Child Attitude Toward Illness Scale (CATIS)

Abstract

The Child Attitude Toward Illness Scale (CATIS) is a 13-item self-report measure developed in the United States by Austin and Huberty (1993). Its primary function is to assess the specific attitudes that children and adolescents hold regarding their chronic health condition. Although the measure was initially designed and validated for use with children diagnosed with epilepsy, its strong validity and high adaptability have allowed for its successful application across a broad spectrum of chronic conditions, including asthma. The original development study established the scale for 8- to 12-year-olds; however, subsequent research has confirmed its psychometric suitability for populations ranging from 8 to 22 years of age (Ramsey et al., 2016).

Keywords

Child Attitude Toward Illness Scale, CATIS, Chronic illness, Internalized stigma, Pediatric psychology, Self-management, Attitude, Epilepsy, Asthma, Self-report measure.

Authors

Jacqueline K. Austin, T. J. Huberty

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Purpose

The core objective of the CATIS is to measure the spectrum of favorable versus unfavorable attitudes young people hold toward having a chronic condition. This assessment is vital because a robust body of research has demonstrated a strong correlation between positive cognitive appraisals of illness and more beneficial treatment outcomes and recovery trajectories.

Furthermore, the scale was developed to address the negative psychological consequences associated with chronic illness. Children who perceive themselves as fundamentally different or less worthy than their peers due to their condition are susceptible to adverse psychosocial outcomes, including social isolation, behavioral problems, poor self-concept, and lowered academic functioning. The CATIS was one of the first instruments specifically designed to quantify these subjective attitudes directly from the child’s perspective.

Construct

The CATIS is designed to measure a single, unitary construct: the child’s overall attitude toward their specific illness. This construct encompasses the child’s acceptance or rejection of their illness identity, which is closely intertwined with the psychological phenomenon of internalized stigma.

For individuals managing a chronic condition, high levels of internalized stigma often manifest as negative cognitive appraisals, such as feelings of guilt, disappointment, inferiority compared to others, and diminished self-esteem and self-efficacy. Measuring these attitudes is critical in clinical settings, especially those focused on Self-Management models, because negative self- and illness-appraisals can significantly undermine a young person’s ability to engage successfully in adaptive health behaviors and impede overall treatment efficacy.

Validity

The validity of the CATIS has been consistently supported and generalized across multiple chronic populations. Initially validated for children with epilepsy (8–12 years), its utility has been confirmed for conditions like asthma and validated for an expanded age range up to 22 years (Ramsey et al., 2016).

In a comprehensive systematic review assessing 21 instruments measuring internalized stigma (Stevelink et al., 2012), the CATIS was evaluated using a rigorous quality criteria framework encompassing content validity, construct validity, and criterion validity, among others. The review concluded that the CATIS was one of only two instruments to receive the most positive ratings regarding its overall psychometric properties.

Despite strong evidence of generalizability and robust construct validity, systematic reviews have identified certain limitations. Specifically, there is sparse evidence supporting the CATIS’s predictive validity. Furthermore, variations in administration methods, settings, and adaptations for different illnesses and age groups limit its utility for direct comparison across different research studies.

Reliability

The CATIS demonstrates strong evidence of reliability, confirming its suitability for clinical and research applications. In the original scale development, the internal consistency for the total scale was high, yielding a coefficient alpha of 0.80.

Test-retest reliability was also established as good. While the difference between the mean scores at Time 1 (M = 3.09, SD = 0.65) and Time 2 (M = 3.30, SD = 0.75) was statistically significant [t(47) = 3.1, p < 0.01], the overall measure of stability was considered robust. A recent systematic review confirmed the consistent and robust reliability of the CATIS across various chronic illnesses (Ramsey et al., 2016).

Factor Analysis

To confirm the scale’s underlying structure, a Confirmatory factor analysis was performed during the initial development phase. The objective was to verify the hypothesis that the 13 items load onto a single dimension representing the attitude toward illness.

The results of the analysis strongly supported the unitary construct of the scale. The Goodness-of-Fit Index (GFI), which measures the relative variance and covariance and is preferred for assessing single-factor models, was 0.86. Further supporting the unidimensional structure, the coefficient of determination was 0.53, and the lambda values ranged between 0.33 and 0.84. Additionally, the t values used to test the relationship between latent variables all exceeded the threshold of 2.0, providing definitive support for the CATIS as a unidimensional scale.

Instrument

Test Type: Self-report psychological measure

Format: 13 items rated on a 5-point Likert-type scale

Language Available: Primarily English (US). Cross-cultural research remains sparse.

Population Group: Children and adolescents with chronic physical conditions.

Age Group: 8–22 years (Original development: 8–12 years).

Population Details: Applicable to a range of chronic conditions; specifically validated for epilepsy and asthma. The scale lacks established norms, allowing clinicians flexibility in interpreting findings based on individual context.

Test Methodology: The administrator adapts each item to the child’s specific illness (e.g., inserting the name of the condition). Items are summed after necessary reverse scores are calculated, and then divided by 13. The possible score range is 13 to 65, with higher scores reflecting a more positive attitude toward the condition.

Keywords

Pediatric psychology, Chronic illness, Attitude assessment, Stigma, Epilepsy, Asthma, Psychometric properties, Unidimensional scale, Coefficient alpha.

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Authors

Author ORCID Identifier: N/A

Affiliation Email addresses: N/A

Correspondence Address: N/A

Permissions & Fee and Test Year

Permissions & Fee: The source content does not provide current details regarding permissions or usage fees. Researchers are advised to contact the journal of publication (Journal of Pediatric Psychology) or the original authors for current licensing requirements.

Test Year: 1993 (Austin & Huberty).

Reference’s

• Austin, J. K., & Huberty, T. J. (1993). Development of the child attitude toward illness scale. Journal of Pediatric Psychology, 18(4), 467-480.
• Heimlich, T. E., Westbrook, L. E., Austin, J. K., Cramer, J. A., & Devinsky, O. (2000). Brief report: Adolescents’ attitudes toward epilepsy: further validation of the Child Attitude Toward Illness Scale (CATIS). Journal of Pediatric Psychology, 25(5), 339-345.
• Ramsey, R. R., Ryan, J. L., Fedele, D. A., Mullins, L. L., Chaney, J. M., & Wagner, J. L. (2016). Child Attitude Toward Illness Scale (CATIS): A systematic review of the literature. Epilepsy & Behavior, 59, 64-72.
• Stevelink, S. A. M., Wu, I. C., Voorend, C. G., & van Brakel, W. H. (2012). The psychometric assessment of internalized stigma instruments: A systematic review. Stigma Research and Action, 2(2).

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Items of the Child Attitude Toward Illness Scale (CATIS)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

The CATIS structure allows the administrator to adjust each item to correspond with child/adolescent’s specific illness. For example:

• How good or bad do you feel it is that you have [insert specific illness]?

Each item is rated on a 5-point scale:

• Very Good – A Little Good – Not Sure – A Little Bad – Very Bad.