Using CANS as a Placement
Decision Support Algorithm to
Predict Outcome of Youth in Child
Welfare Placed in Residential
Treatment
Northwestern University Feinberg School of Medicine
Mental Health Services & Policy Program
Brian Chor, B.S., Gary McClelland, Ph.D., & Neil Jordan, Ph.D.
6/29/2009
Residential Treatment & Placement

Most expensive form of mental health treatment
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
Least restrictive setting

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Per diem ≈ $100 ~ $600; Annual cost /child ≈ $50,000 ~
$75,000
In Illinois in 1995, $350 million/$450 million budget invested in
residential treatment
To protect children and provide services in least restrictive
setting available; efficacy of community-based treatment
Misconstrued as “fail to proceed”, last resort placement
Absence of standard placement criteria


Inconsistency and fallibility of judgment
Non-clinical criteria (e.g., bed availability, location)
Introduction → Hypothesis → Methods
→ Results → Discussion
Multi-Disciplinary Team
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
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Enhances traditionally individualized clinical decisions
Pooled, multi-disciplinary expertise
Family and youth participation
Shared responsibility; consensual decisions
Develops and sustains consistent and accountable
decisions
Limited evidence of efficacy
 Group better than individual decision-making?
 Group incurs same limitations of individual decisionmaking
 ↑ Group members ≠ ↑ Consistent decisions
 Feasibility and complexity of multi-disciplinary process
Introduction → Hypothesis → Methods
→ Results → Discussion
Decision Support Algorithm
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Articulates and clarifies logic of placement criteria best
served by a level of care
Level of Care = f (Criteria)
Standardizes criteria, restores clinical focus
Enhances quality, consistency, and predictability of
decisions
Aids, not replaces, human clinical judgment
Empirically predicts differential anticipated outcomes
 Children deemed not eligible should not benefit
Versatility
 Mental health
 Substance abuse
 Nursing care
 Hospitalization
Introduction → Hypothesis → Methods
→ Results → Discussion
Synthesis & Hypothesis

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High cost
Policy of least restrictive
setting
Lack of standardized
placement criteria

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Limited empirical research
on placement decisionmaking
Needs-based and
evidence-based practices
Understanding 2 models of placement decisions through the language of
clinical outcome is necessary
Hypothesis: Concordant placement decisions between the 2 models
predictive of greater clinical improvement in subsequent residential
treatment than discordant decisions:
Multidisciplinary Predicted Clinical
Team
Improvement
Concordant
Residential
Residential
Greater
Discordant Less Restrictive
Residential
Less
Decision
Algorithm
Introduction → Hypothesis → Methods
→ Results → Discussion
Sample

544 wards of Illinois DCFS whose residential placements were
determined by the multidisciplinary Child and Youth Investment
Teams (CAYIT); CANS algorithm separately recommended
level of care using clinical ratings obtained during CAYIT
staffings:
Group
CANS Algorithm
CAYIT
Residential
Less Restrictive
Residential
Residential
Concordant
Discordant
Concordant (n=449)
Mean / %
14.8
Age
Gender
Male
62.8%
African American
Caucasian
Hispanic & Other
Completed placement
Length of placement (Day)
Length of wait till placement (Day)
61.5%
32.0%
6.5%
54.6%
363.1
79.6
Ethnicity
Predicted Clinical
Improvement
Greater
Less
Discordant (n=95)
Mean / %
p
14.6
n.s.
n.s.
60.0%
n.s.
58.5%
36.2%
5.3%
56.8%
n.s.
354.7
n.s.
84.1
n.s.
Introduction → Hypothesis → Methods
→ Results → Discussion
CANS Algorithm Criteria for Residential Treatment: Requires
both Risk Behaviors & Emotional/Behavioral Issues
Criteria
1. At least 2 or more '3' among the
following needs
2. At least 3 or more '2' among the
following needs
CANS Item
14
46
47
48
49
50
51
52
53
54
55
56
57
58
Adjustment to Trauma
Psychosis
Attention/Impulse
Depression
Anxiety
Oppositional
Conduct
Substance Abuse
Attachment
Eating Disturbance
Affect Dysregulation
Behavioral Regression
Somatization
Anger Control
14
46
47
48
49
50
51
52
53
54
55
56
57
58
Adjustment to Trauma
Psychosis
Attention/Impulse
Depression
Anxiety
Oppositional
Conduct
Substance Abuse
Attachment
Eating Disturbance
Affect Dysregulation
Behavioral Regression
Somatization
Anger Control
3. A rating of '2' or '3' on Developmental 32 Developmental
4. At least 1 or more '3' among the
following risk behaviors
5. At least 3 or more '2' among the
following risk behaviors
59
60
61
62
63
65
67
59
60
61
62
63
64
65
66
67
68
69
Suicide Risk
Self Mutilation
Other Self Harm
Danger to Others
Sexual Agression
Delinquency
Fire Setting
Suicide Risk
Self Mutilation
Other Self Harm
Danger to Others
Sexual Agression
Runaway
Delinquency
Judgment
Fire Setting
Social Behavior
Sexually Reactive Behavior
CANS Domain
Traumatic Stress Symptoms
Behavioral/Emotional Needs
Decision Rules
Rule #1:
Traumatic Stress Symptoms
(Criteria 1 or 2 or 3) AND (Criteria 4 or 5)
Rule #2:
Behavioral/Emotional Needs
Consider a specialty Residential
Treatment if Rule #1 is met and a ‘2’ or ‘3’
is rated on any of the following items
CANS Item
Life Domain Functioning
Risk Behaviors
32
36
37
63
65
CANS Domain
Developmental
Life Domain Functioning
Medical
Physical
Sexual Agression
Risk Behaviors
Delinquency
Risk Behaviors
Introduction → Hypothesis → Methods
→ Results → Discussion
Clinical Outcome
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∆ CANS standardized scores in 5 domains:
Mixed Design ANOVA – Group x (Time x Domain)
 T0: CANS at CAYIT staffing
 T1: Interim residential CANS
 T2: 3-6 months residential CANS
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Placement stability:
Survival Analysis
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Hospitalization rates:
Zero-inflated Poisson Regression
 Between date of CAYIT and placement entry
 Between placement entry and 6 months after
Introduction → Hypothesis → Methods
→ Results → Discussion
CANS
Strengths
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
0.4
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
T0
T1
Time
T2
T0
Risk Behaviors
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
-1.4
-1.4
-1.4
T1
Time
T2
T0
T1
Time
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
0.4
-
0.2
0
-0.2
Concordant Group
Discordant Group
-0.4
Note. Higher score denotes
greater severity.
-0.6
-0.8
-1
-1.2
-1.4
-1.4
T0
T1
Time
T2
Behavioral/Emotional Needs
Standardized CANS Scores
Standardized CANS Scores
Life Domain Functioning
Standardized CANS Score
0.4
Standardized CANS Scores
Standardized CANS Scores
Trauma Symptoms
T2
T0
T1
Time
T2
Introduction → Hypothesis → Methods
→ Results → Discussion
CANS
Discordant
Standardized CANS Scores
0.4
0.2
Trauma Symptoms
0
Strengths
-0.2
Behavioral/
Emotional Needs
-0.4
-0.6
-0.8
Life Domain
Functioning
-1
-1.2
Risk Behaviors
-1.4
T0
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T1
Time
T2
Standardized CANS Scores
Concordant
0.4
0.2
0
-0.2
Trauma Symptoms
-0.4
Strengths
Behavioral/
Emotional Needs
-0.6
-0.8
-1.2
-1.4
Note. Higher score denotes
greater severity.
Life Domain
Functioning
-1
Risk Behaviors
T0
T1
Time
T2
Note. Higher score denotes
greater severity.
Group x Time: p <.05; Group x (Time x Domain): p=.07
T0→T1 or T2: Improvement of Concordant group significantly
greater than Discordant group in Behavioral/Emotional Needs,
Risk Behaviors, and Life Domain Functioning.
By T2: No significant differences between Concordant and
Discordant groups across 5 domains.
Introduction → Hypothesis → Methods
→ Results → Discussion
Placement Stability
Residential Treatment
Group
Completed
Yes
No
Total
Concordant
245
190
449
Discordant
54
40
94
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Discordant Group more likely to disrupt (HR=1.13, n.s.)
Controlling for other predictors
 No significant Group differences
 Prior runaway predictive of disruption (HR=1.63, p<.001)
 Male predictive of stability (HR=0.59, p<.05)
Introduction → Hypothesis → Methods
→ Results → Discussion
Hospitalization Rates
Incidence Rate (IR)
–/-- Concordant Group
–/-- Discordant Group
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
High Risk
Hospitalization
Low/Medium Risk
Hospitalization
Between Date of CAYIT and
Placement Entry
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Between Placement Entry and 6 Mo.
After
Hospitalization rates improved in both groups over time, though greater
improvement in Discordant Group
During treatment, controlling for other predictors
 Discordant Group resistant to high risk hospitalization (IRR=.32,
p<.01)
 Male resistant to high risk hospitalization (IRR=.34, p<.001)
Introduction → Hypothesis → Methods
→ Results → Discussion
Summary
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Clinical outcomes supporting the hypothesis and validity
of the algorithm were supplemented by less robust
findings regarding placement stability and hospitalization
rates
Caveat:↑Room for clinical improvement in Concordant
group suggests regression to the mean, but
 Baseline differences required to differentiate Group
membership
 Regression to the mean could not make groups equal
at T2, or account for all improvement
Introduction → Hypothesis → Methods
→ Results → Discussion
Implications

Following the CANS algorithm
(Concordant decisions)
predicted greater clinical
improvement in behavior and
emotional symptoms
CANS algorithm improves
residential placement
decisions
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Over-treating wards
(Discordant decisions) by
ignoring CANS algorithm
decisions led to fewer and
inconsistent clinical gains
Less restrictive, communitybased treatment for overtreated wards
Placement decisions based on standardized clinical criteria
are encouraged. CANS algorithm needs to be refined and
expanded
Introduction → Hypothesis → Methods
→ Results → Discussion
Implications


Less robust outcome in placement stability and
hospitalization rates likely due to lack of comparisons of
Concordant/Discordant decisions in lower levels of care
and inter-site variation in crisis management, respectively.
Future research should
 Account for placement of origin and wait time for
placement
 Examine predictors of Concordant vs. Discordant
decisions
 Evaluate the long-term impact of decisions beyond
immediate placement
 Expand outcome variables by considering adverse
events (e.g., runaway)
Introduction → Hypothesis → Methods
→ Results → Discussion