Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Child and Adolescent Needs and Strengths (CANS) Massachusetts For Children and Youth ages Birth through Four This document contains: Form for Identifying Children / Adolescents with Serious Emotional Disturbances (SED) Item coding definitions (guidelines for each section) CANS items (all items with space to record responses) You should also refer to this document: Item glossary for ages Birth through Four (a detailed guide to coding each item) Instructions: • To complete the CANS, you must be CANS certified by Massachusetts. • For more information on training and certification, visit https://masscans.ehs.state.ma.us • Complete all items, except for those that are explicitly excluded because of the child’s age. If you know • that it will not be possible to obtain data to complete all items, see below (“Incomplete but Final”) for • instructions. • Use the Comment field that follows each section to clarify any item responses where appropriate (for • example, when conflicting information comes from different sources, or when n of the available • responses conveys the clinical reality) and to add essential contextual information. (Each comment field • must contain some response, even if “n/a”.) • Complete and sign the form titled “Identifying Children / Adolescents with Serious Emotional • Disturbances”. • When the CANS is complete (response to all items), check it as “complete” and sign and date it on the final page. • If completion of the CANS will not be possible, (for example, if client did not return to complete the • behavioral health assessment) check it as “Incomplete but Final,” give the reason for inability to complete, and sign and date it on the final page. • When final, all the data in “Identifying Children / Adolescents with Serious Emotional Disturbances” and in the CANS become part of the client’s medical record. • CANS information should be updated at the time of each treatment plan review. For more information and frequently asked questions visit: www.mass.gov/MassHealth/ChildBehavioralHealth More questions? Email CBHI at: CBHI@state.ma.us Praed Foundation Copyright 1999 John S. Lyons, Ph.D. Praed Foundation jlyons@ouotta.ca www.buddinpraed.org praedfoundation@yahoo.com ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ MassHealth ID: Name (Last, First) DOB (mm/dd/yyyy) Gender M F O RACE: Check up to three races that the client identifies as White Black or African American Native Hawaiian or other Pacific Islander American Indian/Alaska Native (Wampanoag) Hispanic/Latino/Black Chooses not to Self-Identify American Indian/Alaska Native (Other Tribal Nation) Hispanic/Latino/White Other Asian Hispanic/Latino/other ETHNICITY: Check up to three ethnicities that the client identifies as Afghan African American Albanian American Arab Argentinean Armenian Asian Indian Austrian Belgian Bhutanese Brazilian British Bulgarian Cambodian Canadian Cape Verdean Chilean Chinese Chooses not to self-identify Columbian Costa Rican Cuban Czech Danish Dominican Dutch Ecuadorian Egyptian English Ethiopian Filipino Finnish French French Canadian German Ghanian Greek Guatemalan Haitian Hmong Honduran Hungarian Indonesian Iranian Iraqi Irish Israeli Italian Jamaican Japanese Kenyan Korean Laotian Latvian Lebanese Liberian Lithuanian Mexican Moldovian Moroccan Myanmar/Burmese Nigerian Norwegian Other Other – African Other – Asian Other – Caribbean Other – European Other – Latin America Pakistani Panamanian Peruvian Polish Portuguese Puerto Rican Romanian Russian Salvadoran Scandinavian Scottish Scottish Irish Sierra Leonean Somalian Sudanese Swedish Swiss Syrian Thai Turkish Ugandan Ukrainian Venezuelan Vietnamese Welsh West Indian ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ PRIMARY LANGUAGE: Identify from the list below _______________________________________________________________________ LANGUAGE at HOME: Identify from the list below _______________________________________________________________________ English Farsi/Iranian/Persian Japanese Spanish Albanian Finnish Khmer/Cambodian Tagalog/Filipino American Sign Language French Korean Tamil Amharic German Lao Thai Arabic Greek Mandarin Tigrigna Armenian Haitian Creole Polish Turkish Bosnian Hebrew Portuguese Urdu Cantonese Hindi Russian Vietnamese Cape Verdean Ibo/Igbo Serbian-Croatian Yiddish Chinese Italian Somali Unknown Other REFERRED by: Check from the list below Inpatient Behavioral Health Unit DYS Clergy Emergency Services provider Court Managed Care Company CBAT School Other behavioral health provider DMH Primary Care Provider Other DDS Family member DCF Friend ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Identifying Children /Adolescents with Serious Emotional Disturbances1 1 SED = “Serious emotional disturbance” 2 The determination that a child meets these clinical criteria is not an evaluation under federal and state laws addressing special education. Serious Emotional Disturbance (SED) is a term that encompasses or more mental illnesses or conditions. Whether a member has a SED can be determined by applying either Part I or Part II, below, or both. Identifying a child as having SED is step in the determination of medical necessity for Intensive Care Coordination. In addition, MassHealth will be tracking SED determinations to guide service system improvements for children and families. Accurate identification of children with SED will help MassHealth improve services for this population in the future. A child may have a SED under Part I or Part II or both2. All criteria in part 1 and part 2 must be considered and ruled in or out. Part I: Please answer the following questions according to your current knowledge of the child or adolescent: 1. Does the child currently have, or at any time in the last 12 months has had, a diagnosable DSM-IV or ICD-10 disorder(s)? Developmental disorders, substance abuse disorders or V-codes are not included unless they co- occur with another DSM-IV or ICD-10 diagnosis. Yes No 2. If yes to question 1, please indicate whether those diagnoses resulted in functional impairment which substantially interferes with, or limits, the child’s role or functioning in any of the following areas. (Functional impairment is defined as difficulties which substantially interfere with or limit his or her ability to achieve or maintain or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills. Functional impairments of episodic, recurrent, and continuous duration are included unless they are temporary and expected responses to stressful events in the environment) Family School Community activities No functional impairment as defined. 3. If yes to question 1, and you checked “no functional impairment as defined” in question 2: Would the child have met or more of the functional impairment criteria in question 2 without the benefit of treatment? (Children who would have met functional impairment criteria during the year without the benefit of treatment or other support services are included.) Yes No Part II: 4. Please indicate if the child has exhibited any of the following over a long period of time and to a marked degree that adversely affects the child’s educational performance: (a) An inability to learn, that cannot be explained due to intellectual, sensory, or health factors. Yes No ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ If yes to (a), is this solely the result of autism, mental retardation, specific learning disability, hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a serious emotional disturbance? Yes No (b) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers. Yes No If yes to (b), is this solely the result of autism, mental retardation, specific learning disability, hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a serious emotional disturbance? Yes No (c) Inappropriate types of behavior or feelings under normal circumstances. . Yes No If yes to (c), is this solely the result of autism, mental retardation, specific learning disability, hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a serious emotional disturbance? Yes No (d) A general pervasive mood of unhappiness or depression.. Yes No If yes to (d), is this solely the result of autism, mental retardation, specific learning disability, hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a serious emotional disturbance? Yes No (e) A tendency to develop physical symptoms or fears associated with personal or school problems. . Yes No If yes to (e), is this solely the result of autism, mental retardation, specific learning disability, hearing impairment, visual impairment, deaf-blindness, speech or language impairment, orthopedic impairment, traumatic brain injury, other health impairment, or multiple disabilities not including a serious emotional disturbance? Yes No 5. Please check this box if you identified a functional impairment in question 2 or answered “yes” to question 3. The child /adolescent has SED under Part I. 6. Please check this box if you checked or more “no” boxes in the right hand column of question 4 . The child /adolescent has SED under Part II. Clinician name, degree (print): Clinician signature: Date: _________________________ ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ For Life Domain Functioning, Behavioral/Emotional Needs, Risk Behaviors, Cultural Considerations, Transition to Adulthood, Caregiver Needs and Strengths the following categories and action levels are used: 0 - Indicates a dimension where there is no evidence of any needs. 1 - Indicates a dimension that requires monitoring, watchful waiting, or preventive activities. 2 - Indicates a dimension that requires action to ensure that this identified need or risk behavior is addressed. 3 - Indicates a dimension that requires immediate or intensive action. For Child Strengths the following categories and action levels are used: 0 - Indicates a domain where strengths exist that can be used as a centerpiece for a strength-based plan. 1 - Indicates a domain where strengths exist but require some strength building efforts in order for them to serve as a focus of a strength-based plan. 2 - Indicates a domain where strengths have been identified but they require significant strength building efforts before they can be effectively utilized as a focus of a strength- based plan. 3 - Indicates a domain in which efforts are needed in order to identify potential strengths for strength building efforts. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ LIFE DOMAIN FUNCTIONING Circle one 1.FAMILY - This item evaluates and rates the child according to who is in his/her family. Take into account the relationship the child has with his/her family as well as the relationship of the family as a whole. 0 No evidence of problems in relationships with family members and/or child is doing well in relationships with family members. 1 There is a history or suspicion of problems and/or child is doing adequately in relationships with family members although some problems may exist. For example, some family members may have mild problems in their relationships with child including responding to infant’s non-verbal cues such as seeking eye-contact or pointing. 2 Child is having moderate problems with parents, siblings and/or other family members. Child observes arguing and/or family has difficulty responding to clear cues i.e. crying, putting hands up to be picked up. 3 Child is having severe problems with parents, siblings, and/or other family members. This would include problems of domestic violence, constant arguing between parents/caregiver, and aggression with siblings, observing episodes of domestic violence and/or family generally ignores child’s initiations of social contact. Circle one 2. LIVING SITUATION - This item refers to how the child is functioning in his/her current living arrangement which could be with a relative, a temporary foster home, shelter, etc. 0 No evidence of problems with functioning in current living environment. 1 There is a history, suspicion or mild problems with functioning in current living situation. Caregivers are concerned about child’s behavior or needs at home. 2 Moderate problems with functioning in current living situation. Child has difficulties maintaining his/her behavior in this setting creating significant problems for others in the residence. Parents of infants concerned about irritability of infant and ability to care for or comfort infant. 3 Profound problems with functioning in current living situation. Child is at immediate risk of being removed from living situation due to his/her behaviors or unmet needs. Circle one 3. PRESCHOOL/CHILDCARE - This item rates the child’s behavior in settings of preschool and/or childcare. 0 No evidence of problems with functioning in current preschool or childcare environment. 1 There is a history, suspicion or mild problems with functioning in current preschool or daycare environment. 2 Moderate problems with functioning in current preschool or daycare environment. Child has difficulties maintaining his/her behavior in this setting creating significant concerns or problems for others. 3 Profound problems with functioning in current preschool or daycare environment. Child is at immediate risk of being removed from program due to his/her behaviors or unmet needs. Circle one 4. SOCIAL FUNCTIONING - This item rates any difficulties a child may have with social skills and relationships. 0 No evidence of problems and/or child has developmentally appropriate social functioning. 1 There is a history, suspicion or child is having some minor problems in social relationships. Infants may be slow to respond to or engage adults, toddlers may need support to interact positively with peers and toddlers and preschoolers may be withdrawn. 2 Child is having some moderate problems with his/her social relationships. Infants and toddlers may be unresponsive to adults or peers, hard to soothe, and show difficulty in focusing on toys in a social situation. Toddlers may be aggressive. Preschoolers may argue excessively with adults and peers and lack ability to play in groups even with adult support. 3 Child is experiencing severe disruptions in his/her social relationships. Infants and toddlers show limited ability to signal needs or express pleasure. Infants, toddlers, preschoolers are consistently withdrawn and unable to relate to familiar adults. Preschoolers show no joy or sustained interaction with peers or adults, and/or aggression may be putting themselves or others at risk. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 5. RECREATION/PLAY - This item rates the degree to which an infant/child is engaged in play, which should be understood developmentally. 0 No evidence that infant or child has problems with recreation or play. 1 There is a history, suspicion or child is doing adequately with recreational or play activities although some problems may exist. Infants may not be easily engaged in play. Toddlers and preschoolers may seem uninterested and poorly able to sustain play. 2 Child is having moderate problems with recreational activities. Infants resist play or do not have enough opportunities for play. Toddlers and preschoolers show little enjoyment or interest in activities within or outside the home and can only be engaged in play/recreational activities with ongoing adult interaction and support. 3 Child has no access to or interest in play or toys. Infant spends most of time not interacting with toys or people. Toddlers and preschoolers, even with adult encouragement, cannot demonstrate enjoyment in “pretend” play. Circle one 6. DEVELOPMENTAL/COGNITIVE DELAY - This rating describes the child's development as compared to standard developmental milestones, as well as the child’s cognitive/intellectual functioning, including attention span, persistence, and distractibility. 0 No evidence of developmental delay or the child has no developmental/cognitive problems. 1 There is a history or there are concerns about possible developmental/cognitive delay. Child may have low IQ. 2 Child has developmental/cognitive delays or mild mental retardation. 3 Child has severe and pervasive developmental/cognitive delays or profound mental retardation. Circle one 7. SELF CARE - This rating describes participating in age appropriate routines of daily living e.g. feeding self, washing hands, putting away toys, toilet training and dressing self. 0 No evidence of problems with self care. 1 There is either a history of self care problems or slow development in this area. 2 The child does not meet developmental milestones related to self care tasks and experiences problems in functioning in this area. 3 The child has significant challenges with self care tasks and is in need of intensive or immediate help in this area. Circle one 8. SENSORY - This rating describes the child's ability to use all senses including vision, hearing, smell, touch, and kinesthetics (the ability to feel movements of the limbs and body). 0 No evidence of sensory problems. 1 There is either a history of sensory problems or less than optimal functioning in this area. 2 The child has challenges in either sensory abilities or processing. 3 The child has significant challenges in either sensory abilities or sensory processing. Circle one 9. MOTOR - This rating describes the child's fine (e.g. hand grasping and manipulation) and gross (e.g. sitting, standing, walking) motor functioning. 0 No evidence of fine or gross motor development problems. 1 There is a history, suspicion or child has some indicators that motor skills are challenging and there may be some concern that there is a delay. 2 Child has either fine and/or gross motor skill delays. 3 Child has significant delays in fine and/or gross motor development. Delay causes impairment in functioning. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 10. COMMUNICATION, COMPREHENSION AND EXPRESSION - This rating describes the child's ability to communicate through any medium including all spontaneous vocalizations and articulations. 0 No evidence of communication, comprehension or expression problems. 1 There is a history of communication, comprehension or expression problems and/or there are concerns of possible problems. An infant may rarely vocalize; a toddler may have very few words and become frustrated with expressing needs; a preschooler may be difficult for others to understand. 2 Child has either receptive or expressive language problems, comprehension or expression problems that interfere with functioning. Infants may have trouble interpreting facial gestures or initiate gestures to communicate needs. Toddlers may not follow simple1-step commands. Preschoolers may be unable to understand simple conversation or carry out 2-3 step commands. 3 Child has serious communication, comprehension or expression difficulties and is unable to communicate in any way including pointing and grunting. Circle one 11. MEDICAL - This item rates the child’s current health status. 0 No evidence that child has a medical issue and/or child is healthy. 1 There is a history or the child has some medical problems that require medical treatment. 2 Child has a chronic illness that requires ongoing medical intervention. 3 Child has a life threatening illness or medical condition. Circle one 12. PHYSICAL - This item rates the child’s physical limitations. 0 No evidence that the child has any physical limitations. 1 There is a history, suspicion or the child has some physical condition that places mild limitations on activities. Conditions such as impaired hearing or vision would be rated here. Treatable medical conditions that result in physical limitations (e.g. asthma) will be rated here. 2 Child has physical condition that notably impacts activities. Sensory disorders such as blindness, deafness, or significant motor difficulties would be rated here. 3 Child has severe physical limitations due to multiple physical conditions. Circle one 13. SLEEP - Please remember to take the child’s development into account when rating this item. This rating describes how difficult it is for a child to fall asleep, resists going to sleep and/or wakes frequently during the night. Any disruption of a full night of sleep would be rated here. When rating an infant, it is important to rate actual sleep issues which are outside the realm of typical infancy sleep issues. 0 No evidence the child has problems with sleep. 1 There is a history, suspicion or the child has some mild problems with sleep. Toddler resists sleep and consistently needs a great deal of adult support to sleep. Preschoolers may have either a history of poor sleep or continued problems 1-2 nights per week. 2 Child is having problems with sleep. Toddlers and preschoolers may experience difficulty falling asleep, night waking, night terrors or nightmares on a regular basis. 3 Child is experiencing significant sleep problems that result in sleep deprivation. Parents have exhausted numerous strategies for assisting child. Circle one 14. FEEDING DISORDERS – Please remember to take the child’s development into account when rating this item. This rating describes issues with feeding such as, food aversions, symptoms of failure to thrive and/or Pica. When rating this item, please take into account if a baby is having issues latching on and/or sucking. 0 No evidence that the child has a feeding disorder. 1 Child has a history of feeding issues such as sensory aversions to food, failure to thrive or eating unusual or dangerous materials, but has not d so in the last 30 days. 2 Child has had a feeding issue such as sensory aversions to food, failure to thrive or eating unusual or dangerous materials consistent with a diagnosis of Pica in the last 30 days. 3 Child has become physically ill during the past 30 days by eating dangerous materials or is currently at serious medical risk due to weight or growth issues. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 15. PARENT/CHILD INTERACTION - This rating describes how the parent and child relate to each other and the level of relationship that exists. 0 No evidence of problems in the parent/child interaction. 1 There is either a history of problems or suboptimal functioning in parent/child interaction. There may be inconsistent interactions or indications that interaction is not optimal, but this has not yet resulted in problems. 2 The parent/child dyad interacts in a way that is problematic and this has led to interference with the child’s growth and development. 3 The parent/child dyad is having significant problems that can be characterized as abusive or neglectful. Circle one 16. RELATIONSHIP PERMANENCE - This rating refers to the stability of significant relationships in the child’s life. This likely includes family members but may also include other individuals. 0 There is no evidence of a problem with relationships. Family members, friends, and community have been stable for most of child’s life and are likely to remain so in the foreseeable future. Child is involved with both parents. 1 There is either a history of instability and/or the child has had stable relationships but there is some concern about instability in the near future ( year) due to transitions, illness, or age. A stable relationship with only parent may be rated here. 2 This level indicates a child has had at least stable relationship over his/her lifetime but has experienced other instability through factors such as divorce, moving, removal from home, and death. 3 This level indicates a child who does not have any stability in relationships with any caregiver; adoption must be considered. 17. Comments on LIFE DOMAIN FUNCTIONING CHILD BEHAVIORAL/EMOTIONAL NEEDS Circle one 18. ATTACHMENT - This item should be rated within the context of the child's significant parental or caregiver relationships. 0 No evidence of problems with attachment. 1 There is a history, suspicion or mild problems with attachment. Infants appear uncomfortable with caregivers, e.g. may be hard to soothe, resist touch, or appear anxious and clingy some of the time. Caregivers may feel disconnected from infant. Older children may be overly reactive to separation or seem preoccupied with parent. Boundaries may seem inappropriate with others. 2 Moderate problems with attachment are present. Infants from 9-18 months may fail to demonstrate stranger anxiety or have extreme reactions to separation resulting in interference with development. Older children may have ongoing problems with separation, may consistently avoid caregivers and have inappropriate boundaries with others, putting them at risk. 3 Severe problems within attachment are present. Infant is unable to use caregivers to meet needs for safety and security. Older children present with either an indiscriminate attachment pattern of reaching out to adults or are withdrawn with inhibited attachment patterns. A child that meets the criteria for Reactive Attachment Disorder would be rated here. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 19. REGULATORY: BODY CONTROL/EMOTIONAL CONTROL - This item refers to the child’s ability to be comforted as well as regulate bodily functions such as eating, sleeping and elimination, as well as activity level/intensity and sensitivity to external stimulation. The child’s ability to regulate intense emotions (joy, as well as anger and sadness) is also rated here. 0 No evidence of regulatory problems. 1 There is a history, suspicion or some mild problems with regulation are present. Infants may have unpredictable patterns and be difficult to console. Older children may require a great deal of structure and need more support than other children in coping with frustration and difficult emotions. 2 Moderate problems with regulation are present. Infants may demonstrate significant difficulties with transitions and irritability, such that, consistent adult intervention is necessary and disruptive to the family e.g. transitioning from activity to another, waking to sleeping, and sleeping to waking. Older children may demonstrate severe reactions to sensory stimuli and emotions that interfere with their functioning and ability to progress developmentally and may demonstrate such unpredictable patterns in their eating and sleeping routines that the family is disrupted and distressed. 3 Profound problems with regulation are present that place the child’s safety, well-being and/or development at risk. Circle one 20. DEPRESSION – This item rates displayed symptoms of a change in emotional state and can include sadness, irritability and diminished interest in previously enjoyed activities. 0 No evidence of problems with depression. 1 There is a history, suspicion or some indicators that the child may be mildly depressed or have experienced situations that may lead to depression. Infants may be observed to be slow to engage or express emotions in a muted way. Older children are irritable and/or do not demonstrate a range of affect. 2 Moderate problems with depression are present. Infants demonstrate a change from previous behavior and are observed to have a flat affect especially the absence of pleasure or joy and may have little responsiveness to adults. Older children may have negative verbalizations, dark themes in play and demonstrate little enjoyment in play and interactions. The child may meet criteria for a DSM IV diagnosis. 3 Clear evidence of overwhelming depression that is disabling for the child in all life domains. Circle one 21. ANXIETY – This item rates evidence of symptoms associated with worry, dread, or panic. 0 No evidence of anxiety problems. 1 There is a history or suspicion of anxiety problems or mild anxiety. An infant may appear anxious in certain situations but has the ability to be soothed. Older children may appear in need of extra support to cope with some situations but are able to be calmed. 2 Clear evidence of anxiety associated with either anxious mood or significant fearfulness. Anxiety has interfered significantly in child’s ability to function in at least life domain. Infants may be irritable, over-reactive to stimuli, have uncontrollable crying; demonstrate vigilance in observing caregivers, and/or significant separation anxiety. Older children may have all of the above with persistent reluctance or refusal to cope with some situations. 3 Clear evidence of debilitating level of anxiety and vigilance that makes it virtually impossible for the child to function in any life domain. Circle one 22. ATYPICAL BEHAVIORS - This rating describes behaviors that may include mouthing after 1 year, head banging, smelling objects, spinning, twirling, hand flapping, finger-flicking, rocking, toe walking, staring at lights, or repetitive and bizarre verbalizations. 0 No evidence of atypical behaviors in the infant/child. 1 There is a history, suspicion or reports of atypical behaviors from others that have not been observed by caregivers. 2 Clear evidence of atypical behaviors reported by caregivers that are observed on an ongoing basis. 3 Clear evidence of atypical behaviors that are consistently present and interfere with the infants/child’s functioning on a regular basis. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 23. HYPERACTIVITY/IMPULSIVITY – Please rate this item ‘0’ if the child is under 3 years of age. This item rates behavioral symptoms associated with hyperactivity and/or impulsiveness, i.e. loss of control of behaviors, which includes, but is not limited to, Attention Deficit/ Hyperactivity Disorder (ADHD) and disorders of impulse control. 0 Child is under age 3 or there is no evidence of symptoms of hyperactivity or lack of impulse control. 1 There is a history, suspicion or some mild problems with impulsive, distracted or hyperactive behavior that places the child at risk of future difficulty in functioning. 2 Clear evidence of problems with impulsive, distracted, or hyperactive behavior that interferes with the child’s ability to function in at least life domain. The child may run and climb excessively even with adult redirection. The child may not be able to sit still even to eat. The child may blurt out answers to questions without thinking, have difficulty waiting turn and intrude on others’ space. 3 Clear evidence of a dangerous level of impulsive and hyperactive behavior that places the child at risk of physical harm. Circle one 24. OPPOSITIONAL – Please rate this item ‘0’ if the child is under 3 years of age. This item rates the child’s relationship with authority figures. 0 Child is under age 3 or there is no evidence of oppositional behaviors. 1 There is a history or mild level of defiance towards authority figures that has not yet begun to cause functional impairment. 2 Clear evidence of oppositional and/or defiant behavior towards authority figures, which is currently interfering with the child’s functioning in at least life domain. This behavior is persistent and caregiver’s attempts to change behavior have failed. 3 Clear evidence of a dangerous level of oppositional behavior involving the threat of physical harm to others. Circle one 25. ADJUSTMENT TO TRAUMA - This item is used to describe the child who is having difficulties adjusting to a traumatic experience. Please note that to rate this item a traumatic event is not required to meet the DSM-IV TR definition of trauma, but rather an event defined as traumatic by the child. There can be an inferred link between the trauma and current behavior. 0 No evidence of problems associated with traumatic life events. 1 The child has experienced a traumatic event and is not demonstrating symptoms or there are mild changes in the child’s behavior that are controlled by caregivers. 2 Clear evidence of adjustment problems associated with traumatic life event/s. Adjustment is interfering with child’s functioning in at least life domain. Infants may have developmental regression, and/or eating and sleeping disturbance. Older children may have all of the above as well as behavioral symptoms, tantrums and withdrawn behavior. 3 Clear evidence of debilitating level of trauma symptoms that makes it virtually impossible for the child to function in any life domain. Circle one 26. ATTENTION - This rating describes the level to which the child can maintain focus, within what is developmentally appropriate for the child. 0 No evidence of attention problems. 1 There is either a history of attention problems or sub-optimal functioning in this area. 2 There is clear evidence that the child demonstrates attention problems that interferes with functioning. 3 The child has significant challenges in attention that is causing delay or problems in development. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ 27. Comments on CHILD BEHAVIORAL/EMOTIONAL NEEDS CHILD RISK FACTORS & BEHAVIORS Circle one 28. SELF HARM - This item is used to describe repetitive behavior that results in physical injury to the child, e.g. head banging, etc. 0 No evidence of self harm behaviors. 1 There is a history, suspicion or a mild level of self harm behavior. 2 Moderate level of self harm behavior such as head banging that cannot be impacted by caregiver and interferes with child’s functioning. 3 Severe level of self harm behavior that puts the child’s safety and well-being at risk. Circle one 29. AGGRESSION - This item rates the child’s violent or aggressive behavior. The intention of this behavior is to cause significant bodily harm to others. 0 No evidence of aggressive behaviors. 1 There is either a history of aggressive behavior or mild concerns in this area that have not yet interfered with functioning. 2 There is clear evidence of aggressive behavior towards others, behavior is persistent and caregiver’s attempts to change behavior have not been successful. 3 The child has significant challenges in this area that is characterized as a dangerous level of aggressive behavior that involves the threat of harm to others or problems in more than life domain that significantly threatens the child’s growth and development. Circle one 30. SANCTION SEEKING BEHAVIOR - Please rate this item ‘0’ if the child is under 3 years of age. This item refers to instigating behaviors with the intention of being sanctioned by adults. 0 Child is under age 3 or there is no evidence of problematic instigating behavior and/or child does not engage in behavior that forces adults to sanction him/her. 1 There is a history, suspicion or mild level of problematic sanction seeking behavior. This might include occasional inappropriate sanction seeking behaviors that force adults to sanction the child. 2 Moderate level of problematic sanction seeking behavior. Sanction seeking behavior causes problems in the child’s life. Child may be intentionally getting in trouble in child care setting or at home. 3 Severe level of problematic sanction seeking behavior. This level would be indicated by frequent serious sanction seeking behavior that forces adults to seriously and/or repeatedly sanction the child. Sanction seeking behaviors are sufficiently severe that they place the child at risk of significant sanctions (e.g. expulsion from day care, preschool, and/or removal from the community). ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 31. FRUSTRATION TOLERANCE/TANTRUMMING – This item rates a child’s level of agitation and/or anger when frustrated. 0 No evidence of any challenges dealing with frustration. Child does not tantrum. 1 Child demonstrates some difficulties dealing with frustration. Child may sometimes become agitated or verbally hostile or aggressive or anxious when frustrated. 2 Child struggles with tolerating frustration. Child’s reaction to frustration impairs functioning in at least life domain. He/she may tantrum when frustrated. 3 Child engages in violent tantrums when frustrated. Others may be afraid of child’s tantrums or child may hurt self or others during tantrums. 32. Comments on CHILD RISK FACTORS & BEHAVIORS CULTURAL CONSIDERATIONS Circle one 33. LANGUAGE - This item looks at whether the child and family need help to communicate with you or others in English. This item includes spoken, written, and sign language, as well as addresses issues of literacy. This item should be rated without considering the child as an adequate interpreter. Interpreting for a parent may place a burden on a child and/or negatively impact the quality of care the child or family receives. If another adult family member serves as an interpreter in a behavioral health setting, the quality of this interpretation and confidentiality of the patient cannot be assured. Interpreting and written translation are complex skills. Trained and accredited interpreters and translators are impartial, confidential, and accountable to a code of ethics. Some families may have difficulty communicating due to issues beyond language difference, such as hearing issues or difficulty reading written English language. In addition, families may have difficulty understanding mental/behavioral health terminology. Issues such as these should be rated here. If there are language differences between family members, this would also be rated in the Cultural Differences Within a Family item. 0 No evidence that there is a need or preference for an interpreter or bilingual services and/or the child and family speak, hear and read English. 1 Child and/or family speak or read English, but potential communication problems exist because of limited vocabulary or comprehension of the nuances of the language. 2 Child and/or significant family members possess only limited ability to speak and/or read English. While basic communication may be possible, a bilingual provider or interpreter is needed to assure that adequate communication is possible for extensive work. 3 Child and/or significant family members do not speak English. A bilingual provider or interpreter is needed for all communication. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 34. DISCRIMINATION/BIAS - This item refers to any experience of discrimination or bias that is purposeful or accidental, direct or indirect. Discrimination may be based on gender, race, ethnicity, socioeconomic status, religion, sexual orientation, skin shade/color/complexion, linguistic ability, body shape/size, etc. Any statement of discrimination by a client should be acknowledged and respected. Children, youth and families’ feelings are what matter. These feelings can impact how a child or family function and creates stress for the child and/or family which can correlate with depression and/or poor health outcomes. The presence of such discrimination or experiences may present a barrier to accessing supports or services that may be helpful to the child or family. When families report feelings of discrimination providers can discuss those feelings and how they impact functioning, create an advocacy statement in the treatment plan, or assist the family in finding a better fit for necessary services. 0 No report of experiences of discrimination that impacts the child or family’s ability to function and/or creates stress. 1 Child or family reports experiences of discrimination that occurred recently or in the past, but it is not currently causing any stress or difficulties for the child or family. 2 Child or family reports experiences of discrimination which is currently interfering with the child or family’s functioning. 3 Child or family reports experiences of discrimination that substantially and immediately interferes with the child or family’s functioning on a daily basis and requires immediate action. Circle one 35. CULTURAL IDENTITY - This item refers to a child’s feelings about her/his cultural identity. Research shows a strong and positive cultural identity may help protect children from mental/behavioral health problems. However, in some cases, because of pressure to identify with a particular group or sub-group, negative societal messages about their group, or previous discrimination, children may be conflicted about their identity, feel caught between several cultural identities, or struggle with the dominant responses to their preferred identity. This item measures the extent to which those feelings may cause stress for or influence the behavior of the child 0 No evidence of an issue with the child’s cultural identity or child has a strong and positive racial/ethnic/cultural identity. 1 Child has struggled in the past with her/his group or sub group membership, but is presently comfortable with her/his identity or there are mild issues related to identity. 2 Child expresses some distress or conflict about her/his racial/ethnic/cultural identity which interferes with the child or family’s functioning. 3 Child expresses significant distress or conflict about her/his racial/ethnic/cultural identity. Child may reject her/his cultural group identity, which severely interferes with the child or family’s functioning and/or requires immediate action. Circle one 36. CULTURAL DIFFERENCES WITHIN A FAMILY - Sometimes individual members within a family have different backgrounds, values and/or perspectives. In many cases, this may not cause any difficulties in the family as they are able to communicate about their differences, but for others it may cause conflict, stress, or disengagement between family members and impact the child’s functioning. This might occur in a family where a child is adopted from a different race, culture, ethnicity, or socioeconomic status. The parent may struggle to understand or lack awareness of the child’s experience of discrimination. Additionally this may occur in families where the parents are first generation immigrants to the United States. The youth may refuse to adhere to certain cultural practices, choosing instead to participate more in popular US culture. . 0 No evidence of conflict, stress or disengagement within the family due to cultural differences or family is able to communicate effectively in this area. 1 Child and family have struggled with cultural differences in the past, but are currently managing them well or there are mild issues of disagreement. 2 Child and family have struggled with cultural differences in the past, but are currently managing them well or there are mild issues of disagreement. 3 Child and family experience such significant difficulty managing cultural differences within the family that it interferes with the child’s functioning and/or requires immediate action. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 37. YOUTH/FAMILY RELATIONSHIP TO SYSTEM - There are situations and instances when people may be apprehensive to engage with the formal behavioral health care or helping system. Clients, as well as providers, bring their cultural experiences to the treatment relationship. Members of some cultural groups may be accustomed to the use of traditional healers or self-management of behavioral health issues or are simply distrustful of Western medicine. Undocumented individuals may be fearful of interaction with the health care system because of their legal status. These complicated factors may translate into generalized discomfort with the formal behavioral health care system. This item rates the degree to which the family’s apprehension to engage with the formal health care system creates a barrier for receipt of care. Additionally, the professionals’ relationship with the family may require the clinician to reconsider their approach. For example a family who refuses to see a psychiatrist due to their belief that medications are over-prescribed for children in their community. A clinician must consider this experience and understand its impact on the family’s choices. 0 The caregiver/child expresses no concerns about engaging with the formal helping system. 1 The caregiver/child expresses little or mild hesitancy to engage with the formal helping system that is easily rectified with clear communication about intentions or past issues engaging with formal helping system. 2 The caregiver/child expresses moderate hesitancy to engage with the formal helping system that requires significant discussions and possible revisions to the treatment plan. 3 The caregiver/child expresses significant hesitancy to engage with the formal helping system that prohibits the family’s engagement with the treatment team at this time. When this occurs, the development of an alternate treatment plan may be required. Circle one 38. AGREEMENT ABOUT STRENGTHS AND NEEDS -(Between provider and family) This item refers to the agreement between the family’s explanation and the treatment team’s understanding of the child’s presenting issues and treatment. The treatment planning process is more effective when the family and the provider understand each other’s perspectives and can agree on the issue and subsequent course of action. Typically, disagreement is present at some point during this process, however when it becomes problematic and children/youth are not getting their needs met it requires that the provider validate the feelings of the family and work with them towards agreement, or the provider can help the family find a provider who might be a better match for them. . 0 Treatment team and family have a shared understanding of the presenting needs and strengths of the child. 1 Small or mild disagreement between the clinician and the family with regard to the child’s presenting needs and strengths that are easily rectified or past issues of disagreement between clinician and family. 2 Moderate disagreement between the clinician and the family with regard to the child’s presenting needs and strengths that require consideration in treatment planning in order to create a therapeutic alliance. 3 Significant disagreement about the child’s needs and strengths that is currently preventing a successful alliance between the family and provider. 39. Comments on CULTURAL CONSIDERATIONS ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ CHILD STRENGTHS Circle one 40. FAMILY - This item refers to the presence of a sense of family identity as well as love and communication among family members. 0 Family has or more strong relationships where communication is effective. 1 Family has or more good relationships, and/or communication is good. 2 Strength building is required to develop stronger relationships and/or strengthen the family’s ability to communicate. 3 There is no evidence of any family relationships as a strength at this time or the child has no identified family, or the family requires significant assistance to develop relationships and the ability to communicate. Circle one 41. INTERPERSONAL - This item is used to identify a child’s social and relationship skills. 0 Significant interpersonal strengths. Child has a pro-social or “easy” temperament and is interested and effective at initiating relationships with other children or adults. If still an infant, child exhibits anticipatory behavior when fed or held. 1 Good level of interpersonal strengths. Child has formed a positive interpersonal relationship with at least non- caregiver. Child responds positively to social initiations by adults, but may not initiate such interactions by him/ herself. 2 Mild level of interpersonal strengths. Child may be shy or uninterested in initiating interactions or responding to adults or other children; or if still an infant, child may have a temperament that makes attachment to others a challenge. 3 There is no evidence of observable interpersonal strengths. Child does not exhibit any age-appropriate social gestures (e.g. social smile, cooperative play, responsiveness to social initiations by non-caregivers). An infant that consistently exhibits gaze aversion would be rated here. Circle one 42. ADAPTABILITY - This rating describes how well a child can adjust in times of transition. 0 Child has a strong ability to adjust to changes and transitions. 1 Child has some ability to adjust to changes and transitions and when challenged, the infant/child is successful with caregiver support. 2 Child has difficulties much of the time adjusting to changes and transitions even with caregiver support. 3 There is no evidence of adaptability and/or child has difficulties most of the time coping with changes and transitions. Adults are minimally able to impact child’s difficulties in this area. Circle one 43. PERSISTENCE - This rating describes how well a child can continue an activity when feeling challenged. 0 Infant/child has a strong ability to continue an activity when challenged or meeting obstacles. 1 Infant/child has some ability to continue an activity that is challenging. Adults can assist a child to continue attempting the task or activity. 2 Child has limited ability to continue an activity that is challenging and adults are only sometimes able to assist the infant/child in this area. 3 There is no evidence of persistence and/or child has difficulties most of the time coping with challenging tasks. Support from adults minimally impacts the child’s ability to demonstrate persistence. Circle one 44. CURIOSITY - This rating describes the child’s self-initiated efforts to discover his/her world. 0 This level indicates a child with strong curiosity. Infant displays mouthing and banging of objects within grasp; older children crawl or walk to objects of interest. 1 This level indicates a child with good curiosity. An ambulatory child who does not walk to interesting objects, but who will actively explore them when presented to him/her, would be rated here. 2 This level indicates a child with limited curiosity. Child may be hesitant to seek out new information or environments, or reluctant to explore even presented objects. 3 There is very limited or no observable evidence of curiosity. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 45. PLAYFULNESS - This rating describes the child’s enjoyment of play, alone and with others. 0 The child consistently demonstrates the ability to make use of play to further his/her development. His/her play is consistently developmentally appropriate, spontaneous, self-initiated and enjoyable. 1 The child demonstrates play that is developmentally appropriate, self-initiated, spontaneous and enjoyable much of the time. Child needs some assistance making full use of play. 2 The child demonstrates the ability to enjoy play and uses it to support his/her development some of the time or with the support of a caregiver. Even with this in place, there does not appear to be investment and enjoyment in the child. 3 There is no evidence of or the child does not demonstrate the ability to play in a developmentally appropriate or quality manner. Circle one 46. CREATIVITY/IMAGINATION - Please rate this item ‘3’ if the child is under 18 months of age. Most relevant for older toddlers and preschoolers. This rating describes how well a child can use his/her imagination in normal activities. 0 The child consistently demonstrates a significant level of creativity. This appears interwoven into his/her normal routines and chosen activities. 1 The child demonstrates a good level of creativity that can be useful to the child. 2 The child shows a mild level of ability in this area. Parents and caregivers need to be the primary support in this area. 3 Child is under age 18 months or there is no evidence of the child demonstrating creativity/imagination. Circle one 47. CONFIDENCE - Please rate this item ‘3’ if the child is under 18 months of age. This rating describes how well a child demonstrates his/her sense of mastery of activities. 0 The child consistently demonstrates a significant level of self confidence. This consistently supports the child in his/her development and functioning. 1 The child demonstrates a good level of confidence that is of benefit to the child. 2 The child shows a mild level of ability in this area. Parents and caregivers are the main supporters of the child in this area and the child needs continued development for this to be a significant strength. 3 Child is under age 18 months or there is no evidence of the child demonstrating confidence. 48. Comments on CHILD STRENGTHS CAREGIVER RESOURCES and NEEDS Caregivers are rated by household. The needs and resources of multiple caregivers are combined based on how they affect care giving. Caregiver Name: ___________________________Relationship to Child: ____________________ ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 49. MEDICAL/PHYSICAL - This item refers to medical and/or physical problems that the caregiver(s) may be experiencing that prevent or limit his/ her ability to parent the child. 0 No evidence of caregiver medical/physical problems and/or caregiver is generally healthy. 1 There is a history or suspicion and/or caregiver is in recovery from medical/physical problems. 2 Caregiver has medical/physical problems that interfere with his/her capacity to parent. 3 Caregiver has medical/physical problems that make it impossible for him/her to parent at this time. N/A There is no permanent caregiver known at this time. Circle one 50. MENTAL HEALTH - This item refers to any serious mental health issues among caregivers that might limit their capacity to provide care for the child. 0 No evidence of caregiver mental health difficulties and/or caregiver has no mental health needs. 1 There is a history or suspicion of mental health difficulties and/or caregiver is in recovery from mental health difficulties. 2 Caregiver has some mental health difficulties that interfere with his/her capacity to parent. 3 Caregiver has mental health difficulties that make it impossible for him/her to parent at this time. N/A There is no permanent caregiver known at this time. Circle one 51. SUBSTANCE USE - This item describes the impact of any notable substance use by caregivers that might limit their capacity to provide care for the child. 0 No evidence of caregiver substance use issues and/or caregiver has no substance use needs. 1 There is a history, suspicion or mild use of substances and/or caregiver is in recovery from substance abuse difficulties where there is no interference in his/her ability to parent. 2 Caregiver has some substance abuse difficulties that interfere with his/her capacity to parent. 3 Caregiver has substance abuse difficulties that make it impossible for him/her to parent at this time. N/A There is no permanent caregiver known at this time. Circle one 52. DEVELOPMENTAL DELAY - This item describes the presence of limited cognitive capacity that challenges his or her ability to parent. 0 No evidence of caregiver developmental delay and/or caregiver has no developmental needs. 1 There is a history or suspicion and/or caregiver has developmental delays, but these do not currently interfere with parenting. 2 Caregiver has developmental challenges that interfere with his/her capacity to parent. 3 Caregiver has severe developmental challenges that make it impossible for him/her to parent at this time. N/A There is no permanent caregiver known at this time. Circle one 53. FAMILY STRESS - This item is used to describe the impact of the child’s behavioral and emotional needs on the stress level of the family. 0 No evidence of caregiver having difficulty managing the stress of the child’s needs. 1 There is a history or suspicion and/or caregiver has some problems managing the stress of child/children’s needs. 2 Caregiver has notable problems managing the stress of child/children’s needs. This stress interferes with his/her capacity to give care. 3 Caregiver is unable to manage the stress associated with child/children’s needs. This stress prevents caregiver from parenting. N/A There is no permanent caregiver known at this time. Circle one 54. HOUSING STABILITY - This item rates the housing stability of the caregiver(s) and does not include the likelihood that the child or youth will be removed from the household. 0 No evidence of instability in the caregiver’s housing and/or caregiver has stable housing for the foreseeable future. 1 There is a history of housing instability and/or caregiver has relatively stable housing, but either has moved within the past three months, or there are indications of housing problems that might force him/her to move within the next three months. 2 Caregiver has moved multiple times in the past year and/or housing is unstable. 3 Caregiver has experienced periods of homelessness in the past six months. N/A There is no permanent caregiver known at this time. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ Circle one 55. SUPERVISION - This item refers to the caregiver’s ability to monitor and discipline the child. 0 No evidence caregiver needs help or assistance in monitoring or disciplining the child and/or caregiver has good monitoring and discipline skills. 1 There is a history or suspicion of need for assistance monitoring or disciplining child, but caregiver generally provides adequate supervision. Caregiver may need occasional help or assistance. 2 Caregiver reports difficulties monitoring and/or disciplining child. Caregiver needs assistance to improve supervision skills. 3 Caregiver is unable to monitor or discipline the child. Caregiver requires immediate and continuing assistance. Child is at risk of harm due to absence of supervision. N/A There is no permanent caregiver known at this time. Circle one 56. INVOLVEMENT – This item is used to rate caregiver knowledge of their child, their child’s rights and options, as well as, participation in services. 0 No evidence of problems with caregiver involvement in services or interventions and/or caregiver is able to act as an effective advocate for child. 1 There is a history or suspicion of need for assistance seeking help and/or caregiver has history of seeking help for his/her child. Caregiver is open to receiving support, education, and information. 2 Caregiver does not actively become involved in services and/or interventions intended to assist his/her child. 3 Caregiver wishes for the child to be removed from his/her care. N/A There is no permanent caregiver known at this time. Circle one 57. ORGANIZATION – This item is used to rate the caregiver’s ability to manage their household within the context of community services. For example, he/she may be forgetful about appointments or occasionally fail to return case manager calls. 0 No evidence of difficulties the caregiver may have in organizing and maintaining the household to support needed services and/or caregiver is well organized and efficient. 1 There is a history or suspicion of minor difficulty and/or caregiver has minimal difficulties organizing and maintaining the household to support needed services. 2 Caregiver has moderate difficulty organizing and maintaining household to support needed services. 3 Caregiver is unable to organize household to support needed services. N/A There is no permanent caregiver known at this time. Circle one 58. NATURAL SUPPORTS - This item describes the caregiver’s resources to support caring for his/her child. 0 No evidence of caregiver needing help to utilize their social network, family or friends to help with child rearing and/or caregiver has significant social network, neighbors, family and friends who actively help with childcare. 1 There is a history or suspicion of difficulties with the use of social network, and/or caregiver has some social network, neighbors, family or friends who actively help with childcare. 2 Evidence that caregiver has limited access to a social network, neighbors, family or friends who may be able to help with childcare. 3 Caregiver has no family or social network that may be able to help with child rearing. N/A There is no permanent caregiver known at this time. Circle one 59. FINANCIAL RESOURCES – This item refers to the income and other sources of money available to caregivers that can be used to address family needs. 0 No evidence of financial issues for the caregiver and/or caregiver has financial resources necessary to meet needs. 1 There is a history or suspicion, or existence of mild difficulties. Caregiver has financial resources necessary to meet most needs; however, some limitations exist. 2 Moderate difficulties. Caregiver has financial difficulties that limit his/her ability to meet significant family needs. 3 Significant difficulties. Caregiver is experiencing financial hardship, poverty. N/A There is no permanent caregiver known at this time. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ 60. Comments On CAREGIVER RESOURCES and NEEDS DIAGNOSES 61. AXIS I 62. AXIS II 63. AXIS III 64. AXIS IV 65. AXIS V Circle one 66. DIAGNOSTIC CERTAINTY- This item refers to the degree to which the symptoms are clear and consistent with a specific psychiatric diagnosis or diagnoses. Concerns regarding certainty could revolve around issues such as inconsistent symptom presentation, the presence of behavioral health or medical rule outs, etc. 0 The child’s behavioral health diagnoses are clear and there is no doubt as to the correct diagnoses. Symptom presentation is clear. 1 Although there is some confidence in the accuracy of the child’s diagnoses, the child’s symptom presentation is sufficiently complex, raising concerns that the diagnoses may not be accurate. 2 There is substantial concern about the accuracy of the child’s diagnoses due to the complexity of the child’s presentation of symptoms. 3 It is currently not possible to accurately diagnose the child’s behavioral health condition(s). Circle one 67. PROGNOSIS-This item refers to the expected trajectory of the recovery of the child based on their current diagnosis, symptoms and functioning when compared with children having similar diagnostic, symptomatic, and functioning presentations. 0 Behavioral health problems began during the past six months, and there is a clear stressor to which they can be attributed. 1 Behavioral health problems have been ongoing, but can be anticipated to be anticipated within the next year. 2 Behavioral health problems have been ongoing and are anticipated to continue to be a problem for at least another year. 3 Behavioral health problems have been ongoing and are anticipated to continue through to adulthood. ======================= Massachusetts Child and Adolescent Needs and Strengths Ages Birth through Four Child Name: ________________________________ Organization Name: ____________________________________ Other: _______________________________________________ 68. Comments on DIAGNOSES: 69. Summary: Clinician name, degree (print): ______________________________________________ Clinician signature: ________________________________________________________ Date: _______________________________ . Complete . Incomplete but Final If incomplete, reason for incompletion: . Client did not return . Other: _____________________________________