Measuring children's mental health functioning: Confirmatory factor analysis of a multidimensional measure

As mental health systems respond to policy definitions of serious emotional disturbance and the need to prioritize and evaluate mental health services, there is an increasing need for multidimensional measures of children's mental health functioning. The Colorado Client Assessment Record (CCAR)is one of two multidimensional measures currently in use in state systems. The validity of the dimensional structure of the CCAR was assessed using exploratory and confirmatory factor analysis with a sample of child mental health service recipients. The nine-dimension conceptual model that undergirds the CCAR was found to fit the data well. Key words: child mental health; confirmatory factor analysis; level of functioning; mental health Since the early 1980s public children's mental health services systems have focused on the development of a "system of care" (Stroul & Friedman, 1986) that can provide a continuum of services to children with mental health problems and their families. Some researchers have noted that development and implementation of systems of care have proceeded without adequate information on the outcomes achieved both by individual service components and by systems as a whole. They have identified the lack of child outcome information as a critical issue (Heflinger, 1992; Rugs & Kutash, 1994). Increased interest in managed care administrative structures has elevated the importance of documented client outcomes (Kane, Bartlett, & Potthoff, 1995), particularly measures that have been validated for child service recipients (Kutash, Duchnowski, Johnson, & Rugs, 1993). In this context, interest in measuring children's mental health functioning has become a critical issue for researchers and public mental health administrators (Charous & Carter, 1996; Dana, Conner, & Allen, 1996). Because federal definitions of children with serious emotional disturbance (SED) require an assessment of "functional impairment" (Federal Register, 1993), the Center for Mental Health Services (CMHS) recently commissioned a review of measures of impairment currently in use in the states (Hodges & Gust, 1995). Sixteen states, including Colorado, were found to be using at least one of five measures of impairment. Of these five measures, only two assessed multiple dimensions of functioning. Porkorny (1991), in a review of level of functioning measures used by state mental health agencies, has noted that although evidence of the utility of these measures for agency administrators is clear, evidence for the soundness of such measures (that is, their reliability and validity) is much less compelling. This need for increased attention to the psychometric properties of these instruments is echoed in Hodges and Gust's (1995) more recent review of children's level-of-functioning measures. The Colorado Client Assessment Record (CCAR) is a multidimensional level-of-functioning measure that has been gathered on all clients served in the Colorado mental health system for some 20 years. The CCAR is one of the two multidimensional measures of functioning currently in use in state systems (Porkorny, 1991). Although some analysis of the structure of the CCAR has been done for adult populations (Wackwitz, Foster, & Ellis, 1990), the instrument has not been examined for a population of children. This article reports the results of a preliminary instrument validation study in which both exploratory and confirmatory factor analyses were used to examine the factorial structure of the CCAR with a sample of child recipients of mental health services. SERIOUS EMOTIONAL DISTURBANCE IN CHILDREN: IMPORTANCE OF FUNCTIONAL CRITERIA The importance of child level of functioning as a research construct has its origins in the evolving definitions of child mental health problems and in the evolution of assessment approaches. There is little consensus on the definition of SED in children and the resultant criteria for mental health services (Brandenberg, Friedman, & Silver, 1990; Lourie et al. …