Using Standardized Assessments for Service Eligibility & Delivery in the Children's Behavioral Health System: Observations & Recommendations from a Midwestern State

Background/Purpose: Mental health is an essential component of child wellbeing. Unfortunately, close to 15 million U.S. children will experience symptoms of a mental disorder in any given year (Centers for Disease Control [CDC], 2013) diminishing their ability to function in their home, school, or community setting. For some children and adolescents, mental illness symptoms persist to the point where they are considered to be experiencing a severe emotional disturbance (SED).  These children not only experience symptoms associated with a mental illness, but the symptoms are so severe they significantly impact the child’s ability to function in their home, school, and/or community. In an effort to effectively treat these children, many states have utilized the 1915(c) Waiver program to develop community based mental health services for children and families experiencing SED. In order to determine eligibility for these specialized services, states typically utilize a standardized assessment tool, such as the Child and Adolescent Functional Assessment Scale (CAFAS). However, even with standardized tools, assessment processes may vary depending on agency processes or the training and experience of the clinician, which could ultimately impact who receives specialized services. Using case observations, this study examines the variability in administration of standardized assessments at clinical service eligibility appointments at community mental health centers in one Midwestern state.

Methods: Researchers partnered with twenty-five community mental health centers throughout one Midwestern state. From a list of scheduled intake appointments, researchers randomly selected assessments to observe. Community mental health center clinicians conducted the Waiver eligibility appointment as normal but with researchers observing. Throughout the appointment, researchers took structured notes, specifically regarding how the CAFAS was being delivered to families. The structured notes examined four specific domains: (1) was the child present; (2) were all CAFAS domains discussed; (3) were family/caregiver strengths and resources discussed; and (4) was the interview structured. In total, there were approximately 100 case observations.

Results: Through the observation of eligibility appointments, researchers found extreme variability in how clinicians from mental health centers across the state administer the CAFAS to children and families seeking SED Waiver eligibility. The primary variance centered on clinicians not maintaining interview structure. Clinicians often asked both the caregiver and the child questions, frequently using a mix of information to determine final scoring on the CAFAS. The time of reference for examining the child’s behavior also demonstrated variance. Some clinicians made it clear to caregivers that behavior was only being examined for a certain period time while others did not. Finally, no clinician utilized the caregiver resources portion of the CAFAS, and no clinician asked families about their strengths that could be utilized to address some behavior concerns.

Conclusions & Implications: Despite completing the same standard training for the CAFAS, administration of this assessment varied greatly across clinicians and agencies in this state. Variability in assessment procedures for services for youth with more impaired functioning may differentially impact who has access to the specialized services. Future research needs to explore what drives these differences and how they impact the services received.