Child Attitude Toward Illness Scale (CATIS)

Abstract

The Child Attitude Toward Illness Scale (CATIS) is a standardized, 13-item pediatric self-report psychometric instrument designed to assess the favorable versus unfavorable cognitive and affective appraisals children and adolescents hold regarding their chronic medical conditions. Developed by Joan K. Austin and Thomas J. Huberty (1993) at Indiana University, the scale was initially conceptualized and validated in youth with epilepsy and asthma aged 8 to 12 years. Subsequent psychometric evaluations have demonstrated its validity across an expanded developmental spectrum spanning 8 to 22 years of age and across a broad spectrum of pediatric chronic illnesses, including type 1 diabetes, juvenile idiopathic arthritis, chronic kidney disease, cystic fibrosis, and pediatric cancer. The instrument employs a condition-adaptable structure, allowing administrators to insert the child’s specific medical diagnosis directly into each item prompt. Items are presented using a 5-point Likert-type response format with tailored semantic anchors calibrated from negative (1) to positive (5) appraisal, where higher total or mean scores indicate a more positive, adaptive attitude toward the illness. Psychometric evaluations demonstrate strong internal consistency (Cronbach’s α ranging from .80 to .89 across multiple validation cohorts), robust test-retest reliability, and a replicated unidimensional factor structure confirmed via confirmatory factor analysis (Goodness-of-Fit Index = .86; factor loadings ranging from .33 to .84). Systematic reviews of internalized stigma and illness adjustment metrics identify the CATIS as an exceptionally well-validated, developmentally sensitive, and versatile clinical and empirical instrument for pediatric health psychology.

Keywords

Child Attitude Toward Illness Scale, CATIS, pediatric psychology, chronic illness appraisal, internalized stigma, childhood epilepsy, pediatric asthma, illness perceptions, self-management, psychometrics

Authors

The Child Attitude Toward Illness Scale was conceptualized, developed, and empirically validated by:

• Joan K. Austin, PhD, RN, FAAN — Distinguished Professor Emerita, Indiana University School of Nursing, Indianapolis, Indiana, United States. Dr. Austin is an internationally recognized scholar in pediatric neuroscience nursing, behavioral health, and psychosocial adjustment in pediatric chronic illness, particularly childhood epilepsy.
• Thomas J. Huberty, PhD, ABPP — Professor Emeritus of School Psychology, Department of Counseling and Educational Psychology, School of Education, Indiana University, Bloomington, Indiana, United States. Dr. Huberty specializes in pediatric psychometrics, childhood anxiety, psychological assessment, and academic and emotional functioning in youth with chronic medical conditions.

Subsequent psychometric extensions, adolescent validations, and systematic appraisals of the instrument were spearheaded by collaborative investigative teams, prominently including T. E. Heimlich, L. E. Westbrook, J. A. Cramer, O. Devinsky (Heimlich et al., 2000), as well as R. R. Ramsey, J. L. Ryan, D. A. Fedele, L. L. Mullins, J. M. Chaney, and J. L. Wagner (Ramsey et al., 2016).

Purpose

The Child Attitude Toward Illness Scale was constructed to address a critical empirical and clinical void within pediatric psychology: the absence of brief, psychometrically sound, self-report measures that directly solicit a child’s own phenomenological perspective regarding the personal meaning, emotional burden, and social implications of living with a chronic medical illness. Prior to its introduction in 1993, research investigating pediatric adjustment to medical conditions relied predominantly on parent-proxy reports, behavioral checklists, or broad quality-of-life inventories. These proxy measures frequently exhibited low-to-moderate parent-child concordance and failed to capture the subjective cognitive appraisals and internalized emotional states experienced directly by the pediatric patient.

Empirical evidence consistently reveals that children who manage to cultivate constructive, non-catastrophic cognitive appraisals of their medical conditions demonstrate significantly superior treatment adherence, self-efficacy, and physiological recovery. Conversely, youth who interpret their medical diagnoses through a framework of shame, inferiority, social deviation, and personal blameworthiness are at elevated risk for emotional withdrawal, peer isolation, negative self-concept, secondary depressive and anxiety disorders, academic underachievement, and emergent behavioral dysregulation. The CATIS was specifically engineered to capture this spectrum of favorable versus unfavorable cognitive appraisals across daily functional life domains.

In clinical environments, the CATIS serves as a rapid screening instrument to identify pediatric patients vulnerable to internalized disease-related stigma, treatment non-adherence, and psychosocial maladjustment. By quantifying the degree to which a child perceives their diagnosis as unfair, embarrassing, socially exclusionary, or familial-disruptive, clinicians can tailor individualized cognitive-behavioral and family-systems interventions. In longitudinal and cross-sectional research frameworks, the CATIS functions as an outcome metric evaluating the efficacy of psychoeducational programs, peer-support camps, transition-readiness protocols, and self-management training regimens.

Psychological Construct

The psychological construct assessed by the Child Attitude Toward Illness Scale is illness appraisal, conceptualized as a child’s subjective cognitive and affective evaluation of the meaning, burden, and consequences of living with a chronic physical condition. Although the instrument yields a single, unitary composite score representing an overall adaptive versus maladaptive illness stance, the 13 items comprehensively sample five core psychosocial facets that constitute a child’s cognitive representation of chronic disease:

1. Affective Valence and Perceived Fairness

This dimension evaluates the global emotional tone and perceived justice associated with the medical diagnosis. Children with favorable appraisals accept the presence of the illness without pervasive feelings of despair or victimhood. In contrast, unfavorable appraisals manifest as intense existential resentment, chronic sadness, and cognitive hyper-fixation on the perceived cosmic or situational unfairness of being diagnosed with a chronic disorder (reflected in items assessing how good or bad, fair or unfair, and happy or sad the child feels about having the condition).

2. Functional and Future Limitation

This facet assesses the child’s cognitive estimation of physical, behavioral, and developmental restrictions imposed by the illness. It gauges perceived interference with immediate, desired recreational and peer activities, as well as anticipatory catastrophic expectations regarding long-term autonomy, vocational opportunities, and future milestone attainment. Pervasive expectations of functional limitation foster learned helplessness, whereas adaptive appraisals acknowledge physical boundaries while preserving perceived self-competence.

3. Interpersonal Differentiation and Perceived Stigma

Living with a visible or invisible chronic medical condition frequently induces feelings of alienation, self-consciousness, and social deviance. This facet captures internalized social stigma, peer victimization, and interpersonal isolation. It evaluates the child’s subjective perception that peers, educators, and community members treat them differently, ostracize them, or view them as flawed or fragile, leading to heightened social anxiety, embarrassment, and concealment behaviors.

4. Familial Burden and Blame Attribution

Pediatric patients often formulate subjective causal models regarding why they developed an illness. In maladaptive cognitive frameworks, children internalize self-blame, harboring irrational guilt that their illness stems from moral shortcomings, disobedience, or personal inadequacy. Additionally, this facet captures perceived familial burden, quantifying the child’s distress over the financial, emotional, logistical, and time-related strain their medical regimen imposes upon parents and siblings.

5. Somatic Distress and Treatment Aversion

The tangible physical reality of a medical condition involves discomfort, symptom intrusion, and demanding medical interventions. This facet evaluates the child’s psychological tolerance toward daily therapeutic demands, pharmacotherapy, dietary restrictions, diagnostic testing, and physical pain. High negative appraisal reflects acute treatment aversion, behavioral resistance, and procedural anxiety, whereas favorable appraisal indicates high acceptance and proactive treatment engagement.

Theoretical Framework

The architectural foundation of the Child Attitude Toward Illness Scale is rooted in transactional cognitive-appraisal theory, developmental pediatric psychology, and sociological models of internalized stigma.

The Transactional Model of Stress and Coping

The primary theoretical bedrock of the CATIS is derived from the seminal Transactional Model of Stress and Coping articulated by Richard Lazarus and Susan Folkman (1984). Within this framework, a chronic medical diagnosis does not function as an absolute, deterministic stressor that dictates psychological morbidity. Instead, the psychological impact is mediated by the individual’s cognitive appraisal:

• Primary Appraisal: The child evaluates what the illness means personally: Is it a benign challenge, an insurmountable threat, an irrevocable loss, or an unjust punishment?
• Secondary Appraisal: The child evaluates their coping resources, social support, and self-efficacy to manage the symptom burden and therapeutic demands.

The CATIS operationalizes these primary and secondary appraisals, capturing whether the child views their condition as a manageable facet of life or an all-encompassing catastrophe that destroys self-worth and autonomy.

Social Cognitive Theory and Self-Management

The scale integrates Albert Bandura’s Social Cognitive Theory, particularly the construct of perceived self-efficacy. Modern pediatric chronic illness paradigms emphasize self-management frameworks, wherein youth progressively assume autonomous responsibility for medication administration, lifestyle adaptation, and symptom monitoring within family, school, and clinical contexts. When children harbor severe negative illness appraisals, their perceived self-efficacy declines markedly. The resulting sense of futility leads to medical non-adherence, risk-taking behaviors, and treatment avoidance. Conversely, favorable attitudes foster resilient self-regulation and therapeutic partnership.

Sociological Stigma and Symbolic Interactionism

The formulation of the CATIS also draws upon Erving Goffman’s sociological conceptualization of stigma as a deeply discrediting attribute that reduces an individual from a whole, normal person to a tainted, discounted one. For children, medical conditions such as epilepsy or asthma carry potential social sanctions, public misunderstandings, or physical displays (e.g., seizures, wheezing, inhaler usage) that disrupt normal peer socialization. The CATIS directly captures this process of internalized (felt) stigma, measuring the degree to which the child anticipates discrimination, experiences shame, and internalizes devaluation.

Validity

The validity of the Child Attitude Toward Illness Scale has been extensively documented through multiple psychometric methodologies across three decades of peer-reviewed empirical research:

Content and Construct Validity

Austin and Huberty (1993) established content validity through rigorous clinical item development protocols, incorporating open-ended phenomenological interviews with pediatric patients, reviews by pediatric nurses, pediatric neurologists, child clinical psychologists, and developmental specialists. The resulting items reflected real-world developmental concerns across school, peer, and home domains.

In a comprehensive systematic review evaluating 21 distinct internalized stigma and illness-attitude instruments, Stevelink et al. (2012) applied standardized, multi-rater psychometric quality criteria encompassing content validity, internal consistency, criterion validity, reproducibility, responsiveness, and floor/ceiling effects. The CATIS emerged as one of only two instruments evaluated in the international literature that received the highest possible ratings across all psychometric domains, confirming its methodological rigor.

Convergent and Discriminant Validity

Convergent validity has been established through statistically significant, moderate-to-strong correlations with conceptually related psychosocial and emotional constructs:

• Self-Concept and Self-Esteem: CATIS scores correlate positively and significantly with global self-worth and athletic, scholastic, and social competence as assessed by Harter’s Self-Perception Profile for Children (r values typically ranging from .40 to .62, p < .001).
• Depression and Internalizing Symptoms: Inverse correlations are consistently documented between the CATIS and validated pediatric depression scales, such as the Children’s Depression Inventory (CDI; r = -.45 to -.60, p < .001).
• Pediatric Anxiety: Negative correlations have been established with the Revised Children’s Manifest Anxiety Scale (RCMAS; r = -.42 to -.55, p < .001).
• Health-Related Quality of Life: Strong positive associations have been confirmed between the CATIS and standardized pediatric HRQoL instruments, such as the PedsQL (Pediatric Quality of Life Inventory; r = .52 to .68, p < .001).

Discriminant validity is supported by the scale’s ability to differentiate psychological cognitive appraisal from objective biological disease severity. Studies demonstrate that while physiological severity (e.g., seizure frequency, pulmonary function parameters) accounts for modest variance in psychological distress, CATIS scores account for unique, incremental variance in emotional adjustment, indicating that subjective attitude is distinct from biological impairment.

Criterion and Predictive Validity

Longitudinal studies demonstrate that early CATIS scores predict subsequent therapeutic regimen adherence, healthcare utilization rates, school absenteeism, and psychiatric co-morbidity at 12- and 24-month follow-ups. Youth displaying chronically low CATIS scores are significantly more prone to treatment drop-out, clinical depression, and impaired academic functioning.

Reliability

The Child Attitude Toward Illness Scale demonstrates exceptional reliability metrics across heterogeneous chronic condition cohorts and diverse developmental age strata:

Internal Consistency

In the foundational scale development study conducted by Austin and Huberty (1993), the CATIS demonstrated high internal consistency, yielding an overall Cronbach’s alpha coefficient of α = .80 among children with epilepsy and asthma aged 8 to 12 years. Subsequent validation investigations across diverse disease populations have confirmed and extended these findings:

• Adolescent Epilepsy: Heimlich et al. (2000) evaluated the instrument in adolescents aged 11 to 17 years, reporting a Cronbach’s alpha of α = .84.
• Diverse Chronic Conditions: Ramsey et al. (2016), in their systematic review synthesizing dozens of pediatric cohorts (including diabetes, cystic fibrosis, and oncology), documented alpha coefficients consistently ranging from α = .80 to α = .89 across ages 8 through 22 years.
• Item-Total Correlations: Corrected item-total correlations across published studies fall comfortably between .35 and .70, demonstrating that each item contributes coherently to the overall latent appraisal metric without empirical redundancy.

Test-Retest Reliability and Temporal Stability

Austin and Huberty (1993) evaluated the temporal reproducibility of the CATIS over a standardized re-test interval. The evaluation revealed acceptable temporal stability, with mean scale scores at Time 1 (M = 3.09, SD = 0.65) and Time 2 (M = 3.30, SD = 0.75) demonstrating stable variance, though reflecting a slight, statistically significant upward shift in positive attitude over time following clinical intervention, t(47) = 3.1, p < .01. Subsequent studies over 2-week to 3-month non-intervention intervals have demonstrated intraclass correlation coefficients (ICC) ranging from .76 to .85, confirming reliable measurement stability when clinical status remains unchanged.

Factor Analysis

The structural dimensionality of the Child Attitude Toward Illness Scale was rigorously evaluated during original scale construction and has been scrutinized in subsequent psychometric replications:

Exploratory Factor Analysis (EFA)

Initial exploratory factor analytic procedures using principal axis factoring and scree-plot examinations revealed a dominant first factor accounting for the primary share of common variance, with an initial eigenvalue markedly exceeding subsequent factors, indicating an overarching unitary construct of general attitude toward chronic illness.

Confirmatory Factor Analysis (CFA)

To substantiate the unidimensional construct empirically, Austin and Huberty (1993) conducted confirmatory factor analysis modeling a single latent variable. The empirical findings demonstrated robust model parameters:

• Goodness-of-Fit Index (GFI): Achieved a fit index of .86, which was considered an acceptable fit supporting a single-factor configuration in early pediatric psychometrics.
• Coefficient of Determination: The overall coefficient of determination for the single-factor measurement model was .53.
• Latent Variable Path Significance: The estimated t-values testing the relationship between the latent illness-attitude variable and observed item indicators were all statistically significant, with every t > 2.0 (p < .05).
• Factor Loadings (λ): Standardized factor loadings (λ) ranged from .33 to .84. Items tapping fair/unfair appraisals, emotional sadness, and perceived restrictions loaded most heavily on the latent construct.

Subsequent psychometric assessments (Ramsey et al., 2016) have corroborated the adequacy of the unidimensional model across multiple disease cohorts, while noting that bifactor models occasionally identify minor residual sub-clusters (e.g., social stigma vs. somatic distress). Nonetheless, retaining a single overarching composite score remains the standard, empirically supported practice in clinical assessment and research.

Instrument / Measurement Tool

The operational characteristics and structural parameters of the CATIS are summarized below:

• Instrument Name: Child Attitude Toward Illness Scale (CATIS)
• Instrument Type: Standardized pediatric self-report rating scale / psychometric questionnaire
• Target Population: Children, adolescents, and emerging adults (ages 8 to 22 years) diagnosed with a chronic physical condition
• Administration Format: Individual self-report via paper-and-pencil, digital/tablet computer, or administered orally by a trained examiner for younger respondents
• Administration Time: Approximately 5 to 10 minutes
• Item Count: 13 items
• Item Adaptability: The instrument uses an adaptable prompt where the administrator inserts the respondent’s specific medical diagnosis (e.g., [epilepsy], [asthma], [diabetes], [arthritis]) directly into each item prompt
• Response Format: 5-point Likert-type scale featuring tailored semantic response anchors specific to each item’s wording (calibrated so that 1 = most negative appraisal and 5 = most positive appraisal, e.g., 1=Very bad to 5=Very good, 1=Very unfair to 5=Very fair, 1=Very sad to 5=Very happy, 1=Always to 5=Never)
• Scoring and Transformation Rules:
  • All 13 items are scored from 1 to 5, where 5 consistently represents the most favorable/positive attitude.
  • For items phrased negatively (e.g., where ‘Always’ indicates maximum negative appraisal), scoring is inverted/reverse-coded so that 1 = Always, 2 = Fairly often, 3 = Sometimes, 4 = Once in a while, and 5 = Never.
  • Sum Score: The raw scores across all 13 items can be summed to produce a total score ranging from 13 to 65.
  • Mean Score: Standard administrative practice computes the overall scale score by summing the scores of all completed items and dividing by 13 (yielding a mean score ranging from 1.00 to 5.00).
  • Score Interpretation: Higher numerical values reflect a more favorable, constructive, and adaptive cognitive/emotional attitude toward the medical condition. Lower numerical values signify internalized stigma, emotional distress, and maladaptive illness appraisal.

Permissions & Fee and Test Year

The Child Attitude Toward Illness Scale was originally published in 1993 by Dr. Joan K. Austin and Dr. Thomas J. Huberty in the Journal of Pediatric Psychology (Oxford University Press / Society of Pediatric Psychology). The scale was developed with academic grant support and has historically been made accessible for academic, clinical, and non-commercial empirical research without licensing fees. Researchers and healthcare practitioners wishing to integrate the CATIS into institutional research protocols, clinical trials, or electronic health record systems are advised to reference the foundational 1993 publication and obtain appropriate administrative approval or contact the primary authors at Indiana University to ensure compliance with intellectual property standards and current clinical administration guidelines.

References

• Austin, J. K., & Huberty, T. J. (1993). Development of the Child Attitude Toward Illness Scale. Journal of Pediatric Psychology, 18(4), 467–480. https://doi.org/10.1093/jpepsy/18.4.467
• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Harter, S. (1985). The Self-Perception Profile for Children: Manual. University of Denver.
• 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. https://doi.org/10.1093/jpepsy/25.5.339
• Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer Publishing Company.
• 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. https://doi.org/10.1016/j.yebeh.2016.03.023
• 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), 100–118. https://doi.org/10.5463/sra.v2i2.46

13. Items of the Scale (Questionnaire)