the item selection and revision pro-
cess, nor how the input and suggestions were obtained
and used. From the available literature, it cannot be
determined whether the CAFAS items and subscales
were primarily derived using empirical or rational
methods.
According to the manual (Hodges, 1997), the
CAFAS is not based on a particular theory of child
psychopathology. Thus, ratings are not intended to
reflect any underlying etiology or dynamics regarding
the youth’s problems, but to profile the degree of dis-
ruption in the youth’s current functioning. It may be
argued, however, that scale development (selection of
items, determination of content area, etc.) must be in-
fluenced by some theoretical assumptions about child
development and functioning, whether the developer
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Bates
is fully aware of these assumptions or not (Reckase,
1996). Without specifically addressing these assump-
tions, the scale developer leaves it to the user to in-
fer them from the scale’s construction and scoring
scheme.
Scoring
According to the author, each item on the
CAFAS is presented in specific behavioral terms and
assigned to a given functional impairment score as
follows:
1. “30”: Severe—severe disruption or incapaci-
tation;
2. “20”: Moderate—persistent disruption or ma-
jor occasional disruption of functioning;
3. “10”: Mild—significant problems or distress;
and
4. “0”: Minimal or No Impairment—no disrup-
tion of functioning.
On each subscale, multiple items are given for each
severity level. To generate a score for a scale or
subscale, the highest indicated level of severity is
recorded, even if multiple items at that severity level
are endorsed. For example, a rater would assign a
score of 20 (for Moderate impairment) to a subscale
whether one or three Moderate items were endorsed
(assuming that no Severe items were endorsed). Us-
ing the original scoring scheme for the Role Perfor-
mance and Moods/Emotions scales, the highest sub-
scale score is recorded as the overall scale score. Thus,
a child who is rated 20 on School/Work, 10 on Home,
and 30 on Community would receive a Role Perfor-
mance score of 30 (the highest of the subscale scores).
It is important to emphasize that, according to the
scoring directions suggested in the manual, only items
within the maximum severity level endorsed for a
given subscale are evaluated by the rater. Thus, if one
or more items in the Severe category are endorsed,
the rater would skip the Moderate, Mild, and Mini-
mal items and proceed to the next subscale.
For each of the five CAFAS scales the possible
scores range from 0 to 30 (by tens). A total scale
score is generated by summing the five-scale scores,
and can range from 0 to 150. It should be noted
that, although this scoring system is suggested in the
original manual (Hodges, 1989), the revised version
(Hodges, 1997) expands the scoring range to 0–240
by retaining each of the three School/Work, Home,
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Table III. Relationship Between Scoring Systems for the 5-Scale and 8-Scale Versions of the CAFAS
8-Scale
School/work
Community
Home
Behavior toward others
Moods/emotions
Moods/self-harm
Thinking
Substance use
Range (0–240)
Note. Each CAFAS subscale score ranges from 0 to 30 by tens, such that the total score for the 5-scale version has only 16
possible values (25 possible values for the 8-scale version).
and Community Role Performance scores and both
of the Moods/Emotions and Moods/Self-Harm scores
(see Table III). One concerning trend is that multi-
ple scoring schemes have been employed in published
CAFAS studies. For example, Furlong, Casas, and col-
leagues (Robertson et al., 1998; J. Rosenblatt et al.,
1998; Wood et al., 1998) employed the five-scale scor-
ing method following the original manual guidelines.
J. Rosenblatt and A. Rosenblatt (1999) employed the
eight- scale scoring method as suggested in the revised
manual. Lemoine and McDermott (1998) used the
five-scale scoring scheme and included the two care-
giver scales in the total score to generate a possible
0–210 range. Hersch (1998) eliminated the Commu-
nity Role Performance and Substance Use subscales
from the eight-scale scoring scheme to generate a
possible total score range from 0 to 180. The state
of Indiana uses a miniscale version of the CAFAS
that includes two additional subscales—Environment
and Reliance (J. Phillips, personal communication,
January 28, 2000). With such nonconformity in scor-
ing the instrument, it is imperative to clearly specify
how the total scores were calculated when comparing
CAFAS scores across studies or programs.
Target Population
The CAFAS is intended for use with “children
and adolescents who have or may have emotional,
behavioral, substance use, psychiatric, or psycholog-
ical problems” (Hodges, 1997, p. 1-1). This includes
youths who are referred for these problems or who
are at risk for developing them. The author suggests
that the CAFAS is particularly useful in assessing out-
comes for youths with SED. It is intended for children
aged 6–17 years, although there is also a version for
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73
Name of scale 5-Scale
¯
¯
¯
¯→ Role performance (max. score)
¯
¯
¯ Moods/emotions (max. score)
¯→
TOTAL SCORE Range (0–150)
younger children aged 4–7 years—the Preschool and
Early Childhood Functional Assessment Scale (PEC-
FAS; Hodges, 1997). Hodges and Wong (1996) found
no significant differences in CAFAS scores between
gender and racial/ethnic groups, suggesting that it may
be a useful component of culturally competent assess-
ment. A Spanish language version is also available.
Raters and Training
The CAFAS was designed to be completed by
clinicians or other trained administrators who are
working with the youth and family. It is also preferred
that raters have graduate training in a mental health
field and “be knowledgeable about the spectrum of
behavioral and emotional problems which [sic] chil-
dren may experience” (Hodges, 1997, p. 6-2). Non-
clinicians may complete the scale, but it is suggested
that they receive full training and use the optional
structured interview to collect information about the
youth. One particularly strong feature of the CAFAS
is the availability of a well-developed training manual
with numerous training vignettes. Clinician raters may
use various sources of information to complete the
CAFAS, including interviews with the child and fam-
ily, interviews with other professionals familiar with
the child’s behaviors, and record reviews.
EVALUATION OF THE CAFAS
The following section describes an evaluation of
the CAFAS, using the previously outlined criteria
for assessing treatment outcome measures. Evidence
from the manual (Hodges, 1997) and relevant arti-
cles are explored in the context of the categories of
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psychometric properties, validity for use with target
population, ease of use, and utility.
Psychometric Properties
The following psychometric properties are
addressed: (a) internal consistency reliability, (b) in-
terrater reliability, (c) stability of scores, (d) con-
tent and structural validity, (e) concurrent valid-
ity, (f) criterion-related validity, and (g) predictive
validity.
Internal Consistency Reliability
Little information about the internal consistency
reliability of the CAFAS and its scales is available in
the manual and none appears in published articles.
In the manual, Hodges (1997) stated that the inter-
nal consistency coefficient (Cronbach’s alpha) values
ranged from 0.63 to 0.68 for the different waves in
the FBEP (Breda, 1996), and cited her own psycho-
metric paper (Hodges & Wong, 1996) as the source
for these data. Unfortunately, these data do not ap-
pear in this paper and therefore the context under
which they were generated is unclear. In the manual,
Hodges (1997) stated that these internal consistency
values (0.63 to 0.68) “reflect on the homogeneity of
the scales of the CAFAS” and “are supportive of
the reliability of the CAFAS” (p. 2-1). The author
also stated that this reliability evidence is “especially
true [sic] given that the separate scales are intended
to assess different domains of impairment” (p. 2-1),
and that the reliability of the entire scale would de-
crease with the omission of any of the individual
scales.
These arguments can be critically examined on
several points. First, coefficient alpha values of 0.63–
0.68 are generally considered relatively low and do
not provide compelling evidence of internal consis-
tency (Clark & Watson, 1995; Schmitt, 1996). Instead,
lower values of coefficient alpha suggest variability in
item content, which may still be congruent with the
desired goals of a particular scale depending on the
heterogeneity of the construct under study (Clark &
Watson, 1995; Schmitt, 1996). Second, the procedures
for completing the scale require selecting items in only
the most impaired category on each subscale. Thus, on
a given subscale, several items within the same impair-
ment category may be endorsed, but never can two
16:45 Style file version Nov. 07, 2000
Bates
items of different severities be endorsed. This neces-
sitates a correlation of zero between items in differing
impairment categories. As a result, estimates of coef-
ficient alpha will be greatly attenuated. It can there-
fore be concluded that internal consistency reliability
of the CAFAS has not been established. Given that
this appears to be an inappropriate method of eval-
uating LOF measures, however, this does not appear
to be a critical weakness of the scale.
Interrater Reliability
In contrast to internal consistency reliability, ev-
idence for interrater reliability for the CAFAS has
been well-documented (Hodges, 1997; Hodges &
Wong, 1996). Using 20 training vignettes and four
discrete samples (N = 54) of undergraduate students,
graduate students, and child service agency staff
members, Hodges and Wong (1996) assessed inter-
rater reliability in two ways. First, they calculated
Pearson product moment correlations between the
raters scores and a criterion score for each vignette.
Criterion scores were generated by consensus of the
primary author and a board-certified child psychia-
trist. Pearson coefficients were then transformed to
z-scores and averaged across raters. Second, they cal-
culated intraclass correlations (ICC) based on anal-
ysis of variance procedures to provide an estimate
of raters agreement with each other. Aggregated
Pearson coefficients for each of the four samples
ranged from .74 to .99; ICC correlations ranged from
.63 to .96.
Most of these values indicate good interrater re-
liability. However, this method of reliability estima-
tion is suspect in that the reliability coefficients were
generated from ratings of subscales, not individual
items. Thus, it provides no information about the de-
gree of agreement between raters on actual behav-
iors, but only on severity of groups of behaviors. Two
raters could disagree about the behaviors a given child
exhibits, but appear to be perfectly reliable if these
behaviors were assigned to equivalent severity cate-
gories. Furthermore, rater A could endorse five se-
vere items on a subscale whereas rater B could en-
dorse only one severe item, yet by these methods
they would demonstrate perfect agreement due to the
maximum scoring criteria. It would be of interest to
examine interrater reliability of the CAFAS, using in-
dividual items as the unit of analysis. It would also
be of interest to replicate this reliability study using a
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larger sample of raters, using raters involved in child
treatment, or using “real life” ratings as opposed to
vignettes.
According to the authors, values for the Think-
ing subscale were not reported “due to low frequency
of formal thought problems or organicity in the vi-
gnettes, which were designed to be representative of
typical clinical presentations” (Hodges & Wong, 1996,
p. 499). This argument begets the following question:
why was this subscale included on the CAFAS if it
does not contribute to the assessment of “typical” clin-
ical presentations? Is this subscale less important than
the other scales? Even if this were the case, it would
still be necessary to explore the interrater reliability
of this subscale to establish reliability estimates for
the entire CAFAS. Thus, it would be desirable to in-
clude formal thought problems or organicity on future
interrater reliability training vignettes.
Ogles, Davis, and Lunnen (1999) tested the in-
terrater reliability of the CAFAS under two meth-
ods of presentation of case data: (a) manual vignettes
and (b) archival data from actual cases. As would
be expected, the interrater correlations for CAFAS
total scores generated using manual vignettes by three
groups of raters [undergraduate students (.88), grad-
uate students (.89), and case managers (.94)] dropped
considerably by using actual case data (.66, .75, and
.55, respectively). A major drawback of this study,
however, was small sample size: there were only four
raters in each of the three groups.
Given these questions about the interrater reli-
ability studies of the CAFAS, it cannot be concluded
that raters tend to agree with each other on specific
items. It may be reasonably concluded, however, that
they do tend to agree fairly well with each other on the
severity of behaviors, at least on four of the five sub-
scales, in response to vignettes. Given that the severity
level (as opposed to the item level) is the suggested
level of analysis for the CAFAS, this evidence pro-
vides, at the very least, moderate support for the inter-
rater reliability of the CAFAS when used under these
conditions. Closer inspection of the CAFAS training
vignettes, in fact, reveals that case information often
contains wording that is identical to that of individ-
ual items on the scale, creating a rating situation that
is likely much less complex than actual usage condi-
tions. Furthermore, as previously discussed, estimates
of interrater reliability are maximized under condi-
tions when information variance is low. Thus, it would
still be necessary to demonstrate that the interrater
reliability of the CAFAS holds up under actual usage
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75
conditions—that is, when client information is varied
or limited.
Stability of Scores
Only one study (Hodges, 1995) has examined
the test-retest reliability of the CAFAS. In this
study, CAFAS ratings were gathered by two differ-
ent raters at 1-week intervals via telephone inter-
views with mothers of 56 youths. Interviews were
conducted by trained graduate students. The Pearson
product—moment correlation coefficients between
the two scores were as follows: Total Score = 0.95;
Role Performance score = 0.84; Behavior Toward
Self and Others = 0.82; Moods/Emotions = 0.91; and
Thinking = 0.89. No explanations were provided for
the absence of correlations for the Substance Use sub-
scale. Results of follow-up t-tests indicated no signif-
icant differences between Time 1 and Time 2 ratings
for any of the scale scores or the total score. In gen-
eral, these findings provide fairly strong evidence that
CAFAS scores are stable over a period of 1 week, us-
ing the interview protocol. Again, it would be infor-
mative to explore the stability of scores generated by
clinician raters under actual usage conditions.
Content and Structural Validity
To date, there is no available information in
either the published literature or the manual con-
cerning the content validity of the CAFAS items.
As previously discussed, only one secondary source
(California Department of Mental Health, 1997) has
addressed the details of item selection. Given this lim-
ited information regarding the development of the
scale, several problems emerge. First, it is unclear how
items were selected for inclusion in the scale, what the
underlying factor structure of the instrument is, and
whether individual items represent the constructs to
which they were assigned. As most scale development
scholars agree (cf., Reckase, 1996), it is imperative
to have clear theoretical and empirical reasoning to
make meaningful decisions about inclusion of items
and creation of subscales. To demonstrate this reason-
ing, for example, one might summarize ratings from
expert judges (theoretical) or conduct factor analy-
ses (empirical). Given that this reasoning is lacking,
it must be concluded that the content validity of the
CAFAS is suspect. Second, given that the construct
of global functioning and its subscale domains are not
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operationalized, it is unclear whether the items pro-
vide sufficient or excessive coverage. It is also unclear
whether the CAFAS items represent the most theo-
retically or technically sound items from a larger pool,
or whether they were subjected to any form of item
analysis.
Evidence supporting the structural and scaling
validity of the CAFAS is also unavailable. In other
words, there is no supporting evidence suggesting that
items in the “Severe” (“Moderate,” etc.) category
actually reflect severe (moderate, etc.) functional im-
pairment. On the School/Work Role Performance
scale, for example, the following items are scored 30
for “severe impairment”:
#004 – “Harmed or made serious threat to hurt a
teacher/peer/co-worker/supervisor. . .”
#006 – “Chronic truancy resulting in negative conse-
quences (e.g., detention, loss of course credit, failing
courses or tests, parents notified. . .)”
#008 – “Disruptive behavior, related to poor attention
or high activity level, persists despite the youth hav-
ing been placed in a special learning environment
or receiving a specialized program or treatment. . .”
It may be the case that these items do reflect a simi-
lar level of functional impairment. Conversely, these
items may be associated with different levels of im-
pairment. One could argue, for example, that a stu-
dent who harmed or threatened a teacher is more
functionally impaired than a student who received
a detention for repeated truancy. What is clearly
needed is empirical evidence to demonstrate that the
CAFAS items reflect a unidimensional continuum of
severity and are appropriately scaled. Such evidence
would greatly enhance the construct validity of this
instrument.
One potential problem with the scaling of the
CAFAS is that the items comprising the “Minimal or
No Impairment” severity level do not contribute to
the total score. Thus, a child’s subscale and total scores
are not affected by whether these items are endorsed
or not. It appears then, that the purpose of these items
is purely descriptive in nature. From initial inspection
of the items, it appears that some attempt to reflect
the absence of impairment (e.g., #030 – “Functions
satisfactorily even with distractions”), whereas oth-
ers seem to reflect positive functioning (e.g., #037 –
“Graduated from high school or received GED”). It
is interesting that both of these behaviors are scored
0 even though one could argue that they represent
different levels of functioning. Certainly this informa-
tion would be important to understanding the scope
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of a youth’s functioning, but insufficient attention is
given to positive functioning on the CAFAS (as it
does not even affect the score). One might reasonably
conclude that the CAFAS is aimed at assessing only
impairment in functioning, rather than positive func-
tioning, for the majority of items are in the “Severe”
and “Moderate” severity levels. It thus appears that
the items in the “Minimal or No Impairment” sever-
ity category are superfluous to its use as an objective
outcome measure.
Upon face inspection, there also appear to be a
number of items with overlapping content. For exam-
ple, it may be argued that the following items repre-
sent essentially equivalent content:
#012 – “Non-compliant behavior which results in per-
sistent or repeated disruption of group functioning
or becomes known to authority figures other than
classroom teacher (e.g., principal) because of sever-
ity and/or chronicity”
#013 – “Inappropriate behavior which results in per-
sistent or repeated disruption of group functioning
or becomes known to authority figures other than
classroom teacher (e.g., principal) because of sever-
ity and/or chronicity” [emphases added]
In the interest of parsimony, it would be desirable
to reduce item redundancy by eliminating extrane-
ous items or combining items with similar content.
Item analysis—a critical step in scale construction and
refinement—would be appropriate to achieve these
aims to select the “best” items for the scale.
Another problem is that the suggested scoring
system for the CAFAS employs a theoretically con-
fusing scoring system that combines compensatory
and maximum strategies. Within each subscale, the
maximum severity is scored, and then these scores
are summed across subscales to generate a global
score, apparently combining two theoretically com-
peting scoring models. Certainly there are other scor-
ing models that might be applied to the CAFAS (and
other multidimensional LOF scales) that might prove
equally or more valid. A variety of scoring models
might be particularly useful for LOF assessment, in-
cluding compensatory, average, conjunctive, or dis-
junctive models. Because choice of scoring model can
have significant impact on the relative ranking of re-
spondents (see Bates, 1999 for discussion), it is sug-
gested that the original scoring system of the CAFAS
be revisited and examined using empirical methods.
To address these problems, Bates (1999) recently
completed a study investigating the scaling properties
of CAFAS items. The study was conducted in three
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Review and Current Status of the CAFAS
phases. In Phase 1, a group of expert raters was asked
to indicate (a) the degree to which each of the items
represents the subscale construct to which it was orig-
inally assigned, and (b) how well the item tapped the
given construct. In Phase 2, additional expert raters
was asked to indicate their perceptions of severity by
assigning to each item a severity rating on a 9-point
scale. Using these ratings, successive intervals scaling
techniques were used to generate weighted rankings
for each item. These rankings were then used to cal-
culate weights for each items, providing a method to
investigate the validity of the original scoring system.
In Phase 3, CAFAS data were collected on a sample of
youths with SED enrolled in a cross-agency system of
care project for youths with serious emotional distur-
bance. CAFAS scores calculated with these derived
item weights and a consistent average scoring model
were then compared with CAFAS scores generated by
the original method with reference to the strengths of
their associations with other outcome measures such
as the CBCL, risk factors, and educational indicators.
The results of this study generally failed to sup-
port the suggested scoring system for the CAFAS and
instead indicated that empirically guided alterations
in the scoring system performed as well or better than
the original in several measures of concurrent valid-
ity. Specifically, there were multiple occasions of item
order reversal, where the relative severity rankings us-
ing the empirically derived values were reversed com-
pared with the values suggested in the original version
(e.g., an item with an original severity of 20 had a
higher empirically derived weight than an item with
an original severity of 30 did). More problematic was
the finding that empirically derived item weights did
not hold equivalency across subscales, such that items
with original severity values of 30 on the Community
subscale, for example, were rated as much more se-
vere than items with original severity values of 30 on
the School/Work subscale. These results call into ques-
tion the structural validity of the CAFAS and should
cause concern about the validity of current and past
usage of the instrument.
Concurrent Validity
There have been several investigations of the
concurrent validity of the CAFAS total score. In
the first study,4 the relationship between CAFAS
4 Thisstudy was reported in the CAFAS manual (Hodges, 1997),
but no reference was given.
February 27, 2001 16:45 Style file version Nov. 07, 2000
77
total scores and scores on the CGAS was investi-
gated in the FBEP sample. Pearson correlations be-
tween the CAFAS and the CGAS ranged from −0.72
to −0.91 for three time periods of data collection
[Note: correlations are negative because higher val-
ues of CAFAS scores reflect greater impairment,
whereas lower CGAS scores reflect greater impair-
ment]. There was also significant agreement between
the CAFAS and CGAS in categorization of youths
in one of four levels of impairment: severe, moderate,
mild, or slight/none. Although no further information
about this study is available, it does provide prelimi-
nary, albeit limited, evidence of the construct validity
of the CAFAS.
In the second study (Hodges & Wong, 1996),
also using the FBEP data, analyses were conducted to
demonstrate the construct validity of the CAFAS by
investigating its relationships with global measures of
psychopathology and problematic behaviors. Evalua-
tion measures collected in the FBEP project included
(a) the Child Assessment Scale (CAS; Hodges, 1990)
and its parent form, the Parent Child Assessment Scale
(PCAS; Hodges, 1990), which generate global scores
indicating general psychopathology; (b) the Burden of
Care Questionnaire (BCQ; Bickman, 1996b; Bickman
et al., 1992), developed specifically for use with the
FBEP to assess objective and subjective burden ex-
perienced by parents of children with serious emo-
tional or behavioral problems; and (c) the Child Be-
havior Checklist (CBCL; Achenbach, 1991) for the
parent, the Youth Self-Report (YSR; Achenbach &
Edelbrock, 1983) for youths aged 11 and older, and the
Teacher Report Form (TRF; Edelbrock & Achenbach,
1984) for the teacher—instruments designed to as-
sess perceptions of problematic behaviors from mul-
tiple informants. Correlations between the CAFAS
and other global measures of problematic function-
ing across four points in time were as follows: PCAS
(.59, .62, .58, .63); CBCL (.42, .49, .48, .47); CAS (.54,
.56, .55, .52); and BCQ (.36, .42, .43, .42). As indi-
cated, moderate positive correlations were found for
all measures across all time periods, providing evi-
dence of concurrent validity between the CAFAS and
a constellation of problematic behaviors.
Criterion-Related Validity
To measure the association between CAFAS
total scores and individual problematic behaviors
(data gathered through interviews with parents, and
CBCL, TRF, and YSR scores), Hodges and Wong
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78
(1996) bifurcated CAFAS total scores into two cat-
egories: presence and absence of pathology. For the
first wave of data (intake), the authors used a total
score of 80 as the cutoff between the categories; a
score of 50 was used as a cutoff for the three follow-up
time periods of 6, 12, and 18 months postintake. Little
explanation was given of the rationale for choosing
these cutoff scores, other than the observation that
approximately 20% of each sample comprised the
“pathological” group. [The authors stated that they
“considered these respondents to be seriously im-
paired” (p. 455), yet did not explain why they did
not consider respondents who scored between 50 and
70 at intake to also be seriously impaired.] A series
of logistic regression analyses were then conducted
using CAFAS category as a criterion and the fol-
lowing variable sets as predictors: (a) problems in
social relationships (with other children, other stu-
dents, siblings, parents, and teachers); (b) risk behav-
iors (physically attacked people, threatened people,
talked about killing self); (c) involvement in juvenile
justice (arrested, convicted of crime, placed on pro-
bation, spent time in correctional facility, saw proba-
tion/law enforcement officers, detention center); and
(d) school-related behaviors (disliked school, skipped
school, disciplined in school, suspended, grades, hap-
piness at school, worked much less hard than others,
repeated grade). Results indicated that each of these
variables was highly significant in predicting CAFAS
category for at least one (and oftentimes all four) of
the time periods. The authors concluded that these
results provide support for the validity of the CAFAS
as a measure of impairment across multiple spheres
of functioning.
Predictive Validity
In a third study involving the FBEP, Hodges and
Wong (1997) investigated the predictive validity of
the CAFAS total score. CAFAS total scores at in-
take were used to predict restrictiveness of care lev-
els, cost of services, and number of services at both 6
and 12 months postintake. Restrictiveness of care was
operationalized along the following continuum: out-
patient care, intensive nonresidential care, residential
care (e.g., group home), residential treatment center,
and inpatient hospitalization. Cost of services was op-
erationalized as the total cost of all services received,
whereas number of services received was operational-
ized as the number of bed days (for inpatient or resi-
16:45 Style file version Nov. 07, 2000
Bates
dential) and total number of days on which any service
was delivered. [At 6 months postintake, the number
of service days ranged from 1 to 370, raising questions
about how this variable was operationalized.] Results
indicated that even after controlling for the effects of
other instruments (e.g., CBCL, CAS, PCAS, BCQ),
the CAFAS total scores significantly predicted these
indicators of service utilization at both follow-up time
periods, with proportion of unique variance explained
ranging from .04 to .11. Although these values appear
low, the CAFAS total score was the single best predic-
tor of service utilization and cost. The results of addi-
tional analyses indicated that the CAFAS total score
in combination with psychiatric diagnostic informa-
tion [e.g., DSM-IV (1994) diagnosis] best predicted
service utilization and cost.
Validity for Use With Target Population
The CAFAS was designed for use with youths
with a variety of emotional and behavioral prob-
lems, specifically those with SED. The psychometric
data previously presented were collected through the
Fort Bragg Evaluation Project (Bickman, 1996b), a
demonstration project comparing a continuum of care
with traditional mental health services for youths with
SED. Thus, these psychometric data are clearly rele-
vant to the target population and do provide prelim-
inary support for its valid use with children and ado-
lescents with SED. As previously discussed, SED is a
heterogeneous diagnostic category covering a wide ar-
ray of symptoms and problem behaviors. The CAFAS
has face validity in that its items appear to cover the
breadth and depth of emotional and behavioral prob-
lems that children and adolescents with SED face. Yet,
its construct validity would be enhanced with an item
analysis to ensure that item coverage is truly repre-
sentative of SED. At the least, the strategies used to
select items should be addressed in the manual.
In an attempt to demonstrate validity for use with
a diverse population, Hodges (1996) also reported
that, using strict criteria, no significant differences
in CAFAS were found across gender, racial/ethnic,
or caregiver education level groupings. Although this
speaks to the comparability of CAFAS scores, it does
not provide sufficient evidence to conclude that the
scale holds equivalent meaning across groups. Al-
though a discussion of necessary conditions to estab-
lish equivalence is beyond the scope of this paper,
Reid (1995) provided a well-reasoned model for
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Review and Current Status of the CAFAS
demonstrating cross-cultural equivalence of rating
scales. He highlighted the need to explore four forms
of equivalence: (a) linguistic – the degree to which
“. . . content and grammar have similar connotative
and denotative meaning across cultures” (Marsella &
Kameoka, 1989, p. 239 as cited in Reid, 1995); (b) con-
ceptual – the degree to which constructs in assess-
ment hold similar conceptual meaning; (c) scale – the
degree to which raters share a common understanding
of the uses and metric of a scale; and (d) normative –
the degree to which norms developed for one culture
are appropriate for another. Thus, further study of the
CAFAS items and structure, and how these are inter-
preted by various cultural groups (or other meaning-
ful groupings), needs to occur before the equivalence
of the scale can be established.
Ease of Use
Hodges (1997) stated that the CAFAS takes
about 10 min to complete if the rater is very famil-
iar with the child’s behavior and functioning. No time
guidelines are given for raters who are unfamiliar with
the child. In practical terms, the CAFAS may actually
take longer than 10 min to complete, given the large
number of items. Nonclinicians can use the CAFAS,
although it is suggested they receive full training and
use a structured interview to gather information. The
training materials included with the CAFAS are ex-
tensive, consisting of detailed instructions for scoring,
demonstration vignettes with ratings provided, and
10 vignettes for testing rater reliability. To provide
a simple measure of the ease of use of the CAFAS,
states are required to report their evaluation instru-
ments used in children’s mental health services to
the Georgetown University National Technical As-
sistance Center (GUNTAC) and are asked to rate the
burden of these instruments on a 5-point scale (1: low
burden, 5: high burden). Of the 18 reporting this data
on the CAFAS, more than half gave a rating of 4 or
5 (mean = 3.6; GUNTAC, 2000). Thus, there does ap-
pear to be some burden associated with the use of the
CAFAS.
Utility
One of the strengths of the CAFAS, as with most
LOF measures, is its clinical utility. The CAFAS total
score appears to provide a meaningful metric by which
February 27, 2001 16:45 Style file version Nov. 07, 2000
79
to compare youths with a variety of emotional and
behavioral difficulties, although there remain ques-
tions about its validity. It also appears to be easily
understood by nonclinicians. One potential problem
in tracking clinical changes, however, is that there is
no associated meaning with the scale’s intervals. This
is essentially an issue of social or clinical validity. The
clinical utility of the CAFAS would greatly benefit
from supporting evidence of this type (Sechrest et al.,
1996). Other evidence in support of the CAFAS’ util-
ity comes from the extent to which it has been adopted
on both the state and local levels.
RECOMMENDATIONS FOR FUTURE
RESEARCH
The CAFAS has been implemented extensively
on the state and local levels. Despite this trend, there
is surprisingly little evidence supporting the psycho-
metric and clinical validity of this scale. Indeed, it is
disconcerting that the CAFAS has been so widely en-
dorsed, especially at the legislative level, without em-
pirical demonstration of its validity for use in mak-
ing the types of treatment decisions for which it is
currently being employed across the nation. Further-
more, there appears to be little concern (at least as
expressed in the available literature) among mental
health researchers, practitioners, administrators and
state legislators about these apparent limitations of
the CAFAS.
The widespread use of the CAFAS is an indica-
tion that there is a growing recognition of the need
to assess multiple dimensions of functional impair-
ment. With managed care and new regulations (e.g.,
changes in the federal definition of SED), policy mak-
ers, administrators, treatment providers, and program
evaluators are increasingly faced with the dilemma of
selecting objective and valid measures of children’s
functioning and having none to choose from. At the
time this review was written, the CAFAS was the only
children’s multidimensional LOF instrument with any
published articles on its technical merits. Several other
measures of children’s functioning have been intro-
duced and implemented in recent years (e.g., Ohio
Youth Scales, Ogles, Melendez, et al., 1999; Child and
Adolescent Scale of Temperament and Life Function-
ing (CASTLE); and Child Functional Assessment Rat-
ing Scale (CFARS), no references given but men-
tioned in GUNTAC, 2000), yet no information about
them exists in the published literature and it is unclear
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80
to what extent they have demonstrated validity for the
purposes for which they are being used. Given this
context, the CAFAS may represent the best available
option, thus accounting for its widespread use.
The potential benefits of the establishment of
objective and valid level-of-need criteria, using the
CAFAS, are numerous, and clearly the interest in do-
ing so is high. Presumably, such a development would
lead to increased precision in decision-making for the
delivery of mental health services, which would, in
turn, lead to lower costs and better care management.
It may also lead to improvements in matching the level
of care to the level of client need. For any of these ben-
efits to be realized, however, the psychometric limita-
tions of the CAFAS identified in this review need to
be addressed. Toward this aim, the following section
provides suggested directions for further research on
the CAFAS.
1. Technical properties – Further research is
needed on the technical properties of the
CAFAS, particularly its factor structure, inter-
rater reliability, and stability. A more in-depth
investigation of whether the subscale domains
hold up to empirical analysis would be desir-
able. As discussed in this review, analyses of the
interrater reliability on an item level and test-
retest reliability are also needed. These analy-
ses should be performed on all of the CAFAS
subscales, even if the incidence of certain items
(e.g., Thinking) is low in the clinical population.
2. Concurrent validity – Further evidence of the
CAFAS’s concurrent validity with additional
measures is needed. Potential concurrent mea-
sures to establish the validity of the CAFAS
might include another measure of LOF, more
elaborate measures of school functioning, self-
and parent-report measures of substance use,
juvenile justice indicators, diagnostic indica-
tors such as DSM-IV (1994) diagnoses, as well
as additional behavioral, social, and emotional
assessments.
3. Discriminant validity – Studies of the CAFAS’s
discriminant validity would be useful in deter-
mining whether scores can reliably differen-
tiate between samples of interest (e.g., clini-
cal vs. nonclinical). Many scholars (cf., Bird &
Gould, 1995; Weissman, Warner, & Fendrich,
1990) have espoused the utility of LOF assess-
ment for improving the precision of nosologi-
cal diagnoses, such as employed in the DSM-
IV (1994). For example, Bird and Gould (1995)
16:45 Style file version Nov. 07, 2000
Bates
reported that studies using symptomatic crite-
ria alone have overestimated the prevalence
rates of most childhood disorders, such that as
many as “one-third to one-half of the children
in a population have been found to meet crite-
ria for one or more diagnostic categories” (p.
92). When information about symptom sever-
ity and dysfunctionality are included, these
rates drop to levels more in line with theoretical
and clinical consensus. Demonstration of dis-
criminant validity, using the CAFAS, therefore,
would presumably lead to fewer misclassifica-
tion rates and greater confidence in diagnos-
tic decision making (e.g., type and amount of
services rendered; Herman & Mowbray, 1991;
Srebnik et al., 1998).
4. Predictive validity – Perhaps the most pressing
need is to establish the predictive validity of
the CAFAS. Because it is commonly used at
intake to make treatment decisions, it is vital
to investigate whether CAFAS scores predict
important treatment variables, such as number
and amount of services, length of treatment,
and cost of treatment. Newman and Tejeda
(1996) reported the initiation of such a project
through the Indiana Division of Mental Health
(IDMH) and indicated that the CAFAS was
the intended instrument for use with children
and adolescents (with a multidimensional adult
LOF measure to be developed by the first au-
thor). Briefly, the aims of this project are to
(a) investigate the psychometric properties of
the LOF measures, (b) track LOF and ser-
vice data from service providers, and (c) iden-
tify “cost-homogenous groups” (or clusters of
clients with similar LOF and service costs),
with the ultimate goal of providing data for
the creation of actuarial criteria. These crite-
ria will then be revisited and refined as needed
on an ongoing basis. Other states have initi-
ated similar projects, using the CAFAS (see
Table I; Behar & Stelle, 1997; Heflinger &
Simpkins, 1997; Hersch, 1998; Hodges, Warren,
& Wotring, 1998; Schwartz & Perkins, 1997)
and other scales (Newman & Tejeda, 1996;
Srebnik et al., 1998). Such studies might even-
tually produce valid and empirically based al-
gorithms for matching CAFAS scores with lev-
els of care.
5. Applications – A variety of other applications
of the CAFAS appear to hold promise to
increase its clinical utility in the delivery of
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Review and Current Status of the CAFAS
mental health services to youths. One innova-
tive approach to classification of psychopathol-
ogy in both adults and children has involved the
application of cluster analysis to client charac-
teristics, particularly LOF, to generate client
typologies. Herman and Mowbray (1991), for
example, assessed 2,447 adults with serious
mental illness using 16 scales of daily function-
ing (e.g., community living, substance abuse,
level of health care needs) and subjected these
data to cluster analysis to “organize and iden-
tify the patterns within the rich array of in-
formation provided by multidimensional LOF
assessments” (p. 102). Results indicated six
relatively homogenous clusters or client types
that were then used to facilitate analysis of ser-
vice utilization patterns and population differ-
ences across service sites. Several other studies
have demonstrated the clinical utility of clus-
ter analyses in child populations (Lahey, et al.,
1988; McDermott & Weisz, 1995; Rosenblatt et
al., 1998; Wood et al., 1998).
Herman and Mowbray (1991, p. 111) concisely
supported the utility of cluster analysis as follows:
The cluster analysis . . . has the descriptive advantages
expected: it succinctly summarize [sic] a substantive
amount of data about client functioning and sever-
ity levels overall, as well as about special treatment
needs, such as health care and substance abuse. Data
from statewide studies in the past have been difficult
to use because agencies were presented with dozens
of variables and asked to meaningfully interpret why
their clients are more functional than the state av-
erages on some variables, less functional on others,
etc. With a cluster analysis, agencies are presented
with simple statements . . . regarding the proportion
of clients they serve from each cluster. Thus, cluster
analysis based on LOF data appears to be a burgeon-
ing and useful technique to summarize and interpret
an often overwhelming amount of client data.
In sum, the CAFAS holds substantial promise
as an important tool for use in diagnosis, treatment,
and evaluation of youths with EBD. This review sug-
gests that the technical adequacy of the CAFAS has
yet to be clearly established. It is hoped that more
defensible, empirically based methods can be used to
assess children’s global functioning more efficiently
and accurately, with the ultimate goal to enhance al-
location of resources and service delivery to youths
with emotional and behavioral disorders.
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