Assessing Multiple Methods for Measuring Clinical Change Using the Child and Adolescent Needs and Strengths (CANS) Assessment
The Child and Adolescent Needs and Strengths (CANS) is a structured assessment used in 27 states in at least one of their child-serving systems. The CANS is used for service planning, decision making, quality improvement and outcome monitoring. Despite broad use, few efforts have explored how the CANS could be used to assess changes in clinical functioning over time.
This presentation aims to:
(1) demonstrate several approaches for using the CANS to measure temporal change;
(2) explore the relationship between treatment factors (living situation, placement stability, length of stay) and CANS scores at baseline and over time; and
(3) recommend methods of measuring change using the CANS that have the greatest validity.
This study uses CANS data at intake and discharge for 574 youth (mean age=14.1; SD=3.49) that were placed for at least six months in Treatment Foster Care, Group Homes, Therapeutic Group Homes or Diagnostic Programs within the child welfare system in one state. The CANS were completed by trained staff who had demonstrated sufficient reliability in scoring the instrument.
To answer the research questions, we calculated three different change scores (raw sum change, dichotomizing response options and assessing change between states, and the Reliable Change Index [RCI] at the 90% confidence interval) for the study sample. We then compared findings across method to demonstrate how the method changes the substantive findings related to the number of youth who show improvement over time. Then, we conducted bivariate and multivariate analysis to determine what youth and treatment factors were associated with baseline CANS scores and improvement over time and how this varied by method of calculating improvement.
Youth being served in different levels of care had significantly different baseline CANS scores, with youth in family care demonstrating a lower level of baseline need than those in group care (t=-2.04, p=.017). We also found considerable differences in the number of youth demonstrating improved clinical functioning between baseline and discharge depending on the measurement method used. The Reliable Change Index (RCI) was most conservative, estimating the fewest youth demonstrating improvement over time (30%). The raw score change and dichotomized response change showed higher rates of improvement (54% and 51%, respectively).
In addition, we explored relationships between CANS improvement over time and youth and treatment factors. After controlling for baseline CANS score and the time between the baseline and discharge assessments (mean=11.2 months, SD=5.94), age was related to improvement over time, as measured by the raw score change (O.R.=1.07, p=.019) and dichotomized response change (O.R.=1.06, p=.025). Level of care, length of stay, race/ethnicity, and gender were not related to CANS improvement using any of the three measurement methods.
Conclusions and Implications:
Findings from this study illustrate the importance of careful consideration for how to measure change over time with the CANS. Rates of improvement varied dramatically by methods. Additionally, youth with fewer treatment needs are less likely to demonstrate improvement using the CANS, which has implications for using this measurement tool for low-risk youth and families.