Examples of Principles/Values

STAGE 2 ~ ATTACHMENT F

Child & Adolescent Needs and Strengths (CANS) Methodology for Children and Adolescents with Special Needs: An Information Integration/Decision Support Tool for Planning and Monitoring Services in Home and Community Based Systems of Care for Children & Adolescents and their Families. This is an overview of the CANS information integration tool. It has been used successfully in several communities and six states.

Attachment F-1 STAGE 2 ~ ATTACHMENT F

CHILD & ADOLESCENT NEEDS AND STRENGTHS (CANS) METHODOLOGY For Children and Adolescents with Special Needs

An Information Integration/Decision Support Tool for Planning and Monitoring Services in Home and Community Based Systems of Care for Children & Adolescents and their Families

Copyright, 1999 The copyright for the CANS information integration tool is held by the Buddin Praed foundation to ensure that it remains an open tool free for anyone to use. Information on guidelines for use and development can be obtained by contacting Melanie Lyons of the Foundation at 847-501-5113 or [email protected]

For more information on how the CANS is used in various settings please contact:

John S. Lyons, Ph.D., Patricia Tennant Sokol, MSW, D.P.A. Institute for Health Services Research and President and CEO Policy Studies The New Center, Inc. Northwestern University 4061 SE 25th Terrace 339 East Chicago Avenue, Weibolt 717 Ocala, Florida 34480 Chicago, Illinois 60611 (352) 671-9513 (312) 503-0425 Fax (352) 671-9514 Fax (312) 503-2936 [email protected] [email protected]

M. Connie Almeida, Ph.D. David F. Sokol, CPM, Ph.D. Children’s Project Director Director, Faith Based Division Texana MH/MR The New Center, Inc. 711 South 11th Street 4061 SE 25th Terrace Richmond, Texas 77469 Ocala, Florida 34480 (281) 342-0090 (352) 671-9513 Fax (281) 341-9388 Fax (352) 671-9514 [email protected] [email protected]

Ardas Khalsa, MSW Monica Thyssen Operations Manager Supervisor, Parent Liaisons The Children’s Partnership The Children’s Partnership 1430 Collier 1430 Collier Austin, Texas 78704 Austin, Texas 78704 (512) 445-7780 (512) Fax (512) 445-7701 Fax (512) 445-7701 [email protected] [email protected]

Harry M. Shallcross, Ph.D. Michael E. Lee, MA, MPA P O Box 1442 Bureau of Performance & Outcomes 41 Teepee Court Management Medford, New Jersey 08055 New York Office of Mental Health (609) 654-5977 44 Holland Avenue Fax (609) 654-5974 Albany, New York 12229 [email protected] (518) 473-6383 Fax (518) 474- 7361 [email protected]

INTRODUCTION AND METHODOLOGY

We have used a uniform methodological approach to develop information integration tools to guide service delivery for children and adolescents with mental, emotional and behavioral health needs, mental retardation/developmental disabilities, and child welfare and juvenile justice involvement. The basic approach as allows for a series of locally constructed decision support/information integration tools that we refer to as the Child & Adolescent Needs and Strengths (CANS). It provides a communication framework so that different child serving partners can develop a common language on which to communicate about the characteristics needs and strengths of children and their families. While blended funding, system of care, and other service integration strategies offer significant potential for helping child serving agencies work more closely in the interest of the children they serve, communication represents a separate, independent challenge to these collaborations.

The background of the CANS comes from our prior work in modeling decision-making for psychiatric services. In order to assess appropriate use of psychiatric hospital and residential treatment services, Dr. Lyons and others developed the Childhood Severity of Psychiatric Illness (CSPI). This measure was developed to assess those dimensions crucial to good clinical decision-making for expensive mental health service interventions. We have demonstrated its utility in reforming decision making for residential treatment (Lyons, Mintzer, Kisiel, & Shallcross, 1998) and for quality improvement in crisis assessment services (Lyons, Kisiel, Dulcan, Chesler & Cohen, 1997; Leon, Uziel-Miller, Lyons, Tracy, 1998). The strength of this measurement approach has been that it is valid and easy-to-use, yet provides comprehensive information regarding the clinical status of the child or youth.

The CANS builds on the methodological approach of the CSPI but expands the tool to include a broader conceptualization of needs and the addition of an assessment of strengths of the child and the family (Lyons, Uziel-Miller, Reyes, Sokol, 2000). It is a tool developed to assist in the management and planning of services to children and adolescents and their families with the primary objectives of permanency, safety, and improved quality in of life. The CANS is designed for use at two levels: 1) for the individual child and family and 2) for the system of care. The CANS provides a structured profile or “picture” of a child and family along a set of dimensions relevant to service planning and decision-making. Also, the CANS provides information regarding the child and family's service needs for use during system planning and/or quality assurance monitoring. Due to its modular design the tool can be adapted for local applications without jeopardizing its psychometric properties. The goal of the measurement design is to ensure participation of representatives of all partners to begin building a common assessment language. The CANS measure is then seen predominantly as a communication strategy.

The CANS is designed to be used either as a prospective information integration tool for decision support during the process of planning services or as a retrospective decision support tool based on the review of existing information for use in the design of high quality systems of services. This flexibility allows for a variety of innovative applications.

As a prospective information integration tool, the CANS provides a structured profile of children along a set of dimensions relevant to case service decision-making. The CANS Attachment F-4 STAGE 2 ~ ATTACHMENT F provides information regarding the service needs of the child and their family for use during the development of the individual plan of care. The information integration tool helps to structure the staffing process in strengths-based terms for the care manager and the family.

As a retrospective decision support tool, the CANS provides an assessment of the children and adolescents currently in care and the functioning of the current system in relation to the needs and strengths of the child and family. It clearly points out "service gaps" in the current services system. This information can then be used to design and develop the community-based, family-focused system of care appropriate for the target population and the community. Retrospective review of prospectively completed CANS allows for a form of measurement audit to facilitate the reliability and accuracy of information (Lyons, Yeh, Leon, Uziel-Miller & Tracy, 1999).

In addition, care coordinators and supervisors can use the CANS as a quality assurance/monitoring device. A review of the case record in light of the CANS tool will provide information as to the appropriateness of the individual plan of care and whether individual goals and outcomes are achieved.

The dimensions and objective anchors used in the CANS were developed by focus groups with a variety of participants including families, family advocates, representatives of the provider community, case workers and state staff. The CANS was originally developed with support from the Texas Health and Human Services Commission and Christ’s Home for Children; additional support for the development of the CANS-DD was provided by the Texas Families Are Valued Project and Texana MH/MR. testing of the reliability of the CANS in its applications for developmental disabilities and mental health indicate that this measurement approach can be used reliably by trained professionals and family advocates.

Following are a summary of the dimensions used in the CANS-MH, the CANS-DD and the CANS-JJ used in several states. Unless otherwise specified, each rating is based on the last 30 days. Each of the dimensions is rated on a 4-point scale after routine service contact or following review of case files.

Even though each dimension has a numerical ranking, the CANS information integration tool is designed to give a profile or picture of the needs and strengths of the child and family. It is not designed to "add up" all of the "scores" of the dimensions for an overall score rating. When used in a retrospective review of cases, it is designed to give an overall "profile" of the system of services and the gaps in the service system not an overall "score" of the current system. Used as a profile based information integration tool, it is reliable and gives the care coordinator, the family and the agency, valuable existing information for use in the development and/or review of the individual plan of care and case service decisions.

The basic design of the ratings is:  ‘0’ reflects no evidence,  a rating of ‘1’ reflects a mild degree of the dimension,  a rating of ‘2’ reflects a moderate degree, and  a rating of ‘3’ reflects a severe degree of the dimension.

Another way to conceptualize these ratings is:  ‘0’ indicates no need for action,  ‘1’ indicates a need for watchful waiting to see whether action is warranted (i.e., flag for monitoring and/or prevention)  ‘2’ indicates a need for action, and  ‘3’ indicates the need for either immediate or intensive action.

The rating of "U' for unknown should be considered a flag for a need to find this information for a complete profile or picture of the needs and strengths of the child and their family. The rating of “U” should be used only in those circumstances in which you are unable to get any further information. It is considered an item for immediate action to find the missing information in order to have a complete profile (picture) of the strengths and needs of the child and the family for a viable care coordination plan.

In order to maximize the ease of use and interpretation, please note that the last two clusters of dimensions, Caregiver Capacity and Strengths, are rated in the reverse logical manner to maintain consistency across the measure, i.e., a rating of “O” is seen as a positive strength. The following is the conceptualization that we use for the strengths based dimensions:

 '0' indicates a strength on which to build,  '1' indicates an opportunity for strength development and use in planning,  '2' indicates a need for strength development  '3' indicates a need for significant strength identification and/or creation

Thus, in all cases in the strengths section, a low rating is positive.

The “comment section” is used to clarify information or to add to the information based on the child and/or family’s comments.

The CANS is an effective information integration tool for use in either the development of individual plans of care or for use in designing and planning community-based, family- focused systems of care for children and adolescents with serious mental, emotional and behavioral disorders and their families. To administer the CANS information integration tool, the care coordinator, family advocate or other service provider has several options. 1) The interviewer can read the anchor descriptions for each dimension and then record the appropriate rating on the assessment form or 2) they can use a semi-structured interview questions to generate a discussion with the family. One CANS form is completed for each case reviewed or for each individual child and family interviewed.

When the CANS is used in an initial interview process with the child and family, the person completing the CANS (parent advocate, care coordinator, etc., should be sufficiently familiar with the form to listen to the family’s “story” as they would like to tell it. The interviewer can then ask those questions needed to obtain the information needed to complete the CANS

CHILD & ADOLESCENT NEEDS AND STRENGTHS For Children and Adolescents with Mental Health Challenges (CANS-MH)

Problem Presentation Risk Behaviors Psychosis Danger to Self Attention Deficit/Impulse Control Danger to Others Depression/Anxiety Elopement Oppositional Behavior Sexually Abusive Behavior Antisocial Behavior Social Behavior Substance Abuse Crime/Delinquency Adjustment to Trauma Situational Consistency of Problems Temporal Consistency of Problems

Functioning Care Intensity & Organization Intellectual/Developmental Monitoring Physical/Medical Treatment Family Transportation School/Day Care Service Permanence Sexual Development

Family/Caregiver Needs and Strengths Strengths Physical Family Supervision Interpersonal Involvement with Care Relationship Permanence Knowledge Education Organization Vocational Resources Well-being Residential Stability Spiritual/Religious Safety Talents/Interest Inclusion

CHILD & ADOLESCENT NEEDS AND STRENGTHS For Children and Adolescents with Developmental Disabilities (CANS-DD)

Functioning Risk Behaviors Motor Danger to Self Sensory Danger to Others Intellectual Agitation/Self Stimulation Communication Runaway Developmental Social Behavior Self Care Crime/Delinquency Independent Living Skills Physical/Medical Family School/Day Care

Co-Existing Conditions Care Intensity & Organization Psychotic Symptoms Monitoring Depression/Anxiety Assistance Impulse Control Treatment Oppositional Funding/Eligibility Substance Abuse Transportation Adjustment to Trauma Service Permanence

Caregiver Capacity Strengths Physical Family Supervision Interpersonal Involvement Relationship Permanence Knowledge Education Organization Vocational Home Adaptability Well-being Resources Spiritual/Religious Safety Talents/Interest Inclusion

CHILD & ADOLESCENT NEEDS AND STRENGTHS For Children and Adolescents in the Juvenile Justice System (CANS-JJ)

Criminal and Delinquent Behavior Functioning Seriousness of Criminal Behavior Intellectual/Developmental History of Criminal Behavior Physical/Medical Violence Family Sexually Abusive Behavior School/Day Care Peer Involvement Parental Involvement

Mental Health Complications Other Risk Behaviors Psychosis Danger to Self Attention Deficit/Impulse Control Social Behavior Depression/Anxiety Elopement Oppositional Behavior Antisocial Behavior Substance Abuse Temporal Consistency of Problems

Care Intensity & Organization Caregiver Capacity Monitoring Physical Treatment Supervision Transportation Involvement with Care Service Permanence Knowledge Organization Resources Safety

Strengths Family Interpersonal Relationship Permanence Education Vocational Well-being Spiritual/Religious Talents/Interest Inclusion

CHILD & ADOLESCENT NEEDS AND STRENGTHS For Children and Adolescents in the Child Welfare System (CANS-CW) Functional Status Mental Health Intellectual Serious mental Illness Developmental Attention Deficit/Impulse Control Physical/Medical Depression/Anxiety Family Anger Control Attachment Oppositional Behavior Antisocial Behavior Sexual Development Adjustment to Trauma School/Day Care Situational Consistency of Problems Temporal Consistency of Problems Abuse history Family History of Mental Illness

Caregiver Needs and Strengths Care Management Physical Urgency Supervision Monitoring Involvement with Care Treatment Knowledge Transportation Organization Service Permanence Resources Residential Stability

Child Safety Child Risk Behaviors Abuse Danger to Self Neglect Runaway Permanency Social Behavior Exploitation

Substance Abuse Criminal and Delinquent Behavior Severity of Substance Abuse Seriousness of Criminal Behavior Duration of Substance Abuse History of Criminal Behavior State of Recovery Violence Peer Involvement Sexually Abusive Behavior Parental Involvement Peer Involvement in Crime Parental Criminal Behavior Strengths Family Interpersonal Relationship Permanence Education Vocational Well-being Spiritual/Religious Creative/Artistic Inclusion

REFERENCES

Leon, SC, Lyons, JS, Uziel-Miller, ND, Tracy, P. (1999). Psychiatric hospital utilization of children and adolescents in state custody. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 305-310.

Lyons, JS, Uziel-Miller, ND, Reyes, F, Sokol, P. (2000). Strengths of children and adolescents in residential settings: prevalence and associations with psychopathology and discharge placement. Journal of the American Academy of Child and Adolescent Psychiatry 29, 176-181.

Lyons, JS, Kisiel, CL, Dulcan, M, Cohen, R, Chesler, P. (1997). Crisis assessment and psychiatric hospitalization of children and adolescents in state custody. Journal of Child and Family Studies, 6, 311-320.

Lyons, JS, Mintzer, LL, Kisiel, CL, Shallcross, H. (1998). Understanding the mental health needs of children and adolescents in residential treatment. Professional Psychology: Research and Practice, 29. 582-587.

Lyons, JS, Yeh, I, Leon, SC, Uziel-Miller, ND, Tracy, P. (1999). Use of measurement audit in outcomes management. Manuscript under review.

Lyons, JS (1998). Severity and Acuity of Psychiatric Illness Manual. Child and Adolescent Version. The Psychological Corporation, Harcourt Brace Jovanovich, San Antonio, Texas.

Lyons, JS, Howard, KI, O’Mahoney, MT, Lish, J (1997). The measurement and management of clinical outcomes in mental health. John Wiley & Sons, New York.

Lyons, JS (1997). The evolving role of outcomes in managed mental health care. Journal of Child and Family Studies, 6, 1-8.

Lyons, JS, Chesler, P, Shallcross, HM (1996) Using a Measure of Children’s Mental health Needs to Inform system changes. Family Matters, a national newsletter published by the mental Health Services Program for Youth, funded by the Robert Wood Johnson Foundation, 2nd Special Edition, May, 1996, 1-8.

Lyons, JS, Kisiel C, West C, (1997) Child and Adolescent Strengths Assessment: a Pilot study, Family Matters, a national newsletter published by the mental Health Services Program for Youth, funded by the Robert Wood Johnson Foundation, Fall 1997, 30-32.

Lyons, JS, Holzberg, MA, (1997), Improving The Use of Psychological Testing Through Decision support, Gatekeeping, and Credentialing, Family Matters, a national newsletter published by the mental Health Services Program for Youth, funded by the Robert Wood Johnson Foundation, Summer 1997, 5- 7.

Lyons, JS, Shallcross, HM, Sokol, PT, (1998) Using Outcomes Management for systems Planning and Reform, The Complete guide To Managed Behavioral Healthcare, Chris E. Stout, Editor, John Wiley & Sons, Inc., Chapter K.

Attachment F-11