Early Childhood (Birth to 5) Score Sheet
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CHILD AND ADOLESCENT NEEDS AND STRENGTHS (CANS) Alameda County BHCS Birth to Five Years Old version Date: Type: Initial Assessor ID: Client ID: Race: DOB: Grade: DEVELOPMENTAL HISTORY CHILD STRENGTHS 0 = No evidence of problems; no reason to believe item requires action. 1 = Watchful waiting; monitoring or possibly preventive action. 2 = Need for action. Some strategy needed to address problem/need. 3 = Need for Immediate action. Safety concern; priority for intervention. 0= 1= 2= 3= N/A 1) 2) 3) 4) 5) Birth Weight Prenatal Care Substance Exposure Labor and Delivery Maternal/Primary Caregiver Availability 0 1 2 17) 18) 19) 20) N/A 0 1 2 3 Family Relationships Daycare/Preschool (1) Medical Physical Developmental Functioning Motor Communication Autism Spectrum Social Functioning Recreation/Play Cognitive Sleep Regulatory Functioning Regulatory: Body/Emotional Control Eating Elimination Sensory Reactivity BHCS CANS (0-5) Dec 2015 Well developed or centerpiece strength; may be a protective factor. Useful strength but requires effort to maximize; useful in treatment. Strength identified but requires significant strength-building efforts. No current strength identified; no strength in this area . 0 0 = No evidence of problems; no reason to believe item requires action. 1 = Watchful waiting; monitoring or possibly preventive action. 2 = Need for action. Some strategy needed to address problem/need. 3 = Need for Immediate action. Safety concern; priority for intervention. 10) 11) 12) 13) 14) 15) 16) Zip Code: 3 LIFE DOMAIN FUNCTIONING 6) 7) 8) 9) Discharge RU#/Program: Client Name: Gender: Reassessment 21) 22) 23) 24) 25) 26) 27) 28) 29) Family Support Interpersonal Adaptability Persistence Playfulness Creativity/Imagination Curiosity Relationship Permanence Natural Supports 1 2 3 BEHAVIORAL/EMOTIONAL NEEDS 0 = No evidence of any needs. 1 = History or sub-threshold; watchful waiting or preventive activities. 2 = Need causing problems, consistent with diagnosable disorder. 3 = Need causing severe/dangerous problems; requires immediate/ intensive action. 30) 31) 32) 33) 34) 35) 36) 37) Attachment Depression Anxiety Failure to Thrive Atypical Behaviors Self Harm Aggression Adjustment to Trauma (2) 0 1 2 3 1 EXTENSION MODULES TRAUMATIC/ADVERSE CHILDHOOD EXPERIENCES 0 = No evidence of any trauma of this type. 1 = Mild exposure, a single incident or suspicion of this trauma type. 2 = Moderate degree or multiple incidents of this trauma type. 1 - School 3 = Repeated and severe incidents of this trauma with medical/physical consequences. 38) 39) 40) 41) 42) 43) 44) 45) 46) 47) 48) 49) 50) 51) 0 1 2 3 Sexual Abuse (2a) Physical Abuse Neglect Emotional Abuse Medical Trauma Natural Disaster Witness to Family Violence Witness to Community Violence School Violence War Affected Terrorism Affected Witness /Victim of Criminal Acts Parental Criminal Behavior Disruption in Caregiving/Attachment Losses CULTURAL FACTORS 2 - Trauma 1. SCHOOL Preschool/Daycare Quality Preschool/Daycare Behavior Preschool/Daycare Achievement Preschool/Daycare Attendance 0 2. 0 TRAUMA Traumatic Stress Symptoms Affective/Physical Dysregulation Intrusions Traumatic Grief Re-experiencing Hyper arousal Avoidance Numbing Dissociation Time Before Treatment Sexual Abuse (2a) Emotional Closeness of Perpetrator Frequency of Abuse Duration Physical Force Reactions to Disclosure 1 2 1 3 2 3 0 = No evidence of problems; no reason to believe item requires action. 1 = Watchful waiting; monitoring or possibly preventive action. 2 = Need for action. Some strategy needed to address problem/need. 3 = Need for Immediate action. Safety concern; priority for intervention. 0 52) 53) 54) 55) 56) Language Cultural Identity Ritual Discrimination/Bias Cultural Differences within the Family 1 2 3 Note: Shaded ratings trigger required Extension Modules (next column) BHCS CANS (0-5) Dec 2015 2 CAREGIVER NEEDS 0 = No evidence of need; potential resource for the child/youth. 1 = Watchful waiting; monitoring or possibly preventive action. 2 = Need for action. Some strategy needed to address problem/need. 3 = Need for Immediate action. Safety concern; priority for intervention. Caregiver Information First name: Additional Caregiver First name: Last name: Last name: Caregiver type Adoptive parent Aunt Biological parent Foster parent Adoptive parent Aunt Biological parent Foster parent 0 76) 77) 78) 79) 80) 81) 82) 83) 84) 85) 86) 87) 88) Caregiver type Adoptive parent Aunt Biological parent Foster parent Adoptive parent Aunt Biological parent Foster parent 1 Supervision Involvement with Care Knowledge Organization Resources Residential Stability Physical Mental Health Substance Use Developmental Safety Family Stress Legal 2 3 Last name: Last name: 0 76) 77) 78) 79) 80) 81) 82) 83) 84) 85) 86) 87) 88) Supervision Involvement with Care Knowledge Organization Resources Residential Stability Physical Mental Health Substance Use Developmental Safety Family Stress Legal Caregiver type Adoptive parent Aunt Biological parent Foster parent Adoptive parent Aunt Biological parent Foster parent 1 2 Adoptive parent Aunt Biological parent Foster parent 3 1 Supervision Involvement with Care Knowledge Organization Resources Residential Stability Physical Mental Health Substance Use Developmental Safety Family Stress Legal Additional Caregiver First name: Adoptive parent Aunt Biological parent Foster parent Adoptive parent Aunt Biological parent Foster parent 0 76) 77) 78) 79) 80) 81) 82) 83) 84) 85) 86) 87) 88) Additional Caregiver First name: Caregiver type Adoptive parent Aunt Biological parent Foster parent Adoptive parent Aunt Biological parent Foster parent Supervision Involvement with Care Knowledge Organization Resources Residential Stability Physical Mental Health Substance Use Developmental Safety Family Stress Legal 3 Adoptive parent Aunt Biological parent Foster parent 0 76) 77) 78) 79) 80) 81) 82) 83) 84) 85) 86) 87) 88) 2 1 2 3 Clinician Signature & date: Supervisor Signature & date: BHCS CANS (0-5) Dec 2015 3
