CANS Executive Summary
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The Child and Adolescent Needs and Strengths (CANS) is a multi-purpose tool developed for children’s services to support decision making, including level of care and service planning, to facilitate quality improvement initiatives, and to allow for the monitoring of outcomes of services. Versions of the CANS are currently used in 25 states in child welfare, mental health, juvenile justice, and early intervention applications. A comprehensive, multi-system version exists as well.
The CANS was developed from a communication perspective so as to facilitate the linkage between the assessment process and the design of individualized service plans including the application of evidence-based practices. The CANS is easy to learn and is well liked by parents, providers and other partners in the services system because it is easy to understand and does not necessarily require scoring in order to be meaningful to an individual child and family. The way the CANS works is that each item suggests different pathways for service planning. There are four levels of each item with anchored definitions; however, these definitions are designed to translate into the following action levels (separate for needs and strengths):
- No evidence
- Watchful waiting/prevention
- Immediate/Intensive Action
- Centerpiece strength
- Strength that you can use in planning
- Strength has been identified-must be built
- No strength identified
Decision support applications include the development of specific algorithms for levels of care including treatment foster care, residential treatment, intensive community services, and traditional outpatient care. Algorithms can be localized for sensitivity to varying service delivery systems and cultures. The applications of CANS-based decision algorithms have documented dramatic impacts on service system. In Illinois, use of a simple decision model for residential treatment resulted in savings of approximately $80 million per year in residential treatment in the late 1990’s. In Philadelphia, their use of a decision model for Treatment Foster Care reduced lengths of stay dramatically and saved the city $11 million in the first year of use.
In terms of quality improvement activities, a number of settings have utilized a fidelity model approach to look at service/treatment/action planning based on the CANS assessment. A rating of ‘2’ or ‘3’ on a CANS needs suggests that this area must be addressed in the plan. A rating of a ‘0’ or ‘1’ identifies a strength that can be used for strength-based planning and a ‘2’ or ‘3’ a strength that should be the focus on strength-building activities.
Finally, the CANS can be used to monitor outcomes. This can be accomplished in two ways. First, items that are initially rated a ‘2’ or ‘3’ are monitored over time to determine the percent of youth who move to a rating of ‘0’ or ‘1’ (resolved need, built strength). Or, dimension scores can be generated by summing items within each of the dimensions (Problems, Risk Behaviors, Functioning, etc). These scores can be compared over the course of treatment. CANS dimension scores have been shown to be valid outcome measures in residential treatment, intensive community treatment, foster care and treatment foster care, community mental health, and juvenile justice programs.
The CANS has demonstrated reliability and validity. With training, any one with a bachelor’s degree can learn to complete the tool reliably, although some applications require a higher degree. The average reliability of the CANS is 0.75 with vignettes, 0.84 with case records, and can be above 0.90 with live cases. The CANS is auditable and audit reliabilities demonstrate that the CANS is reliable at the item level. Validity is demonstrated with the CANS relationship to level of care decisions and other similar measures of symptoms, risk behaviors, and functioning.
The CANS is an open domain tool that is free for anyone to use. There is a community of people who use the various versions of the CANS and share experiences and additional items and supplementary tools.
SIX KEY COMPONENTS OF A COMMUNIMETRIC TOOL
- Items are selected based on relevance to planning.
- Action levels for all items
- Consider culture and development before establishing the action level
- Agnostic as to etiology—descriptive, no cause and effect
- About the child, not about the service. Rate needs when masked by interventions.
- Specific ratings window (e.g. 30 days) can be over-ridden based on action levels
To view either the manual or the form of the CANS, click on one of the links below:
For a better idea of how the CANS is spread out across the US and Canada click here to open a PowerPoint displaying the CANS map.
For more information:
- John S. Lyons, Ph.D.
RELIABILITY AND VALIDITY OF THE CANS
There is substantial research involving the CANS. Reliability studies have demonstrated that the CANS is reliable at the item level. Training and certification is required for the use of the CANS and the recommended minimum for certification is a reliability of 0.70 using an intraclass correlation coefficient on a test vignette. Average reliability after training is approximately 0.80. Reliability on case record reviews has been demonstrated to be 0.85 while reliability with live interview strategies is above 0.90.
Validity has been demonstrated through the relationship of the CANS to other measures of similar constructs such as the CAFAS and CBCL. In addition, validity has been demonstrated through the relationship of the CANS to service use and outcomes. A bibliography of CANS research can be found on this website.
IMPACT OF THE CANS ON SERVICE SYSTEMS
The CANS and related tools have been implemented a number of states. These tools support Total Clinical Outcomes Management (TCOM) strategies for transforming service systems. The following results are among those that have been documented in the service systems which utilize the approach:
- The investment of $50 million new dollars in intensive community services in New York instead of an expansion of residential treatment
- The reduction of unnecessary (and harmful) psychiatric hospitalizations in Illinois
- The elimination of racial disparities in the decision to hospitalize children in Illinois.
- The improvement in access to mental health services for children in the Chicago Public School system
- A reduction by 1/3 of residential placements in Illinois’ child welfare system in an 18 month period.
- Clear evidence that residential treatment and psychiatric hospitalization benefit children who need these interventions but harm children who do not need these interventions.
- An expansion of foster care stabilization services in Illinois based on the demonstrated effectiveness of the program to reduce placement moves.
- An increased recognition of the role of trauma experiences and adjustment in the lives of children.
- The reduction in re-arrest rates for juveniles with serious mental illness who were arrested and detained from 72% to 26%.
- An improvement in residential outcomes state-wide by more effectively identifying those youth likely to benefit from this type of intensive treatment.
THE CANS AND TCOM AS A MASS COLLABORATION
Mass Collaboration is a term used by Tapscott and Williams in their book “Wikinomics” to describe open processes whereby individuals working in the same marketplace can share resources. The concept as it applies to the child serving system is that we do not have enough money to serve all of those in need so to the extent that we can reduce the costs of the infrastructure of the system through sharing, the more money is left to actually serve children and families. As a mass collaboration, the CANS and TCOM are open domain and free for anyone to use as long as they do so responsibly. In addition, all advancements using these approaches are shared back into the collaboration creating a learning environment where all participants are engaged in a process to help better serve children and families by keeping the focus on the child serving system on this shared vision.