CANS assessment – needing to read between the lines

In U.S. residential treatment, the CANS (Child and Adolescent Needs and Strengths) is a widely used decision-support tool. 

In the US, CANS (Child and Adolescent Needs and Strengths) is an evidence-based, standardised assessment tool heavily used by state Medicaid programmes and child welfare systems. It measures a child’s behavioural, emotional, and life-functioning needs, as well as caregiver resources.

Notes for readers

Before reading this summary documents readers are recommended to absorb the careful analysis, discussion and conclusions in the following document:

Scottish Journal of Residential Child Care: Volume 21.1
Danielle Day, Sarah Elgie, Christopher Robinson

This document has to be read with the ideas that are gathered in the DfE Reset document, and their deployment through regional care co-operatives.

In this document readers might find themselves reminded of recent statements made regarding care and residential care in particular, i.e. cost, use of data, outcomes focus, short use of residential care, evidence care models, ‘wrong sort of homes’, ‘children who did not need residential care’.

Readers will need to ‘read between the lines’, translating the USA context into what is being described by Josh MacAllister and the DfE as the future of residential care in England.

NCERCC sees that undoubtedly the future being described and built in England shows many features of the USA thinking and system.

This briefing is important in the light of DfE UK4 Tender Notice- Assessment of Needs Tool and Digital Platform for Children at Risk of Deprivation of Liberty
https://d3tenders.com/contract/?ocid=ocds-h6vhtk-065f95

Introduction

In the USA the adoption of Family First thinking and policy includes the use of accredited care models delivered by qualified health professionals in treatment centres (inevitably larger and so ‘institutional’ in the definition surmised to be used by Josh MacAllister. This translates to short term treatment before return to family-based settings. It is reported that many residential settings have been closing.

This would match the idea of the reduced use of residential care as outlined by the Minister and DfE documents. CANS is proving to be the essential enabler of this USA approach to care. 

CANS

Clinicians use it to assess children’s mental health, traumatic stress, and risk behaviours, as well as to identify core strengths.

For example, Washington State Hospital use the Child and Adolescent Needs and Strengths (CANS-SCREEN) in the form of Washington State Intensive Mental Health Services Screening Tool Children and Adolescents 5-20 With Mental Health Challenges. Scores translate directly into actionable treatment plans and monitor progress over time.

The CANS focuses on “communimetrics” designed to facilitate clear communication among clinicians, child welfare caseworkers, caregivers, and the children themselves.

Its specific uses in residential treatment planning include:

1. Determining Level of Care and Admission

• Evaluating Unmet Needs: CANS profiles support treatment centres establish specific thresholds for eligibility. It ensures that intensive residential placement is reserved for children who actually require that level of restrictive care.
• Placement Matching: It guides the determination of the most appropriate setting by matching the severity of needs to available facility resources.

AACAP Principles of Care for Treatment of Children and Adolescents with Mental Illnesses in Residential Treatment Centers (June 2010) These guidelines were developed by the Work Group on Healthcare Access and Financing, in collaboration with the AACAP Committee on Quality Issues, to establish clear principles for safe, ethical, evidence‑based residential treatment for children and adolescents.

2. Guiding Individualised Treatment Planning

• Actionable Ratings: Items are scored on a scale from 0 to 3, where scores of 2 or 3 indicate an actionable need. This pinpoints exactly which symptoms or behaviours require immediate intervention.
• Module Triggers: Scoring a “need” in key areas triggers specific extension modules (e.g., assessing juvenile justice involvement, trauma, or developmental disabilities), creating a highly personalised treatment roadmap.

3. Emphasising Strengths

• CANS identifies strengths and measures protective factors (e.g., coping skills, family support, talents). Clinicians build upon these existing assets to improve mental health functioning. Advocates of CANS criticise other diagnostic tools as having a focus entirely on pathology. (NCERCC note: this depends on use e.g. a low score can be a strength and asset).

4. Progress Monitoring and Discharge

• Outcomes Management: Clinicians administer the CANS at admission, during care, and at discharge. This allows care teams to evaluate whether behavioural health needs and risk behaviours are successfully improving.
• System-Wide Evaluation: State child welfare and mental health agencies aggregate CANS data from treatment centres to evaluate the overall effectiveness of their programmes and allocate funding accordingly.

Its application by insurance in the US involves the following actionable frameworks:

• Medicaid and State Behavioural Health: State health authorities widely mandate CANS to determine the severity of a child’s mental health issues and to justify Medicaid-funded behavioural health and rehabilitation services (e.g., Illinois’ IM+CANS program and New York’s HCBS system).
• Level of Care Decisions: The scores (rated on a 0-to-3 scale) guide insurers and clinicians in deciding the appropriate treatment intensity, determining if a child requires outpatient therapy, intensive in-home care, or residential placement.
• Outcome Monitoring: Insurers use aggregated CANS data and Praed Foundation frameworks to monitor if specific therapies yield positive functional outcomes for youth.
• Private Insurance Limitations: While private insurers are mandated by the Affordable Care Act (ACA) to cover essential mental health benefits, they generally use their own proprietary criteria (such as CALOCUS-CASII – see below) for level-of-care decisions rather than universal adoption of the state-run CANS methodology.

CALOCUS-CASII© level of care/service intensity definitions and utilisation criteria

The CALOCUS-CASII (Child and Adolescent Level of Care/Service Intensity Utilization System) is a standardised assessment tool used by insurers and healthcare providers to match mental health patients (ages 4–18) with the appropriate level of service intensity based on their clinical needs.

It evaluates patients across 8 dimensions (including risk of harm, functionality, co-morbidity, and environmental stressors) to assign one of six levels of care.

The 6 Levels of Care

Insurers utilise these 6 defined levels of service intensity to determine medical necessity and coverage: (NCERCC note: this seems to mirror English Family First).

• Level 1: Basic Care (Recovery Maintenance & Health Management)
  • Intensity: Lowest. Periodic monitoring, consultation, or school-based support. The patient is stable and has strong support systems.
• Level 2: Low Intensity (Outpatient Services)
  • Intensity: 1–2 hours per week. Regular outpatient therapy, medication management, and family support for symptom management.
• Level 3: Moderate Intensity (Intensive Outpatient Services – IOP)
  • Intensity: 3 or more hours per week. Typically includes multi-disciplinary team involvement, individual/group therapy, and case management.
• Level 4: High Intensity (Partial Hospitalization Program – PHP)
  • Intensity: Daily programming (often 20+ hours per week), but the child returns home at night. High clinical oversight.
• Level 5: Intensive, Integrated Care (Residential Treatment)
  • Intensity: 24/7 care in a structured, non-hospital setting. For youth requiring intensive supervision and clinical treatment.
• Level 6: Secure, Inpatient Care (Acute Inpatient)
  • Intensity: 24/7 medical and psychiatric care in a hospital setting. Geared toward immediate stabilization of severe risk of harm.

Why Insurers Use It

Insurers use the CALOCUS-CASII System to evaluate the clinical efficacy of a proposed treatment plan, ensure care transitions dynamically as the child’s needs change, and prevent both over-treatment and under-treatment. It aims to provide an objective, multidimensional algorithm to justify the medical necessity of higher levels of care, such as Residential Treatment (Level 5) or Inpatient hospitalisation (Level 6).

To get a deeper look at the exact scoring mechanism, you can review the official CALOCUS-CASII Service Intensity Definitions published by healthcare networks.