Child Attitude Toward Illness Scale (CATIS)

The Child Attitude Toward Illness Scale (CATIS) is 13-item self-report measure developed in the United States. It was originally designed for children with epilepsy, but has been validated for use with asthma, and is considered applicable to a range of chronic conditions because of its adaptability and strong validity. The original development study validated the CATIS for 8 -12 year olds. Subsequent studies have demonstrated the CATIS validity for use with 11 – 17 years (Heimlich et al., 2000), and 8 – 22 year olds (Ramsey et al., 2016).

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.

To score the CATIS items are summed and divided by 13, after the necessary reverse scores are calculated. Higher scores indicate a more positive attitude towards the condition. The possible range of score is 13 to 65.

Why was the scale developed?

Research has shown that young people who could focus on the positive aspects of their condition had more favorable treatment outcomes and recovery from illness compared to those who did not. Research has also shown that children who viewed themselves as different and less worthy than their peers because of their illness were likely to become withdrawn, socially isolated, have poor self-concept, lowered academic functioning, and behavioral problems. The CATIS was developed to measure these favorable/unfavorable attitudes and was one of the first measures to directly ask children their attitudes about having a chronic condition.

There is strong evidence regarding high levels of internalized stigma across multiple health conditions. For people with a chronic illness, internalised stigma may manifest as:
feelings of disappointment and guilt for becoming ill, feelings of inferiority compared to others because of their illness, as well as low self-esteem and self-efficacy.

A more recent focus on Self-Management models for those with chronic conditions encompasses the development in people with chronic illness to develop skills to manage health behaviours, skills to manage illness in the context of everyday life. Also important is that patients develop understanding the interactive nature of these issues in the context of family, community, and healthcare settings. The negative cognitive appraisals of self and illness associated with internalized stigma (due to illness) can impact the success of self-management skill development. Young people may instead engage in maladaptive behaviors that impede treatment efficacy and worsen disease course.

CATIS Psychometric Properties

In the original scale development, the internal reliability for the total scale had a coefficient alpha of .80. The test-retest was good with difference between the means at time 1 (M = 3.09, SD = 0.65) and time 2 (M = 3.30, SD = 0.75) being statistically significant t(47) = 3.1, p < .01.  Confirmatory factor analysis was carried out to confirm the single dimension of the scale. They used the goodness-of-fit (GFI) index which was considered better for assessing single factor and is a measure of its relative variance and covariance, was .86. The coefficient of determination was .53, and the t values testing the relationship between latent variables were all over 2.0. Lamda values ranged from .33 to .84 and these results supported the unitary construct of the scale.

A recent systematic review of the literature on internalized stigma instruments (Stevelink et al., 2012) assessed 21 scale development studies using a comprehensive quality criteria framework for psychometric properties, including: Content validity, internal consistency, criterion validity, construct validity, reproducibility, responsiveness, floor and ceiling effects, and interpretability. These criteria were applied by two or more independent raters and a consensus determined regarding the results. They found that the CATIS was one of two instrument that received the most positive ratings.

Even more recently there was systematic review of the literature on the CATIS (Ramsey et al., 2016). It confirmed the robust reliability and validity of the CATIS across different chronic illnesses. The review also highlighted the CATIS’ good generalizability, affordability and determined it was good for both research and clinical contexts. But they highlighted some limitations too. Because the CATIS is delivered in different settings and via different methods, adapted to different illnesses and ages, it has limited cross study utility. They also noted that there have been no studies looking at minimum cognitive capabilities required for the CATIS (for those with developmental delays or IDs), no cross-cultural comparison research, and sparse evidence for the CATIS’ predictive validity. The CATIS also has no norm because clinicians can use and interpret the findings as they see fit. They determined that, while it was a good and useful scale, more research would be advantageous.


Austin, J. K., & Huberty, T. J. (1993). Development of the child attitude toward illness scale. Journal of Pediatric Psychology18(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 Psychology25(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 & Behavior59, 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 Action2(2).