Ten-Year Review of Rating Scales, VII: Scales Assessing Functional Impairment

RESEARCH UPDATE REVIEW

Ten-Year Review of Rating Scales, VII: Scales Assessing Functional Impairment NANCY C. WINTERS, M.D., BRENT R. COLLETT, PH.D.,

AND

KATHLEEN M. MYERS, M.D., M.P.H.

ABSTRACT Objective: This is the seventh in a series of 10-year reviews of rating scales. Here the authors present scales measuring functional impairment, a sequela of mental illness. The measurement of functional impairment has assumed importance with the recognition that symptom resolution does not necessarily correlate with functional improvement. Method: The authors reviewed functional impairment from multiple sources over the past 20 years. Thus, this article includes a variety of scales ranging from those that have been subject to critical review with strong psychometric support to those that have not been critically reviewed but are in widespread use to those that are still finding their niche. Results: These scales represent a continuum of constructs from symptoms to functional impairment to contextual factors that affect youths’ functioning. Most older scales have focused on developmentally delayed youths. Newer scales strive to measure functional impairment separate from symptomatology. Some newer scales are also keyed to determination of level of service need. Conclusions: Scales measuring functional impairment can elucidate the impact of illness on youths, identify targets for treatment, determine service needs, and monitor treatment effectiveness. These scales are widely used in community mental health and health service delivery. They can assist in providing evidence-based treatment. J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(4):309–338. Key Words: rating scales, functional impairment, adaptive functioning, service planning.

This article is the seventh, and final, in a series of 10year reviews on the use of rating scales in child and adolescent psychiatry (Collett et al., 2003a,b; Myers and Winters, 2002a,b; Ohan et al., 2002; Winters et al., 2002). The current article reviews scales that assess functional impairment and/or adaptive functioning. These scales differ from the previous scales reviewed in that they are not keyed to specific psychiatric symptoms or diagnoses but rather tap deficits in functioning or adaptation that may be related to the illness in several ways. Functional impairment may result from the Accepted October 26, 2004. Dr. Winters is with the Oregon Health and Science University, Portland; Drs. Collett and Myers are with the Division of Child and Adolescent Psychiatry at Children’s Hospital and Regional Medical Center and in the Department of Psychiatry and Behavioral Sciences at the University of Washington, Seattle. Correspondence to Dr. Kathleen M. Myers, Division of Child and Adolescent Psychiatry, 6F-1, Children’s Hospital and Regional Medical Center, Box 5371, 4800 Sand Point Way, NE, Seattle, WA 98105; e-mail: kathleen.myers@ seattlechildrens.org. 0890-8567/05/4404–0309Ó2005 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000153230.57344.cd

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psychiatric illness, may have a shared etiology with the illness, or in some cases deficits in functioning may themselves lead to psychiatric sequelae. Therefore, these scales are often used concurrently with scales measuring psychopathology. The broad construct of ‘‘functioning’’ comprises a variety of related concepts and terminology is often used interchangeably. The various scales assessing ‘‘functioning’’ have used this terminology somewhat differently according to their particular focus. These terms include, but are not limited to, functional impairments, adaptive functioning, psychosocial functioning, level of functioning, social competence, and social adaptation. In this article, we limit our focus to the concept of functional impairments, i.e., specific deficits in multiple domains of functioning developing subsequent to a disorder, and the concept of adaptive functioning, i.e., adjustment to life’s demands across multiple domains including potential areas of strength. Adaptive functioning has been conceptualized as the interplay between the individual and the social environment and can be conceptualized in terms of role performance and role

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satisfaction across multiple life domains, such as cognitive abilities, performance in school or at work, interpersonal relations, age-appropriate capacity for selfcare, and the capacity to enjoy life including using leisure time for self-fulfillment (Bird, 1999). Adaptive functioning or functional impairment is often confused with severity of a disorder. Although these concepts are closely related, they are not interchangeable. Severity of illness is a characteristic of a disorder that indicates the extent to which the disorder is manifested or the level of seriousness of the disorder itself. Some disorders are inherently severe, such as schizophrenia and autism at the severest end of the spectrum for pervasive developmental disorders, whereas others demonstrate a wide range of severity, such as attentiondeficit/hyperactivity disorder (ADHD) or major depressive disorder (MDD). This variability across diagnoses demonstrates that a disorder itself does not equate to severity of illness or to functional impairment. Severity of illness is generally determined by summing the number of criterion symptoms defining a disorder. Severity may affect an individual’s functioning and influence the types of interventions used. However, it does not explicitly identify the domains of life in which the individual struggles, nor does it implicitly suggest how the individual has adapted to the illness or which domains of functioning may be preserved. By contrast, functional impairment is a characteristic of the individual that indicates in a more global way how the individual functions across life’s roles (Bird, 1999). As an example, children below the diagnostic threshold for depression may demonstrate many symptom-related impairments, whereas, conversely, children reaching the symptom threshold for disruptive behavioral disorders may not demonstrate major impairments (Pickles et al., 2001). The importance of functional impairment cannot be addressed fully with cross-sectional data. It requires longitudinal information to evaluate the stability of psychiatric conditions and to learn whether the stability of the disorder is related to the level of functional impairment or whether stability of the disorder and functional impairments deteriorate as a result of iatrogenic effects, such as decreased socialization due to weight gain with neuroleptic medication, or recurrent institutional programming. Identification of deficits in adaptive functioning or functional impairment may aid in understanding psychiatric disorders by elucidating underlying psychopathology or etiology. For example,

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by identifying the difficulties of a child with ADHD in the classroom, investigators elucidated the core deficit of inattention, or by identifying a depressed youth’s difficulties with sleep, dysregulation of biological rhythms were elucidated. Identifying functional impairments in life satisfaction, treatment responses, and outcomes also helps to target areas for intervention. Because problems in adaptive functioning may precede the overt onset of psychopathology, information on the youth’s adaptive functioning may also lead to strategies to prevent the evolution of frank symptoms (Biederman et al., 1993). Furthermore, because functional impairments may resolve more slowly than recovery from the disorder itself, information on the youth’s adaptive functioning is needed to assess and facilitate full psychosocial recovery (Puig-Antich et al., 1985, 1993). Of course, some youths do not show deteriorations in adaptive functioning but start life with serious functional impairments. In these cases, data on children’s baseline functioning are needed to determine how well they respond to subsequent multidisciplinary interventions. Interest in scales measuring functional impairment has mushroomed due to the convergence of clinical work in three areas. The first and best known area emphasizing functional impairment has been the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994, 2000a,b). The DSM-IV nomenclature requires subjective distress or functional impairment to make a psychiatric diagnosis, in other words, to define ‘‘caseness.’’ The inclusion of functional impairment criteria reduces the rates of psychiatric disorders based only on symptom presence. This is particularly relevant in community or epidemiological studies in which many individuals meet diagnostic symptom criteria but are not receiving treatment and/or are functioning well. The inclusion of functional impairment ratings reduces caseness two to threefold below that for diagnoses based only on symptom presence (Bird, 1999) and aligns caseness identified in the community with caseness found in clinical settings. Also of particular relevance to child and adolescent psychiatry, consideration of functional impairment increases mother– child agreement for many disorders, further honing diagnostic accuracy (Weissman et al., 1990). It is, therefore, critical to have measures to reliably and validly define caseness. Indeed, this is what clinicians routinely do in diagnosing youths and deciding their treatment needs (Bird, 1999). Third-party payers also consider

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such a dimensional approach when setting functional guidelines that justify inpatient versus outpatient or residential care. The second area of clinical work interested in functional assessment has been a consortium of health care administrators, clinicians, and parents. They have emphasized the centrality of ‘‘improvement in functioning’’ in the assessment of treatment outcome. Outcomes such as youths’ ability to live at home with their families, to attend school, and to function competently in social situations benefit youths and their families as well as contribute to the public good. The consumer perspective places a high value on functional outcomes because functional impairment creates more hardship for families. Public agencies’ decisions regarding funding are tied to functioning in other systems, such as juvenile justice and education. Finally, youths designated by schools or federal agencies as meeting criteria for ‘‘severe emotional or behavioral’’ disturbance are among the highest users of mental health services and often have multiple psychiatric and developmental diagnoses, so that their treatment needs are better delineated when functional impairment is considered along with their diagnoses. Responding to these stated needs for broad assessment of treatment outcome, multidimensional models have been proposed that include the usual clinical dimensions such as amelioration of symptoms, consumer/family perspectives, systems factors, and youths’ functioning. (Hoagwood et al., 1996). The third area emphasizing the importance of determining functional impairment has been outcomes research that has demonstrated that psychosocial improvements do not necessarily correlate with symptom resolution of major psychiatric disorders (Geller et al., 2001; Lewinsohn et al., 2003; Puig-Antich et al., 1985, 1993; Rohde et al., 1994; Weiss and Hechtman, 1993). Furthermore, the increasing demand for evidence-based treatments emphasizes outcome in multiple domains of functioning. Thus, the definition of treatment success should consider youths’ return to prior functioning or optimizing their functioning, not just amelioration of their symptoms or remission of their disorder. It is interesting to note the parallel trend in medicine toward adding functional assessment to measures of disease severity. Measures of functioning and quality of life are routinely used in research on disorders such as asthma, diabetes, and cancer. These measures provide important information about the impact of the illness as well as the

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success of treatment. Level of functioning may also have a substantial impact on the course of these disorders. There are several challenges in measuring functional impairment. The first is defining the concept to be measured, as noted above. A second challenge is that levels of functioning generally vary across domains of functioning, so that domains chosen for measurement will influence the overall findings. For example, socially anxious youths may maintain adequate academics but withdraw from peer relationships. Oppositional youths may struggle with authority but do well with younger children or pets. The third challenge is that problems in functioning may be situation specific, so that different informants will provide different assessments of functioning. Therefore, multiple informants may be required to get a comprehensive picture of functioning. For example, the impulsivity of an ADHD youth may be missed by a recess monitor because his or her high activity level is less noticeable in the context of expected physical and spontaneous activity, whereas his or her impulsivity manifesting as interrupting and blurting out would be less acceptable in the classroom. Thus, his or her classroom teacher would be a more sensitive informant. Similarly, the same youngster may attend more effectively to his or her homework with individual attention from his or her parents than in the classroom with little individualized attention from the teacher. Therefore, an informant who interacts with the child may not only affect the child’s functioning by providing more or less support but may also have different perceptions of the problem based on differential expectations. A fourth challenge in measuring functional impairment, also related to context, is how to take into consideration the cultural milieu in which the behavior occurs. Expectations for normative behaviors, including differential expectations for males and females, may vary considerably in different cultures. What may be perceived as a mild functional limitation in one culture may be more troubling in another and vice versa. Most scales measuring functional impairment do not optimally address cultural context. A fifth challenge is the variability of functional impairments found in disorders with specific functional limitations, such as neurodevelopmental disorders. In such situations, broad-based functional measures may not apply as well as measures specifically tapping the domains affected by the disorder. Scales assessing functional impairment are heterogeneous. The specific construct assessed depends on the

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population evaluated and the purpose of measurement. Similarly, scales used will depend on the question to be addressed, the methodology to be employed, design constraints such as age of youths, use of lay versus clinician interviewers, and whether lifetime or crosssectional assessments are needed. For example, in epidemiological studies, a scale may be needed that quickly and globally rates impairment to optimally identify youths most needing health services, i.e., to define caseness (Bird et al., 1996). In service-use determination, a scale may be needed that quantifies specific impairments that tie into the level of services that the youths could receive, i.e., outpatient services or more intensive and costly inpatient services. In clinical practice, a scale may be needed to determine youths’ strengths and weaknesses in structuring interventions. Therefore, both global rating scales and multidimensional impairment scales have been developed. Furthermore, the latter multidimensional scales may focus on different constructs, e.g., severity of the disorder, impairments resulting from the disorder, adjustment to illness, or strength-based functioning. The choice of a global or a multidimensional scale depends on multiple factors. Global scale scores can be assigned quickly and easily in the context of a broader evaluation of the child’s symptomatology and functioning. Global scales allow the rater to synthesize a youth’s functioning over many domains. However, they can confound functioning with diagnosis or with severity of illness (Bird et al., 1996; Shaffer et al., 1996). Parental expectations of youths’ adaptive functioning can also affect global ratings (Canino and Bravo, 1999). Multidimensional scales are varied in their focus and intent. Some have tried to measure symptom or diagnosis-specific impairment. However, such scales present difficulty for youths with comorbid diagnoses because it is difficult to differentially attribute impairment to each of the comorbid disorders. Such scales have not found wide applicability. Other scales have examined both the psychopathology and severity of a youth’s disorder and the impairment resulting from the disorder. This approach recognizes the natural tendency to equate severity of symptomatology with dysfunction. However, it also may confound the two constructs. Other, more recently developed scales have focused on functional impairment or adaptive functioning across multiple domains independent of diagnosis or symptom severity. These multidimensional scales vary in whether they

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require the rater to make clinical judgments or whether they rely on the responder’s judgment, either adult or youth. Scale selection in this article reflects the relatively new and rapidly evolving field of functional assessment. To provide a broad perspective, the search strategy and selection criteria used differ somewhat from those of the previous review articles. Multiple sources were reviewed, including peer-reviewed literature, scientific meeting abstracts, book chapters; Web sites, and large public mental health systems using scales developed for their specific purposes. Additionally, input was sought from researchers specializing in functional assessment. The final scale selection was intended to give the reader a broad representation of the variety and scope of available measures as well as the status of their development and implementation. A few scales have been used for more than a decade with considerable peer-reviewed publications and widely accepted applications. Others may be newer modifications of well-known scales that have been adapted for use by laypersons and have only preliminary supportive data. However, several scales have not been peer reviewed and/or do not yet have even a modest literature supporting their technical properties or documenting their applicability. Therefore, they lack clear guidelines regarding their use but, nevertheless, may be in widespread use. Some such measures appear to fill a particular niche in research, clinical work, and service planning that warrants presentation here. Where the literature on such an instrument is scant, we have indicated it in the text and provided the rationale for inclusion, such as the imminent publication of the scale or a scale potentially filling a special need in service delivery. As with earlier reviews in this series, we have chosen not to include subscales from popular broad-band instruments such as the Child Behavior Checklist (CBCL) (Achenbach and Rescorla, 2000) and Behavior Assessment System for Children (Reynolds and Kamphaus, 1992). These scales are often used in clinical applications and research, including psychometric studies to support the validity of some of the scales reviewed here. However, due to their breadth of coverage, broadband scales include few items specifically assessing adaptive behaviors and do not provide an in depth assessment of these constructs. The scales are presented in both tables and text. The tables provide practical information regarding scale format, the publisher for obtaining the cited scales,

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and major references documenting the scales’ properties, and psychometric properties. When possible, we have provided actual numerical values for the psychometrics. When such quantitative data were not available or when there were multiple different sources of data to collate, we summarized reliability and validity data according to published guidelines (Andrews et al., 1993): excellent >0.90; good 0.80–0.90; moderate 0.50–0.70; low 0.30–0.50; poor <0.30. However, the reader should be aware that these guidelines do not generalize well across reliability and validity or even across the various forms of reliability and validity. For example, the magnitude of reliability coefficients is generally expected to be high, but the acceptable range varies for different types of reliability. Internal consistency reliabilities are expected to be above 0.80, but interrater reliability is often lower, particularly among adults who interact with youths in different contexts, such as home versus school. Even parents interacting with a youth in the same home may only demonstrate moderate concordance. In such cases, interrater reliability estimates in the 0.30 range are not uncommon and are not considered a prohibitive flaw. Test-retest reliability will vary depending on the construct being measured. For constructs presumed to be stable over time such as shyness or impulsivity, coefficients in the 0.80 range are expected for retest over brief intervals, whereas lower coefficients of approximately 0.60 are acceptable for retest over longer intervals. Also, constructs that are inherently unstable such as suicidality or depression are expected to demonstrate lower coefficients than more stable constructs. Validity coefficients are even more variable. Although validity estimates should be statistically significant, they are expected to be lower in magnitude than reliability coefficients. For example, a correlation of 0.90 between a new scale and an established scale may support convergent validity but also suggests that the new scale is redundant with the established scale and does not contribute anything new to the measurement of a particular construct. Conversely, validity coefficients of 0.30 or lower may support a particular type of validity, divergent validity. In this case, lower order correlations support the hypothesized divergence of the new scale’s construct from the construct measured by another scale. To account for these differences, we complement the quantitative values in the tables with in-text descriptions of the significance of such estimates. The text also provides other information relevant to these scales and their

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use in various applications. Finally, the reader should be aware that many of the indicators of convergent validity provided for these scales represent their correlations with scales rating symptomatology. As mentioned earlier, there is some overlap between functional impairment and symptomatology. However, ideal measures of functional impairment would not include ratings of symptomatology or would parcel out symptomatology. Therefore, these correlations with symptomatology are not ideal estimates of the validity of these scales. Some of the scales have validity established in relation to other constructs, such as competence, but these are in the minority. Finally, some scales have claimed discriminant validity due to their detection of differences between relevant clinical groups. Such detected differences alone do not constitute discriminant validity. In fact, many well-known scales in multiple areas of clinical work have never had discriminant validity established. To deal with this situation, we have avoided such terminology and referred to a scale’s ability to ‘‘differentiate’’ clinical groups. Overall, potential users of these scales should be aware of the limited validity data currently available for most of these scales due to their recent development. UNIDIMENSIONAL SCALES

Unidimensional, or global, scales of functional impairment assign a single summary score to describe the youth’s overall functional impairment or adaptive functioning. The simplicity of a single score allows comparison of functional impairment between groups of patients with different diagnoses as well as ease of measuring functional change over time (Goldman et al., 1992; Skodol et al., 1988). However, global scales tend to confound functioning with diagnosis or symptomatology due to a particular disorder. In addition, the global approach fails to provide information about which specific domains of functioning are the most impaired and thereby comprise the most suitable targets for treatment planning. Therefore, global scales are not optimal for many purposes that require more precise assessment of adaptive functioning (Goldman et al., 1992). Their popularity and usefulness in clinical work are evidenced by their comprising Axis V of the DSM-IV (American Psychiatric Association, 1994) and in their incorporation into protocols for epidemiological research. These unidimensional scales are presented in Table 1.

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Scale (Ages) (Administration) Ref. Availability CGAS (4–16 yr) (Clinician interview) Shaffer et al., 1983 Available: Bird, 1999; American Psychiatric Association, 2000

CIS (7–17 yr; parent version for <9 yr) (Layperson interview) Bird et al., 1993 Available: Bird, 1999 American Psychiatric Association, 2000

TABLE 1 Psychometric Properties of Functional Impairment Scales: Global Scales Normative Data and Items Reliabilities for Total Validities for Total Scale Subscales Scale and Subscales and Subscales Scoring (Samples) (Samples) 1 item 1 factor 100 points

13 items 1 factor 5 points

No normative data reported IC: N/A IR: 0.83–0.91 (research) 0.53–0.63 (Clinical practice) 3-wk TR: 0.85 (epidemiological sample) 3-mo TR: 0.83–0.85 (case vignettes) No normative data reported IC: 0.85–0.89 (parent) 0.70–0.78 (youth) IR: N/A 2-wk TR: 0.89 (parent) 0.63 (youth)

Other

CONV: 0.25–0.92 with CBCL Total and Competence Scales; IQ; spec ed DIFF: differentiates inpt vs. outpt; case vs. noncase PRED: service use

Administration time: 5 min (does not include data collection)

CONV: 0.32–0.71 with CGAS; also correlates with ecological measures (parent form) DIFF: differentiates clinical vs. community; differentiates subtypes depression (parent and child forms) PRED: N/A

Administration time: 5 min (does not include data collection) Separate parent and youth forms

No training materials provided Nonclinician CGAS available for 4–16 yr-olds

Note: CGAS = Children’s Global Assessment Scale; IC = internal consistency reliability; IR = interrater reliability; TR = test-retest reliability; CONV = convergent validity; CBCL = Child Behavior Checklist; Spec Ed = special education; DIFF = shows statistical differentiation of groups but no formal discriminant validity; inpt = inpatient sample; outpt = outpatient sample; PRED = predictive validity; CIS = Columbia Impairment Scale; N/A = not available. Children’s Global Assessment Scale (CGAS)

General Description. The CGAS (Bird, 1999; Shaffer et al., 1983) is a unidimensional, clinician-rated scale adapted from the adult version, the Global Assessment Scale (Endicott et al., 1976). The rater gathers a broad range of clinical data regarding the youth’s history, symptomatology, and behavior at home and school and in social settings. This information is then synthesized into the final score, similar to other global rating scales. Although the CGAS score can be quickly assigned, data gathering may be time-consuming because multiple sources of information must be integrated to determine the final global score. Typically, this information gathering is part of the clinical interview that leads to diagnosis and additional data gathering is not needed. However, such data are slanted toward symptomatology rather than functioning, in part accounting for the tendency of the CGAS to confound these constructs. The Nonclinician CGAS, an adaptation of the CGAS that

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can be administered by laypersons, has also been developed for use in epidemiological research (Bird et al., 1996). Scales and Scoring. The CGAS is unidimensional with 10 anchors representing scoring deciles (e.g., 1–10, 11–20, 91–100). Scores range from 1 (most impaired) to 100 (least impaired) to reflect the degree of functional impairment. For each decile, a brief paragraph describing characteristics of functioning at that level of impairment guides raters in assigning the global score. The rating reflects impairment during a time period specified by the user, such as the previous week or previous 3 months. In a large series of studies evaluating CGAS thresholds, caseness was determined by service use, perceived need for services, and behavior problem scores on the CBCL. The CGAS threshold that best distinguished cases from noncases was between 61 and 70 (Bird et al., 1988, 1990). A CGAS score below 61 was considered a ‘‘definite’’ case; scores between 61 and 70 were

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considered a ‘‘possible’’ or ‘‘probable’’ case, and scores above 70 were considered noncases. Examination with a German sample similarly found that a score of 70 differentiated clinical groups (Steinhausen, 1987). The Nonclinician CGAS is a shorter and simpler version of the CGAS. It features the same deciles and scoring system as the CGAS, but the anchor points are described in lay terms, such as ‘‘obvious problems’’ as opposed to ‘‘moderate degree of interference in functioning in most social areas or severe impairment of functioning in one area.’’ Normative Data. Formal, nationally representative normative data for the CGAS have not been collected. However, the CGAS has been used in several large epidemiological studies that provide some standardized data. The best known of these, the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study, collected data from youths and their parents/caregivers in four metropolitan areas of diverse ethnic and socioeconomic populations (Lahey et al., 1996). Reports from this study have been used to establish caseness and criteria for identifying children and adolescents in need of mental health services (Bird et al., 1987, 1988, 1990). Psychometric Properties. When used in a controlled research context, interrater reliability of the CGAS was good (Bird et al., 1987; Shaffer et al., 1983; Weissman et al., 1990). However, it dropped to moderate levels in several studies conducted in clinical settings (Green et al., 1994; Rey et al., 1995). Moderate agreement between clinician and nonclinician ratings supports use of the nonclinician version of the CGAS (Bird et al., 1996). Good test-retest reliability has been found using second-year psychiatry residents to rate clinical case vignettes initially and again 6 months later (Shaffer et al., 1983). Similarly good stability over 3 weeks was found in an epidemiological sample (Bird et al., 1987). There is considerable evidence to support the convergent validity of CGAS. In its original examination, the CGAS showed low correlations with the Conners Hyperactivity Index (Shaffer et al., 1983). Subsequently, it has correlated with the CBCL’s Total Problem score and Competence scores (Bird et al., 1990; Green et al., 1994; Sourander and Piha, 1997) as well as with IQ, involvement in special education, suicide attempts in youths at risk of depression (Weissman et al., 1990), and measures of family dysfunction (Vandvik, 1990).

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Research suggests that psychiatric inpatients score significantly lower than outpatients on the CGAS (Shaffer et al., 1983) and that CGAS scores below 61 differentiate clinically significant global impairment in children of depressed parents from nondepressed controls (Weissman et al., 1990). More recently, the MECA study also found that scores below 61 predicted service use (Bird et al., 1990) and that children meeting diagnostic criteria on structured interviews received lower scores than noncase children (Bird et al., 1987). Applications. The CGAS has been used extensively in research and clinical settings, both domestically and internationally, to describe global functional impairment. It has been used most frequently to characterize psychosocial functioning in various clinical samples, including medically ill youths (Vandvik, 1990). When examined over 6 years in a sample of youths at risk of depression, CGAS scores were sensitive to change, decreasing with new onset of depression, and correlating with other indices of poor psychosocial functioning (Weissman et al., 1990). On the other hand, it did not show predictive power in determining the persistence of depression (Sanford et al., 1995). The CGAS has also been incorporated as a treatment outcome variable to complement measures of syndromal improvement in both psychosocial (Crawford and Manassis, 2001; Masi et al., 2001; Muratori et al., 2002, 2003; Santor and Kusumakar, 2001; Sourander et al., 1996) and pharmacological intervention studies (Findling et al., 2003; Masi et al., 2001, 2002). Finally, the CGAS has been widely used in international samples (Muratori et al., 2003; Sourander et al., 1996). Advantages and Disadvantages. The extensive use of the CGAS as a measure of global functioning highlights its advantages. It is a very brief scale with a score that is easily obtained and interpreted with sensitivity to treatment effects. Thus, it has very high utility. In particular, its sensitivity to change (Bird, 1999) and adequate stability make it a good choice for treatment studies. CGAS scores have been found to differentiate youths with varying degrees of impairment, suggesting that the scale may be used as an adjunct to diagnostic evaluation to evaluate acuity and treatment need. However, future evaluation of its sensitivity and specificity would be helpful in this regard. The nonclinician version appears promising and should be especially useful for epidemiological studies. The CGAS has been incorporated into many clinical and research protocols, and its

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wide applicability allows potential users to gain a good perspective of its relevance for, and performance in, their own applications. Despite its advantages, the CGAS has been criticized for several reasons. Its lack of specific training materials and mixture of objective (e.g., ‘‘stays at home, in ward, or in bed all day without taking part in social activities’’) and subjective descriptors (e.g., ‘‘disturbance would be apparent to those who encounter the child in a dysfunctional setting or time but not to those who see the child in other settings’’) make it vulnerable to respondent bias (Hodges and Gust, 1995). This could be particularly relevant if the score is used to determine eligibility for services. When used in research applications, training guidelines and ongoing assessment of interrater agreement are essential to accurately interpret findings. Considerable time may be needed to gather all relevant information needed to score the CGAS, which could reduce its utility. Other potential disadvantages relate to the global approach to characterizing functioning, which may not provide enough specific information about the nature of youths’ impairments and which precludes differentiation between symptom severity and functioning. Thus, it may be most useful when combined with other more objective and/or multidimensional measures of psychosocial functioning. Finally, application of the CGAS to youths with mental retardation or developmental disorders may artificially classify them as in need of psychiatric services because it does not take into account expected functional limitations associated with these disorders (Bird et al., 1990). The Columbia Impairment Scale (CIS)

General Description. The Columbia Impairment Scale (Bird, 1999; Bird et al., 1993) is a respondentbased global impairment scale that can be administered by a lay interviewer. In a respondent-based scale, the interviewee, or respondent, determines the score, in contrast to scales in which an interviewer makes a clinical judgment about the rating. There are separate parent report and adolescent report versions, which are nearly identical in format and content. Scales and Scoring. The 13-items are intended to tap four domains of functioning: interpersonal relations, broad psychopathological domains, functioning in schoolwork or job, and use of leisure time. However,

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factor analyses suggest a unidimensional structure, leading the authors to recommend using a total or composite score rather than scoring the four domains separately. Items are scored on a 5-point scale, with 0 indicating ‘‘no problem’’ and 4 indicating ‘‘very big problem.’’ Normative Data. The CIS was developed in conjunction with the MECA study, which provides good standardization data. Data were initially collected during the pilot study with youths 9 to 17 years of age, including both clinical and community samples. Later, data were collected at each of the five MECA sites. Thus, the standardization sample is nearly identical to that used for the CGAS. As with the CGAS, nationally representative normative data and data stratified by age and/or gender are not available. Psychometric Properties. In both the pilot study (Bird et al., 1993) and the MECA study (Bird et al., 1996), internal consistency reliability was very good for the parent version and moderate for the youth version. Testretest reliability was very good with parent report and moderate for youth report. Interrater reliability, such as agreement between caregivers, is not reported. Significant differences were observed between clinical and community samples on both parent and child versions of the CIS, suggesting that the scale differentiates youths with varying degrees of impairment. Convergent validity was demonstrated by moderate, statistically significant, negative correlations with the CGAS. The CIS also showed moderate to high correlations with other ecologically valid measures of impairment, such as school difficulties and referral for mental health services. Validity estimates were higher with the parent version than with the youth version. Applications. In several studies, CIS scores were shown to correlate with psychopathology, trauma history, or treatment outcome (Flisher et al., 1997; Goodman et al., 2000; Hamilton and Bridge, 1999). In the examination of youths with chronic medical illness, the CIS performed better than other standard checklists in detecting youths in need of mental health treatment (Harris et al., 1996). Finally, in a Swiss epidemiological study, a German translation of the CIS supported the scale’s concurrent validity (Steinhausen and Metzke, 2001). Gender differences were revealed with estimates of validity found to be higher among girls than boys. Advantages and Disadvantages. The CIS has the advantage of being a very brief, respondent-based, and

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layperson-administered scale with solid psychometric properties. The CIS has good utility for research applications requiring a brief measure with relatively little training or clinical judgment needed for administration. In these respects, it may be an improvement over the CGAS. The availability of both parent-rated and child-rated versions allows comparison of parents’ and youths’ perceptions, as is becoming standard practice with many symptom-based rating scales. As with those scales, the youth-rated CIS appears to have poorer psychometric properties than the adult-rated version. Disadvantages are several. Although designed to tap four domains of functioning, it appears to function as a unidimensional scale. Like the CGAS, symptom-related questions are included along with items purely rating functioning. Most important is the CIS’ limited use in the literature, making it difficult to determine its utility with various clinical samples. Although the scale was developed with a large, heterogeneous sample, nationally representative normative data are not available. Given the recently reported gender differences (Steinhausen and Metzke, 2001), gender-specific normative data may improve the scale’s utility. Finally, further psychometric data establishing interrater agreement and sensitivity to treatment effects would increase clinical utility. MULTIDIMENSIONAL SCALES

Multidimensional scales measuring functional impairment and adaptive functioning have been developed in response to the perception that global scales do not yield sufficiently specific information about youths’ functioning. These scales are composed of multiple subscales that describe different aspects of youths’ functioning that may be impaired by mental health problems. The specific functional domains included vary with each scale and reflect its intended use and target population. The development of these scales underscores many interesting theoretical and clinical issues relevant to understanding the effects of mental illness on youths’ lives. For example, assessing the impairments resulting from illness might inform clinicians about how mental illness leads to social disability. On the other hand, measuring youths’ adjustment to illness might elucidate areas that are more resilient to the effects of mental illness. Understanding youths’ strengths might emphasize ways to prevent handicap. All these aspects of youths’ functioning are important and have led to the development of diverse scales.

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A variety of multidimensional scales is included here to represent the continuum of constructs from symptoms to functional impairment to contextual factors that may be useful to measure according to patient need and agency mandate, e.g., developmental assessment, educational planning, clinical interventions. Some of these scales are also keyed to determination of level of service need and planning. The Vineland Adaptive Behavior Scales (VABS), the Scales of Independent Behavior (SIB-R), and the Adaptive Behavior Assessment System–Second Edition (ABAS-2) provide a measure of adaptive functioning compared with age-related norms. The Social Adjustment Inventory for Children and Adolescents (SAICA) measures social adjustment specifically. The Behavioral and Emotional Rating Scale (BERS) measures strengths in functioning that have applicability to educational planning. The Child and Adolescent Functional Assessment Scale (CAFAS), and the Child and Adolescent Needs and Strengths-Mental Health (CANS-MH) are used in service delivery systems to measure areas of impairment that may influence treatment planning decisions. These multi-dimensional scales are presented in Table 2. Two newer scales that are promising and have good preliminary psychometric data are mentioned briefly and are summarized in Table 3: the Brief Impairment Scale (BIS) and the Child and Adolescent Level of Care Utilization System (CALOCUS). VABS Survey Form

General Description. The VABS (Sparrow et al., 1984) comprise the prototypical measure of youths’ functioning. These scales have received extensive clinical and research use, particularly with youths diagnosed with developmental delays and autism spectrum disorders. The VABS are a revision of the Vineland Social Maturity Scale (Doll, 1965), which was among the earliest measures of adaptive behavior. The VABS are intended for youths aged birth through 18 years old and are completed as a semistructured interview with caregivers. Specialized training is not required to use the VABS, although familiarity with comparable structured interviews and adequate knowledge of child and adolescent development are necessary. Multiple forms are available. The Survey Form is the version most frequently used in the literature and is the focus of this review. There is also an Expanded Form, which includes the items from the Survey version as well as additional

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TABLE 2 Psychometric Properties of Functional Impairment Scales: Multimimensional Scales Scale (Ages) (Administration) Ref. Copyright/Availability

Items Subscales Scoring

VABS (birth–18 yr) (Clinician interview) Sparrow et al., 1984 Copyright: American Guidance Service (www.agsnet.com)

297 items 4 composite subscales + optional Maladaptive Behavior Scale 3 points

SIB-R (3 mon to >80 yr) (Interview or checklist administration) Bruininks et al., 1996 Copyright: Riverside Publishing Co (www. riverpub.com)

259 items in Full Scale form 4 Adaptive Behavior Scale + 3 Problem Behavior Scale 4 points

ABAS-2 (birth–89 yr) (Adult report of child; adolescent and adult self-report) Harrison and Oakland, 2003 Copyright: Phychological Corporation (www. psychcorp.com)

193–241 items (depending on response form) 4 composite subscales + ‘‘guess’’/validity scale 4 points

SAICA (6–18 yr) (Clinician interview but respondent based) John et al., 1987 Available: John et al., 1987

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77 items 11 subscales 4 point

Normative Data and Reliabilities for Total Scale and Subscales (Samples) Normative data reported Supplementary autism norms reported IC: 0.70–0.98 (normative sample) 0.93–0.99 (autism sample) IR: 0.80–0.95 (normative sample) 2–4-wk TR: 0.76–0.92 (normative sample) Normative data reported Supplementary norms for blind reported IC: 0.84–0.98 (normative sample) 0.98–0.99 (children with MR) IR: 0.78–0.95 (normative sample) 0.88–0.97 Adaptive 0.57–0.85 Problem (children with MR) (normative sample) 2–4-wk TR: 0.83–0.98 Adaptive 0.80–0.83 Problem (normative sample) Normative data reported IC: 0.65–0.99 (normative sample) 0.86–0.99 (clinical sample) IR: 0.58–0.93 (normative sample) 10–13-day TR: 0.77– 0.91 (normative sample)

No normative data reported IC: 0.40–0.73 (at-risk and normal youths) IR: ‘‘acceptable’’ (at-risk and normal) TR: ‘‘high’’ (at-risk and normal)

Validities for Total Scale and Subscales (Samples)

Other

CONV: 0.40–0.70 with several measures of functioning 0.25–0.37 (at-risk infants) DIFF: Differentiates Asperger’s vs. autism; ADHD vs. nonclinical; MR vs. MR with comorbidity

Administration time: 20–60 min (includes interview time) Revision in process

CONV: 0.83 Broad Independent Score with VABS Adaptive Behavior 0.82 with WJ-R Cognitive Ability 0.64 (Problem Behavior Scale) w/Reiss Screen for Maladaptive Behavior DIFF: Differentiates mild vs. moderate vs. no MR Differentiates regular vs. spec ed

Administration time: 20–60 min (depending on form used)

CONV: 0.18–0.80 with other measures of adaptive behavior 0.23–0.72 with academic achievement and intelligence DIVG: –0.39 to –0.66 with behavior problems DIFF: Differentiates MR, DD, ADHD, language disabled vs. matched controls PRED: N/A CONV: 0.46–0.51 with GAF 0.51 with CBCL competence scales DIFF: Differentiates selected diagnostic groups and comorbidity ADHD vs controls PRED: N/A

Administration time: 20 min Completed by parent, day care provider, teacher, other adult, or adult self-report Separate forms for infants/toddlers, school-age children, late adolescents/adults

Problem Behavior Scale Special form for individuals who are blind

Administration time: 30–75 min Interview for youth or parents Higher score indicates worse adjustment

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TABLE 2 (Continued ) Psychometric Properties of Functional Impairment Scales: Multimimensional Scales Scale (Ages) (Administration) Ref. Copyright/Availability

Items Subscales Scoring

Normative Data and Reliabilities for Total Scale and Subscales (Samples)

BERS (5–18 yr) (Adult report of child) Epstein and Sharma, 1998 Copyright: PRO-ED, Inc. (www.proedine.com)

52 items 5 subscales 4 points

CAFAS (5–16 yr) (Clinician rating or parent interview) Hodges, 1994 Copyright: Functional Assessment Systems (www.cafas.com)

164 items 5 subscales + 2 optional caregiver scales 4 points

No normative data reported IC: 0.63–0.68 IR: 0.73–0.99 (all using vignettes) TR: 0.82–0.95 (telephone interviews)

CANS-MH (2–20 yr) (Clinician- or laypersonadministered interview or records review) Lyons et al., 1999 Copyright: Buddin Praed Foundation (www. buddinpraed.org)

37–64 6–9 subscales 4 point

No normative data reported IC: Preliminary evidence IR: 0.74 (clinical vignettes) 0.85 (clinical cases) TR: N/A

Normative data reported IC: All >0.80 (half >0.9) (students) IR: 0.83–0.92 (students) 10-day TR: 0.52–078 (students) 6-mo TR: 0.86–0.99

Validities for Total Scale and Subscales (Samples) CONV: 0.39–0.75 with TRF and with Walker Scales of Social Competence DIFF: Differentiates normals vs. SED; LD vs. SED PRED: N/A DIVG: ‘‘Suggested’’ CONV: 0.36–0.59 with CBCL total score and other scales of functioning highly correlated with CGAS DIFF: Differentiates output vs. inpt/RTC PRED: School attendance, legal involvement, service use CONV: Correlates with CAFAS & measures of psychopathology, functioning, and strengths Agrees with expert panel decisions DIFF: Differentiates youths with varying levels of care PRED: N/A

Other Administration time: 10 min

Completed by teacher, parent, or counselor

Administration time: <30 min CAFAS is not an interview but a rating that includes history and observation Structured interview also available to aid data collection PECFAS for preschoolers Administration time: 15–20 min (does not include data collection) Flexible administration (e.g., records review, caregiver/youth interview) Multiple other forms: Juvenile Justice, Developmental Disabilities, Early Development, Child Welfare

Note: VABS = Vineland Adaptive Behavior Scales; CONV = convergent validity; IC = consistency reliability; IR = interrater reliability; TR = test-retest reliability; DIFF = shows statistical differentiation of groups but no formal discriminant validity; ADHD = attention-deficit hyperactivity disorder; MR = mental retardation; SIB-R = Scales of Independent Behavior–Revised; WJ-R = Woodcock Johnson Tests of Achievement–Revised; ABAS-2 = Adaptive Behavior Assessment System–Second Edition; DIVG = divergent validity; DD = developmentally disabled; PRED = predictive validity; inpt: inpatient sample; outpt: outpatient sample; N/A = not available; SAICA = Social Adjustment Inventory for Children and Adolescents; GAF = Global Assessment of Functioning; BERS = Behavioral and Emotional Rating Scale; TRF = Teacher Report Form; SED = seriously emotionally disturbed; LD = learning disabled; CAFAS = Child and Adolescent Functional Assessment Scale; CBCL = Child Behavior Checklist; CGAS = Children’s Global Assessment Scale; RTC = Residential Treatment Facility; PECFAS = Preschool and Early Childhood Functional Assessment Scale; CANS-MH = Child and Adolescent Needs and Strengths

content to assess problem areas and assist with the development of individualized education and treatment programs. Finally, there is a Classroom Edition questionnaire for teacher completion. Scales and Scoring. The VABS Survey Form contains 297 items, each reflecting a developmental skill in five clinically and empirically derived domains: Communica-

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tion, Daily Living Skills, Socialization, and, for children aged birth to 5 years old, a Motor Skills domain. There is also an optional Maladaptive Behavior domain that can be scored for ages 5 years and older only. Rather than administering all items, estimated starting points are provided by age, and basal and ceiling rules are used to ensure that a youth’s abilities are adequately represented.

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SCALE (ages) (Administration) Ref Copyright/Availability BIS (School-age children and adolescents) (Respondent rated) Bird et al., unpublished ([email protected]. columbia.edu) CALOCUS (6–18 yr) (Clinician rated) AACP and AACP, 2003 Copyright: AACP and ACP www.aacap. org/clinical/calocus

TABLE 3 Psychometric Properties of Functional Impairment Scales: Other Scales Normative Data and Items Reliabilities for Total Subscales Scale and Subscales Validities for Total Scale and Scoring (Samples) Subscales (Samples) 23 items 3 subscales 4 points

No normative data reported IC: 0.81–0.88 (total scale) 0.56–0.81 (subscales) 12-day TR: 0.70 (total scale) 0.56, 0.54, 0.76 (subscales)

CONV: 0.45–0.60 with CGAS DIFF: Differentiated. clinical vs. nonclinical samples

8 items scored 6 subscles 5 points

No normative data reported IR: 0.89–0.93 (composite of multisite sample)

CONV: 0.26 with CGAS 0.63 with CAFAS

Other Administration time: 3–5 mins Administered by personal interviewer Recommended cutoff of 12–16 identifies service need Administraton time: 20 min

Note: BIS = brief impairment scale; IC = internal consistency reliability; TR = test-retest reliability; CONV = convergent reliability; CGAS = Children’s Global Assessment Scale; DIFF = shows statistical differentiation of groups but no formal discriminant validity; CALOCUS = Child and Adolescent Level of Care Utilization System; AACAP = American Academy of Child and Adolescent Psychiatry; AACP = American Association of Community Psychiatrists; IR = inter rater reliability; CAFAS = Child and Adolescent Functional Assessment Scale

Interviewers score each item on a three-point Likert scale, with anchors indicating how well the child exhibits a particular skill. A composite score is calculated for the five broad domains and for an Adaptive Behavior Composite. Additionally, each domain is broken down into smaller subscales. For example, in the Communication domain, scores are derived for Expressive, Receptive, and Written Communication. Daily Living Skills are broken down into Personal, Domestic, and Community subscales. Socialization includes Interpersonal Relationships, Play and Leisure Time, and Coping Skills. The Motor Skills Domain includes Fine and Gross Motor subscales. Finally, the Maladaptive Behavior domain is broken down into two parts, the first for all caregivers and the second for the caregivers of youths with more severe pathology. A variety of scores can be derived for each broad domain composite, including standard scores, percentile ranks, qualitative descriptions of adaptive level, and age equivalents. Subscales can be scored using qualitative descriptions of adaptive level and age equivalents. Normative Data. Normative data for the VABS were collected in 1981–1982 and are available for a nationally representative and ethnically diverse sample of 3,000 youths aged birth through 18 years. Supplementary data

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are provided in the VABS technical manual for various clinical populations, such as mentally retarded adults, emotionally disturbed youths, and visually handicapped and hearing-impaired children. Supplementary norms have recently been published based on a national sample of 684 individuals with autism spectrum disorders, 2 to 59 years old (Carter et al., 1998). Separate norms are also provided for verbal versus nonverbal patients. Finally, percentile scores are provided for each of the five broad domain composites. Psychometric Properties. In the VABS standardization and supplementary samples, the five broad domains demonstrated moderate to excellent internal consistency reliability. Internal consistencies for the various subscales within each domain were much more variable, ranging from poor to excellent. Test-retest reliability was examined over 2 to 4 weeks for a subset of youths, indicating moderate to excellent stability for domain scores and for the Adaptive Behavior Composite. Interrater reliability was examined by having a second interviewer complete the VABS 1 week after the initial assessment. Correlations between the two administrations were at least good, which may comprise a conservative estimate of concordance as the measurement was somewhat confounded by stability of the VABS over the

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interim week. Parents’ and teachers’ adequate agreement regarding the developmental functioning of youths with pervasive development disorder also supports interrater reliability (Szatmari et al., 1994). Validity of the VABS has been demonstrated over many years. In the technical manual (Sparrow et al., 1984), convergent validity is supported by the low to moderate correlations with other measures of adaptive behavior. The VABS correlate poorly to moderately with measures of intelligence and receptive language; with correlations higher for overlapping content areas, as might be expected (Atkinson et al., 1992; Raggio et al., 1994). For example, scores on the VABS Communication domain correlated better with measures of receptive language and academic achievement than did the other VABS domains. Validity of the Motor domain has also been supported for younger children (Taylor et al., 1990). Furthermore, low to moderate correlations have recently been found between the VABS and neuropsychological measures in children born at extremely low birth weight (Rosenbaum et al., 1995). Factor analyses provide some support for the VABS’s separate domain scores, although interpretation is somewhat complicated given that some subscales are not relevant for all ages, for example, Written Communication with children younger than 4 years of age. Furthermore, mentally retarded children have scored lower than children with normal intellect (Balboni et al., 2001) and children with Asperger’s disorder have scored higher than those with autism on the Communication, Socialization, and Daily Living Skills domains of the VABS (Szatmari et al., 1995), suggesting that VABS scores differentiate clinical from nonclinical groups. Applications. The VABS have been successfully used in many diverse applications over the past three decades, including validating other scales (Middleton et al., 1990) and in international studies (Fombonne and Achard, 1993). The VABS have been used with very young children (Irwin et al., 2002; Raggio and Massingale, 1993; Stone et al., 1999), making it a popular scale for use with developmentally impaired infants and preschoolers. It has also been extensively used with youths diagnosed with autism spectrum disorders (Venter et al., 1992) and establishing baseline functioning in youths undergoing genetic assessment (Szatmari et al., 2002). Other developmental disorders, such as fragile X syndrome, are also readily assessed with the VABS (Dykens et al., 1996). The differential functioning of youths with

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various psychiatric disorders has also been examined. For example, adolescents with ADHD showed lower VABS scores on Socialization compared with learning disabled youths (Wilson and Marcotte, 1996). Finally, the VABS have been used to assess treatment outcome with pharmacotherapy (Belsito et al., 2001) and educational programming (Panerai et al., 1997). Advantages and Disadvantages. The VABS are the most established scales reviewed here, with a particular niche for school-age children and adolescents with neurodevelopmental disorders, such as autism spectrum disorders or language delays. The VABS have longevity and several advantages making them the standard measure of adaptive behavior in research and clinical practice. They have a good normative base and their supplemental norms are a unique strength. This facilitates comparisons of clinically referred youths with normative peers, as well as with peers of comparable clinical and developmental status. The psychometric properties of the VABS are well established. The VABS are also considered to have an adequate basal or ‘‘floor’’ for the assessment of school-age youths and adolescents with developmental delays. This optimizes assessment for youths with severe delays. In addition, the VABS’ relevance over the life span allows a single scale to be used to follow youths’ progress over developmental stages. Finally, the availability of multiple published studies supports the validity of the scales validity and their use for a variety of applications with diverse clinical populations. Many of the disadvantages may be addressed in the upcoming revision of the VABS. The normative data are now somewhat dated and warrant an update. In some cases, item content has poor face validity. In other words, some of the items may seem irrelevant to respondents. Although the scale is intended to be administered as a free-flowing, semistructured interview rather than an item-by-item interview, it is often difficult to cover all items using this approach. Normative data are available from early infancy through early adulthood, but the scales may be less sensitive at these extremes. However, these disadvantages are relative and not easy to address with any scale. Scales of Independent Behavior–Revised (SIB-R)

General Description. The SIB-R (Bruininks et al., 1996) are a newer measure of adaptive and problem

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behaviors that have been used less extensively than the VABS. The SIB-R purport to measure not just adaptive behavior but independence in those behaviors. They cover a broad age range from infancy to adulthood and have both interview-administered and checklistadministration procedures. Their primary use is to identify individuals who lack adaptive, functional independence in particular contexts for the purpose of developing individualized plans in educational or other service settings. Authors note that the SIB-R do not require extensive training. Scales and Scoring. The SIB-R have a total of 259 items. There are several forms: the Full Scale, the Short Form, and the Early Development Form. The Problem Behavior Scale is designed to be added to any of these forms. The SIB-R Full Scale is composed of 14 subscales divided into four adaptive behavior clusters: Motor Skills (with Gross and Fine subscales), Social Interaction and Communication (with Social Interaction, Language Comprehension, and Language Expression subscales), Personal Living Skills (with Eating and Meal Preparation, Toileting, Dressing, Personal Self-Care, and Domestic Skills subscales), and Community Living (with Time and Punctuality, Money and Value, Work Skills, and Home/Community Orientation subscales). Subscales contain as many as 20 items, each of which is scored on a 4-point Likert scale based on performance of the task. The Full Scale form takes less than an hour to administer. The Short Form is a brief overall screening tool for individuals of any age containing 40 items selected from subscales of the Full Scale form; administration requires 15 to 20 minutes. The Early Development form is applicable from early infancy to 6 years of age or for individuals with developmental levels below age 8. It contains a sampling of 40 items from the Full Scale form. Like the VABS, estimated starting points are provided by age, and basal and ceiling rules are used to ensure that an individual’s abilities are adequately represented. The SIB-R Problem Behavior Scale rates eight problem behavior areas. It contains three broad maladaptive behavior indexes that are further broken down into subscales: Internalized Maladaptive Behavior, Asocial Maladaptive Behavior, and Externalized Maladaptive Behavior. The respondent is asked to provide openended descriptions of specific problem behaviors within each subscale. Each specific problem behavior named is rated along four dimensions: the description of specific

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problem behavior, frequency of occurrence, severity, and usual management response by others. The authors selected this approach to be more representative of the impact of problem behaviors on functioning. A total score on the maladaptive index is derived, ranging from good to extremely serious. Using the norm tables, each cluster raw score and the Broad Independence raw score (obtained by averaging the cluster scores) are further translated into the Relative Mastery Index (RMI), standard score, percentile rank, and an adaptive behavior skill level. The Problem Behavior scoring is simpler. It derives a raw score for each Maladaptive Index and a General Maladaptive Index score. Finally, a Support Score from 0 to 100 is derived from the Broad Independence and General Maladaptive Index scores. A computerized scoring program is available. Normative Data. Normative data for the SIB-R were collected from 2,182 individuals aged 3 months to 90 years in a nationally and ethnically representative sample during the 1980s. Data were also collected on samples of children with mental retardation and blind individuals. Psychometric Properties. The SIB-R technical manual reports good to excellent internal consistency reliability for the Adaptive Behavior cluster scores and Broad Independence score. Excellent internal consistency reliability was reported in a smaller sample with mental retardation. The SIB-R have excellent stability over a 4-week period; somewhat higher test-retest reliabilities are reported for the composite than for the individual cluster scores. The manual reports good interrater reliability between parent respondents on the cluster scores and excellent interrater reliability on the Broad Independence score. Similarly, good interrater reliability was reported among teachers of students with mental retardation but was lower for the Problem Behavior scores. Convergent validity is supported by good correlation between the SIB Broad Independence score and VABS Adaptive Behavior Composite (Middleton et al., 1990). The SIB-R Problem Scale showed only moderate correlation with the Reiss Screen for Maladaptive Behavior, likely reflecting differences in the problem behaviors tapped by the scales (McIntyre et al., 2002). SIB-R scores have been found to differentiate between levels of mental retardation and degree of restrictiveness of educational placement (Bruininks et al., 1996).

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Applications. There are relatively few published studies using the SIB-R or their predecessor. In a recent study, the Problem Scale of the SIB-R was used as one measure of the impact of the dual diagnosis of intellectual disability and mental disorder in young adults (McIntyre et al., 2002). The authors report that the SIB-R are in wide use in preschool and special education programs, but they do not appear to have supplanted the better known VABS. Advantages and Disadvantages. The SIB-R offer several distinctive features as scales of adaptive functioning. They specifically address the issue of independence that may be especially relevant for older teens approaching independent living. The SIB-R reliably measures both adaptive and maladaptive behaviors, and the balance between them is summarized in a Support score that can be used to determine service intensity. Administration of the SIB-R does not require extensive training, and several shorter forms are available, including a checklist form that can be completed in lieu of an interview. Like the VABS, the SIB-R have a special niche among youths with developmental disabilities and allows their adaptive skills to be followed over time. Disadvantages include its relative lack of empirical data and applications. Scoring of the Adaptive Behavior section is complex such that completing and scoring the Full Scale SIB-R and the Problem Behavior Scales are timeconsuming, decreasing utility of this scale. Adaptive Behavior Assessment System–Second Edition (ABAS-2)

General Description. The ABAS-2 (Harrison and Oakland, 2003) is a multidimensional instrument that is commercially published and receives use in clinical settings, particularly with developmentally delayed individuals. The ABAS-2 is intended for use with individuals aged birth through 89 years. In an effort to tailor the scales to this wide age range, there are separate forms of the ABAS-2 by age with variations in item content. These include parent report forms for young children ages 0 to 5 years and those 5 to 21 years, teacher/day care provider report for children ages 2 to 5 years and teacher report for youths 5 to 21 years, and a self-report form for adolescents ages 16 and older through elderly adults. The self-report adolescent/adult form can be completed by a caregiver for developmentally delayed individuals unable to provide accurate data.

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Scales and Scoring. The ABAS-2 parent and teacher/day care provider forms for young children include subscales assessing communication, community use, functional preacademics, school/home living, health and safety, leisure, self-care, self-direction, social skills, and motor development. The parent, teacher, and self-report forms include 10 subscales: Communication, Community Use, Functional Academics, School/Home Living, Health and Safety, Leisure, Self-Care, Self-Direction, Social, and Work. At all ages, scores from these subscales are used to calculate composites for Conceptual, Social, and Practical domains. These domains overlap with those identified by the American Association on Mental Retardation (2002) and in DSMIV-TR (American Psychiatric Association, 2000a) for adaptive behavior delays required for a diagnosis of mental retardation. Items on the ABAS-2 ask respondents to indicate whether the individual is able to perform the skill independently and how frequently he or she demonstrates the skill when required. Items are rated on a 4-point Likert-type scale with anchors ranging from ‘‘never’’ to ‘‘always.’’ One innovation unique to this scale is an opportunity for respondents to indicate whether they ‘‘guessed’’ on each of the items; in other words, whether they were unsure whether the individual could perform the skill based on their own observations. These ‘‘guessed’’ items are counted and, if more than 3 items are checked, reviewed with the respondent. This allows clinicians to assess the respondents’ ability to rate their patient and either interpret scores with caution or discard ratings deemed to be invalid. Scaled scores are derived for each subscale, and standard scores are calculated for the Conceptual, Social, and Practical domains and for a total score. Normative Data. Standardization data were collected for a very large, ethnically and regionally diverse sample. More importantly, the normative samples are large for each of the developmental stages and for the various forms of the ABAS-2. For example, the normative data for young children ages 0 through 5 are based on 750 teacher/day care provider ratings and 1,350 parent ratings; for the school-age forms, norms are based on 1,690 teacher and 1,670 parent ratings and for the adult self-/other report forms, normative data were collected for 990 self-reports and 920 other caregiver reports.

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Psychometric Properties. Internal consistency reliabilities for the ABAS-2 composite scores range from moderate to excellent, with most values being very good to excellent for all age groups. Importantly, internal consistency reliability remains strong for youths from the normative sample who received below average scores and in clinical populations, such as those diagnosed with ADHD, mental retardation, and autism. Shortterm test-retest reliability is also strong, with values ranging from good to excellent for composite scores. Interrater reliabilities, including teacher-teacher and parent-parent agreement, are moderate to very good and are generally higher than observed with other behavior rating scales. As might be expected, correlations between parent and teacher ratings are lower, although these are still in the moderate to good range. The validity of the ABAS-2 is supported in several respects. The scale was found to correlate significantly with the VABS Classroom Edition, the VABS Survey Form, and the SIB-R Early Development and Short Forms. Correlations range from low-moderate to good’’ in magnitude. Low to moderate correlations were also observed between the ABAS-2 and the Wechsler Intelligence Scales, the Wechsler Academic Achievement Scales, and the Stanford-Binet Intelligence Test. These findings all lend support to the scale’s convergent validity. Evidence of divergent validity is provided by statistically significant, inverse correlations with the Internalizing Problems, Externalizing Problems, and Behavior Symptoms Indices of the Behavior Assessment System for Children. In other words, increased behavior problems on the Behavior Assessment System for Children were associated with poorer adaptive functioning. Abundant evidence is provided to support the clinical validity and utility of the ABAS-2. For example, the ABAS-2 differentiates typically developing youths from demographically matched youths with mental retardation, developmental delays, biological risk factors for developmental delay, motor or other physical impairment, receptive/expressive language disorders, autism spectrum disorders, ADHD, behavioral/emotional disorders, and learning disabilities. Within these clinical groups, youths with mental retardation received lower scores than those with ADHD and those with behavioral/emotional disorders. Further, these groups differed with regard to their score profiles: youths with mental retardation received their lowest scores in Communication and Functional Skills domains,

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whereas those with ADHD and behavioral/emotional disorders received their lowest scores in Self-Direction skills. Sensitivity and specificity are not provided. Applications. No published applications with the ABAS-2 were located. Advantages and Disadvantages. The technical properties of the ABAS-2 are impressive, and set it apart from most of the other measures reviewed here. The scale is based on a very large normative sample including large samples for each age group. This lends confidence in comparisons between a given youth and his or her peer group, which is very important in clinical assessment. The utility of the scale is increased substantially by having multiple response forms, with modifications for developmental stage and for a variety of respondents. In developmentally delayed populations, there is often interest in tracking the development of adaptive behaviors over long-term intervals, such as over the course of their special education enrollment. This is important in that it allows for adequate assessment of a broad range of skills at these developmental levels. The opportunity for respondents to indicate whether they have ‘‘guessed’’ on items is unique. Clinically, parents and teachers will often skip items if they are unsure and/or will provide a rating without indicating their uncertainty. Both of these scenarios can be problematic. Collecting these data allows clinicians to gauge the validity of respondents’ ratings. Finally, it is advantageous that the developers of the ABAS-2 have focused the assessment of adaptive behavior on areas established by the American Association on Mental Retardation and in DSM-IV-TR criteria for mental retardation because such assessment will be the primary use of the scale. The primary disadvantage relates to the absence of published applications. To some extent, this may relate to the recent development of the ABAS-2, although applications with the original version also could not be located in the literature. This makes it difficult to determine whether the reliability and validity data obtained in the development of the scale will be replicated with new samples, including various clinically referred populations. Particularly important would be studies investigating the scale’s diagnostic sensitivity and specificity and sensitivity to treatment effects. The ABAS-2 is lengthy, reducing its utility in many applications and making it most appropriate for initial assessment rather than repeated administration.

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The Social Adjustment Inventory for Children and Adolescents (SAICA)

General Description. The SAICA (John et al., 1987) is another scale with considerable longevity. It is a clinician-administered, semistructured interview that assesses multiple domains of social functioning. It is intended to capture a youth’s strengths and weaknesses in social behavior across multiple contexts, including school, home, and community. The SAICA is appropriate for ages 6 to 18 and can be completed as either a youth report or parent report measure. Because the scale is respondent based, it does not require clinician judgment in assigning scores. Administration of the SAICA does not require specific training, although authors have recommended that interviewers have knowledge of child development and clinical experience with children and adolescents (John et al., 1987). Scales and Scoring. The SAICA’s 77 items tap four major areas of social functioning: school, peer relations, home life, and spare time activities. Factor analysis revealed three primary factors, labeled Spare-Time Sociability, Family Relations, and Task Performance (John et al., 1987). However, these empirically derived scales are seldom used because previous authors have suggested that they may obscure clinically important aspects of social behavior. Rather, the SAICA is scored according to multiple clinically derived subscales: School-Academic, School-Social, Social Problems, SpareTime Activities, Peer Relationships, Peer Problems, Peer Heterosexual Adjustment, Sibling Relationships, and Home Problems. Average item scores are calculated for each subscale, as well as a Total or Global Adjustment score. The SAICA uses a 4-point rating scale, where 1 represents ‘‘best adjustment’’ and 4 represents ‘‘worst adjustment.’’ Normative Data. No normative data have been published. Psychometric Properties. Published psychometric data available for the SAICA are limited. In the most extensive psychometric study using 124 children of depressed and normal parents, low to moderate internal consistency for the scale composite or total score was reported (John et al., 1987). This apparently suboptimal internal consistency is not necessarily a disadvantage for this type of scale because each subscale assesses a different area of a youth’s functioning. Impairment or adjustment in one area may not be expected to greatly overlap with how

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a youth does in another area. High interrater agreement for subscales has also been reported (King et al., 1993). Convergent validity has been established in relation to the Social Competence Scales of the CBCL and the Global Assessment of Functioning (John et al., 1987) as well as in relation to youths with ADHD (Biederman et al., 1993). Validity is also supported by significant differences between ADHD youths and nonclinical controls (Biederman et al., 1993). Further, comorbid diagnoses such as conduct disorder, major depression, and anxiety were associated with greater social impairment. Applications. Since its development, the SAICA has received sporadic use in the literature. The SAICA has predominantly been used as a research measure to assess impairment and adjustment of youths dealing with specific clinical disorders and involvement with mental health services. Clinical samples have included children with ADHD (Biederman et al., 1993; Greene et al., 1996), youths with bipolar disorder (Robertson et al., 2001), and adolescents at risk of schizophrenia (Hans et al., 2000). SAICA scores have also predicted posthospitalization social adaptation (King et al., 1996; 1997). In another study, the SAICA was able to detect differences between two at-risk groups of children, further supporting its clinical validity (Nunes et al., 1998). Advantages and Disadvantages. Among the scales reviewed here, the SAICA has the unique advantage of an exclusive focus on and in-depth assessment of social adjustment, a dimension that is affected by most psychiatric disorders. Other advantages include its ability to differentiate clinical from nonclinical populations and ease of administration, especially because clinical judgment is minimized. The use of the SAICA in previous research with diverse clinical samples supports the scale’s utility. The SAICA’s primary disadvantage relates to the lack of established normative data. This severely limits use in clinical settings, where the primary interest would be in evaluating patients’ social functioning relative to sameage peers. Psychometric examination has been limited. Although research utility appears more promising, the scale is lengthy, requiring at least 30 minutes for completion. This may limit use in some research protocols, particularly in epidemiological research and/or when multiple measures are being collected. In addition, because the initial psychometric data were reported with clinically trained interviewers, further assessment is needed to determine whether the SAICA can be reliably

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administered by lay interviewers, as the authors intended. Layperson administration would greatly increase its utility. Finally, the direction of scoring is not intuitive, i.e., higher scores indicate worse adjustment. Behavioral and Emotional Rating Scale (BERS)

General Description. The BERS (Epstein and Sharma, 1998) is a newer scale for both children and adolescents, although its development and psychometric properties have been well described in the literature. The BERS was one of the first scales to assess youths’ functioning by emphasizing their strengths rather than their deficits. Strength-based treatment planning has come into favor as one of the essential elements of the ‘‘wraparound’’ approach to treatment planning (VanDenBerg and Grealish, 1996), which evolved out of the Child and Adolescent Service System Program (Lourie et al., 1996; Stroul and Friedman, 1986). By emphasizing strengths within the wraparound approach, youths may be better served within their communities with a flexible array of services rather than being treated in more restrictive settings. The BERS also includes items specific to school functioning and has developed a particular niche in special education settings. The scale is completed by an adult knowledgeable about the youths, such as a parent, teacher, or counselor. Scales and Scoring. The BERS is a 52-item scale measuring children’s emotional and behavioral strengths. The BERS underwent a three-step development process (Epstein, 1999; Epstein et al., 2002a,b). Initial items were contributed by a group of educators and parents to ensure relevance to the school and home setting. Then items were selected from this pool based on their ability to discriminate between youths with serious emotional or behavioral disorders attending an alternative school and students attending a general high school. Items were then subjected to factor analysis, yielding the final five factors or subscales: Interpersonal Strengths (e.g., reacts to disappointment in a calm manner), Family Involvement (e.g., participates in family activities), Intrapersonal Strengths (e.g., demonstrates a sense of humor), School Functioning (pays attention in class), and Affective Strengths (e.g. acknowledges painful feelings). The BERS is scored on a 4-point Likert scale. Scores are derived for each of the subscales and for a Composite Strength Quotient.

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Normative Data. The BERS was standardized on a nationally representative community sample of 2,176 nondisabled children and adolescents and 861 children with emotional and behavioral disorders (Epstein, 1999). The manual includes norms for each subscale both as raw score means and as standard scores. Psychometric Properties. Psychometric properties of the BERS have been described in several publications. The BERS has demonstrated good to excellent internal consistencies, interrater reliability, short-term test stability, and adequate long-term test stability (Epstein et al., 1999, 2001b). Convergent validity has been evaluated in special education students with teachers as informants (Epstein et al., 2002a; Harniss et al., 1999). Some support for convergent validity was shown through positive correlations with the Achenbach Teacher’s Report Form (Achenbach, 1991) and other scales of social competence such as the Walker-McConnell Scale of Social Competence (Walker and McConnell, 1996). As might be expected, higher correlations were found with more similar aspects of the scales. For example, the BERS subscale of Interpersonal Strength correlated highly with the Walker-McConnell subscale of Self-Control and with the Achenbach Teacher’s Report Form Externalizing dimension and less well with the Academic Performance items of the Teacher’s Report Form subscales. The BERS has also differentiated normal subjects from those designated as seriously emotionally disturbed and, more impressively, youths with learning disabilities from those with emotional/behavioral disturbances (Reid et al., 2000). Applications. The BERS is a relatively new scale that has already been widely used in educational settings and community mental health settings with strength-based planning initiatives. Its authors recommend several uses for the BERS, including use in developing goals and objectives for individualized educational planning and use as an outcome measure to document progress with specialized services. It is appealing as an evidence-based outcome measure documenting response to school interventions. As noted above, it has been used to examine strengths in youths with learning disabilities, emotional disturbances, and disruptive behaviors. The BERS has been compared with the Childhood Severity of Psychiatric Illness (CSPI) (Lyons, 1998) to examine the role of strengths in decisions about placement (Oswald et al., 2001). Child strengths on the BERS were negatively

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correlated with CSPI symptoms, functional impairment, and risk and showed an association with children’s placement. These findings suggest some degree of divergent validity. A recent review indicated that a number of statewide mental health initiatives are using the BERS to monitor outcomes, predict success of community placements, and characterize children receiving services (Epstein et al., 2001a). Advantages and Disadvantages. The primary advantages of the BERS are twofold: its unique emphasis on youths’ strengths, especially because this has become a major focus of the community mental health movement, and its incorporation into educational planning for emotionally and behaviorally disturbed youths. A scale that is specific to the multiple needs of this challenging population should find widespread applications. Additionally, unlike most scales assessing functional impairment, the BERS’ psychometric functioning has been well examined and demonstrates sound properties. However, the BERS does not address all aspects of functioning needed for treatment planning or for studying treatment outcomes. Another potential problem is that different informants seem to be required to adequately rate a youth in different domains and yield an accurate summary score (Friedman et al., 1999). The need for more than one informant decreases the utility of the BERS. However, these disadvantages are relatively minor given its focus on a special-needs and difficult-to-serve population. Child and Adolescent Functional Assessment Scale (CAFAS)

General Description. The CAFAS (Hodges, 1994) is a clinician-administered interview that is among the most widely used multidimensional scales measuring functional impairment in children and adolescents. It was adapted as a child and adolescent version of the North Carolina Functional Assessment Scale for adults and used to evaluate the Fort Bragg Child and Adolescent Mental Health Evaluation Project (Bickman, 1996). The CAFAS assesses the degree of impairment associated with emotional, behavioral, or substance abuse problems. It provides several levels of information to guide treatment planning and evaluation. The CAFAS has found a special niche in mental health services research, community mental health settings, and mental health administration.

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Scales and Scoring. The original version of the CAFAS consisted of 164 items in seven subscales reflecting distinct domains of youths’ functioning. It is not clear whether the items or domains were clinically or empirically derived. Five of the subscale domains pertain to the youth’s functioning and two assess the youth’s caregivers. The youth subscales include Role Performance (how effectively the youth fulfills societal roles in school, home, and community), Behavior Toward Self and Others (appropriateness of the youth’s daily behavior), Thinking (ability to use rational thought processes), Moods/Emotions (modulation of the youth’s emotional life), and Substance Abuse (extent of use and degree to which it is disruptive). The caregiver subscales include Basic Needs (caregiver ability to provide for the child’s basic needs) and Family/Social Support (the degree to which the relationship and nurturance provided by the caregiver meets the child’s needs). Although the caregiver scales are optional and do not contribute to the scale’s scoring, they provide useful clinical information, particularly because they give a contextual perspective within which to consider youths’ needs in treatment planning. Each subscale, or domain, receives a single score denoting one of four possible levels of functional impairment: minimal or no impairment, mild impairment (significant problems or distress), moderate impairment (persistent disruption or occasional major disruption in functioning), and severe impairment (severe disruption or incapacitation). Each impairment level contains specific behavioral descriptors from which the rater chooses all applicable items, starting with items in the severe impairment category. Ratings reflect the most severe level of dysfunction within the time period specified by the user (usually 1–3 months). Each of the youth’s five subscales yields a separate score, and the five subscales are summed to generate a total score, with higher scores reflecting greater impairment. Although the scoring itself is relatively brief if the rater is familiar with the youth’s behavior and functioning, a considerable amount of clinical data are needed from multiple sources. A structured 30-minute interview has been developed to obtain the information needed from the caregiver and child to score the CAFAS (Hodges, 1995), but it is not essential to its use. There is no literature examining differences in the quality of information obtained using this structured interview versus information obtained in usual data gathering.

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The second revision of the CAFAS (Hodges, 2000) contains 315 items and expands the scoring range by generating separate scores for each of the Role Performance areas (School/Work, Community, and Home) and separate scores for Moods/Emotions and Moods/Self-Harm. Unfortunately, this has led to multiple scoring schemes in published studies, making comparability of scores problematic (Bates, 2001). Overall, the CAFAS provides several levels of information: the specific behavioral items endorsed, the level of impairment for each subscale, and the summary score reflecting overall impairment. Normative Data. No normative data are available. However, such a normative base may not be so relevant for the CAFAS when used to determine the appropriate level of services to be provided in a particular setting. Psychometric Properties. The CAFAS has shown only moderate total scale internal consistency reliability (Hodges and Wong, 1996). As noted above, this is not necessarily prohibitive given the expected variability among subscales in a multidimensional instrument. Interrater reliability has been examined with different groups of trained raters, including community mental health workers, graduate students, and layperson raters (Hodges and Wong, 1996), using detailed clinical vignettes. Interrater reliability was excellent for the Total score, excellent for the Substance Abuse subscale, good to excellent for the Behavior Toward Others/Self and the Role Performance subscales, moderate to excellent for the Moods/Emotions, and moderate to good for the Caregiver subscales. The Thinking subscale was not included in the analysis because thought disorder occurred at a low frequency in the clinical vignettes. Interrater reliability has not been described for actual subjects versus clinical vignettes or for settings in which raters are involved in the youth’s treatment (Bates, 2001). CAFAS scores appear stable over a 1-week interval in telephone interviews (Hodges, 1995). There is also good evidence of convergent validity because the CAFAS is highly correlated with the CGAS and moderately correlated with the CBCL’s Total Problems score as well as with other measures of youths’ functioning (Hodges and Wong, 1996). CAFAS scores have also correlated well with independent ratings by parents, teachers, and youths regarding specific problem behaviors in social relationships, school, and legal areas (Hodges and Wong, 1996). Scores on the CAFAS have been found to differentiate outpatient youths from those

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in inpatient or residential treatment settings (Hodges and Wong, 1996). Scores have also been found to predict use and cost of mental health services (Hodges and Gust, 1995), juvenile recidivism (Quist and Matshazi, 2000), contact with the law, and poor school attendance (Hodges and Kim, 2000). These findings all lend support the scale’s predictive validity. Applications. The CAFAS is used extensively in health services research, in mental health administration, by state health administrators, and in clinical settings. The author provides group training to interested users and there is a Web site to update users on new information (www.cafas.com). Most notably, the CAFAS was the major outcome variable in two large studies of health service delivery: the Fort Bragg Evaluation Project (Lambert and Guthrie, 1996) and the Comprehensive Community Mental Health Services for Children and Their Families Program (Hodges et al., 1999; 2000). In these investigations and other work, the CAFAS has been sensitive to treatment gains (Walrath et al., 2001), has been shown to predict outcomes in youths receiving residential treatment (Gorske et al., 2003), and to predict service use over 6 months for youths with serious emotional disturbance (Hodges and Wong, 1997; Hodges et al., 2000). The CAFAS has also been used along with other behavior rating scales in a combined screening protocol intended to identify young children at risk of disruptive behavioral disorders (Casat et al., 1999, 2000), indicating some potential as a screening tool. The CAFAS has been used to establish convergent validity for newly developed scales, such as the Target Symptoms Rating (Barber et al., 2002). Clinically, the CAFAS is being used by many states to determine eligibility for state-funded programs or for measuring the performance of mental health programs (Hodges and Gust, 1995; Hodges et al., 1998). Finally, the CAFAS has been revised for use with preschoolers, the Preschool and Early Childhood Functional Assessment Scale. Examination with a normative Head Start sample demonstrated good interrater reliability, good internal consistency for the five subscales, and concurrent validity with referrals for mental health evaluations and teacher ratings of behavior problems (Murphy et al., 1999). Advantages and Disadvantages. The CAFAS has many advantages. It provides several levels of information about impairment in each specific area of functioning, allowing precise assessment of areas needing clinical

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intervention. The selection of specific behavioral descriptors to determine severity level for each subscale may make the CAFAS less subject to rater bias than some global scales or even multidimensional scales that rely on rater judgment. These specific descriptors are recorded and can then be tracked as treatment progresses. This is a very nice feature to establish evidence-based treatment and to develop dialogue with families about youths’ improving functioning in different contexts. If no functional progress is noted, the treatment plan can then be revised with the family to better target relevant functional domains. Psychometric properties are good. Furthermore, the use of the CAFAS in several large studies allows potential users to determine how appropriate it may be for their intended use. Availability of the Preschool and Early Childhood Functional Assessment Scale allows younger children to be included in assessments and provides continuity of instrumentation in longitudinal assessment from preschool onward. A potential disadvantage of the CAFAS’ design is the mixture of symptom-based items along with items assessing functioning. For example, the Thinking and Moods/Emotions subscales contain items typically associated with mood and psychotic symptoms. Thus, the scale is not a ‘‘pure’’ measure of functional impairment. In fact, the inclusion of symptom areas may explain the CAFAS’ ability to predict service use given that both problems in functioning (such as aggression or school attendance) and specific symptoms (such as suicidal behavior and psychosis) are likely to be determinants of level of care decision making. Nonetheless, there are now multiple studies showing the value of scores on the CAFAS in the prediction of ecologically valid indicators of functioning, such as school performance, contact with the legal system, and use of services. There may also be a disadvantage to the scoring that gives precedence to the behavioral descriptor indicating the highest level of severity. Although the most severe problem may be most relevant to clinical planning in most cases, there may also be situations in which the scoring fails to capture areas of strength and overrates impairment. Although reliability using clinical vignettes has been established, reliability in clinical settings where information is more varied, limited, or skewed remains undetermined. Also, the CAFAS has been criticized regarding its psychometric functioning and/or the lack of rigorous examination of its functioning (Bates, 2001).

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Although completion of the CAFAS can be accomplished in 10 minutes, collection of the data needed to rate the CAFAS is time-consuming, and it has been suggested that clinicians perceive some burden associated with its use (Bates, 2001). Child and Adolescent Needs and Strengths–Mental Health (CANS-MH)

General Description. The CANS-MH (Lyons et al., 1999) is a newer scale based on the authors’ previous work with the Childhood Severity of Psychiatric Illness Scale (CSPI) (Lyons, 1998). Although the CSPI is no longer commercially available or routinely used, we refer to it here to provide some foundation for understanding functioning of the CANS-MH, which is in its early stages of implementation. The CSPI was a multidimensional measure of both psychiatric illness and functional impairment that attempted to measure mental health treatment outcome beyond symptom resolution. It addressed multiple aspects of youths’ treatment needs, including severity of symptoms, level of risk, and contextual information regarding residential placement and functioning across settings (Lyons et al., 1996, 1997a). The authors then took the next step to develop a strength-based instrument, the CANS-MH. The CANS-MH is a layperson- or clinician-administered interview intended to measure the functional impairments and strengths of youths with emotional and behavioral disorders and to use these results to develop treatment algorithms that guide service delivery. This scale expands beyond the CSPI to include not only the assessment of strengths, but also a broader conceptualization of needs. The CANS-MH is designed for use at two levels. For the individual youth and family, the CANS-MH uses a structured assessment of youths along a set of dimensions relevant to decision making that aids in developing an individual plan of care. For the system of care, the CANS-MH provides information regarding the youth’s and family’s service needs for use during system planning and/or quality assurance monitoring (Lyons et al., 1999). As with the CSPI, the CANS-MH may be used as either a prospective assessment tool or a retrospective assessment tool based on review of existing information. As a prospective tool, the CANS-MH assesses youths at presentation to develop a plan of care. As a retrospective tool, the CANS-MH provides an assessment of records of youths already

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in care as well an assessment of the current system serving them. The system of care is evaluated in relation to the needs and strengths of the youth and family and may point out gaps in the service system in addressing those needs and strengths. This information is then used to develop the community-based, family-focused system of services appropriate for the target population and the community. The CANS actually comprises a system of scales relevant to youths in different systems of care. Because the children’s service system is diverse and complex, the CANS seeks to support communication across different child-serving agencies and approaches. Thus, there are other forms of the CANS tailored to youths with developmental disabilities (CANS-DD), in the child welfare system (CANS-CW), and in the juvenile justice system (CANS-JJ). There is also a form for early development (CANS 0 to 3). These forms were developed using focus groups with families, family advocates, providers, and mental health caseworkers, emphasizing its focus on promoting communication. The CANS system is unique in its broad systems applications. Scales and Scoring. The CANS-MH consists of six clinically derived dimensions: Problem Presentation, Risk Behaviors, Functioning, Care Intensity and Organization, Family/Caregiver Needs and Strengths, Strengths. These last two dimensions focusing on strengths are the main features distinguishing the CANS-MH from the CSPI. Each of these six dimensions is rated on a 4-point Likert type scale that is geared to how much action, or service, is indicated, e.g., 0 = no need for action; 1 = need for watchful waiting; 2 = need for action; 3 = need for either immediate or intensive action. Each point on the rating scale has multiple examples specific to the different types of problems within each dimension. As an example, the Family/Caregiver Needs and Strengths dimension contains eight items: physical/behavioral health, supervision, involvement, knowledge, organization, resources, residential stability, and safety. Each of these eight items then has its own 4-point rating with descriptors for each of these rating points. Individual scores are then applied to an algorithm to determine treatment needs, specifically the level of care that a youth needs. The algorithm can be adapted and individualized to different applications (Lyons, 2004). Dimensional scores are used to monitor outcomes.

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Although each dimension has a numerical ranking, the CANS-MH is designed to give a profile of the needs and strengths of the child and family. It is not designed to sum the scores of the dimensions into an overall rating, although such scoring is an option. When used in a retrospective review of cases, it is designed to give a profile of the system of services and the gaps in the service system not an overall score of the current system. Normative Data. No formal normative data are available, although the authors have noted data from a large sample that has been used in a normative manner (Lyons et al., 2004). The CANS-MH predecessor, the CSPI, has been used with large, ethnically and diagnostically heterogeneous samples of youths in age from 2 to 20 years, providing good clinical comparison data for users who are interested in these scales’ functioning. However, as the CANS-MH is intended for use in service delivery, such normative data may not be as relevant as for symptom-based rating scales. Psychometric Properties. The authors report examining the CANS-MH in many studies, some of which have been published (Anderson et al., 2003), but many of which are cited in book chapters (Lyons, 2004; Lyons et al., 2004) or on the author’s Web site (www.buddinpraed.org) and therefore have not yet been subject to peer review. Preliminary internal consistency reliability appears adequate (Lyons et al., 2004). Reportedly, in more than 20 studies using clinical vignettes and involving hundreds of trainees, the interrater reliability was in the moderate range, similar to the concordance reported for its predecessor, the CSPI, in both clinical vignettes and field applications (Leon et al., 1999; Lyons et al., 2000). This functioning of the CSPI in the field may lend some support for interrater reliability of the CANS-MH in actual practice. In chart reviews, 25 reviewers demonstrated good overall interrater reliability and moderate reliability at the item level. Interrater reliability of the six dimensions ranged from moderate (Caregiver Needs and Strengths) to very good (Functioning). Test-retest reliability has not been reported. The authors note that in terms of validity, the CANSMH correlates with other measures that also assess psychopathology, functioning, and strengths, such as the CAFAS. Also, when used as a decision-support tool, the CANS-MH agreed with an expert panel of clinicians 91% of the time. In a large sample of more than 1,500 youths in 15 different programs the six dimensions of the CANS-MH successfully differentiated youths’ level

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of care. Also, the CANS has been shown to distinguish levels of care and intensity of services. Indirect support for validity of the CANS-MH may be also be derived from validation studies with the CSPI, which provided evidence for divergent validity (Lyons et al., 2000); differentiation of offenders in institutional versus community detention settings (Lyons et al., 2001); and prediction of psychiatric hospitalization (Leon et al., 1999; Lyons et al., 1997b). Applications. Because the CANS-MH is very new, there are few studies published in peer-reviewed journals. The scale has been successfully used in many states for decision support (e.g., level of care and service planning), quality assurance, and outcome monitoring activities (Lyons, 2004). It also demonstrated good concordance between clinicians’ and researchers’ assessment of youths from direct interviews and from chart reviews (Anderson et al., 2003). The CANS-MH has also been used to examine outcomes in a juvenile detention population with mood and psychotic disorders (Lyons et al., 2003) and, most recently, in a study on pharmacological management of youths with multiple comorbid disorders. The latter investigation led to an initiative regarding quality improvement in the use of psychotropic medications with youth (Lyons et al., 2004). Despite the dearth of published work, the CANS-MH has already found diverse applications in community mental health settings across the nation, as noted on the author’s Web site (www.buddinpraed.org). These include use in Alaska’s Alaskan Youth Initiative to assess service need in Sitka, Alaska, and Philadelphia to monitor treatment adherence in a wraparound fidelity model; in New York’s Single Point of Accountability model for children’s services; and in the Illinois Department of Children and Family Services as an outcome tool in its new Systems of Care initiative. Advantages and Disadvantages

One major advantage of the CANS-MH is its tying youths’ functioning to treatment planning and to service delivery, one of few scales to provide such a comprehensive and contextual conceptualization of youths’ needs. Another advantage is its focus on strengths, which is emphasized by the community systems of care movement that focuses on youths as part of their family and community and strives to build strengths that maintain family integrity. Its incorporation into many states’ planning provides potential users information

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about how the CANS-MH functions across these settings. Such information is conveniently shared on a Web site (www.buddinpraed.org). The CANS-MH also shares many of the strengths of the earlier CSPI, such as a flexible administration format. Also, these scales’ considerable use with youths in state custody and/or residential facilities is an advantage because such youths are among the most stressed of young people and represent clinical extremes on most rating scales. Thus, the availability of a scale specific to their needs and situation ensures clinical and contextual relevance of the obtained data. The flexible format of the CANS-MH, allowing for completion via records review or caregiver and/or youth interview, also ensures the scale’s utility with this population. Youths in state custody and those in residential treatment facilities often have extensive clinical records that can be easily accessed for review; but it is frequently difficult to complete an interview with caregivers who have adequate familiarity to provide functional impairment ratings. The use of well-defined, objective anchors on these scale limits reliance on clinician judgment and improves interrater reliability. Finally, the multiple versions of the CANS tailored to the needs of particular clinical groups represent a distinct advantage among the scales reviewed here. Of course, the major disadvantage is the limited peerreviewed published data, especially regarding psychometrics to guide the user in deciding whether the CANS-MH will function well in a selected application. Although the CANS-MH appears quite appropriate for clinical samples, the lack of formal normative data makes it impossible to compare a youth’s score with same-age peers. Also, it remains to be seen whether the scale adequately reflects impairment across developmental levels. For now, the CANS-MH may be most relevant for older latency-age children and younger adolescents. Also, data supporting the scale’s sensitivity to treatment effects is needed to better establish the CANS-MH’s utility for outcomes assessment, a major reason for using this scale. It should also be noted that the CANS-MH’s theoretical advantage of measuring both severity of symptomatology and functional impairment cuts both ways because its inclusion of symptom severity may obfuscate understanding of youths’ functioning apart from psychiatric morbidity. Finally, scoring guidelines are not well outlined in the manual or on the Web site. Thus, implementation of the scale needs clarification. The authors do provide training in the use

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of the CANS-MH and are reportedly very available to assist users with the implementation of the measure in their particular setting, which may help to address this concern. The CANS-MH will likely be increasingly used, particularly in community mental health, but for now its niche is still evolving. Other Scales

Because interest in youths’ functional impairments and adaptive functioning is new and growing, other scales are being developed. Two interesting newer scales will be briefly described. The Brief Impairment Scale (BIS) (Bird, unpublished) builds on previous research with the CGAS and the CIS. Like the CIS, it is a brief, respondent-rated measure. However, it is somewhat longer than the CIS and attempts to assess multiple domains of functional impairment independently of psychiatric symptomatology. Thus, the BIS addresses the confounding of functioning by symptomatology noted by many of the aforementioned scales. It assesses three domains of functioning: Interpersonal Relations, School/Work; and Self-Fulfillment. The BIS is a very brief scale that can be administered by a layperson, and thus it has high utility. The respondent-based format minimizes clinician judgment in scoring. Preliminary psychometric examination is quite promising. The BIS was examined in a large sample comprising one clinical and two community samples (Bird, unpublished). Two subsamples were Puerto Rican children for whom a carefully translated Spanish form of the BIS was used. The study showed good internal consistency and moderate to good stability. Some evidence of convergent validity has been established in relation to the CGAS, and the BIS differentiated mental health service users from nonusers. Further examination of the BIS to assess its clinical utility as well as public health and epidemiological research applications will be of interest in the future. The Child and Adolescent Level of Care Utilization System (CALOCUS) (American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists, 2003) is another newer scale relevant to functional assessment. Like the CANS-MH, the intent of the CALOCUS is to guide treatment planning by measuring different dimensions of functional impairment and other contextual issues important to placement decisions (Sowers et al., 2003). The CALOCUS is rated by a clinician in the context of a clinical

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evaluation. There are six dimensions from which a final rating or level of care is derived: Risk of Harm, Functional Status, Comorbid Medical or Developmental Diagnoses, Recovery Environment, Resiliency and Treatment History, and Treatment Acceptance and Engagement. Each of these six dimensions is rated according to level of severity using a 5-point scale, with objective descriptions anchoring each severity level. An algorithm is used to translate dimensional scores into one of six recommended levels of care. The CALOCUS defines each level of care operationally and offers a flexible array of ways in which to meet the identified service needs. Although the literature on the CALOCUS is limited, initial psychometric data from a national multisite trial (American Academy of Child and Adolescent Psychiatry, 2001; Fallon et al., 2001) show excellent levels of interrater reliability and adequate convergent validity when compared with the CGAS and the CAFAS, especially the subscales that are related to child functioning. More recently, the CALOCUS has shown correlation with the CBCL (Pumariega et al., 2003). Several studies have examined the CALOCUS in a child welfare population (Kilgus et al., 2003; Pumariega et al., 2003), and further field trials with child welfare and juvenile justice samples are currently under way, but data are not yet available. The appeal of the CALOCUS is that it offers a way to address the complex relationship between symptomatology, functional impairment, and treatment placement. This may explain why it has been adopted in several public mental health systems and other clinical settings. However, the training and clinical background required for its use are likely to make it less attractive in epidemiological studies, other large scale applications, and some clinical settings. More experience will be needed to determine its utility. Selecting a Scale to Assess Functional Impairment

The selection of a scale to assess functional impairment and adaptive functioning is rather straightforward because the scales cover such a narrow conceptual range, there are so few scales covering this domain, and each scale has its own relatively special focus. Major issues relate to the need for a global versus multidimensional scale, a focus on strengths rather than deficits, and how to link the assessment of youths’ functioning to service implementation. The first decision is whether a global

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scale or a multidimensional scale is needed to assess youths’ functioning. If a scale is needed that provides an overall measure of youths’ functioning across many domains of life, then both the CGAS and CIS are good choices. The CGAS clearly has the better database supporting its psychometric functioning and a wealth of published experience to guide the potential user in determining whether this scale would fit the intended application. Its stability and sensitivity to change make it an excellent choice for treatment studies, and its determination of caseness could give it a role in screening if adequate other data are collected so as to allow scoring of the CGAS. Perhaps the best reason to prefer the CIS, which has not been as well examined as the CGAS, is its administration by lay interviewers and the parallel parent and youth versions. Thus, in either clinical or research protocols for which time and cost are core constraints, the CIS could provide greater utility than the CGAS. More information will be needed about the BIS before specific applications can be recommended. However, it may be an improvement over the CIS because it pairs ease of use with an expanded and multidimensional format. If a scale is needed that measures youths’ functioning in specific dimensions of life to tailor treatment planning to specific needs, then the choice of scale is driven by several considerations, including the domains covered by a scale, the inclusion of symptomatology in the scale’s domains, the link with service development, available psychometric properties, and the particular application. For example, if the youth presents with functional difficulties in both mental health and developmental disabilities, one might consider any of these scales to establish those difficulties in functioning. However, if the youth is very young and problems are predominantly related to developmental disabilities, then the VABS, ABAS-2, or SIB-R might be preferred due to their age range over the life span. Each of these measures has been carefully developed and well standardized, with particular relevance for developmentally impaired youths. Also, because these instruments can be administered to the caregiver and/or teacher, the youth does not need to participate in the scale’s administration, possibly an advantage with very disabled children. Of these, the VABS has the advantage of numerous published applications and separate normative data for visually handicapped, hearing impaired, and autistic youths.

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If the focus of assessment is strength based, then the BERS and the CANS-MH are two major possibilities, and the SAICA may also be relevant. The BERS has developed a special focus in schools. Thus, the existing literature provides the potential user with a wealth of information regarding applications in school settings. As all youths with mental health difficulties, regardless of the specific problem or the involvement with various agencies, attend school, the BERS should be applicable to all emotionally and behaviorally challenged youths. Furthermore, in addition to its School Functioning dimension, the other subscale dimensions (Interpersonal Strengths, Intrapersonal Strengths, Affective Strengths, and Family Involvement) all nicely dovetail with school issues, probably because parents and educators contributed to the development of all scales. The BERS also has a normative base and has been well examined psychometrically, unlike most other scales presented here. Thus, this is likely the best choice for strength-based assessment of adaptive functioning, especially when school is a major focus. Of course, the BERS was not developed only for school, and it seems equally suited for the assessment of youths’ adaptive functioning in the community. However, it is not clear how to ‘‘link’’ the derived information with community service planning as it is with service planning in the school system. The CANS-MH may be the better strength-based scale for the community mental health service system, especially considering its special focus on youths in state custody and/or in residential settings. Perhaps, this explains the CANS-MH’s inclusion of more clinical dimensions related to symptomatology (Problem Presentation, Risk Behaviors). The ability to reliably use the CANS-MH retrospectively gives the scale a special niche. There appear to be two downsides of the CANS-MH compared with the BERS. First, it has a greater risk of confounding symptomatology with functioning and second it has not yet been sufficiently examined psychometrically in peer-reviewed publications. Both scales have been widely used by multiple states in community planning, but the BERS has a longer track record. Overall, if potential users want a tool to guide their thinking and assist decision making, either scale may be helpful. However, when potential users need a scale for research purposes, to reliably monitor outcomes, or to validly differentiate youths for interventions, then the BERS may be the preferred scale at this time. A major role for the SAICA is not so clear.

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Although this scale does assess strengths over relevant dimensions of youths’ lives, it may be too symptom or disorder focused. Indeed, the SAICA seems to have been mostly used by clinicians to assess functioning in the face of specific disorders rather than by mental health planners to determine service needs. However, the SAICA has not been widely used despite its longevity. It certainly has advantages, such as minimizing clinician judgment by being respondent based and not requiring specific training. Perhaps it will have a renaissance as interest in measuring youths’ functioning grows. If selecting a scale that will indicate the level and types of services that youths need is the main focus, then the CAFAS, CANS-MH, and CALOCUS best ‘‘link’’ youths’ functioning with services. The CAFAS is by far the better known scale with widely diverse national applications in clinical, research, and administrative work. It also has a good psychometric base, allowing its incorporation into both clinical and research protocols, including discriminating youths in different levels of care, predicting outcomes, and monitoring treatment. However, the newer CANS-MH appears to have better assessment of caregiver needs that is helpful in planning appropriate home and community interventions and also provides algorithms that aid decision making and treatment planning. In addition, it emphasizes strengths, an important aspect in community systems of care. Both the CAFAS and CANS-MH provide Web sites and enjoy large-scale use in various communities throughout the country providing a reference base for potential users of such scales. Perhaps the best argument for the CALOCUS, despite its recent development, is its clear ‘‘linking’’ of youths’ functional impairments to service needs and then offering a flexible array of ways in which to meet these service needs. Thus, the CALOCUS may have broader appeal for nonmetropolitan communities that struggle to meet the needs of youths with mental health difficulties. Finally, some comment is warranted regarding the use of both global and multidimensional scales. In research and clinical work on specific symptoms and disorders, it has become common to use a combination of instruments including global and multidimensional scales. For example, in depression research, the Clinical Global Impressions Scale has been combined with the Hamilton Depression Inventory or the Children’s Depression Inventory, and a semistructured interview.

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Similarly, because each measure of functional impairment gives different information about the range, severity, and clinical significance of a youth’s functional impairments, it may be useful to combine global and multidimensional measures, such as the CGAS and CAFAS, as well as an instrument in which functional impairments are linked to service planning, such as the CANS-MH or CALOCUS. Such an approach helps to put a youth’s impairments into context for treatment planning, which, in the end, is the purpose of using these scales. FUTURE DIRECTIONS

Scales measuring functional impairment have broad appeal in clinical, research, and administrative applications that seek to better use community resources for individual youths and to better tailor a continuum of services within a community. There are a number of areas in which further work is needed to advance this promising and rapidly evolving field. The first is additional theoretical work on the issues raised by Bird (1999) as to whether functional impairments should be specifically linked to the diagnosis responsible for the impairment and how the inclusion of both symptom and impairment measurement in the same instrument (e.g., in the CGAS) affects the utility of the scale. If one totally removes the symptom-related issues, is this truly an accurate picture of functioning? A related area that should be examined is the question of which informant is most appropriate because multiple domains of functioning may be clinically relevant and accurate assessment of functioning in different domains may require multiple informants. The preference for caretakers as informants for many of these scales may generally yield more accurate results but does eliminate the youth’s perspective, which may be relevant in selection of treatment. The second area concerns the issue of cultural variation and specificity. These scales need to be evaluated in more culturally diverse samples to assess how variations in expectations for normative behavior (which can also be present within a culture) should influence scale development, scoring, or recommended cutoffs. In the clinician-rated scales, the rater would need to be knowledgeable about these variations to avoid under- or overrating functional impairment, and many clinicians lack this knowledge base. A third area for future work has to

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do with identifying appropriate versus inappropriate applications of the scales. Some of the newer scales have been used for a multiplicity of clinical, administrative, and research applications. Further research is needed to ascertain how these scales function for specific populations, contexts, and purposes. For example, use of these scales to determine eligibility for services or entitlements such as social security disability and supplemental security income (SSD/SSI) may predispose them to rater bias. In such situations, the resulting data cannot be used for other purposes such as assessment of mental health need in a community. Additional studies of predictive validity will be particularly useful to establish whether the scales can predict specific outcomes or service use in specific populations. Further work is also needed on the use of these scales as outcome measures. It will be important to demonstrate not only their sensitivity to change but also whether they can tap the specific area of change that is being targeted by the intervention. Those scales that are more cumbersome may be less useful as outcome measures in clinical settings. Readers interested in the field of functional impairment will likely have increasing access to more flexible and user-friendly measures over the next decade. Disclosure: The authors have no financial relationships to disclose.

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