Use of the Child and Adolescent

Functional Assessment Scale to

Predict Service Utilization and Cost
Kay Hodges, Ph.D.
Maria M. Wong, Ph.D.

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

Information that assists in predicting service utilization and cost is critical to managing the limited
resources available for treatment of mentally ill youths. Funds received through block grants to the
states for community mental health services are to be used to provide services to children with serious
emotional disturbance (SED). Identifying SED children requires information about their diagnosis
and impairment, because SED youths have been defined as having a psychiatric disorder, and the
disorder has resulted in "functional impairment which substantially interferes with or limits the
child's role or functioning in family, school, or community activities. ''1 Unfortunately, there are few
measures of functioning available that are designed for use with children who are psychiatrically
disturbed. 2 Axis V of the Diagnostic and Statistical Manual of Mental Disorders) which is also
referred to as the Global Assessment of Functioning (GAF) Scale, provides a global score indicating
overall level of functioning. However, in a recent study of hospitalized children and adolescents, 4
GAF scores did not predict length of hospital stay, whereas other variables such as previous
hospitalization and for-profit hospital status did.
This study reports on the use of the Child and Adolescent Functional Assessment Scale (CAFAS) 5
as a predictor of service utilization and cost. The data were collected as part of the Evaluation Study
of the Ft. Bragg Demonstration Project. 6 Respondents were rated on the CAFAS and were admin-
istered a variety of outcome measures at three time points: intake (wave 1), 6 months (wave 2) post-
intake, and 12 months (wave 3) postintake. The relationship between the youth's CAFAS score at

Address correspondenceto Kay Hodges, Ph.D., Departmentof Psychology,Eastern Michigan University,537 Mark
Jefferson, Ypsilanti,Michigan48197.
Mafia M. Wong, Ph.D., is a research fellow at the Institute for Social Researchof the Universityof Michigan at Ann
Arbor.

278 The Journal of Mental Health Administration 24:3 Summer 1997

intake and subsequent service utilization and cost is reported. In addition, the predictive power of
the CAFAS is compared to other outcome measures and to information about the youths' diagnosis.

Method

Respondents
The sample was recruited from youths 5 to 17 years old, who were referred for mental health
services at three army bases (i.e., Ft. Bragg, North Carolina; Ft. Campbell, Kentucky; and Ft. Stewart,
Georgia) from 1991 through 1993. There were 984 respondents at intake, and service utilization
data were available on 979 respondents at 6 months and 590 at 12 months. Attrition, which is detailed
in Breda (1996), 6 was roughly 16% at wave 2 and 27% at wave 3. The reasons for the attrition
included failure to locate the subjects, subject refusal, and incomplete data collection. In addition,
children younger than 8 years old, who represented 24% of the sample, were not administered some
of the measures (e.g., structured diagnostic interview). For youths 8 years and older, the sample size
was 603 at wave 2 and 357 at wave 3.
About two-thirds of the sample were males, with a mean age of 11 years. There were more
preadolescent boys (63%) than adolescent boys (37%), whereas there were about equal numbers of
preadolescent girls (49%) and adolescent girls (51%). The majority of the youths were Caucasian
(79.1%), with 20.5% being African American. In the modal family, at least one parent figure had
some education beyond high school (but was not a college graduate), the household income was
between $20,000 and $30,000, and there were two caregivers in the home. The demographics of the
sample at 6 months and 12 months were very similar to that at intake. See Table 1 for a summary
of the demographic data across all three waves.

Raters
The CAFAS was rated by 28 interviewers who administered all of the questionnaires and
interviews to the respondents. Raters were recruited via advertisements in newspapers in the local
towns (i.e., Fayetteville, NC, Clarksville, KY, and Savannah, GA) and through informal contacts
with the professional community in the area. The job was part-time and without benefits or
guaranteed minimal income. The interviewers were required to provide their own transportation, to
work evening and weekend hours, to go to the homes of families in which a child was psychiatrically
ill, and to complete the data collection within a specified time frame. Seventy-five percent of the
raters/interviewers were female. They were trained by the first author in five separate training
sessions, spanning a three-year period (September 1989 through September 1992). Except for one
rater, all had a college degree or were currently enrolled in undergraduate education. None of the
interviewers had direct experience providing psychiatric services to children and adolescents,
although four raters had master's degrees: two in educational guidance and counseling and two in
social welfare. Ten other raters had master's degrees in fields other than mental health (i.e., theology,
music, business, education, political science). The raters were hired by the Evaluation Study and
were not involved in the treatment or treatment decisions for any of the respondents. The research
protocols were collected, stored, and processed by the research team employees only. Training
entailed a workshop for one day and a half in which the trainees had an opportunity to rate videotaped
clinical interviews, a patient on an adolescent psychiatric unit who volunteered to be interviewed,
and written vignettes. Interrater reliability was evaluated with 20 written protocols that summarized
responses to a structured interview with the child and parent. 7 Through the remainder of the study,
10% of the interviews were reviewed via videotape. Feedback was given as needed to address rater
drift.

CAFAS HODGES,WONG 279

 Table 1
Characteristics of Respondents in the Study
Wave 1 Wave 2 Wave 3
(N = 984) (N = 979) (N = 590)
n % n % n %

Age
5-7 236 24.0 235 24.0 137 23.2
8-10 187 19.0 187 19.1 110 18.6
11-13 219 22.3 218 22.3 142 24.1
14 and above 342 34.8 339 34.6 201 34.1
Gender
Male 622 63.2 621 63.4 382 64.7
Female 362 36.8 358 36.6 208 35.3
Race
Caucasian 778 79.1 773 79.0 473 80.1
African American 202 20.5 202 20.6 111 18.8
Other 14 0.4 4 0.4 6 0.1
Family income
< $I0,000 15 1.5 15 1.5 9 1.5
$10,000-14,999 18 1.8 17 1.7 9 1.5
$15,000-19,999 91 9.2 90 9.2 49 8.3
$20,000-29,999 165 16.8 165 16.9 98 16.6
$30,000-39,999 334 33.9 333 34.0 200 33.9
$40,000-59,999 176 17.9 176 18.0 110 18.6
$60,000 or more 126 12.8 125 13.8 81 13.8
Caregiver's education
Some high school 7 0.7 7 0.7 4 0.7
High school graduate 159 16.2 158 16.1 79 13.4
Some college 548 55.7 544 55.6 331 56.1
College graduate 143 14.5 143 14.6 101 17.1
Some postcollege 45 4.6 45 4.6 24 4.1
Advanced graduate 71 7.2 71 7.3 44 7.5

Measures of Psychopathology
The measures described here were part of a larger battery, which is described elsewhere6 and
included the CAFAS, the Child Assessment Schedule (CAS), and its parallel version for parents
(PCAS), s~~the Child Behavior Checklist (CBCL), H and the Burden of Care Questionnaire (BCQ)? 2
All of these measures are scored in the direction of a higher score reflecting more pathology or
problems.

Child and Adolescent Functional Assessment Scale ( CAFAS). The CAFAS 5 assesses degree of
impairment in functioning in children and adolescents secondary to emotional, behavioral, or
substance use problems. It is essentially a list of behavioral descriptors from which the rater chooses

280 The Journal of Mental Health Administration 24:3 Summer 1997

those that describe the youth. The CAFAS takes about 10 minutes to complete and can be based on
a variety of information sources (e.g., clinical interview, intake assessment, etc.).
The CAFAS is composed of seven scales, five that rate the youth's functioning and two that assess
the youth's caregivers. The total score for the youth was used in the analyses in this study. It is the
sum of the five scale scores for the youth, which are as follows: Role Performance (i.e., how
effectively the youth fulfills societal roles), Thinking (i.e., ability of the youth to use rational thought
processes), Behavior Toward Self and Others (i.e., appropriateness of the youth's daily behavior),
Moods/Emotions (i.e., modulation of the youth's emotional life), and Substance Use (i.e., the youth's
substance use and the extent to which it is inappropriate and disruptive).
For each scale, the rater determines the severity level that best describes the youth's most severe
level of dysfunction during the last month. The scores assigned to each of the categories are as
follows: 30 for Severe (severe disruption or incapacitation), 20 for Moderate (persistent disruption
or major occasional disruption of functioning), 10 for Mild (significant problems or distress), 0 for
Minimal or No Impairment (no disruption of functioning). For each scale and each severity level,
there is a set of items describing behavior. The rater reviews the items in the Severe category first.
If any item describes the youth's functioning, the youth is assigned a score of 30. If none of the items
in the Severe category characterize the youth, the rater continues to the Moderate category, progressing
through the remainder of the categories as needed to describe the youth's level of functioning.

Child Behavior Checklist (CBCL). The CBCL was designed to obtain ratings of the competencies
and behavioral/emotional problems of children aged 4 to 16 years old, as reported by parents. The
child is rated on 118 problem items using a three-point scale for how true the item was for the child
over the last six months. The T score for the CBCL total problem score was used in the present study.
The psychometric data are provided in the manual for the CBCL."

Child Assessment Schedule ( CAS) and Parent Version--Child Assessment Schedule (PCAS). The
CAS is a structured diagnostic interview that provides information about diagnoses as well as
difficulties across various life areas, such as school, peers, and family. There are parallel versions
for the child and the parent, with the latter referred to as the PCAS. About half of the items on the
interview are diagnostically related, with the remaining items inquiring about the youth's problems/
conflicts in various life spheres. For each question, there is a response criterion, with the scoring
options being true, false, ambiguous, or not applicable. For the analyses in the present study, two
sets of information were used: (1) total number of endorsements for all PCAS and CAS items, with
higher scores reflecting more pathology; and (2) presence/absence of diagnoses based on the PCAS,
generated by computer algorithms that accompany the interview.13 Diagnostic algorithms were based
on the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).3
Data on the reliability and validity of the CAS are summarized in a review article by HodgesJ 4

Burden of Care Questionnaire (BCQ). The BCQ was developed for use in the Evaluation Study
to assess the impact on the family of having a child with serious emotional or behavioral problems. 12
Six areas of caregiver strain were included: disruption of family life and relationships, demands on
time, negative mental and physical health effects for any member, financial strain, disruption of
social/community life for any member, worry and emotional strain, and embarrassment. It is a
42-item self-report instrument with responses scored on five- or three-point scales. The BCQ
generates a total score, which was used in this study.

Utilization and Cost Indicators

Information on utilization of services was collected for two six-month periods: between intake
and 6 months postintake (referred to as wave 2 data) and between 6 and 12 months postintake
(referred to as wave 3 data). Information is reported for restrictiveness of care, cost of care, and

CAFAS HODGES,WONG 281

number of units of care received. All of the indicators are scored in the direction of higher values
reflecting more services, higher costs, or greater restrictiveness. The data were obtained from the
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) for recipients at Ft.
Stewart and Ft. Campbell, and from the management information system developed for the Ft. Bragg
Demonstration Project. For Ft. Bragg, cost was determined using guidelines set forth by the State
of North Carolina Department of Human Resources for tracking expenditures by providers contract-
ing with the state. (See Summerfelt, Foster, and Saunders 15and Foster, Summerfelt, and Saunders 16
for a more detailed description of the databases and procedures used to generate cost and other
indicators.) Service utilization was determined independent of CAFAS scores. Administrators and
clinicians who made the decisions regarding service utilization had no prior knowledge of the
respondents' CAFAS scores. CAFAS raters did not make any decisions regarding service utilization.

Restrictiveness of Care Levels. Services were described along a continuum of restrictiveness of

care. Beginning with the least restrictive level and progressing to the most restrictive, the levels were
categorized as follows: outpatient care, intensive nonresidential care (e.g., home-based treatment,
day treatment), residential care (e.g., therapeutic/specialized foster care, group home), residential
treatment center (RTC), and inpatient hospitalization. For waves 2 and 3, the youth received a score
indicating the most restrictive level of care received during the specified time period, using a
five-point scale.

Cost of Services. The total cost for all services delivered per respondent was calculated. 16For Ft.
Stewart and Ft. Campbell, financial transaction records were obtained from the records of the
CHAMPUS system, which provided information regarding the type of service, the date that the
service was delivered, and the amount and cost of service received. For Ft. Bragg, the management
information system specifically designed for the Demonstration Project offered information about
service type, number of service units received by each recipient, the date of service, and so forth.
However, the management information system did not offer direct information on cost of service
received. Instead, the total cost of different services was determined using guidelines set forth by
the State of North Carolina Department of Human Resources for tracking expenditures by providers
contracting with the state. The average cost per unit of a specific type of service was computed using the
total number of services provided in that category. The cost of services per respondent was then calculated.

Number of Services. Two indicators were provided: number of bed days (i.e., inpatient, RTC, and
other residential care) and total number of days of service. The total number of days of service was
generated by summing the number of days on which any services were delivered. By way of
example, all three of the following scenarios would be counted as one unit of service: one day of
inpatient care, one hour of outpatient therapy, and one day in which three types of nonresidential
services were rendered (e.g., case management, home-based therapy session with the family, and a
school visit).

Procedures
Children and parents were interviewed at the clients' convenience, either in their home or at an
agency. The information garnered was used for research purposes only.

Results

Descriptive Statistics
The CAFAS total scores for the respondents ranged from 0 to 140 (M = 45.65, SD = 26.47). We
first examined whether demographic variables such as age, gender, ethnicity, family income, and

282 The Journal of Mental Health Administration 24:3 Summer 1997

caregivers' education level were related to total score on the CAFAS. Bivariate regression analyses
showed that age had a significant positive effect on the CAFAS total score (6 = .18, p < .001),
indicating that older respondents tended to have a higher score than younger respondents. There was
no significant difference between male and female respondents in the total CAFAS scores (t[982]
=. 14, n.s.). Caucasians had a slightly higher CAFAS total score than respondents from other ethnic
groups (Caucasians: 46.49, Others: 42.48, t[982] = 1.94, p = .05). Bivariate regression analyses
using caregivers' education as a predictor of the CAFAS total score did not yield any significant
result. On the other hand, annual family income was a significant predictor of the CAFAS total score.
When compared with those with a high family income, respondents with low family income had a
higher score (13 = -.09, p < .01).
Four service utilization variables (i.e., restrictiveness of care levels, cost of service, number of
bed days, and total number of days of service) were analyzed for the first six months (wave 2) and
for the time period between the 6th and 12th months (wave 3) postintake. The frequencies of
restrictiveness of care levels varied across waves 2 and 3. At wave 2, 63.9% of all respondents
received outpatient service, 9.7% received intensive nonresidential care, 3.4% received other
residential care, 0.6% received RTC care, and 22.3% received inpatient hospitalization. The
corresponding figures at wave 3 were 67.9%, 15.1%, 7.0%, 1.5%, and 8.5%. The total cost of service
ranged from $0 to $124,011.20 at wave 2 (M = $9,706.44, SD = $18,237.20), and from $0 to
$91,958.61 at wave 3 (M = $6,784.64, SD = $15,019.67). Total number of bed days had a range of
0 to 184 at wave 2 (M = 14.40, SD = 35.59), and 0 to 183 at wave 3 (M = 11.10, SD = 33.08). Total
number of days of service also varied a great deal among the respondents. At wave 2, the number
ranged from 1 to 370 (M = 39.08, SD = 59.95). At wave 3, the number had a range of 0 to 379 (M =
35.31, SD = 61.94).

Using the CAFAS to Predict Service Utilization

To examine the relationship between the CAFAS and service utilization, we used the CAFAS
total score obtained at the beginning of the study to predict service utilization 6 and 12 months later.
As can be seen in Table 2, CAFAS total scores significantly predicted service utilization at both 6
and 12 months later. High impairment scores were related to more restrictive care, higher cost, more
bed days, and a higher number of services. The relationship between the CAFAS and utilization
variables at 6 months postintake was slightly stronger than that of 12 months postintake.

Comparing CAFAS With Other Instruments

in the Prediction of Service Utilization
Although the CAFAS predicted service and cost utilization well, it is important to determine the
usefulness of the CAFAS when compared with other existing measures of psychopathology.
Zero-order correlation between the independent variables (i.e., psychopathology measures and
present absence of diagnoses) and the dependent variables (i.e., utilization and cost indications) are
shown in Table 3.
Table 4 presents the results from the simultaneous multiple regression analyses* using the intake
CAFAS, PCAS, CBCL, CAS, and BCQ to predict service utilization 6 and 12 months after intake.
The total number of respondents in these analyses has dropped from 979 to 603 at wave 2 and from
590 to 357 at wave 3. This was due to the fact that the CAS was only administered to respondents

* Simultaneous multiple regression analyses were performedbecause our goal was to examine the usefulness of the
CAFASrelativeto the otherpsychopathologymeasures.No assumptionwas maderegardingthe orderof the variablesentered
into the analyses,which rendered the use of hierarchical regressionless appropriate.Stepwiseregression was not selected
because we were not interestedin findingout what independentvariablesshouldbe selectedor eliminated. However,for the
sake of comparison, hierarchical and stepwise regressions were performed and the results were similar to those of the
simultaneousregressionspresentedin the article.

CAFAS HODGES, WONG 283

 Table 2
Regression Analyses with CAFAS a Scores at Wave 1 as the
Independent Variable and Utilization and Cost Indicators at
Waves 2 and 3 as the Dependent Variables
Utilization and Cost Indicators
Restrictiveness Total Cost Number of Total Number
CAFAS Total of Care of Services Bed Days of Days of Service

Wave 2 ( N = 979)
.45 .41 .37 .38
R .45 .41 .37 .38
R2 .21 .17 .14 .14
Wave 3 ( N = 5 9 0 )
.35 .30 .31 .33
R .35 .30 .31 .33
R2 .12 .09 .10 .11
a. CAFAS = Child and Adolescent Functional Assessment Sacle.
Note: All regression coefficients were significant at p < .001.

who were aged 8 or older. The results suggested that even after controlling for the effects of other
instruments, the CAFAS remained a significant predictor of utilization and cost indicators. In fact,
its predictive power was the strongest among all independent measures. When compared with other
psychopathology measures, the CAFAS was the strongest predictor of restrictiveness of care, total
service cost, number of bed days, and total number of days of service at 6 months postintake. The
BCQ and, for restrictiveness of care, the CAS, were also significant predictors of utilization, but
their effects were relatively weaker. At 12 months postintake, the CAFAS was the only significant
predictor of service utilization. No other instruments were found to be significant.

Comparing CAFAS With Psychiatric Diagnoses and

Symptoms in the Prediction of Service Utilization
The above analyses showed the usefulness of the CAFAS in the prediction of subsequent service
utilization compared to other summary scores for pathology measures. Another logical comparison
is to determine how the CAFAS compares to information on specific psychiatric diagnoses. We used
the CAFAS and the presence or absence of seven major psychiatric disorders to predict service
utilization. Similar to the analyses above, simultaneous multiple regression analyses were
performed.
As seen in Table 5, after controlling for the PCAS diagnoses of seven disorders, the CAFAS was
a significant predictor of all four service utilization variables at 6 and 12 months postintake. The
presence of certain diagnoses also provided additional information to the prediction of service
utilization. Only conduct disorder was positively related to service utilization at both 6 and 12
months after the initial evaluation. Youths diagnosed with conduct disorder were more likely to be
treated in more restrictive settings, to incur a higher total cost of services, to stay longer in residential
settings, and to use a higher number of mental health services when compared with those who did
not have a conduct disorder. Two other disorders were predictive of service utilization only at 6
months postintake. Major depressive disorder was positively related to two of the four utilization
variables, whereas attention deficit-hyperactivity disorder (ADHD) had a negative relationship with
service utilization. Those with a major depressive disorder tended to incur a higher cost of services

284 The Journal of Mental Health Administration 24:3 Summer 1997

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 Table 4
Simultaneous Multiple Regression With Measures of
Psychopathology as the Independent Variables and
Utilization and Cost Indicators as the Dependent Variables
Utilization and Cost Indicators
Wave 2 (N = 603)
Independent Restrictiveness Total Cost of Number of Total Number
Variables at Wave 1 of Care (~) Services (1~) Bed Days (~) of Services ([3)

PCAS .05 .05 .05 .04

CBCL -.07 -.04 -.02 -.02
CAS .09* .03 .00 .01
BCQ .18"** .12"* .11" .17"**
CAFAS .33*** .34*** .30*** .29***
R .47*** .42*** .37*** .39***
R2 .22*** .18"** .14"** .15"**

Wave 3 (N = 357)

PCAS .12 .06 .01 .03

CBCL -.00 .01 -.01 .07
CAS -.03 .01 .03 .03
BCQ .11 .01 .01 .04
CAFAS .21"** .23*** .25*** .24***
R .33"** .27*** .27*** .31"**
R2 .11"** .08*** .07*** .09***
Note: CAFAS = Child and Adolescent Functional Assessment Scale; PCAS = Child Assessment Schedule,
Parent Version; CBCL = Child Behavior Checklist; CAS = Child Assessment Schedule; BCQ = Burden of Care
Questionnaire. All independent variables were entered into the regression models simultaneously.
*p < .05; **p < .01; ***p < .001.

and a higher number of bed days than those without the disorder in the first 6 months of the study.
No such relationship was found at the 12th month. On the other hand, when compared with their
counterparts with other disorders, children and adolescents with ADHD were more likely to be in
the less restrictive settings, to incur lower costs, to spend less time in residential care, and to use a
lower number of services in the first 6 months.
The results presented above indicate that the CAFAS predicted service utilization better than any
psychiatric diagnoses alone. Although we can be confident about the predictive power of the CAFAS,
psychiatric diagnosis also provides additional information about service utilization that cannot
otherwise be obtained by the CAFAS. Whereas certain types of diagnosis like conduct disorder seem
to be related to more restrictive service and higher cost, others like ADHD appear to be related to
less restrictive service and lower cost.

Discussion
The CAFAS total score at intake predicted mental health services utilization for all of the
indicators considered, including restrictiveness of care, cost of services, total number of days of

286 The Journal of Mental Health Administration 24:3 Summer 1997

 Table 5
Simultaneous Multiple Regression With CAFAS Total Score and
Psychiatric Diagnoses on the PCAS as the Independent Variables
and Utilization and Cost Indicators as the Dependent Variables
Utilization and Cost Indicators
Wave 2 (N = 979)
Independent Restrictiveness Total Cost of Number of Total Number
Variables at Wave 1 of Care (13) Services (13) Bed Days (~) of Services (13)

ADHD -.11"** -.13"** -.11"** -.12"**

Oppositional defiant disorder .03 .04 .05 .05
Conduct disorder .07* .14"** .16'** .17"**
Major depressive disorder .05 .09*** .06* .06
Dysthymia .00 .01 -.03 .04
Separation anxiety -.05 -.02 -.04 -.02
Overanxious disorder -.04 -.02 .02 .01
CAFAS total .42*** .35*** .31"** .31"**
R .47*** .45*** .42*** .43***
R2 .22*** .21"** .18"** .18"**

Wave 3 (N = 590)

ADHD -.03 -.02 .01 -.03

Oppositional defiant disorder .05 .04 .02 .04
Conduct disorder .14"* .17"** .14"** .18"**
Major depressive disorder .01 .05 -.02 .07
Dysthymia .03 .06 .01 .03
Separation anxiety -.03 -.03 -.02 -.04
Overanxious disorder .00 -.05 -.06 -.03
CAFAS total .30*** .23*** .28*** .26***
R .38*** .35*** .34*** .38***
R2 .14"** .12"** .12"** .14"**

Note: CAFAS = Child and Adolescent Functional Assessment Scale; PCAS = Child Assessment Schedule,
Parent Version; ADHD = Attention Deficit-Hyperactivity Disorder. All independent variables were entered into
the regression models simultaneously.
*p < .05; **p < .01; ***p < .001.

service, and number of bed days. When only the CAFAS was used as the predictor, it had a highly
significant relationship with all service utilization variables at both 6 and 12 months postintake.
When compared with other instruments yielding summary scores of psychopathology or burden of
care, the CAFAS was clearly the best predictor of service utilization at wave 2. At wave 3, the CAFAS
was the only instrument that significantly predicted service utilization.
Although the CAFAS accounted for the largest part of the variance, information about three
diagnoses also significantly predicted service utilization. Conduct disorder was the only diagnostic
category that significantly predicted all indicators at both wave 2 and wave 3. Conduct-disordered
youths were more likely to cost more and use more services, including residential care. This finding
is consistent with the well-documented poor prognosis for conduct disorder. Conduct-disordered

CAFAS HODGES,WONG 287

youths typically have a continued course of dysfunction into adulthood. 1719Thus, the observation
that conduct disorder, diagnosed at intake, contributes to the prediction of service utilization one
year later is consistent with clinical wisdom and existing empirical data. These results also
underscore the need for research on treatment approaches for conduct-disordered youths. Recent
research suggests that specific treatment approaches, along the lines implemented by Borduin,
Mann, Cone, et al.; 2~Henggeler, Schoenwald, and Pickrel; 21 and Kazdin, Bass, Siegel, et al. 22 are
superior to traditional, individual therapy. A diagnosis of major depressive was associated with more
utilization only at wave 2. High usage of residential services by youths diagnosed with either major
depression or conduct disorder was also observed in another large demonstration project, the
CHAMPUS Tidewater study.23
The results indicating that diagnosis of ADHD was negatively related to all four indicators for
wave 2 is consistent with treatment practices. Children with ADHD are typically treated with
medication, receive outpatient services, and often receive special services at school. 24 In the
Tidewater study, 95% of youths diagnosed as ADHD were treated on an outpatient basis. 23 This
would result in an inverse relationship with high restrictiveness, bed days, and high total cost.

Implications for Mental Health Services

Impairment, as opposed to diagnostic information or symptom counts from the pathology
measures, was more powerful in predicting a youth's need for services. This set of findings is
impressive given that the impairment ratings were made by interviewers hired by the Evaluation
Study who had no input or involvement in the treatment or treatment decisions made about the youth.
The importance of impairment as an indicator of treatment effectiveness has become increasingly
recognized. In the adult literature, functional outcomes have become the major yardstick for judging
efficacy of mental health services, as illustrated in Burns and Santos's 2s review of the randomized
trial studies of Assertive Community Treatment.
The construct of impairment differs from diagnosis in that the latter emphasizes type of problem
and is relatively insensitive to measuring amount (i.e., there is only presence or absence). Total
symptoms counts, as seen in questionnaires, emphasize quantification, but in a deceptively simplistic
way. Two different symptoms that suggest very different implications for day-to-day functioning
(e.g., sets fires versus bites fingernails) receive the same number of points. When viewed from this
perspective, it is not surprising that impairment was the most powerful predictor of service
utilization. As measured in this study, impairment primarily assessed the extent to which the youth's
problems interfered with his or her own functioning across settings and domains of functioning. It
also reflected on the extent to which the youth's behavior had a negative impact on others or was
seen as potentially posing a threat to others. A more detailed discussion of impairment measures and
their psychometric properties is available in a review by Hodges. 26
Use of a low-cost instrument like the CAFAS could provide extremely valuable information about
how to prioritize scarce resources. In this study, hired lay interviewers and very structured interviews
were used, resulting in a thorough but costly evaluation. In contrast, in clinical settings, the CAFAS
is a very low-cost procedure because it does not require any additional administration of interviews
or measures. Rather, the ratings are made by the staff member, on the basis of the information that
is typically collected in clinical settings. Obtaining this information is not an added burden; in fact,
it is part of a clinician's job. A clinician would be remiss in not collecting up-to-date information
about the child's functioning across settings. The actual process of rating the CAFAS generally takes
about 10 minutes. The reason is that the CAFAS is essentially a menu of behavioral descriptors,
from which the rater chooses those that are true for the youth.
In fact, given that the CAFAS lends some organization to the conceptualization of the youth's
problems, it has been viewed as increasing efficiency. For example, it can be a useful means of
focusing treatment plans or treatment team meetings with staff and parents. In clinical applications,

288 The Journal of Mental Health Administration 24:3 Summer 1997

the CAFAS scores are placed on a profile form that gives a visual representation of the youth's
functioning across settings. This profile makes it easy to identify problem areas, sources of strengths,
and signs of pervasiveness and comorbidity. The specific items endorsed can be used as problems
to address in the treatment plan (e.g., get an expelled child back into school). Furthermore, the
CAFAS ensures that the professional's perspective is retained as a measure of clinical outcome. This
is important in light of the increasing reliance on youth and caregiver-completed questionnaires.
The CAFAS uses common terms (e.g., expelled from school), has good face validity, and the
instructions are simple. Even so, training is highly recommended solely because lack of reliability
in any outcome measure can lead to failure to find real treatment effects. That is, a youth improves,
but because of sloppy measurement procedures, this real difference is not found. If a measure, such
as the CAFAS or Axis V, is to be used to assess outcome, it is desirable to have raters demonstrate
that they can reliably score the instrument. For the CAFAS, there is a training manual that can be
entirely self-administered. In fact, good interrater reliability has been established for numerous
samples when used in this way.27Having a training procedure that does not require stafftime beyond
the trainee is important in the real world where there can be a high turnover of staff. An added benefit
of training is that it can encourage group cohesion among staff and help clarify the goals or mission
of the service program.
Ratings of functional impairment, augmented by diagnostic information for conduct disorder and
major depressive episode, could provide the basis for an initial estimate of subsequent need for
services. Determining the presence of these two specific disorders could be done relatively reliably.
However, it would be important that the generation of diagnoses closely follow the D S M diagnostic
criteria. Diagnoses generated by clinicians for the purposes of collecting insurance reimbursements
may not be as reliable. In any system that aims at allocating resources to the most seriously disturbed
youths, the CAFAS could be very useful in determining need for services at the level of the individual
consumer and for planning systemwide resource allocation.

Acknowledgments
This research was supported, in part, by a grant from the National Institute of Mental Health
(RO1 MH46136-01), on which Dr. Leonard Bickrnan was the principal investigator and the first
author was a coinvestigator. Dr. Lenore Behar was also a coinvestigator on the NIMH grant and
generously provided guidance and support. This research was also supported by the U.S. Army
Health Services Command (DADA 10-89-C-0013) as a subcontract from the North Carolina
Department of Human Resources, Division of Mental Health, Developmental Disabilities, and
Substance Abuse Services. Part of this article was presented at the 9th Annual Research Conference:
A System of Care for Children's Mental Health at the Research and Training Center for Children's
Mental Health in Tampa, Florida in February 1996.

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