CANS-NY Home and Community Based Services (HCBS)
- Reference Guide is also available in Portable Document Format (PDF)
(October 2025)
Copyright 2025, 2024, 2023, 2018, 1999 by the Praed Foundation
2025 REFERENCE GUIDE
Center for Innovation in Population Health • 111 Washington Avenue, Ste 201, Lexington, KY 40506 • http://www.iph.uky.edu
ACKNOWLEDGEMENTS
The New York HCBS Eligibility reference guide is a subset of items from the CANS-New York 0-5 and 6+ reference guides. These reference guides are based on the Standard Comprehensive CANS 3.0 and the CANS-New York versions. Many individuals have collaborated in the development of the Child and Adolescent Needs and Strengths (CANS). Along with the CANS and versions for developmental disabilities, juvenile justice, child welfare, and older adults, this information integration tool is designed to support individual case planning and the planning and evaluation of service systems. The CANS is an open domain tool for use in multiple child-serving systems that address the needs and strengths of children, youth, and their families. The copyright is held by the Praed Foundation to ensure that it remains free to use. Training and annual certification is expected for appropriate use.We are committed to creating a diverse and inclusive environment. It is important to consider how we are precisely and inclusively using individual words. As such, this reference guide uses the gender-neutral pronouns "they/them/themselves" in the place of "he/him/himself" and "she/her/herself."Additionally, "child" is utilized to reference "infant," "toddler," or "child," while "child/youth" is being utilized to reference "child," "youth," "adolescent," or "young adult."For specific permission to use please contact the Praed Foundation. For more information on the CANS contact:
John S. Lyons, PhD
Director
Center for Innovation in Population Health
Professor, Health, Management & Policy
University of Kentucky College of Public Health
John.Lyons@uky.edu
Joy Dicus
Implementation Lead
Center for Innovation in Population Health
University of Kentucky College of Public Health
Joy.Dicus@uky.edu
Center for Innovation in Population Health
https://iph.uky.edu
iphcenter@uky.edu
TABLE OF CONTENTS
ACKNOWLEDGEMENTS
TABLE OF CONTENTS
INTRODUCTION
THE NEW YORK HCBS ELIGIBILITY REFERENCE GUIDE
HOW THIS GUIDE IS STRUCTURED
ACTION LEVEL TABLES
SERIOUS EMOTIONAL DISTURBANCE (SED) AGES 0-5
LIFEFUNCTIONINGDOMAIN
TRAUMA MODULE: TRAUMATIC STRESS SYMPTOMS
DEVELOPMENT DOMAIN
BEHAVIORAL/EMOTIONAL NEEDS DOMAIN
RISK FACTORS AND BEHAVIORS DOMAIN: RISK BEHAVIORS
STRENGTHS DOMAIN
CAREGIVER RESOURCES & NEEDS DOMAIN
LIFE FUNCTIONING DOMAIN
TRAUMA MODULE: TRAUMATIC STRESS SYMPTOMS
BEHAVIORAL/EMOTIONAL NEEDS DOMAIN
RISK FACTORS AND BEHAVIORS DOMAIN: RISK BEHAVIORS
STRENGTHS DOMAIN
CAREGIVER RESOURCES & NEEDS DOMAIN
MEDICALLY FRAGILE AGES 0-5 AND 6+
LIFE FUNCTIONING DOMAIN
MEDICAL HEALTH MODULE
MEDICALLY FRAGILE AGES 0-5
DEVELOPMENTAL NEEDS DOMAIN
MEDICALLY FRAGILE AGES 6+
LIFE FUNCTIONING DOMAIN
SELF-CARE ACTIVITIES OF DAILY LIVING MODULE
INTRODUCTION
THE NEW YORK HCBS ELIGIBILITY REFERENCE GUIDE
The New York Home and Community Based Services (HCBS) Reference Guide is a subset items from the CANS-New York (both 0-5 and 6+ versions). Please see the CANS-NY 0-5 Reference Guide and/or the CANS-NY 6+ Reference Guide for complete information on the history of the CANS-NY and how to use this tool.
For brevity and ease of use, this guide is set up in roughly the same order as the worksheets, with some exceptions. To minimize duplication, each domain with action level descriptions is presented once and then referenced afterwards with the page number and a link to the full table. Similarly, each item is presented once and then referenced afterwards with the page number and a link to the original item. Clicking on a hyperlink (i.e., a word or number that is underlined) will take you directly to a referenced page, domain or item.
One note on the items: The 0-5 version references "child," while the 6+ version references "child/youth." When the item is the same with the exception of whether it uses "child" or "child/youth," the version that uses "child" is the one that is referenced. Despite the "child" wording, this item is still applicable for ages 6+. Only if the actual content is different will the original 6+ item be referenced.
NEW YORK HCBS ELIGIBILITY ITEMS
The following items are included in the HCBS eligibility for Serious Emotional Disturbance (SED) and Medically Fragile (MF) children. Note that some items are part of modules. The item that activates a module is included in italics, even though the item itself may not be rated.
SED Ages 0-5
Life Functioning Domain
Living Situation
Social and Emotional Functioning
Preschool/Childcare Behavior
Preschool/Childcare Attendance
Adjustment to Trauma
Trauma Module: Trauma Stress Symptoms
Re-experiencing
Hyperarousal
Avoidance
Numbing
Emotional and/or Physical Dysregulation
Traumatic Grief
Development Domain
Agitation
Sensory Reactivity
Emotional Control
Frustration Tolerance
Temperament
Behavioral/Emotional Needs Domain
Attention/Concentration
Impulsivity/Hyperactivity
Depression
Anxiety
Oppositional Behavior
Pica
Anger Control
Attachment Difficulties
Risk Factors & Behaviors Domain: Risk Behaviors
Self-Harm
Aggressive Behavior
Fire Setting
Intentional Misbehavior
Strengths Domain
Interpersonal
Relationship Stability
Caregiver Resources & Needs Domain
Problem Solving
Family Stress
Care/Treatment Involvement
SED Ages 6+
Life Functioning Domain
Living Situation
Decision Making
School Behavior
School Attendance
Adjustment to Trauma
Trauma Module: Trauma Stress Symptoms
Re-experiencing
Hyperarousal
Avoidance
Numbing
Emotional and/or Physical Dysregulation
Traumatic Grief
Behavioral/Emotional Needs Domain
Psychosis
Attention/Concentration
Impulsivity/Hyperactivity
Depression
Anxiety
Oppositional Behavior
Conduct
Emotional Control
Anger Control
Attachment Difficulties
Eating Disturbance
Risk Factors & Behaviors Domain: Risk Behaviors
Suicide Risk
Non-Suicidal Self-Injurious Behavior
Other Self-Harm
Danger to Others
Fire Setting
Sexually Reactive Behavior
Delinquent Behavior
Bullying
Runaway
Intentional Misbehavior
Strengths Domain
Social Relationships with Adults
Relationship Stability
Caregiver Resources & Needs Domain
Problem Solving
Family Stress
Care/Treatment Involvement
MF Ages 0-5 and 6+
Life Functioning Domain
Medical/Physical
Medical Health Module
Life Threatening
Chronicity
Impairment in Functioning
Intensity of Treatment Support
MF 0-5
Developmental Needs Domain
Eating
Mobility
Positioning
Transferring
Elimination
MF 6+
Self-Care Activities of Daily Living
Self-Care Activities of Daily Living Module
Eating
Elimination and Toileting
Mobility
Positioning
Transferring
The following tables are used to provide guidance on rating items.
LIFE FUNCTIONING DOMAIN
Life domains are the different arenas of social interaction found in the lives of children and their families. This domain rates how they are functioning in the individual, family, peer, school, and community realms. This section is rated using the needs scale and therefore will highlight any struggles the child and family are experiencing.
Question to Consider for this Domain: How is the child functioning in individual, family, peer, school, and community realms?
For the Life Functioning Domain, the following categories and action levels are used:
- No evidence of any needs; no need for action.
- Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
- Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
- Need is dangerous or disabling; requires immediate and/or intensive action.
TRAUMATIC STRESS SYMPTOMS MODULE
The Traumatic Stress Symptoms describe the impact of trauma exposures or experiences on the child within the past 30 days.
For the Traumatic Stress Symptoms items, the following categories and action levels are used:
- No evidence of any needs; no need for action.
- Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
- Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
- Need is dangerous or disabling; requires immediate and/or intensive action.
BEHAVIORAL/EMOTIONAL NEEDS DOMAIN
This section identifies the behavioral health needs of the child. While the CANS is not a diagnostic tool, it is designed to be consistent with diagnostic communication. In the DSM, a diagnosis is defined by a set of symptoms that is associated with either dysfunction or distress. This is consistent with the ratings of '2' or '3' as described by the action levels below.
Question to Consider for this Domain: What are the presenting social, emotional, and behavioral needs of the child?
For the Behavioral/Emotional Needs Domain, use the following categories and action levels:
- No evidence of any needs; no need for action.
- Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
- Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
- Need is dangerous or disabling; requires immediate and/or intensive action.
RISK FACTORS AND BEHAVIORS DOMAIN: RISK BEHAVIORS
This section focuses on behaviors that can get the child in trouble or put them in danger of harming themselves or others. Time frames in this section can change (particularly for ratings '1' and '3') away from the standard 30-day rating window.
For the Risk Behaviors items, use the following categories and action levels:
- No evidence of any needs; no need for action.
- Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion or disagreement.
- Need or risk behavior is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
- Need or risk behavior is dangerous or disabling. Intensive and/or immediate action is required to address the need or risk behavior.
STRENGTHS DOMAIN
This domain describes the assets of the child that can be used to advance healthy development. It is important to remember that strengths are NOT the opposite of needs. Increasing a child's strengths while also addressing their behavioral/emotional needs leads to better functioning, and better outcomes, than does focusing just on their needs.Identifying areas where strengths can be built is a significant element of service planning. Within this domain the 'best' assets and resources available to the child are rated based on how accessible and useful those strengths are. These are the only items that use the Strength Rating Scale with action levels.
NOTE: When you have no information/evidence about a strength in this area, use a rating of '3.'
Question to Consider for this Domain: What individual strengths can be used to support a need?
For the Strengths items, the following categories and action levels are used:
- Well-developed, centerpiece strength; may be used as a centerpiece in an intervention/action plan.
- Identified and useful strength. Strength will be used, maintained or built upon as part of the plan. May require some effort to develop strength into a centerpiece strength.
- Strengths have been identified but require strength-building efforts before they can be effectively utilized as part of a plan. Identified but not useful.
- An area in which no current strength is identified; efforts may be recommended to develop a strength in this area.
CAREGIVER RESOURCES AND NEEDS DOMAIN
This section focuses on the strengths and needs of the child's caregivers. Caregiver ratings should be completed for each caregiver, up to four. If the child/youth is in a foster care or out-of-home placement, please rate each of the identified parents, other relatives, adoptive parents, or caretakers who is planning to assume custody and/or take responsibility for the care of this child.
The items in this section represent caregivers' potential areas of need while simultaneously highlighting the areas in which the caregivers can be a resource for the child.
Question to Consider for this Domain: What are the resources and needs of the child/youth's caregivers?
For the Caregiver Resources & Needs Domain, use the following categories and action levels:
- No current need; no need for action. This may be a resource for the child.
- Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement. This may be an opportunity for resource building.
- Need is interfering with the provision of care; action is required to ensure that the identified need is addressed.
- Need prevents the provision of care; requires immediate and/or intensive action.
SERIOUS EMOTIONAL DISTURBANCE (SED) AGES 0-5
The following items are relevant to the Serious Emotional Disturbance 0-5 worksheet.
LIFE FUNCTIONING DOMAIN
[Return to Table of Contents] [Return to Core Item List]
See page 8 for full table descriptions.
LIVING SITUATION
This item refers to how the child is functioning in their current living arrangement, which could be with a relative, in a foster home, etc. This item should exclude respite, brief medical and psychiatric hospitalization.
Questions to Consider:
- How has the child been getting along with others in the current living situation?
- Has the child had positive or negative experience in the current living situation?
- How does the child deal with issue that might arise with others in the residence?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of problem with functioning in current living environment. Child and caregivers feel comfortable dealing with issues that come up in day-to-day life. - Identified need that requires monitoring, watchfol waiting, or preventive action based on history, suspicion, or disagreement.
In the past, child experienced problems with functioning in current living situation. Or child and caregiver have some difficolty dealing with issues that arise in daily life. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has problems with functioning in current living situation. Child's difficulties in maintaining appropriate behavior in this setting are creating significant problems for others in the residence. Child and caregivers have difficulty interacting effectively with each other much of the time. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child's problems with functioning in current living situation place them at immediate risk of being unable to remain in present living situation due to problematic behaviors.
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SOCIAL AND EMOTIONAL FUNCTIONING
This item rates social skills and relationships. This includes age-appropriate behavior and the ability to engage and interact with others. When rating this item, consider the child's level of development.
Questions to Consider:
- Currently, how well does the child get along with others?
- Can an infant engage with and respond to adults? Can a toddler interact positively with peers?
- Does the child interact with others in an age-appropriate manner?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of problems and/or child has age-appropriate social functioning. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child is having some problems in social relationships. Infants may be slow to respond to adults, toddlers may need support to interact with peers and preschoolers may resist social situations. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child is having problems with their social relationships. Infants may be unresponsive to adults, and unaware of other infants. Toddlers may be aggressive and resist parallel play. Preschoolers may argue excessively with adults and peers and lack ability to play in groups even with adult support. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child is experiencing disruptions in their social relationships. Infants show no ability to interact in a meaningful manner. Toddlers are excessively 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 others at risk.
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PRESCHOOL/CHILDCARE BEHAVIOR
This item rates the child's behavior while attending preschool/childcare.
Questions to Consider:
- Does the child have difficulties with their social relationships or behavior when in preschool or at childcare?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of problematic behavior at preschool/childcare. Child is behaving well in preschool/ childcare. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child is behaving adequately in preschool/childcare although there may be a history of behavioral problems. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child is disruptive and many types of interventions have been implemented. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child is frequently disruptive in preschool/childcare. The threat of expulsion is present.
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PRESCHOOL/CHILDCARE ATTENDANCE
This item describes any challenge, including medically excused absences, to being physically present at school.
Questions to Consider:
- Does the child have difficulties with attending preschool or childcare regularly?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of problems with attendance. Child attends preschool/childcare regularly. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child has some problems attending preschool/childcare but is generally present. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child is having problems with preschool/childcare attendance. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child is absent most of the time, which is causing significant challenges in their achievement, socialization, and following routines.
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ADJUSTMENT TO TRAUMA*
This item is used to describe the child who is having difficulties adjusting to a traumatic experience. This is one item where speculation about why a person is displaying a certain behavior is considered. There should be an inferred link between the trauma and behavior.
(Note: This item is not included in the eligibility model but it is the parent item for the Traumatic Stress Symptoms Module, whose items are included in the model.)
Questions to Consider:
- Has the child experienced any trauma?
- How is the child adjusting to the trauma? Does the child repeatedly 'play out' or 'act out' traumatic experiences?
- How has trauma impacted the child?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence that child has experienced a traumatic life event, OR child is not showing signs that the traumatic/adverse experience has impacted functioning. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
The child has experienced a traumatic event and there are some changes in their behavior that are managed or supported by caregivers. These symptoms are expected to ease with the passage of time and therefore no current intervention is warranted. Child may be in the process of recovering from a more extreme reaction to a traumatic experience, which may require a need to watch these symptoms or engage in preventive action. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Clear evidence of adjustment problems associated with traumatic life event(s). Symptoms can vary widely and may include sleeping or eating disturbances, regressive behavior, behavior problems or problems with attachment or relationships. Adjustment is interfering with child's functioning in at least one life domain. - Need is dangerous or disabling; requires immediate and/or intensive action.
Clear evidence of debilitating level of trauma symptoms that makes it virtually impossible for the child to function in any life domain including symptoms such as flashbacks, nightmares, significant anxiety, intrusive thoughts, and/or re-experiencing trauma (consistent with PTSD).
Supplemental Information: To rate this item a '1,' '2,' or '3,' a traumatic event needs to have occurred and should be identified in the Trauma Module, Potentially Traumatic/Adverse Childhood Experiences section.
*A rating of '1,' '2,' or '3' on this item triggers the completion of the Medical Health Module.
[Return to Table of Contents] [Return to Core Item List]
TRAUMA MODULE: TRAUMATIC STRESS SYMPTOMS
[Return to Table of Contents] [Return to Core Item List]
See page 8 for full table descriptions.
RE-EXPERIENCING
This item describes a child who has intrusive memories or reminders of traumatic events, including nightmares, flashbacks, intense reliving of the events, and repetitive play with themes of specific traumatic experiences. Symptoms also include intense distress or physiological reactivity (sweating, heart racing) after exposure to reminders (external or internal) of the event/events.
Questions to Consider:
- Does the child think about the traumatic event when they do not want to?
- Do reminders of the traumatic event bother the child?
Ratings and Descriptions
- No evidence of any needs; no need for action.
There is no evidence that the child experiences intrusive thoughts of trauma. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or evidence of some intrusive thoughts of trauma but it does not affect the child's functioning. A child with some problems with intrusive, distressing memories, including occasional nightmares about traumatic events, would be rated here. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has difficulties with intrusive symptoms/distressing memories, intrusive thoughts that interfere with their ability to function in some life domains. For example, the child may have recurrent frightening dreams with or without recognizable content or recurrent distressing thoughts, images, perceptions, or memories of traumatic events. The child may exhibit trauma-specific reenactments through repetitive play with themes of trauma or intense physiological reactions to exposure to traumatic cues. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child has repeated and/or severe intrusive symptoms/distressing memories that are debilitating. This child may exhibit trauma-specific reenactments that include sexually or physically traumatizing others. This child may also exhibit persistent flashbacks, illusions or hallucinations that make it difficult for the child to function.
[Return to Table of Contents] [Return to Core Item List]
HYPERAROUSAL
This item refers to a child who experiences prolonged states of physiological arousal following trauma exposure. This may manifest behaviorally, emotionally, and cognitively. The child may appear on edge, easily startled, or wound up. They may be irritable and display outbursts of anger with little or no provocation. They may constantly be on the lookout for threats around them (i.e., hypervigilant). Because of a constant state of hypervigilance regarding their own safety, they may have a hard time concentrating. They may also exhibit physical symptoms such as headaches or stomachaches and may have difficulty falling or staying asleep. They may engage in reckless or self-destructive behavior.
Questions to Consider:
- Does the child feel more jumpy or irritable than is usual?
- Does the child have difficulty relaxing and/or have an exaggerated startle response?
- Does the child have stress-related physical symptoms: stomachaches or headaches?
- Do these stress-related symptoms interfere with the child's ability to function?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child has no evidence of hyperarousal symptoms. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or evidence of hyperarousal that does not interfere with daily functioning. Child may occasionally manifest distress-related physical symptoms such as stomachaches and headaches. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child exhibits one significant symptom or a combination or two or more of the following hyperarousal symptoms: difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hyper vigilance and/or exaggerated startle response. Children who frequently manifest distress-related physical symptoms such as stomachaches and headaches would be rated here. Symptoms are distressing for the child and/or caregiver and negatively impacts day-to-day functioning. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child exhibits multiple and/or severe hyperarousal symptoms including alterations in arousal and physiological and behavioral reactivity associated with traumatic event(s). This may include difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hyper vigilance and/or exaggerated startle response. Intensity and frequency of these symptoms are overwhelming for the child and/or caregiver and impede day-to-day functioning in many life areas.
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AVOIDANCE
This item refers to a child who avoids or tries to avoid places or people who remind them of earlier traumatic experiences. Given a child's lack of control over their circumstances, avoidance behaviors may manifest as clinginess to caregivers.
Questions to Consider:
- Does the child make specific and concerted attempts to avoid sights, sounds, smells, etc. that are related to the trauma experience?
- Does the child act differently around a specific person or place?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child exhibits no avoidance symptoms. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child may have history of or exhibits one primary avoidant symptom, including efforts to avoid thoughts, feelings or conversations associated with the trauma. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child exhibits avoidance symptoms that interfere with their functioning in at least one life domain. In addition to avoiding thoughts or feelings associated with the trauma, the child may also avoid activities, places, or people that arouse recollections of the trauma. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child's avoidance symptoms are debilitating. Child may avoid thoughts, feelings, situations and people associated with the trauma and is unable to recall important aspects of the trauma.
[Return to Table of Contents] [Return to Core Item List]
NUMBING
This item refers to a child who has experienced traumatic events and displays a diminished capacity to feel or experience and express a range of emotions. This may manifest as difficulty feeling or expressing emotions such as happiness, anger, or fear. The child may also withdraw from people and activities the child used to enjoy (e.g., play). The child may also have negative beliefs about self or the world (e.g., "I am bad", "I did this"). The child may also have difficulty remembering important aspects of the event. These numbing symptoms were not present before the traumatic event.
Questions to Consider:
- Does the child experience a normal range of emotions?
- Does the child tend to have flat emotional responses?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child has no evidence of numbing responses. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child exhibits some problems with numbing. The child may have a restricted range of affect or an inability to express or experience certain emotions (e.g., anger or sadness). - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child's difficulties with numbing responses impact their functioning. The child may have a blunted or flat emotional state or have difficulty experiencing intense emotions or feel consistently detached or estranged from others following the traumatic experience. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child's difficulties with numbing are dangerous and place them at risk. Child may have significant numbing responses or multiple symptoms of numbing. The child may have a markedly diminished interest or participation in significant activities and a sense of a foreshortened future.
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EMOTIONAL AND/OR PHYSICAL DYSREGULATION
This item refers to a cluster of symptoms often seen among children who have experienced complex (chronic and interpersonal) trauma. This child often demonstrates difficulty identifying, describing, and regulating internal emotional states (affect) and may also have difficulty managing energy level and related body states/systems (physiological) such as hunger, thirst, sleep, and elimination.
Questions to Consider:
- Does the child have reactions that seem out of proportion (larger or smaller than is appropriate) to the situation?
- Does the child have extreme or unchecked emotional reactions to situations?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child has no problems with emotional or physical regulation. Emotional responses and energy level are appropriate to the situation. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or evidence of difficulties with affect/physiological regulation. The child could have some difficulty tolerating intense emotions and become somewhat jumpy or irritable in response to emotionally charged stimuli, or more watchful or hypervigilant in general or have some difficulties with regulating body functions (e.g., sleeping, eating or elimination). The child may also have some difficulty sustaining involvement in activities for any length of time or have some physical or somatic complaints. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has problems with affect/physiological regulation that are impacting their functioning in some life domains but is able to control affect at times. The child may be unable to modulate emotional responses or have more persistent difficulties in regulating bodily functions. The child may exhibit marked shifts in emotional responses (e.g., from sadness to irritability to anxiety) or have contained emotions with a tendency to lose control of emotions at various points (e.g., normally restricted affect punctuated by outbursts of anger or sadness). The child may also exhibit persistent anxiety, intense fear or helplessness, lethargy/loss of motivation, or affective or physiological over-arousal or reactivity (e.g., silly behavior, loose active limbs) or under arousal (e.g., lack of movement and facial expressions, slowed walking and talking). - Need is dangerous or disabling; requires immediate and/or intensive action.
Child is unable to regulate affect and/or physiological responses. The child may have more rapid shifts in mood and an inability to modulate emotional responses (feeling out of control of their emotions or lacking control over their movement as it relates to their emotional states).Alternately the child may be characterized by extreme lethargy, loss of motivation or drive, and no ability to concentrate or sustain engagement in activities (i.e., emotionally 'shut down'). The child may have more persistent and severe difficulties regulating sleep/wake cycle, eating patterns, or have elimination problems.
Supplemental Information: Affect dysregulation may manifest as problems labeling or expressing feelings, difficult or inability in controlling or modulating emotions, and/or difficulty communicating needs.The child may also exhibit restricted affect punctuated by outbursts of anger or sadness. Overall, it is a pattern of repeated dysregulation that is triggered by exposure to trauma cues or reminders. Once aroused, this child has difficulty modulating feelings and returning to a state of equilibrium. This child may also display over-reactivity or under-reactivity to touch and sounds. Affective and physiological dysregulation may also lead to somatic complaints such as headaches and stomachaches. The child may also exhibit persistent anxiety, intense fear or helplessness, lethargy/loss of motivation, or affective or physiological over-arousal or reactivity or under-arousal.NOTE: This item should be rated in the context of what is normative for a child's age/developmental stage and the child's exposure to trauma. This item is highly related to other items such ashyperarousal, numbing, and anger control; therefore, scores in these items will likely be similar.
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TRAUMATIC GRIEF
This item refers to the grief a child may experience as a result of the death or separation from significant caregivers, siblings, or other important figures in the child's life. This child may be preoccupied with the separation from their parents (e.g., clinginess, worrying about caregivers' safety) and this preoccupation may impact their ability to function in one or more areas. Conversely, the child may actively avoid thinking or talking about the person they lost. This child may also experience repeated images regarding this loss (e.g., intrusive memories or nightmares).(Note: This item is from the 2023 version of the CANS-NY 0-5 reference guide.)
Ratings and Descriptions
- No evidence of any needs; no need for action.
There is no evidence that the child is experiencing traumatic grief reactions or separation from the loss of significant others. Either the child has not experienced a traumatic loss (e.g., death of a loved one) or the child has adjusted well to separation. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child is experiencing traumatic grief due to death or loss/separation from a significant person in a manner that is expected and/or appropriate given the recent nature of loss or separation. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child is experiencing traumatic grief or difficulties with separation in a manner that impairs functioning in some but not all areas of daily functioning. This could include withdrawal or isolation from others or other problems with day-to-day functioning. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child is experiencing traumatic grief reactions and exhibits impaired functioning across most or all areas (e.g., interpersonal relationships, school) for a significant period of time following the loss or separation. Symptoms require immediate or intensive intervention.
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DEVELOPMENT DOMAIN
This section identifies the developmental needs of the child.
Question to Consider for this Domain: Is the child meeting their developmental milestones?
For the Development Domain, the following categories and action levels are used:
- No evidence of any needs; no need for action.
- Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
- Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
- Need is dangerous or disabling; requires immediate and/or intensive action.
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AGITATION
This item describes the degree to which a child's behaviors indicate irritation or restlessness. Examples include biting or hitting, handwringing, dressing and undressing, general restlessness, scratching, grabbing, and spitting.
Questions to Consider:
- What does the child do when they are frustrated or confused?
- Can the child be calmed or soothed when they are agitated?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child does not exhibit agitated behavior. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child becomes agitated on occasion but can be calmed relatively easily. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child becomes agitated often or can be difficult to calm. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child exhibits a dangerous level of agitation. Child becomes agitated often and easily becomes aggressive towards self or others.
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SENSORY REACTIVITY
This item rates the child's ability to organize, process, and integrate sensation (sound, sight, touch, temperature, texture, taste and smell). Infants and young children who are hyper-reactive or hypo-reactive to sensory input should be rated here.
Questions to Consider:
- Does child cry or become irritable with certain types of sensory experiences?
- Does child avoid certain types of sensory experiences?
- Does child have trouble touching things of different textures?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of sensory reactivity. Child integrates and reacts to sensory experience at a developmentally appropriate level. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child demonstrates sensory reactivity in at least one sensory area. Child can function with caregiver support in this area. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has sensory reactivity that impacts functioning in at least one life domain (e.g., taste/texture sensitivity interferes with eating). - Need is dangerous or disabling; requires immediate and/or intensive action.
Child demonstrates significant sensory reactivity. Caregiver cannot mediate effects, and reactivity prevents the child from full participation in age-appropriate activities.
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EMOTIONAL CONTROL
This item describes the child's ability to manage emotions (positive or negative). It describes symptoms of affect dysregulation.
Questions to Consider:
- Does the child have reactions that seem out of proportion to the situation?
- Does the child have extreme or unchecked emotional reactions to situations?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child has no problem with emotional control. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or suspicion of problems with managing emotions or emotional control that can be overcome with caregiver support. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child may quickly become excitable or frustrated and react aggressively, or child's difficulties with controlling emotions are impacting functioning in at least one life domain. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child's emotional control problems are interfering with development and put child at imminent risk of harming self or others. Caregivers are not able to mediate the effects.
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FRUSTRATION TOLERANCE
This item rates a child's tolerance of frustration. This may include becoming upset when something does not go their way, having a difficult time waiting for help or attention, and giving up quickly when faced with adversity, a challenge, loss of control or blocked goals. Some sources of frustration for preschoolers can be peers, adults and new prospects at this developmental stage.
Questions to Consider:
- How does the child control their emotions?
- Does the child get upset or frustrated easily?
- Does the child give up when faced with adversity or challenges?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of any challenges dealing with frustration. Child may become upset when frustrated but is easily distracted or redirected. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child demonstrates some difficulties dealing with frustration. Child may sometimes become agitated, verbally hostile, anxious or give up when faced with a challenge or blocked goals. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child struggles with tolerating frustration. Child's reaction to frustration impairs functioning in at least one life domain. Child may completely abandon the task and give up or have an emotional outburst when frustrated. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child is irritable, has violent outbursts or completely gives up when frustrated, impacting their functioning in more than one life domain. Others may be afraid of child's emotional outbursts or that child may hurt self or others during their outbursts.
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TEMPERAMENT
This item describes the child's general way of being and ability to be soothed.
Questions to Consider:
- What is the child generally like?
- Is the child able to be easily calmed or soothed when upset?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child has an easy temperament. The child is easily calmed or distracted when angry or upset. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child has some problems being calmed, soothed, or distracted when angry or upset. Child may have occasional episodes or extended crying or tantrums. Child may display some fear or clinginess in new situations or around new people, but with encouragement child can eventually acclimate. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has a difficult temperament. Child has difficulty being calmed, soothed, or distracted when angry or upset. Persistent episodes of crying, tantrums, clinginess, or other difficult behaviors are observed that impact the child's functioning in at least one area. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child has difficulties being calmed, soothed, or distracted when angry or upset. Repeated and extreme persistent episodes of crying, tantrums, clinginess, or other difficult behaviors are observed that impact their functioning in multiple areas.
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BEHAVIORAL/EMOTIONAL NEEDS DOMAIN
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See page 9 for full table descriptions.
ATTENTION/CONCENTRATION (3+ years)
Problems with attention, concentration and task completion would be rated here. Inattention/ distractibility not related to opposition would be rated here.
Note: The child should be age 3 or older to rate this item.
Questions to Consider:
- Does the child have challenges with attention or concentration that is beyond what one would expect given their age?
- Do the challenges with attention and concentration impact the child's daily functioning? Home life? Educational setting?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of attention or concentration problems. Child stays on task in an age-appropriate manner. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or suspicion of problems with attention/concentration or some current problems with attention and concentration. Child may have some difficulties staying on task for an age-appropriate time period at school or during play. Difficulties with attention/concentration do not impact the child's functioning. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
In addition to problems with sustained attention, child may become easily distracted or forgetful in daily activities, have trouble following through on activities, and become reluctant to engage in activities that require sustained effort. A child who meets diagnostic criteria for ADHD would be rated here. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child's attention or concentration challenges are dangerous or disabling in several areas of their life.
NA Child is under 3 years of age.
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IMPULSIVITY/HYPERACTIVITY (3+ years)
Problems with impulse control and impulsive behaviors, including motoric disruptions (e.g., tics or sudden, rapid, recurring, nonrhythmic motor movements or vocalizations), are rated here.
Note: The child should be age 3 or older to rate this item.
Questions to Consider:
- Does the child's impulsivity put them at risk?
- How has the child's impulsivity impacted their life?
- Is the child able to control themselves?
- Does the child report feeling compelled to do something despite negative consequences?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of symptoms of loss of control of behavior. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or evidence of some impulsivity evident in action or thought that place the child at risk of future functioning difficulties. The child may exhibit limited impulse control (e.g., child may yell out answers to questions or may have difficulty waiting one's turn). Some motor difficulties may be present as well, such as pushing or shoving others. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Clear evidence of problems with impulsive, distractible, or hyperactive behavior that interferes with the child's functioning in at least one life domain. This indicates a child with impulsive behavior who may represent a significant management problem for adults (e.g., caregivers, teachers, coaches, etc.). A child who often intrudes on others and often exhibits aggressive impulses would be rated here. - Need is dangerous or disabling; requires immediate and/or intensive action.
Clear evidence of a dangerous level of hyperactivity and/or impulsive behavior that places the child at risk of physical harm. This indicates a child with frequent and significant levels of impulsive behavior that carries considerable safety risk (e.g., running into the street, dangerous bike riding). The child may be impulsive on a nearly continuous basis. The child endangers self or others without thinking.NA Child is under 3 years of age.
NA Child is under 3 years of age.
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DEPRESSION
This item rates symptoms such as irritable or depressed mood, social withdrawal, sleep disturbances, weight/eating disturbances, and loss of motivation, interest, or pleasure in daily activities. This item can be used to rate symptoms of the depressive disorders.
Questions to Consider:
- Are the child's caregivers concerned about possible depression or chronic low mood and irritability?
- Has the child withdrawn from normal activities?
- Does the child seem listless, sad, or socially withdrawn?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of depression. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or suspicion of depression or evidence of depression associated with a recent negative life event with minimal impact on life domain functioning. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Clear evidence of depression associated with either depressed mood or significant irritability. Depression has interfered significantly in child's ability to function in at least one life domain. - Need is dangerous or disabling; requires immediate and/or intensive action.
Clear evidence of a disabling level of depression that makes it virtually impossible for the child to function in any life domain.
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ANXIETY
This item rates evidence of excessive fear and anxiety and related behavioral disturbances (including avoidance behaviors).
Questions to Consider:
- Does the child have any problems with anxiety or fearfulness?
- Is the child avoiding normal activities out of fear?
- Does the child act frightened or afraid?
- Has the child ever had a panic attack?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of anxiety. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History, suspicion, or evidence of some anxiety. This level is used to rate either a phobia or anxiety problem that Is not yet causing the child significant distress or markedly impairing functioning in any important context. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Clear evidence of anxiety associated with either anxious mood or significant fearfulness. Anxiety has interfered in the child's ability to function in at least one life domain. - Need is dangerous or disabling; requires immediate and/or intensive action.
Clear evidence of debilitating level of anxiety that makes it virtually impossible for the child to function in any life domain.
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OPPOSITIONAL BEHAVIOR
This item rates the child's relationship with authority figures. Generally, oppositional behavior is displayed in response to conditions set by a parent, teacher, or other authority figure with responsibility for and control over the child. Oppositional behaviors rated here are inconsistent with developmentally appropriate resistance to rule following.
Questions to Consider:
- Does the child follow their caregivers' rules?
- Have teachers or other adults reported that the child does not follow rules or directions?
- Does the child argue with adults when they try to get the child to do something?
- Does the child do things that they have been explicitly told not to do?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of oppositional behaviors. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or evidence of defiance towards authority figures that has not yet begun to cause functional impairment. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Clear evidence of oppositional and/or defiant behavior towards authority figures that is currently interfering with the child's functioning in at least one life domain. Behavior causes emotional harm to others. - Need is dangerous or disabling; requires immediate and/or intensive action.
Clear evidence of a dangerous level of oppositional behavior involving the threat of physical harm to others. This rating indicates that the child has severe problems with compliance with rules or adult instruction or authority.
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PICA
This item describes the child who eats nonnutritive and non-food substances.
Questions to Consider:
- Does the child eat unusual materials? Materials that could be dangerous?
- Has the child received medical attention due to ingesting any unusual or dangerous materials?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence that the child ingests unusual or dangerous materials. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History, suspicion, or evidence of ingesting unusual or dangerous materials. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has ingested unusual or dangerous materials consistent with a diagnosis of Pica. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child has become physically ill or experienced abnormal laboratory levels (e.g., elevated blood lead levels greater than 10mcg/dL) due to ingesting dangerous materials.
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ANGER CONTROL
This item captures the child's ability to identify and manage their anger when frustrated.
Questions to Consider:
- How does the child control their emotions?
- Does the child become angry easily?
- Does the child become angry when facing rejection or criticism?
- Does the child seem to have dramatic mood swings?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of any anger control problems. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History, suspicion, or evidence of some problems with controlling anger. Child may sometimes become verbally aggressive when frustrated. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child's difficulties with controlling anger are impacting functioning in at least one life domain. Child's temper has resulted in significant trouble with peers, family and/or school. Anger may be associated with physical violence. Others are likely quite aware of anger potential. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child's temper or anger control problem is dangerous. Child frequently gets into fights that are often physical. Others likely fear the child.
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ATTACHMENT DIFFICULTIES
This item rates the level of difficulties the child has with attachment and their ability to form relationships.
Questions to Consider:
- Does the child struggle with separating from or connecting with the caregiver?
- Does the child approach or attach to strangers?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of attachment problems. Caregiver relationship with child is characterized by mutual satisfaction of needs and child's development of a sense of security and trust. Caregiver can respond to child cues in a consistent, appropriate manner, and child seeks age-appropriate contact with the caregiver for both nurturing and safety needs. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Some history or evidence of insecurity in the caregiver-child relationship. Caregiver may have difficulty accurately reading child's bids for attention and nurturance; may be inconsistent in response; or may be occasionally intrusive. Child may have some problems with separation (e.g., anxious/clingy behaviors in the absence of obvious cues of danger) or may avoid contact with caregiver in age-inappropriate way. Child may have minor difficulties with appropriate physical/emotional boundaries with others. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Problems with attachment that interfere with child's functioning in at least one life domain and require intervention. Caregiver may consistently misinterpret child cues, act in an overly intrusive way, or ignore/avoid child's bids for attention/nurturance. Child may have ongoing difficulties with separation, may consistently avoid contact with caregivers, and have ongoing difficulties with physical or emotional boundaries with others. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child is unable to form attachment relationships with others (e.g., chronic dismissive/ avoidant/detached behavior in care giving relationships) OR child presents with diffuse emotional/physical boundaries leading to indiscriminate attachment with others. Child is considered at ongoing risk due to the nature of their attachment behaviors. Child may have experienced significant early separation from or loss of caregiver, or have experienced chronic inadequate care from early caregivers, or child may have individual vulnerabilities (e.g., mental health, developmental disabilities) that interfere with the formation of positive attachment relationships.
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RISK FACTORS AND BEHAVIORS DOMAIN: RISK BEHAVIORS
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See page 9 for full table descriptions.
SELF-HARM
This item rates the presence of repetitive behaviors, like head-banging or biting/hitting oneself, that result in physical harm to the child. This rating should consider whether a supervising adult (parent, early childhood professional, medical professional or other involved adult) can impact these behaviors.
Questions to Consider:
- Has the child head banged or done other self-harming behaviors?
- How does the caregiver's support help stop the behavior?
Ratings and Descriptions
- No evidence of any needs; no need for action.
There is no evidence of self-harm behaviors. - Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion or disagreement.
History, suspicion or some evidence of self-harm behaviors. These behaviors are controllable by caregiver. - Need or risk behavior is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Child's self-harm behaviors such as head banging cannot be impacted by supervising adult and interferes with their functioning. - Need or risk behavior is dangerous or disabling. Intensive and/or immediate action is required to address the need or risk behavior.
Child's self-harm behavior puts their safety and well-being at risk.
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AGGRESSIVE BEHAVIOR (24+ months)
This item rates the child's violent or aggressive behavior. The intention of this behavior is to cause significant bodily harm to others. A rating of '2' or '3' would indicate that caregivers are unable to shape/control the child's aggressive behaviors. Child must be at least 24 months old to rate this item.
Questions to Consider:
- Has the child ever tried to injure another person or animal on purpose?
- Do they hit, kick, bite, or throw things at others with intent to hurt them?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence or history of aggressive behaviors or significant verbal aggression towards others (including people and animals). - Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion or disagreement.
History of aggressive behavior toward people or animals or concern expressed by caregivers about aggression. - Need or risk behavior is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Clear evidence of aggressive behavior toward people or others in the past 30 days. Caregiver's attempts to redirect or change behaviors have not been successful. - Need or risk behavior is dangerous or disabling. Intensive and/or immediate action is required to address the need or risk behavior.
The child exhibits a current, dangerous level of aggressive behavior that involves the threat of harm to animals or others. Caregivers are unable to mediate this dangerous behavior.
NA Child is younger than 24 months.
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FIRE SETTING
This item refers to behavior involving the intentional setting of fires that might be dangerous to the child or others. This includes both malicious and non-malicious fire setting. This does NOT include the use of candles or incense or matches to smoke or accidental fire setting.
Questions to Consider:
- Has the child ever started a fire?
- Has the incident of fire setting put anyone at harm or at risk of harm?
Ratings and Descriptions
- No evidence of any needs; no need for action. No evidence of fire setting by the child.
- Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion or disagreement.
History of fire setting. - Need or risk behavior is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Recent fire-setting behavior but not of the type that has endangered the lives of others OR repeated fire-setting behavior in the recent past. - Need or risk behavior is dangerous or disabling. Intensive and/or immediate action is required to address the need or risk behavior.
Acute threat of fire setting. Set fire that endangered the lives of others (e.g., attempting to burn down a house or setting other fires).
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INTENTIONAL MISBEHAVIOR
This item describes intentional behaviors that a child engages in to force others to administer consequences. This item should reflect problematic social behaviors (socially unacceptable behavior for the culture and community in which the child lives) that put the child at some risk of consequences. This item should not be rated for children who engage in such behavior solely due to developmental delays.
Questions to Consider:
- Does the child intentionally do or say things to upset others or get in trouble with people in positions of authority (e.g., parents or teachers)?
- Has the child engaged in behavior that was insulting, rude or obnoxious and which resulted in sanctions for the child such as suspension, etc.?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child shows no evidence of problematic social behaviors that cause adults to administer consequences. - Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Some problematic social behaviors that force adults to administer consequences to the child. Provocative comments or behavior in social settings aimed at getting a negative response from adults might be included at this level. - Need or risk behavior is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Child may be intentionally getting in trouble in school or at home, and the consequences, or threat of consequences, is causing problems in the child's life. - Need or risk behavior is dangerous or disabling. Intensive and/or immediate action is required to address the need or risk behavior.
Frequent seriously inappropriate social behaviors force adults to seriously and/or repeatedly administer consequences to the child. The inappropriate social behaviors may cause harm to others and/or place the child at risk of significant consequences (e.g., expulsion from school, removal from the community).
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STRENGTHS DOMAIN
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See page 10 for full table descriptions.
INTERPERSONAL
This item is used to identify a child's social and relationship skills. Interpersonal skills are rated independently of Social Functioning because a child can have social skills but still struggle in their relationships at a particular point in time. This strength indicates an ability to make and maintain long-standing relationships.
Questions to Consider:
- How does the child interact with other children and adults?
- How does the child do in social settings?
Ratings and Descriptions
- Well-developed, centerpiece strength; may be used as a centerpiece in an intervention/action plan.
Child has well-developed interpersonal skills and healthy friendships. - Identified and useful strength. Strength will be used, maintained or built upon as part of a plan. May require some effort to develop strength into a centerpiece strength.
Child has good interpersonal skills and has shown the ability to develop healthy friendships. - Strengths have been identified but require strength-building efforts before they can be effectively utilized as part of a plan. Identified but not useful.
Child requires strength building to learn to develop good interpersonal skills and/or healthy friendships. Child has some social skills that facilitate positive relationships with peers and adults but may not have any current healthy friendships. - An area in which no current strength is identified; efforts may be recommended to develop a strength in this area.
There is no evidence of observable interpersonal skills or healthy friendships currently and/or child requires significant help to learn to develop interpersonal skills and healthy friendships.
Supplemental Information:
- Action level '0': Child has a prosocial or "easy" temperament and, if old enough, is interested and effective at initiating relationships with other children or adults. If still an infant, child exhibits anticipatory behavior when fed or held.
- Action level '1': Child has formed a positive interpersonal relationship with at least one non-caregiver. Child responds positively to social initiations by adults but may not initiate such interactions by themselves.
- Action level '2': Child may be shy or uninterested in forming relationships with others, or – if still an infant -- child may have a temperament that makes attachment to others a challenge.
- Action level '3': Child with no known 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.
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RELATIONSHIP STABILITY
This item refers to the stability of significant relationships in the child's life. This likely includes family members but may also include other individuals.
(Note: This item is from the 2023 version of the CANS-NY 0-5 reference guide.)
Ratings and Descriptions
- Well-developed, centerpiece strength; may be used as a centerpiece in an intervention/action plan.
Child has stable relationships. Family members, friends, and community have been stable for most of life and are likely to remain so in the foreseeable future. - Identified and useful strength. Strength will be used, maintained or built upon as part of the plan. May require some effort to develop strength into a centerpiece strength.
Child has had stable relationships but there is some concern about instability in the near future due to such things as impending transitions such as illness, divorce, or move. - Strengths have been identified but require strength-building efforts before they can be effectively utilized as part of a plan. Identified but not useful.
Child has had at least one stable relationship over lifetime but has experienced other instability through factors such as divorce, moving, removal from home, or death, for example. - An area in which no current strength is identified; efforts may be recommended to develop a strength in this area.
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CAREGIVER RESOURCES & NEEDS DOMAIN
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See page 11 for full table descriptions.
PROBLEM SOLVING
This item describes the caregiver's ability to problem solve; to plan, implement, and monitor a course of action; and to judge and self-regulate behavior according to anticipated outcomes.
Questions to Consider:
- Does the caregiver report or appear to have difficulties with problem solving or resolving challenges?
- Are there particular situations that the caregiver has difficulty thinking through?
Ratings and Descriptions
- No current need; no need for action. This may be a resource for the child.
Caregiver has good problem-solving skills. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement. This may be an opportunity for resource building.
Caregiver struggles with thinking through problems or situations, but this does not interfere with their functioning as a parent. - Need is interfering with the provision of care; action is required to ensure that the identified need is addressed.
The caregiver has difficulty thinking through problems or situations which interferes with their ability to function as a parent. - Need prevents the provision of care; requires immediate and/or intensive action.
The caregiver has problems with problem solving that places the child at risk.
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FAMILY STRESS
This item refers to the physical, emotional, or financial stress on the family due to the provision of direct care, making and coordinating appointments, or obtaining medical supplies and equipment.
Questions to Consider:
- Do caregivers find it stressful at times to manage the challenges in dealing with the child's medical, behavioral and/or developmental needs?
- Does the stress ever interfere with ability to care for the child?
Ratings and Descriptions
- No current need; no need for action. This may be a resource for the child.
Child's medical, developmental, or behavioral health condition or care is not adding stress to the family. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement. This may be an opportunity for resource building.
Child's medical, developmental, or behavioral health condition or care is a stressor on the family, but family is functioning well. - Need is interfering with the provision of care; action is required to ensure that the identified need is addressed.
Child's medical, developmental, or behavioral health condition or care is a stressor and is interfering with family functioning. - Need prevents the provision of care; requires immediate and/or intensive action.
Child's medical, developmental, or behavioral health condition or care is a significant stressor and is significantly impacting family functioning. Family functioning is characterized by lack of support for or conflict among the family members.
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CARE/TREATMENT INVOLVEMENT
This item rates the caregiver's participation in seeking and supporting care/treatment to address the child's care.
Questions to Consider:
- How involved are the caregivers in services for the child?
- Is the caregiver an advocate for the child's needs?
- Would the caregiver like any help to become more involved?
Ratings and Descriptions
- No current need; no need for action. This may be a resource for the child.
No evidence of problems with caregiver involvement in services or interventions, and/or caregiver can act as an effective advocate for the child. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement. This may be an opportunity for resource building.
Caregiver is involved in the planning and/or implementation of services for the child but may struggle to stay consistently engaged. Caregiver is open to receiving support, education, and information. - Need is interfering with the provision of care; action is required to ensure that the identified need is addressed.
Caregiver is not actively involved in the child's services and/or interventions intended to assist the child. - Need prevents the provision of care; requires immediate and/or intensive action.
Caregiver does not wish to participate in the services and/or interventions intended to assist the child. Caregiver's lack of treatment involvement places the child at imminent risk. Caregiver may wish for child to be removed from their care.
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SERIOUS EMOTIONAL DISTURBANCE (SED) AGES 6+
The following items are relevant to the Serious Emotional Disturbance 6+ worksheet.
LIFE FUNCTIONING DOMAIN
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See page 8 for full table descriptions.
LIVING SITUATION: See item description on page 12.
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DECISION MAKING
This item describes the child/youth's age-appropriate decision-making process and understanding of choices and consequences.
Questions to Consider:
- Does the child/youth make decisions that may negatively impact their health, safety, and/or well-being?
- Does the child/youth typically make good choices.
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of problems with judgment or decision making that result in harm to development and/or well-being. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
There is a history or suspicion of problems with judgment in which the child/youth makes decisions that are in some way harmful to their development and/or well-being. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Problems with judgment in which the child/youth makes decisions that are in some way harmful to their development and/or well-being. As a result, more supervision is required than expected for their age. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child/youth makes decisions that would likely result in significant physical harm to self or others. Therefore, child/youth requires intense and constant supervision, over and above that expected for child/youth's age.
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SCHOOL BEHAVIOR
This item rates the behavior of the child/youth in school or school-like settings.
Questions to Consider:
- How is the child/youth behaving in school?
- Has the child/youth had any detentions or suspensions?
- Has the child/youth needed to go to an alternative school placement?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of behavioral problems at school, OR child/youth is behaving well in school. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child/youth is behaving adequately in school although some behavior problems exist. Behavior problems may be related to relationship with either teachers or peers. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child/youth's behavior problems are interfering with functioning at school. The child/youth is disruptive and may have received sanctions including suspensions. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child/youth is having problems with behavior in school that place them at risk. School placement may be in jeopardy due to behavior.
NA Youth has graduated high school or has their GED.
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SCHOOL ATTENDANCE
This item rates issues of attendance. If school is not in session, rate the last 30 days when school was in session.
Questions to Consider:
- Does the child/youth have any difficulty attending school?
- Is the child/youth on time to school?
- How many times a week is the child/youth absent?
- Once the child/youth arrives at school, does the child/youth stay for the rest of the day?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child/youth attends school regularly. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child/youth has a history of attendance problems, OR child/youth has some attendance problems but generally goes to school. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child/youth's problems with school attendance are interfering with academic progress. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child/youth is generally absent from school.
NA Youth has graduated high school or has their GED.
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ADJUSTMENT TO TRAUMA*: See item description on page 16.
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TRAUMA MODULE: TRAUMATIC STRESS SYMPTOMS
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See page 8 for full table descriptions.
RE-EXPERIENCING: See item description on page 17.
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HYPERAROUSAL: See item description on page 18.
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AVOIDANCE: See item description on page 19.
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NUMBING: See item description on page 20.
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EMOTIONAL AND/OR PHYSICAL DYSREGULATION: See item description on page 21.
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TRAUMATIC GRIEF: See item description on page 23.
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BEHAVIORAL/EMOTIONAL NEEDS DOMAIN
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See page 9 for full table descriptions.
PSYCHOSIS (THOUGHT DISORDER)
This item rates the common symptoms of psychosis including hallucinations (i.e., experiencing things others do not experience), delusions (i.e., a false belief or an incorrect inference about reality that is firmly sustained despite the fact that nearly everybody thinks the belief is false or proof exists of its inaccuracy), disorganized thinking, and bizarre/idiosyncratic behavior.
Questions to Consider:
- Does the child/youth exhibit behaviors that are unusual or difficult to understand?
- Does the child/youth engage in certain actions repeatedly?
- Are the unusual behaviors or repeated actions interfering with the child/youth's functioning?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of psychotic symptoms. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or suspicion of hallucinations, delusions or bizarre behavior that might be associated with some form of psychotic disorder. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Evidence of disturbance in thought process or content that may be impairing the child/youth's functioning in at least one life domain. - Need is dangerous or disabling; requires immediate and/or intensive action.
Clear evidence of dangerous hallucinations, delusions, or bizarre behavior that might be associated with some form of psychotic disorder that places the child/youth or others at risk of physical harm.
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ATTENTION/CONCENTRATION: See item description on page 29.
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IMPULSIVITY/HYPERACTIVITY: See item description on page 30.
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DEPRESSION: See item description on page 31.
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ANXIETY: See item description on page 32.
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OPPOSITIONAL BEHAVIOR: See item description on page 33
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CONDUCT
This item rates the degree to which a child/youth engages in behaviors that show a disregard for and violation of the rights of others such as stealing, lying, vandalism, cruelty to animals, and assault. This item rates the degree to which a child/youth engages in behavior that is consistent with the presence of a Conduct Disorder.
Questions to Consider:
- How does the child/youth handle telling the truth/lies?
- Is the child/youth seen as dishonest?
- Has the child/youth ever tortured animals?
- Has the child/youth ever been arrested?
- Is the child/youth on probation?
- Has the child/youth ever been incarcerated?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of serious violations of others or laws. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History, suspicion or evidence of some problems associated with antisocial behavior including but not limited to lying, stealing, manipulation of others, acts of sexual aggression, or violence towards people, property or animals. The child/youth may have some difficulties in school and home behavior. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Clear evidence of antisocial behavior including but not limited to lying, stealing, manipulating others, sexual aggression, violence towards people, property, or animals. - Need is dangerous or disabling; requires immediate and/or intensive action.
Evidence of a level of aggressive or antisocial behavior that places the child/youth or community at significant risk of physical harm due to these behaviors.
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EMOTIONAL CONTROL
This item describes the child/youth's ability to manage emotions (positive or negative). It describes symptoms of affect dysregulation.
Questions to Consider:
- Does the child/youth have reactions that seem out of proportion to the situation?
- Does the child/youth have extreme or unchecked emotional reactions to situations?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child/youth has no problems with emotional control. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or suspicion of problems with managing emotions or emotional control that can be overcome with caregiver support. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child/youth may quickly become excitable or frustrated and react aggressively, or child/ youth's difficulties with controlling emotions are impacting functioning in at least one life domain.Child/youth may quickly become excitable or frustrated and react aggressively or impulsively. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child/youth's emotional control problems are interfering with development and put child/youth at imminent risk of harming self or others. Caregivers are not able to mediate the effects.
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ANGER CONTROL: See item description on page 35.
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ATTACHMENT DIFFICULTIES: See item description on page 36.
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EATING DISTURBANCE
This item rates problems with eating, including disturbances in body image, refusal to maintain normal body weight (including obesity), and recurrent episodes of binge eating.
Questions to Consider:
- Is the child/youth preoccupied with body image, weight, excessive exercise, refusal to eat, over-eating and/or binging and purging?
- Does the child/youth have any medical problems incidental to eating disorders?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of eating disturbances. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child/youth has an eating disturbance. This could include some preoccupation with weight, calorie intake, or body size or type when of normal weight or below weight. This could also include some binge eating patterns. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child/youth has an eating disturbance which is impacting their ability to function or be healthy. This could include a more intense preoccupation with weight gain or becoming fat when underweight, restrictive eating habits or excessive exercising to maintain below normal weight, or emaciated body appearance. This level could also include more notable overeating that has led to obesity or binge eating episodes that may or may not be followed by compensatory behaviors to prevent weight gain (e.g., vomiting, use of laxatives, excessive exercising). In addition to anorexia and bulimia, food hoarding could also be rated here. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child/youth's eating disturbance is disabling. This could include significantly low weight where hospitalization is required; obesity with significant health problems; or excessive binging or binging then purging behaviors (at least once per day).
Supplemental Information: Include Pica, or the eating of nonnutritive, nonfood substances, in rating this item.
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RISK FACTORS AND BEHAVIORS DOMAIN: RISK BEHAVIORS
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See page 9 for full table descriptions.
SUICIDE RISK
This item is intended to describe the presence of thoughts or behaviors aimed at taking one's life. This rating describes both suicidal and significant self-injurious behavior. This item rates overt and covert thoughts and efforts on the part of a child/youth to end their life. A rating of '2' or '3' would indicate the need for a safety plan.
Questions to Consider:
- Has the child/youth ever talked about a wish or plan to die or to kill themselves?
- Has the child/youth ever tried to commit suicide?
Ratings and Descriptions
- No evidence of any needs; no need for action. No evidence of suicidal ideation or behaviors.
- Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History of suicidal ideation, but no recent ideation or gesture. - Need is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Current evidence of risk of suicide due to suicidal thinking or behaviors. - Intensive and/or immediate action is required to address the need or risk behavior.
Current suicidal ideation and intent OR command hallucinations that involve self-harm.
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NON-SUICIDAL SELF-INJURIOUS BEHAVIOR
This item includes repetitive, physically harmful behavior that generally serves as a self-soothing function to the child/youth (e.g., cutting, carving, burning self, face slapping, head banging, etc.).
Questions to Consider:
- Does the behavior serve a self-soothing purpose (e.g., numb emotional pain, move the focus of emotional pain to the physical)?
- Does the child/youth use self-injurious behavior as a release?
- Does the child/youth ever purposely hurt themselves (e.g., cutting)?
Ratings and Descriptions
- No evidence of any needs; no need for action. No evidence of any forms of self-injury.
- Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
A history or suspicion of self-injurious behavior. - Need is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Engaged in self-injurious behavior that does not require medical attention but is impacting the child/youth's functioning. - Intensive and/or immediate action is required to address the need or risk behavior.
Engaged in self-injurious behavior requiring medical intervention (e.g., sutures, surgery) and that is significant enough to put the child/youth's health at risk.
Supplemental Information: Suicidal behavior is not self-injurious behavior. Carving and cutting on the body are common examples of self-mutilation behavior. Generally, body piercings and tattoos are not considered a form of self-injury. Repeatedly piercing or scratching one's skin would be included. Self-mutilation in this fashion is thought to have addictive properties since generally the self-harm behavior results in the release of endorphins that provide a calming feeling.
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OTHER SELF-HARM (RECKLESSNESS)
This item includes reckless and dangerous behaviors that, while not intended to harm self or others, place the child/youth or others at risk of physical harm.
Note: Suicidal or self-mutilative behaviors are not rated here.
Questions to Consider:
- Does the child/youth make poor decisions that put them in dangerous situations?
- Has the child/youth ever talked about or acted in a way that might be dangerous to themselves (e.g., reckless behavior such as riding on top of cars, reckless driving, climbing bridges, etc.)?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of behaviors that place the child/youth at risk of physical harm. - Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or suspicion of some reckless or intentional risk-taking behavior that placed the child/ youth at risk of physical harm. - Need is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Engaged in reckless or intentional risk-taking behavior that places the child/youth in danger of physical harm. - Intensive and/or immediate action is required to address the need or risk behavior.
Engaged in reckless or intentional risk-taking behavior that places the child/youth at immediate risk of death.
Supplemental Information: This item provides an opportunity to identify other potentially self-destructive behaviors (e.g., reckless driving, subway surfing, unprotected sex, substance use, etc.). If the child/youth frequently exhibits significantly poor decision making that has the potential to place themselves in danger, but has yet to do so, a rating of '1' might be used to indicate the need for prevention. A rating of '3' is used for a child/youth that has placed themselves in significant physical danger during the rating period.
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DANGER TO OTHERS
This item rates the child/youth's violent or aggressive behavior. The intention of this behavior is to cause significant bodily harm to others. A rating of '2' or '3' would indicate the need for a safety plan.
Questions to Consider:
- Has the child/youth ever injured another person on purpose?
- Does the child/youth get into physical fights?
- Has the child/youth ever threatened to kill or seriously injure others?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence or history of aggressive behaviors or significant verbal threats of aggression towards others (including people and animals). - Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History of aggressive behavior or verbal threats of aggression towards others. - Need is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Evidence of aggression towards others. Child/youth has made verbal threats of violence towards others. - Intensive and/or immediate action is required to address the need or risk behavior.
Acute homicidal ideation with a plan, frequent or dangerous (significant harm) level of aggression to others. Child/youth is an immediate risk to others.
Supplemental Information: Imagined violence, when extreme, may be rated here. Physically harmful aggression or command hallucinations that involve the harm of others would be rated a '3.' Reckless behavior that may cause physical harm to others is not rated on this item.
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FIRE SETTING: See item description on page 39.
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SEXUALLY REACTIVE BEHAVIOR
This item refers to sexual behavior that may not be age-appropriate and may put child/youth at risk for adverse outcomes, such as victimization, pregnancy, or STIs.
(Note: This item is from the 2023 version of the CANS-NY 6-21 reference guide.)
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of problems with sexually reactive behaviors. - Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or suspicion of sexually reactive behavior that places child/youth at risk, such as inappropriate sexual language or behavior, or unprotected sex with a single partner. A history of sexually provocative behavior would be rated here. - Need is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Child/youth engages in sexually reactive behavior that places child/youth at risk that negatively impacts functioning. Child/youth may exhibit sexually provocative behaviors. - Intensive and/or immediate action is required to address the need or risk behavior.
Child/youth engages in a dangerous level of sexually reactive behaviors. Child/youth exhibits sexual behaviors that place child/youth or others at immediate risk such as engaging in promiscuous sexual behaviors, or having unprotected sex with multiple partners.
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DELINQUENT BEHAVIOR
This item includes behaviors that may result from child/youth failing to follow required behavioral standards (e.g., truancy, curfew violations, vandalism, underage drinking/drug use, driving without a license). If caught, the child/youth could be arrested for this behavior.
Questions to Consider:
- Do you know of laws that the child/youth has broken (even if they have not been charged or caught)?
- Has the child/youth ever been arrested?
- Is the child/youth on probation?
Ratings and Descriptions
- No evidence of any needs; no need for action. No evidence or history of delinquent behavior.
- Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
History or suspicion of delinquent behavior. - Need is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Child/youth has been engaged in delinquent behavior (e.g., vandalism, shoplifting, etc.) that puts the child/youth at risk of legal involvement. - Intensive and/or immediate action is required to address the need or risk behavior.
Recent acts of delinquent behavior that place others at risk of significant loss or injury resulted in the child having legal involvement. Examples include car theft, residential burglary, rape, armed robbery, and assault.
Supplemental Information: This item uses the mental health rather than the juvenile justice definition of delinquency, reflecting behaviors that we know about. Since the primary goal of the intervention is to prevent the child/youth from future harm, it is necessary to assess behaviors of which we are aware. The general vagueness of this item prevents placing the child/youth in any legal jeopardy from the assessment (i.e., no specific crimes are identified, just a level of risk).
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BULLYING
This item describes perpetrators of the exploitation of others. Generally, this refers to bullying other children or youth (usually smaller or younger ones); however, it could include children/youth who bully adults. Cyberbullying can be rated here.
Questions to Consider:
- Have there been any reports that the child/youth has picked on, made fun or, harassed or intimidated another person?
- Are there concerns that the child/youth might bully other children?
- Does the child/youth hang around with other people who bully?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child/youth has never engaged in bullying at school or in the community. - Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child/youth has been involved with groups that have bullied other children/youth either in school or the community; however, child/youth has not had a leadership role in these groups. - Need is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Child/youth has bullied other children/youth in school or community. Child/youth has either bullied the other children/youth individually or led a group that bullied others. - Intensive and/or immediate action is required to address the need or risk behavior.
Child/youth has repeatedly utilized threats or actual violence to bully children/youth in school and/or community.
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RUNAWAY
This item describes the risk of running away or actual runaway behavior.
Questions to Consider:
- Has the child/youth ever run away from home, school, or any other place?
- If so, where did the child/youth go? How long did they stay away? How was the child/youth found?
- Does the child/youth ever threaten to run away?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child/youth has no history of running away or ideation of escaping from current living situation. - Need or risk behavior that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child/youth has no recent history of running away but has expressed ideation about escaping current living situation. Child/youth may have threatened running away on one or more occasions or has a history of running away but not in the recent past. - Need is interfering with functioning. Action is required to ensure that the identified need or risk behavior is addressed.
Child/youth has run from home once or run from one treatment setting. Also rated here is a child/youth who has run away to home (parental or relative). - Intensive and/or immediate action is required to address the need or risk behavior.
Child/youth has run from home and/or treatment settings in the recent past and presents an imminent flight risk. A child/youth who is currently a runaway is rated here.
Supplemental Information: Include elopement or any planned or impulsive running or 'bolting' behavior that presents a risk to the safety of the child/youth. Factors to consider in determining level of risk include age of the young person, frequency and duration of escape episodes, timing and context, and other risky activities while running.
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INTENTIONAL MISBEHAVIOR: See item description on page 40.
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STRENGTHS DOMAIN
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See page 10 for full table descriptions.
SOCIAL RELATIONSHIPS WITH ADULTS
This item describes the child/youth's social relationships with adults outside of the family.(Note: This item is from the 2023 version of the CANS-NY 6-21 reference guide.)
Ratings and Descriptions
- Well-developed, centerpiece strength; may be used as a centerpiece in an intervention/action plan.
Child/youth is skilled with positive social relationships with adults. - Identified and useful strength. Strength will be used, maintained or built upon as part of the plan. May require some effort to develop strength into a centerpiece strength.
Child/youth shows interest and capability with social relationships with adults. - Strengths have been identified but require strength-building efforts before they can be effectively utilized as part of a plan. Identified but not useful.
Child/youth shows some interest but not current connection to social relationships with adults. - An area in which no current strength is identified; efforts may be recommended to develop a strength in this area.
No evidence of strength specific to child/youth social relationships with adults.
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RELATIONSHIP STABILITY: See item description on page 42.
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CAREGIVER RESOURCES & NEEDS DOMAIN
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See page 11 for full table descriptions.
PROBLEM SOLVING: See item description on page 43.
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FAMILY STRESS: See item description on page 44..
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CARE/TREATMENT INVOLVEMENT: See item description on page 45.
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MEDICALLY FRAGILE AGES 0-5 AND 6+
The following items are relevant to the Medically Fragile 0-5 AND 6+ worksheets.
LIFE FUNCTIONING DOMAIN
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See page 8 for full table descriptions.
MEDICAL/PHYSICAL*
This item includes both health problems and chronic/acute physical conditions or impediments. This item does not rate depression or other mental health issues.
(Note: This item is not in the worksheet, but it is a trigger for the Medical Health Module, whose items are in the worksheet, so it has been included here.)
Questions to Consider:
- Does the child have any medical conditions?
- Does the child have anything that limits their physical activities?
- How much does this interfere with the child's life?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence that the child has any medical or physical problems, and/or child is healthy. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child has transient or well-managed physical or medical problems. These include well-managed chronic conditions like juvenile diabetes or asthma. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has serious medical or physical problems that require medical treatment or intervention. Or child has a chronicillness or a physical challenge that requires ongoingmedical intervention. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child has life-threateningillness or medical/physical condition. Immediate and/or intense action should be taken due to imminent danger to child's safety, health, and/or development.
*A rating of '1,' '2,' or '3' on this item triggers the completion of the Medical Health Module.
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MEDICAL HEALTH MODULE
LIFE THREATENING
This item refers to conditions that pose an impending danger to life or carry a high risk of death if not treated.
Questions to Consider:
- Does the child have a medical condition that poses a risk of death if not treated?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child's current medical condition(s) do not pose any risk to premature death. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child's current medical condition(s) may shorten life but not until later in adulthood. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Current medical condition(s) places the child as risk of premature death before reaching adulthood. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child's current medical condition(s) places the child at imminent risk of death.">Return to Core Item List]
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CHRONICITY
This item refers to a condition that is persistent or long-lasting in its effects or a disease that develops gradually over time and is expected to last a long time even with treatment. Chronic conditions are in contrast with acute conditions which have a sudden onset.
Questions to Consider:
- Does the child have a persistent or long-lasting medical condition?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child is expected to fully recover from current medical condition within the next six months to one year. Note: A child with this rating does not have a chronic condition. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child's chronic condition is minor or well controlled with current medical management. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child's chronic condition(s) have significant effects/exacerbations despite medical management. Child may experience more frequent medical visits, including ER visits, surgeries or hospitalizations for acute manifestation or complications of chronic condition. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child's chronic condition(s) place them at risk for prolonged inpatient hospitalization or out-of-home placement (or in-home care with what would be equivalent to institutionalized care).
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IMPAIRMENT IN FUNCTIONING
This item refers to a reduction in either physical or mental capacity that is sufficient to interfere with managing day-to-day tasks of life. This limitation can range from a slight loss of function to a total impairment which is usually considered a disability. Some impairments may be short-term while others may be permanent. Assessing the impairment can help identify the best course of treatment and whether it is responding to treatment.
Questions to Consider:
- Is the child's medical condition(s) interfering with their day-to-day functioning?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child's medical condition or mental capacity is not interfering with functioning in other life domains. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child's medical condition or mental capacity has a limited impact on functioning in at least one other life domain. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child's medical condition or mental capacity is interfering in more than one life domain or is disabling in at least one. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child's medical condition or mental capacity has disabled them in most other life domains.">Return to Core Item List]
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INTENSITY OF TREATMENT SUPPORT
This item refers to the complexity of the child's medical treatment, including frequency of treatment, whether there is a need for special medical services or equipment, and the extent of support needed by caregivers in the management of the treatment.
Questions to Consider:
- Does the child's medical condition(s) require specialized medical equipment or services?
- Does the child have the support needed to administer and manage their medical treatments?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child's medical treatment is not intrusive in the family's routine. Child and family are maintaining all necessary treatment. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child's medical treatment regimen is getting in the way of the family's routine. They sometimes are unable to complete procedures, and/or require support in administering some of the treatments. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child's medical treatment cannot currently be administered by the child and/or family without some support in the home. - Need is dangerous or disabling; requires immediate and/or intensive action.
Intensity of the child's treatment prevents the caregiver from managing at least one area of the family's life functioning.
Supplemental Information: In considering the intensity of treatment and supports provided, the family's circumstances and child's medical condition(s) and their risk of use of the Emergency Department, Urgent Care, and/or Hospitalization should be considered.
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The following items are relevant to the Medically Fragile 0-5 worksheet.
DEVELOPMENTAL NEEDS DOMAIN
This section identifies the developmental needs of the child.
Question to Consider for this Domain: Is the child meeting their developmental milestones?
For the Development Domain, use the following categories and action levels:
- No evidence of any needs; no need for action.
- Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion or disagreement.
- Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
- Need is dangerous or disabling; requires immediate and/or intensive action.
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EATING
This item refers to the process of getting food into the body by any means.
Questions to Consider:
- Does the child have any challenges with eating?
- Does the child's challenges with eating impact their functioning?
- Does the child require any adaptive equipment or supports to successfully eat?
- Does the child require any specialized medical equipment to obtain needed nutrients?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence of problems related to eating. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion or disagreement.
Child's problems with eating have been present in the past or are currently present some of the time. Child experiences some difficulty eating but manages by themselves. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Problems with eating are present that impact the child's functioning. Child may overeat, have few food preferences or not have a clear pattern of when they eat. Child may need help from another person or the use of adaptive equipment (e.g., adapted utensils) to feed self but manages by themselves. - Need is dangerous or disabling; requires immediate and/or intensive action.
Problems with eating are present and putting the child at risk developmentally. Child is unable to feed themselves (including parental nutrition) or the child and family are very distressed and unable to overcome problems in this area.
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MOBILITY
This item describe the ability of the child to move.
Questions to Consider:
- Is the child able to move independently?
- What supports does the child need to move or ambulate?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child is fully independent in their ability to ambulate, or infant is developmentally on target. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion or disagreement.
Child is generally independent in mobility but has some adaptive technology that facilitates independent mobility. Mobility challenges do not have a notable impact on functioning. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has notable challenges with mobility that interfere with functioning. Limited mobility for short distances or short periods of time can occur when assisted by another person or adaptive technology. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child has motor challenges that prevent them from any mobility without total assistance of another person or support of an adaptive device (e.g., wheelchair or crutches).
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POSITIONING
This item describes the child's ability to move a limb or their entire body while stationary.
Questions to Consider:
- Is the child able to position their body on their own?
- What supports does the child need in order to position their body?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child is fully independent in their ability to position body. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child is generally independent in positioning but has some adaptive technology that facilitates independent positioning. Positioning challenges do not have a notable impact on functioning. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has notable challenges with positioning that interfere with functioning. Physical assistance from others or adaptive technology provides some independence in positioning. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child is unable to reposition self and requires 24-hour monitoring and physical assistance from others to reposition themselves.[Return to Core Item List]
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TRANSFERRING
This item refers to the process of moving between positions (e.g., to and from bed, chair to standing). Note: Transferring does not include transferring to/from toilet.
Questions to Consider:
- Is the child able to independently transition or transfer their body between positions?
- What supports does the child need to be able to transition or transfer their body between positions?
Ratings and Descriptions
- No evidence of any needs; no need for action.
Child is fully independent in their ability to transfer (e.g., in and out of bed, sitting to standing). - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child is generally independent in transferring. Child has some difficulty but can transfer unassisted and transfer challenges do not have a notable impact on functioning. May require the use of assistive devices. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has notable challenges with transfers that interfere with functioning; child needs some assistance from another person to transfer. May or may not require the use of assistive devices. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child is unable to transfer without assistance from another person.
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ELIMINATION
This item describes any needs related to urination or bowel movements.
Questions to Consider:
- Does the caregiver have any concerns about the child's elimination routines?
- Do any medical concerns interfere with urination or bowel movements?
- Do any concerns around elimination get in the way of the child's functioning in other domains?
Ratings and Descriptions
- No evidence of any needs; no need for action.
No evidence that the child has any history of concerns around elimination. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child has had elimination difficulties in the past but is not experiencing consistent difficulties at present. Occasional problems with elimination would be rated here. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child has consistent problems with elimination that require ongoing action or medical intervention. Children who require ongoing medical treatment for impacted bowels and children whose elimination is maintained with an appliance or catheter would be rated here. This rating includes infants who may completely lack a routine in elimination and develop constipation as a result. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child has difficulties with elimination that cause the child significant distress and/or impact physical health and development.
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The following items are relevant to the Medically Fragile 6+ worksheet.
LIFE FUNCTIONING DOMAIN
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See page 8 for full table descriptions.
SELF-CARE ACTIVITIES OF DAILY LIVING*
This item aims to describe the child/youth's ability and motivation to engage in developmentally-appropriate self-care tasks such as bathing, dressing, toileting, and other such tasks related to keeping up with one's personal hygiene.
(Note: This item is not in the worksheet, but it is a trigger for the Self-Care Activities of Daily Living Module, whose items are in the worksheet, so it has been included here.)
Questions to Consider:
- Is the child/youth able to care for themselves?
- Does the child/youth groom on a regular basis?
- Does the child/youth bathe themselves?
Ratings and Descriptions
- No current need; no need for action.
Child/youth's self-care skills appear developmentally appropriate. There is no reason to believe that the child/youth has any problems performing the basic activities of daily living. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child/youth requires verbal prompting on self-care tasks, or child/youth can use adaptations and supports to complete self-care. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child/youth requires assistance (physical prompting) on self-care tasks or attendant care on one self-care task (e.g., bathing, dressing, toileting). - Need is dangerous or disabling; requires immediate and/or intensive action.
Youth requires attendant care on more than one of the self-care tasks (e.g., bathing, dressing, and toileting).
*A rating of '1,' '2,' or '3' on this item triggers the completion of the Self-Care Activities of Daily Living Module.
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SELF-CARE ACTIVITIES OF DAILY LIVING MODULE
EATING: See item description on page 71.
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ELIMINATION AND TOILETING
This item describes the process of elimination as well as toileting tasks – the ability to transfer on and off the commode, adjust clothing, clean oneself following elimination, and washing hands.
Questions to Consider:
- Can the child/youth toilet independently and as expected for their age?
- What supports does the child/youth need in order to toilet appropriately?
- Do any concerns around elimination get in the way of the child/youth's functioning in other domains?
Ratings and Descriptions
- No evidence of any needs; no need for action.
There is no evidence of elimination problems and child/youth can complete the task of toileting independently as needed. - Identified need that requires monitoring, watchful waiting, or preventive action based on history, suspicion, or disagreement.
Child/youth may have a history of elimination difficulties but is presently not experiencing this other than on rare occasion. Child/youth can complete toileting tasks with occasional cues/supervision from another person. - Need is interfering with functioning. Action is required to ensure that the identified need is addressed.
Child/youth demonstrates problems with elimination on a consistent basis or toileting is maintained with the use of an appliance or catheter. This is interfering with child/youth's functioning. Child/youth may completely lack a routine in elimination and as a result develop constipation along with encopresis and enuresis. Child/youth may need assistance (cueing or physical assistance) from another person to initiate or complete toileting tasks or child/youth may require the use of adaptive equipment (e.g., toilet tissue holder, reaching tools) in order to complete toileting tasks. - Need is dangerous or disabling; requires immediate and/or intensive action.
Child/youth demonstrates significant difficulty with elimination to the extent that they and their caregivers are in significant distress, or interventions have failed. Child/youth is completely dependent upon others for completion of toileting tasks.
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MOBILITY: See item description on page 72.
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POSITIONING: See item description on page 73.
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