Children’s Functional Assessment Rating Scale (CFARS)

CFARS Developed by the Florida Mental Health Institute at the University of South Florida Provides a standard measurement to assess functional needs and progress and provide outcomes information

CFARS Developed to monitor agency level quality improvement initiatives and assist clinicians with individualized treatment planning Used statewide in Florida, Illinois, New Mexico, and Wyoming for Medicaid-funded mental health services

CFARS information Resource manual Website http://outcomes.fmhi.usf.edu Each program manager should have the manual available for clinicians to review Website http://outcomes.fmhi.usf.edu Manual Training and test vignettes Training certification

Learning how to complete the CFARS Review the manual Score the 2 practice vignettes and then check your scoring against the standards Note: A range of answers is acceptable. Complete the free on-line certification

Training is important Ratings need to be consistent across clinicians. The CFARS may be used to make important decisions (e.g., service authorizations), therefore clinicians should have a strong understanding of what the scores mean

Training Logistics Training should occur when clinicians are hired, before they start seeing clients, and during periodic refreshers All clinicians should work through the vignettes and on-line training until their ratings are consistent with the standard. On-line training is highly recommended by the County Please keep a copy of the training certificate for your records, in case of a site visit.

CFARS official training The self-paced training and certification process generally takes ~2 hours It is not necessary to complete the training in one sitting Instructions on how to register are on p. 7 of the manual, or on the website

CFARS 16 Functional Domains Depression Anxiety Hyperactivity Thought Process Cognitive Performance Medical/Physical Traumatic Stress Substance Use Interpersonal Relationships Behavior in “Home” Setting ADL Functioning Socio-Legal Work/School Danger to Self Danger to Others Security/Management Needs *Refer to p. 14-29 in manual for definitions of words/phrases in each domain and specific anchor guidelines

CFARS Problem Severity Ratings Each domain is rated on a scale of 1 (No Problem) to 9 (Extreme Problem). Ratings should reflect the degree to which the youth is currently (within past 3 weeks) experiencing difficulty or impairment in the domain.

CFARS Problem Severity Ratings Words and phrases (both positive and negative) that are associated with symptoms or behaviors in each domain are given to help identify issues and help make rating (p. 6 of the manual)

Guidelines for Determining Problem Severity Ratings Within each domain, begin by marking the words/phrases that describes a behavior or symptom of the child you are evaluating. Next, using the general principles and scoring rationale, assign a Problem Severity Rating to describe recent functioning in each domain.

Severity Ratings are associated with: How immediate is the need for intervention in order to stabilize or correct deficits in functioning within the rated domain? Is the need for intensive intervention imperative/immediate (scores 7-9), moderate intervention required (5) not urgent (3)? For this rating, take into account the level of intervention necessary *Refer to p. 13 in manual for “Basic issues to consider when assigning CFARS Problem Severity Ratings to individual functional domains.”

Severity Ratings are associated with: How intrusive is the intervention that is needed to stabilize or correct deficits in functioning within the rated domain? Consider the level of intervention that a child needs [e.g., Imminent need for hospitalization (7-9), outpatient treatment (5), no treatment (3)] *Refer to p. 13 in manual for “Basic issues to consider when assigning CFARS Problem Severity Ratings to individual functional domains.”

Severity Ratings are associated with: How much does functioning in the rated domain impact negatively on or interfere with healthy functioning in other domains? Consider the number of domains impacted. For example, ADHD symptoms may slightly interfere with a child’s functioning at school (5) Depression may be causing a severe problem in the danger to self and school domains (7) *Refer to p. 13 in manual for “Basic issues to consider when assigning CFARS Problem Severity Ratings to individual functional domains.”

General Anchor Guidelines 1 = No Problem Functioning is consistently average or better than what is typical for this person’s age, sex, and subculture. 2 = Less than Slight Problem

General Anchor Guidelines 3 = Slight Problem Functioning falls short for a person of this age, sex, and subculture most of the time. Problem may be intermittent or may persist at a low level. Problem or symptoms have little or no impact on other domains or may be currently controlled by medications. Need for treatment is not urgent but may require therapeutic intervention in the future.

General Anchor Guidelines 4 = Slight to Moderate Problem 5 = Moderate Problem Functioning is clearly marginal or inadequate, not meeting the usual expectations of a typical person of this age, sex, and subculture. Dysfunction or problem may persist at moderate level or become severe on occasion. Problems may be related to problems in other domains and do require therapeutic intervention(s).

General Anchor Guidelines 6 = Moderate to Severe Problem 7 = Severe Problem Functioning in this range is marked by obvious and consistent failures, never meeting expectations of a typical person of this age, sex, and subculture. Dysfunction or problem may be chronic, extends to other domains, and generally interferes with interpersonal or social relationships with others. Hospitalization or some other form of external control may be needed (Note: in San Diego, hospitalization only occurs if there is imminent need) in addition to other therapeutic intervention(s).

General Anchor Guidelines 8 = Severe to Extreme Problem 9 = Extreme Problem Highest level Situation is out of control, unacceptable, and/or potentially life-threatening. The need for external control or intervention is immediate.

General Anchor Guidelines A score of 4 or higher is considered “Clinically Elevated” by the CFARS developers Areas of strength are those rated 1 or 2

Rating Caveat: If a domain is being maintained or controlled by medication or other supports, that domain should not be rated as a “1” or “2”. There are still costs associated with maintaining the intervention and it is possible that decreased functioning could return if the interventions were removed. Refer to pg. 11 in the manual for more information

How does the CFARS relate to the GAF score? You cannot say that a score of XX on the CFARS is equal to a score of YY on the GAF You can use the same information to develop the CFARS and GAF scores. The scores should be similar in nature: a child with severe problems on the CFARS should have a GAF score that reflects those problems.

What about SED? There is no set score on the CFARS that correlates to the SED definition. You can use the CFARS domain information to help determine if a child meets SED criteria.

What about SED? The CFARS scores should be similar in nature to the SED classification A child with severe problems (ratings of 7 and higher) on the CFARS would be likely to meet SED criteria A child with slight problems (ratings of 3 and under) would be unlikely to meet SED criteria.

What happens with the 16 domain scores? Entered on the County forms for UR / DPR Entered into the Data Entry System (DES) and used to generate 4 Index Scores that summarize the domains

Index Scores & Related Domains Relationships: Hyperactivity School / Work Interpersonal Relationships Cognitive Performance Behavior in the Home Danger to Others

Index Scores & Related Domains Safety: Socio-legal Substance Use Security Management Needs Danger to Self

Index Scores & Related Domains Emotionality: Anxiety Traumatic Stress Depression

Index Scores & Related Domains Disability: ADL Functioning Medical / Physical Thought Process

What happens with the 16 domain scores? The Index Scores will appear on the Assessment Summary printout from the DES The Index scores are used in the County’s outcomes objectives Example: For 80% of discharged clients whose episodes lasted 2 months or longer, the CFARS score shall be at least one level higher (improvement) at discharge than at admission in at least one index area.

Additional Resources in CFARS Manual Examples of using CFARS ratings to develop individualized treatment plans or to monitor client change/improvement. Using the clinical scales derived from the 16 domains. Using CFARS domains to help gather info for the mental status exam.