Keywords

Goal/Purpose of Intervention

Recognizing the range of trauma-related responses that may be manifested among children and adolescents in child welfare settings requires that we broaden the way we assess and monitor outcomes, and offer services to children and families. Providing a comprehensive assessment is a key step in identifying and determining how to best address the needs of traumatized children and families, as well as delivering trauma-informed services and interventions within child welfare settings. A comprehensive and trauma-informed approach to assessment gathers information across several key domains, including a wide range of trauma experiences; posttraumatic symptoms; complex trauma responses, including functioning across behavioral, emotional, interpersonal, cognitive, and physiological domains; caregiver functioning; and a range of strengths within both the child and caregiving systems (Cook et al., 2005; D’Andrea, Stolbach, Ford, Spinazzola, & van der Kolk, 2012; Kisiel, Conradi, Fehrenbach, Torgersen, & Briggs, 2014). In addition to assessing the range of symptoms or functional difficulties, strengths and protective factors are equally important to identify. Strengths are essential to the service/treatment planning and service delivery process, yet they may not be captured consistently through routine assessment (Bell, 2001; Griffin, Martinovich, Gawron, & Lyons, 2009; Kisiel, Blaustein, Fogler, Ellis, & Saxe, 2009).

The current authors have proposed guidelines for implementing a comprehensive trauma assessment approach (see Kisiel et al., 2014). In addition to assessing a range of key domains, other important aspects include gathering information from multiple perspectives or informants; utilizing a range of assessment techniques; assessing child and caregiver needs and strengths over time; and translating and integrating assessment findings for use in practice (see Kisiel et al., 2014). The use of a standardized, evidence-informed assessment approach to guide and support trauma-informed services and practice in the child welfare system still remains an important area of need (Kisiel et al., 2009, 2014).

The Child and Adolescent Needs and Strengths (CANS) is a multi-purpose assessment tool that can be used in many capacities, depending on the needs of a particular child-serving system . The CANS addresses some of the existing challenges of assessment within child welfare through supporting clinical decision making, including level of care and placement decisions; linking the findings of the assessment directly to individualized service and treatment plans; engaging family members in the assessment process; and facilitating the planning and evaluation of service systems (Lyons, 2009). Several versions of the CANS have been developed or adapted for use within particular states or child-serving systems. The CANS-Trauma Comprehensive version (or CANS-Trauma), which will be highlighted here, was designed to be applicable in a range of service settings, with an emphasis on assessing the broad range of difficulties exhibited by traumatized children and their caregiving systems; assessing strengths or contextual factors and systems that can support a child’s adaptation from trauma; and supporting and guiding trauma-informed and strengths-based treatment and service planning for children and adolescents with exposure to trauma (Kisiel et al., 2009). While several child welfare systems have adopted the CANS-Trauma (or another version of the CANS that includes trauma items, such as the CANS Comprehensive), other systems utilize a version of the CANS that contains a more limited number of trauma items. While different CANS versions are used across child welfare systems, this chapter focuses on the CANS-Trauma and its “ideal” use, given its relevance to trauma-informed, child welfare practice. That being said, while the CANS also represents an overarching assessment approach and framework, there are certain components that apply to all versions of the CANS. Therefore, in addition to highlighting specific features of the CANS-Trauma, there will also be some reference to the CANS more broadly.

This chapter also addresses the use of the CANS-Trauma in the context of trauma-informed, child welfare practice, overviewing how its use aligns with the key child welfare outcomes of safety, permanency, and well-being. For example, the use of the CANS fosters safety and stabilization by identifying and addressing prior and ongoing trauma exposure; permanency is supported by assessing the range of trauma-related needs and translating this information with caregivers and youth; and well-being is facilitated by reinforcing strengths and strengths-based planning with children and caregivers to enhance secure attachment with caregivers and through engagement with families and caregivers in the assessment process. These areas are elaborated further below.

Description of Intervention or Service

Population Served

Overall, the CANS tools (including the CANS-Trauma) are among the most widely used tools within child-serving systems across the country, including child welfare, mental health/behavioral health, juvenile justice, and early intervention programs. Within child welfare, the CANS is used in many capacities, including as a comprehensive assessment when children come into care; as a guide for service or treatment planning; to support decision making in intensive community-based services, treatment foster care, residential treatment, or outpatient treatment for youth in foster care; or to identify service (including trauma-related) needs early on in preventive or intact services (Anderson, Lyons, Giles, Price, & Estes, 2003; Lyons, 2009). The CANS tools, including the CANS-Trauma, are currently implemented at some level within all 50 states (with some applications in one or more child-serving settings) and specifically within child welfare in 24 states (with either statewide implementation or targeted applications). Specific versions of the CANS have been developed or adapted to meet the needs of special populations and various state systems. In addition to the adaptation for traumatized youth and families, these include CANS versions for juvenile sexual offenders, commercially and sexually exploited youth, complex medically ill youth, and early childhood populations (Cornett & Podrobinok, 2009; Hunter & Cruise, 2009; Huyse et al., 2009; Kisiel et al., 2009; Lyons, 2009).

Staff Qualifications

Training on the CANS tools is needed to build knowledge and skill in its effective and reliable use (Lyons, 2009). This is particularly essential given that the CANS requires a unique way of assessing individuals and families, and utilizing this information in practice is a key part of the process as described below. Further, since the CANS is a provider-report tool, training and certification (either in-person or online) is required in order to ensure an accurate understanding of the tool and its effective use. Certification on the CANS requires completing a test case vignette with a reliability of at least 0.70, in comparison to the “preferred scores” of CANS experts. Annual recertification on the CANS is also required (Lyons, 2004). These requirements are the same for the CANS-Trauma as well as any other version of the CANS that is utilized. Additional steps to support training and effective usage of the CANS include audit processes conducted by reviewing other sources of information on a given case to calculate reliability; and supporting meaningful usage of the tool at various levels of a system, involving monitoring and improving applications at the level of the individual child/family, the supervisor, and program management (Center for Child Trauma Assessment and Service Planning [CCTASP] & Family-Informed Trauma Treatment [FITT] Center, 2015; Kisiel & Fehrenbach, 2014; Lyons, 2009).

For the CANS-Trauma in particular, an online training course is available to offer initial training and certification (see www.canstraining.com). The online or in-person CANS-Trauma training provides a preliminary overview on the impact of childhood trauma and the effects of complex trauma; however, to ensure the most effective usage of the CANS-Trauma, it is also recommended that staff receive more extensive training or follow-up consultation on the impact of child trauma and strategies to support trauma-informed practice in child welfare settings. Implementation support and ongoing monitoring are also recommended as, much like other intervention approaches, CANS implementation is an ongoing process and, therefore, one-time training is insufficient (Kisiel & Fehrenbach, 2014; Lyons, 2009). For the CANS-Trauma, this process has included advanced trainings (also referred to as CANS-Trauma application trainings), monthly consultation calls, and collaborative meetings to support the use of the CANS-Trauma as part of the assessment process or in relation to service or treatment planning. This process of follow-up consultation and ongoing support has proven effective based on recent initiatives, including a national Breakthrough Series Collaborative (BSC) focused on the meaningful use of the CANS-Trauma and FANS-Trauma (Family Assessment of Needs and Strengths) tools in practice with youth and families (CCTASP & FITT Center, 2015; Kisiel & Fehrenbach, 2014).

As far as educational requirements, those with a bachelor’s degree can learn to complete the CANS-Trauma reliably, as with other versions of the CANS. However, as noted above additional training and consultation/support on child trauma would be highly beneficial to enhance the effective use of the CANS-Trauma in practice. For instance, when rating and interpreting information on the more clinically focused domains or items of the CANS-Trauma (e.g., Traumatic Stress Symptoms), master’s level education or training in clinical practice or supervisory support may be useful for bachelor’s level child welfare staff, so they are better able to interpret these items for family members or use CANS information more effectively in practice (Hirsch, Elfman, & Oberleithner, 2009).

How Is the CANS Trauma-Informed?

The trauma version of the CANS was developed in conjunction with partners from the National Child Traumatic Stress Network (NCTSN) , a congressionally established and federally funded initiative. It was developed to provide a comprehensive assessment that captures the range of potential trauma experiences to which children may be exposed, responses to these trauma experiences across several domains or areas of functioning, and relevant contextual factors for youth exposed to trauma. The initial trauma version of the CANS—originally called the CANS-Trauma Exposure and Adaptation version (CANS-TEA) —was developed over a decade ago for use within trauma-focused, clinical settings and was designed to address an existing gap in comprehensive, trauma-informed assessment. While several measures already existed to assess different aspects of trauma-related responses (e.g., trauma exposure, PTSD symptoms, other mental health symptoms/needs, functional outcomes, strengths), there was not one measure to capture the broad range of trauma experiences, trauma-related needs and strengths for youth as well as caregivers. The CANS-TEA was developed in order to meet the need for a comprehensive trauma assessment tool that would capture all of this relevant information in one place and that was straightforward and easy to use for a range of providers (Kisiel et al., 2009). This trauma version has since been updated to the CANS-Trauma Comprehensive (Kisiel, Lyons, et al., 2013), based on feedback from child trauma experts and practitioners, to include additional content that more fully reflects the broad range of potential child trauma responses. The unique contribution of the CANS-Trauma is the inclusion of the Trauma Experiences and Traumatic Stress Symptoms domains in the context of a broader mental health assessment, as described more fully below.

There are also several areas of trauma-informed practice that the CANS-Trauma is designed to support. In brief, these include gathering information on the complex reactions of the child and caregiver to trauma; identifying strengths and protective factors within the child and caregiving context; organizing clinical and case information from multiple sources; guiding trauma-informed treatment and service goals; supporting youth/caregiver/family engagement and collaboration; assisting the clinical decision-making process; facilitating appropriate referrals to services; selecting and sequencing appropriate evidence-based, trauma-focused interventions; monitoring outcomes to inform changes to interventions if needed; and communicating about child/caregiver needs across multiple stakeholders and systems. These features are described in further detail below in relation to the “practice components” of the CANS (CCTASP & FITT Center, 2015).

Program Components

The CANS-Trauma is a tool that is designed to support trauma-informed practice and other practice efforts in a range of service settings. The CANS-Trauma includes 110 items and is comprised of eight primary domains: Potentially Traumatic/Adverse Childhood Experiences (or “Trauma Experiences”), Symptoms Resulting from Exposure to Trauma or Other Adverse Childhood Experiences Domain (or “Traumatic Stress Symptoms”), Child Strengths, Life Domain Functioning, Acculturation, Child Behavioral/Emotional Needs, Child Risk Behaviors, and Caregiver Needs and Strengths. In addition, there are two optional age-related domains: Ratings of Children Five Years and Younger (to assess developmentally specific needs), and Transition to Adulthood (for children over the age of 17, to assess for needs related to independent living). As noted above, the CANS-Trauma is designed to provide a structured assessment of these relevant domains, providing information that is immediately relevant for trauma-informed practice efforts. For most CANS domains, ratings reflect current needs (within the past 30 days). Two exceptions include the Trauma Experiences domain (based on lifetime experience) and items in the Child Risk Behaviors domain (which account for either historical behaviors or actions and more recent actions, such as the past 7 days or past 24 h).

Items in the Trauma Experiences domain assess for lifetime exposure to a range of acute and chronic traumatic events. These items were developed to parallel the broad range of traumatic events recognized by the NCTSN. The Traumatic Stress Symptoms domain assesses PTSD reactions (e.g., avoidance, re-experiencing) as well as more complex trauma reactions (e.g., affect dysregulation, dissociation). The needs domains on the CANS (listed above) include childhood behavioral/emotional problems (e.g., attention, depression, anxiety, attachment); problems in day-to-day functioning (e.g., school, social, developmental); behaviors that put the child or others at risk of harm (e.g., suicide risk, self-harm, delinquency); culturally related needs (e.g., language, ritual); and developmentally specific needs for young children and adolescents (e.g., motor, communication, independent living skills). The CANS-Trauma was designed as a tool to address a broader range of responses to trauma across several domains, given that many traumatized children manifest mental health symptoms, risk behaviors, and functional difficulties, either in addition to or instead of typical PTSD symptoms. This range of complex responses need to be assessed more carefully as potential responses to trauma (Cook et al., 2005; van der Kolk, 2005). Therefore, it is important for providers using the CANS to understand that many items across the CANS needs domains may also be impacted by trauma.

Further, a unique feature of the CANS-Trauma is that it assesses the needs and abilities of the child’s identified caregivers, as well as a comprehensive range of both child and caregiver strengths. The CANS-Trauma includes 11 child strength items (e.g., talents, spiritual, family) and several others for the caregiver (e.g., resources, knowledge), helping providers see the broad range of competencies in the child and caregiver that may contribute to a child or family’s resiliency. This information can be readily utilized when developing strengths-based service or treatment plans. These domains and items are intended to be useful and meaningful to the child and family as they understand the types of services that are needed and how existing strengths can be used or built to support intervention processes, as well as a child and family’s recovery from trauma. See Table 7.1 for a complete list of all CANS-Trauma domains and items.

Table 7.1 CANS-Trauma Comprehensive: Domains and items
Full size table

The CANS-Trauma scoring system is easy to understand and designed to be directly relevant to practice. All items on the CANS-Trauma are scored on a four-point scoring system. (0–3 scale) according to two criteria: the degree of need (or strength), and the degree or urgency for intervention. Lower scores indicate better functioning; however, the meaning of the score differs slightly for strengths versus needs items. Scores of 0 on the strengths items indicate a strength that is well-developed, or a centerpiece strength; a score of 1 indicates a useful strength; a score of 2 indicates an area of potential strength; and a rating of 3 suggests no evidence of a strength. For needs items, a rating of 0 indicates no evidence of a difficulty or problem; a 1 indicates a mild degree difficulty or an area that may be emerging as a need (or an area where more evidence is needed); a 2 indicates a moderate degree of difficulty; and a 3 is severe difficulty or impairment in a given area. The CANS-Trauma, like all CANS tools, has a manual that provides a description and examples of behaviors or responses that would suggest different scoring levels for each item. The examples in the manual are not exhaustive, however, and for this reason the CANS scoring system also incorporates “actions levels” that help providers choose the most accurate score for each child and family (whether or not their presentation matches the example provided in the manual). For example, scores of 2 and 3 on need items are considered “actionable” which means these needs require some level of service or intervention to address and resolve the difficulty (e.g., with immediate or intensive action or intervention for a score of 3). These needs can be translated into a service or intervention plan or used to highlight an area that would need to be monitored or watched closely, despite not needing immediate intervention (e.g., this is referred to as “watchful waiting” and indicated in a score of 1). Scores can be considered separately for each area of need or strength when developing service or treatment plans, or scores may be summed to reflect cumulative difficulties in a particular area or domain (e.g., Trauma Experiences, Child Strengths); however, the CANS does not provide a total or overall score.

While in certain cases, the CANS-Trauma ratings are intended to capture the severity of needs or symptoms that may be associated with particular diagnoses, the CANS-Trauma is not a diagnostic tool. The CANS, however, is designed to be consistent with diagnostic language. For instance, examples of clinically significant symptoms or criteria from particular diagnoses are often included as part of the item descriptors for items in the Behavioral/Emotional Needs domain (e.g., psychosis, oppositional behavior, depression, anxiety).

A unique feature of the CANS-Trauma (along with all other CANS tools) is that it is embedded within a framework referred to as Transformational Collaborative Outcomes Management (TCOM). Broadly, this framework expands traditional outcomes management to a multi-level (i.e., case, program, and system-wide) practice/systems management strategy (Lyons, 2009). The measurement approach of CANS-Trauma (and other CANS tools) is distinct from other psychometric tools in that it emphasizes assessment that has communication value and practical relevance in service delivery settings (e.g., decision support, resource management, and quality improvement). This framework is designed to unify and focus complex child-serving systems on the most essential shared vision—improving the lives of the children and families served. An overarching goal of TCOM is to facilitate the process of truly understanding the needs and strengths of the youth and families that are being served (McGill, 2015). For more information about the TCOM framework, and the communication theory behind the CANS, please see Lyons (2009).

In addition to these components described above, the CANS-Trauma and other CANS tools have demonstrated good measurement properties overall, including good reliability (internal consistency and inter-rater) and validity (Kisiel et al., 2009, 2016; Lyons, 2009). The CANS is also reliable at the item and domain level, which allows for continued adaptation of the tool while still maintaining its integrity (Lyons, 2009). Validity is also demonstrated with the CANS tools and their relationship to level-of-care decisions and other constructs that it is intended to assess (e.g., traumatic stress symptoms, mental health needs, risk behaviors) (Kisiel et al., 2016; Lyons, 2009). These properties of the CANS suggest that it can be used as a reliable and valid, and structured tool in the context of child welfare settings. It is also widely used and established across many child-serving systems.

The components and properties of the CANS outlined above serve as a foundation for the integration and use of the CANS more effectively in practice. In addition to the overarching framework, domains and measurement components of the CANS-Trauma, the trauma-informed practice components of the CANS are described below. Note that these practice components are described primarily in terms of the individual-level applications of the CANS (versus systems-level applications) in order to support child welfare providers’ usage of the tool in a structured manner in direct practice.

CANS-Trauma Practice Components, Competencies, and Strategies

As noted above, the use or translation of assessment information into trauma-informed practice remains a largely unaddressed issue across child- and family-serving settings. To address this challenge, “meaningful use” of the CANS-Trauma can be considered a conceptual framework for outlining practice components and competencies that are crucial for integrating the assessment process as a key part of child welfare practice. Recently, a national Breakthrough Series Collaborative (BSC) focusing on meaningful use of CANS-related tools with youth and families identified key skills or competencies for caseworkers and clinicians in relation to several areas of practice (CCTASP & FITT Center, 2015). These examples are highlighted below in relation to key CANS-Trauma practice components.

Use of the CANS-Trauma as a Comprehensive Assessment and Information Integration Strategy

As described above, the CANS-Trauma is considered a comprehensive assessment tool and strategy with the capacity to integrate information from multiple sources on a range of key domains related to needs and strengths. This addresses an important need in the field in terms of gathering an abundance of relevant information and integrating it for use in practice. This includes information on a range of complex reactions to trauma and caregiver-related needs that may impact a parent/caregiver’s ability to support a child in his/her recovery from trauma. The CANS is also unique in identifying a range of strengths and protective factors within both the child and caregiving context, which other tools do not do in as comprehensive a manner.

Another distinctive feature of the CANS-Trauma is that it is designed as an information-integration tool. In other words, providers can synthesize, integrate, and consolidate information from several other sources when making CANS ratings (e.g., clinical interviews, other standardized measures, behavioral observations of child and family, collateral interviews, review of case files, and clinical judgment). This offers child welfare providers the ability to gather clinical and case information related to multiple domains and document it in a single measure for use in planning. While it is often recommended that varied techniques and tools are used to gather information for a comprehensive trauma assessment (Conradi, Wherry, & Kisiel, 2011; Kisiel et al., 2014), this can also create a burden for staff required to administer multiple tools which may not be readily applicable to clinical practice. The CANS-Trauma is intended to help reduce some of these burdens, as it is designed to incorporate and translate information from a range of sources with a scoring system that is easy to understand and translate. Therefore, it is designed to yield information that is directly relevant to practice.

Use of the CANS to Support Trauma-Informed Service and Treatment Planning

Once all of the relevant information on the child and family is gathered and integrated, using the CANS-Trauma to support the service or treatment planning process becomes the next critical step. As mentioned above, the CANS-Trauma includes a straightforward rating scale for each item that readily translates into “action steps”; as such, each item on the CANS-Trauma suggests different pathways for treatment or service planning. The CANS-Trauma item-level scoring system also identifies the level of severity of symptoms or degree of strengths, which allows for ease of use by caseworkers when prioritizing specific needs and strengths as they formulate service plans.

The CANS-Trauma has been applied in the context of treatment or service planning in meaningful ways across different settings. For instance, scores on the CANS across different domains can help to drive and inform the service goals and recommendations. When using the CANS-Trauma in service planning, it is essential that all items scored as a 3 in any of the needs domains be included in the service plan. All items scored as 2 should also be incorporated into service goals and plans. However, when a large number of items that are scored at the level of 2 or 3 exist, it is beneficial for the caseworker to work together with the family to ascertain which needs can be grouped together when forming service goals and plans. Therefore, a useful strategy in creating trauma-informed service/treatment plans with families involves grouping together CANS-Trauma items in meaningful ways to create targeted goals and using a trauma framework to inform these goals. In this regard, guidelines have been developed to support these efforts of providers when developing trauma-informed plans with the CANS (see below under Strategies and Resources for further details). An additional step that may also be used when developing service goals involves identifying specific needs on the CANS-Trauma that may be connected to specific areas of strength; strengths that need to be built may also be identified in the context of the plan (Caliwan & Furrer, 2009). Family members will ideally be engaged throughout this process in the development of collaborative service or treatment plans as described below.

Finally, CANS-Trauma ratings also enable providers to measure child and family progress in conjunction with existing, as well as new areas of need that may emerge over time, helping maintain the service plan as an active process. For instance, some systems describe how the CANS-Trauma can serve as a “check and balance” system, considering the range of areas of need and strength that are rated “actionable” on the CANS and ensuring they are incorporated and addressed in the plan in some manner. This can be accomplished by working closely with both the family and other providers as needed (e.g., supervisor) prior to and during the service planning process. This also enables providers to establish goals and benchmarks based on CANS ratings that can be evaluated over time in conjunction with services that are offered (Hunter & Cruise, 2009) to ensure that needs are decreasing and strengths are increasing based on the goals outlined in the service or treatment plan.

One of the key steps in using the CANS-Trauma in trauma-informed service or treatment planning efforts is offering trauma-informed training and consultation in conjunction with CANS-Trauma training. This integration of trauma training with CANS training and certification can be used to help providers “connect the dots” between trauma experiences and the range of trauma reactions, help providers to identify potential triggers for these reactions, and support providers in developing trauma-informed service and treatment plans and intervening effectively with families to potentially prevent more serious outcomes over time (Kisiel & Fehrenbach, 2014; Kisiel, Fehrenbach, Small, & Lyons, 2009). To competently use the CANS-Trauma in trauma-informed assessment and service/treatment planning efforts, caseworkers and other providers can build skills in the following areas:

  • Training and certification on use of the CANS-Trauma tool

  • Building basic (at minimum) knowledge in understanding trauma and its effects on children and families, and skills to address these needs through use of trauma-informed practices in the context of service delivery

  • Gathering comprehensive assessment information on a range of trauma-related needs/strengths using multiple sources and types of information and perspectives

  • Making sense of the information gathered by the CANS-Trauma to inform the case conceptualization process

  • Documenting and utilizing information from the CANS-Trauma (including scores or summaries) to inform treatment/service goals and plans, and reviewing these plans in the context of supervision

  • Recognizing and supporting caseworker’s emotional reactions or secondary traumatic stress that may arise in the context of the assessment process

Use of the CANS-Trauma in Family Engagement

In recent years, an enhanced focus has been placed on strategies to engage youth, caregivers, and other family members through the assessment process (Kisiel et al., 2014). “Assessment translation” is a term that has been adopted to describe how assessment information can be used in meaningful ways in practice, with family members and other providers (Kisiel et al., 2014). Despite the value of this approach, however, sharing assessment information with youth and families may not be done on a consistent basis as part of the intervention process. The CANS-Trauma can lend itself to meaningful use with youth and caregivers in particular, given that it is generally well-regarded as easy to use and understand, offers information on contextual variables and child/family strengths, and provides a structure that is directly relevant for families (e.g., action levels with direct relevance to intervention planning). Furthermore, the CANS and TCOM approach is designed to help guide and support youth, caregiver, and family engagement and collaboration (CCTASP & FITT Center, 2015). Throughout the process of assessment and service/treatment planning, family members (both caregivers and youth, as appropriate) are ideally engaged as key partners in this process from the outset. Caseworkers can accomplish this by identifying and developing “collaborative” service or treatment goals and plans with family members; adjusting goals/plans as needed based on new information identified; and reviewing progress toward these goals with family members over the course of service delivery.

In order to effectively use the CANS-Trauma in the process of youth and family engagement, the following areas of skill or competency are recommended for caseworkers or other child welfare professionals:

  • Facilitating initial and ongoing engagement by being transparent with family members from the beginning—explaining the purpose of the CANS-Trauma tool and how it will be used in the context of services and how it may inform decisions about services

  • Offering trauma-informed psychoeducation through use of the CANS-Trauma—by developing a shared understanding about the effects of trauma with children and families through reviewing CANS-Trauma scores and summaries, and helping families make sense of child/caregiver needs across domains in relation to trauma experiences

  • Sharing CANS-Trauma assessment feedback and results with families and engaging them as partners in collaborative service or treatment planning efforts

  • Sharing progress toward goals and changes in needs and strengths over time with family members and making adjustments as needed in collaboration with families

Use of the CANS-Trauma in Provider- and Systems-Level Collaboration

The CANS-Trauma is also a helpful tool to support communication and trauma-focused planning across the various providers and service systems involved in a child and family’s care. The CANS-Trauma is purposefully “simple” in design and in its scoring system in order to facilitate communication between providers across settings. For instance, different providers working with a given family are encouraged to collaborate in completing the CANS-Trauma as appropriate, as certain providers will have more in-depth knowledge in particular areas (e.g., if the child/youth is in mental health treatment, a therapist may have more knowledge regarding traumatic stress symptoms). Within a given system, the CANS-Trauma is also designed to support trauma-informed planning and communication about a particular child/family by sharing the progress made by a child/family as well as persisting areas of need through the easy-to-translate scores on the CANS. The CANS-Trauma can also support multidisciplinary team discussions and communication across systems that a child/family may be involved in by creating a common language in order to ensure everyone accurately understands the needs of the child and family. An important part of this process also involves using the CANS-Trauma as a communication strategy for educating family members and other systems (e.g., schools, juvenile justice settings) about the potential role of trauma in relation to the child’s range of needs, as well as using the CANS to inform recommendations or referral to particular services, and to advocate for trauma-informed services that will address these needs.

To competently use the CANS-Trauma in systems-level collaboration, caseworkers and other providers may build skills in several areas:

  • Joint completion of the CANS-Trauma or sharing CANS results across different providers and systems to support collaboration and transparency

  • Agency provision of support and time for meaningful assessment, including use of supervision time to support the CANS-Trauma and its effective use

  • Organizational support and training offered on use of the CANS-Trauma to support collaboration and trauma-informed practice with family members and other providers

  • Organizational support, guidance, and consultation on strategies for using the CANS-Trauma to support trauma-informed interventions based on the needs/strengths of youth and families

  • Using CANS-Trauma assessment results for monitoring improvements, informing supervision, and guiding systems planning, resource allocation, and effectively meeting the needs of youth and families

Strategies and Resources to Support Development of Competencies and “Meaningful Use”

Organizations across the country have utilized strategies to encourage staff and provider development of the practice components and competencies listed above. Many of these training strategies in particular derive from the national BSC on the meaningful use of the CANS and FANS-Trauma. These include incorporating “meaningful use” language and concepts into basic and advanced CANS-Trauma trainings, including topics such as youth/family engagement practices; understanding child trauma/complex trauma reactions; reflective supervision to address secondary traumatic stress; and using CANS-identified strengths more effectively in planning efforts. These organizations have developed innovative training efforts, including role play exercises (such as a family engagement role play that encourages multiple viewpoints on the trauma-informed assessment process in practice), as well as clinical/casework vignettes that illustrate specific aspects of meaningful use (such as use of the CANS-Trauma in supervision).

Several resources have been developed to support the use of the CANS in trauma-informed practice efforts, including use with providers and family members (see cctasi.northwestern.edu; CCTASP, 2015). These include guidelines for a step-by-step approach to using the CANS-Trauma in trauma-informed treatment/service planning; a tip sheet for use of the CANS in engaging youth and families; a resource on “creative applications” for use of the CANS across different provider roles; videos demonstrating family and youth engagement, and modeling trauma-focused psychoeducation with the CANS; and examples of “family friendly” CANS data reports. While these resources were designed for use with the CANS-Trauma version, they can also be usefully applied with other versions of the CANS that incorporate trauma items or modules. The development of additional resources is also encouraged by agencies/programs to support meaningful use of the CANS-Trauma in practice. Some have found it helpful to supplement the CANS with visual representations of domains and/or scoring systems to make the assessment and assessment translation process more family- and youth-friendly. Others have found utility in creating a “family-friendly” brochure for introducing the CANS to families. Still others have also found utility in integrating the CANS with trauma-informed clinical interventions, by “mapping” CANS items/domains onto treatment components (e.g., Attachment, Self-Regulation, & Competency; ARC; Blaustein & Kinniburgh, 2010). Resources (e.g., scoring templates, visual scoring systems) have also been developed to facilitate this integration of the CANS-Trauma in practice in the above areas.

Additional CANS-Trauma Applications in Practice

Providers and agencies across the country effectively utilize CANS data (from the CAN-Trauma and other tools) for reporting purposes at an individual youth/family or aggregate level. For instance, a family-friendly “change report” of a youth’s CANS strengths and needs may serve as an effective family engagement tool. For agencies or programs, reporting on aggregate and/or longitudinal CANS outcome data may be helpful for “making the case” and demonstrating an empirical basis for compliance reporting, other statewide reporting mandates, program evaluation, or seeking additional funding. Technological advancements in data management/warehousing can make this process more efficient and feasible.

An additional application of the CANS used across several states is the creation of provider peer groups to support the reliable, effective, and innovative use of the CANS in practice. For instance, CANS Super User groups (which are implemented across several states) often represent a cross-section of several different child welfare or behavioral health providers representing various roles and agencies. These groups typically meet on a regular basis to support CANS usage and implementation. Strategies and lessons learned for clinical, casework, supervisory, and administrative applications of the CANS are shared, and networking relationships across agencies are facilitated for ongoing support.

How Does the CANS-Trauma Advance Cultural Competency ?

Assessment within the context of child welfare can be complex for numerous reasons, including the need to recognize and honor the variety of cultures and subcultures represented by the families that come into contact with the system. These include differences in class, race and ethnicity, sexual orientation, family composition, religion, and physical, emotional and developmental capacities. Assessment approaches used within this context need to be sensitive to the diversity of needs and strengths of the population they serve.

The structure, administration, and content of the CANS-Trauma make it a useful tool within diverse settings. The simple scoring system paired with the action levels, for example, is an approach that can be easily explained and understood by those with little formal education, or those who may not speak English as their first language.

Experts have highlighted the need not only to respect differences in cultural beliefs and practices but also emphasize the benefits of conducting assessments in a family’s native language when possible (Kisiel et al., 2014). As a result, the CANS-Trauma manual and scoring sheet have both been translated into Spanish. Likewise, providers who are more comfortable in Spanish can now receive online CANS-Trauma training in Spanish (available at www.canstraining.com).

The flexible administration approach inherent to the CANS-Trauma (along with other CANS tools) also lends to its cultural sensitivity. The tool is administered without the strict interview schedule used by many other comprehensive assessment tools. In fact, it is common for caseworkers or other providers to gather information to complete aspects of the CANS-Trauma during their standard clinical interview or through conversation with the family. By having the flexibility to begin with any domain on the CANS, there is the opportunity to build rapport with items that may be “easier” for a given child or family (e.g., the Strengths domain). This allows for a more natural “give and take,” as the assessor can score the CANS as the family transitions the conversation from one subject to the next.

The CANS-Trauma Acculturation domain assesses child needs related to cultural identity and expression, assessing for opportunities the child may or may not have to engage in cultural practices. It also assesses how well a particular child welfare placement setting (e.g., foster home) may be supporting the child’s specific cultural needs and strengths. When such culturally specific items are not included in an assessment, these important areas related to a child’s overall well-being can be inadvertently overlooked. Likewise, using a tool like the CANS-Trauma may give providers an opportunity to open up necessary, but sensitive, conversations about difficult issues like race and ethnicity at the beginning of services, a practice that can ultimately break down barriers that might otherwise inhibit trust and rapport.

Challenges to CANS-Trauma Implementation

Like any assessment approach, there are issues to keep in mind when using the CANS-Trauma as part of a comprehensive assessment strategy. Depending on the training approach that is taken, some challenges may exist. Certain large-scale, statewide training efforts have focused primarily on staff training and certification on the CANS without a sufficient emphasis on follow-up implementation support. Learning to reliably score the CANS is a necessary and important first step; yet, as previously noted, new CANS users benefit most when they are provided with ongoing training and support in the actual application of the measure in practice. Without this continued support, caseworkers and other providers across many systems may find less value in the tool. It is also possible that use of the tool without sufficient ongoing support and supervision could be less accurate or effective. For example, if staff do not receive adequate training and/or support on administering the more clinical or trauma-specific items on the CANS-Trauma (e.g., Traumatic Stress Symptoms), their own discomfort while discussing any of these items with children and families may reduce the validity of the information and decrease the opportunity for engagement, collaboration, and psychoeducation. Further, the CANS-Trauma is designed to incorporate and integrate information from multiple sources—caregivers, youth, teachers, case files, and other providers working with the youth. Therefore, completing the first CANS on a given youth may require a significant amount of time initially, with the idea that this initial time commitment will help to enhance collaboration and increase the possibility of the caseworker, family members, and other providers having a shared perspective of the case from the start, which leads to a more informed service plan; this allows for transparency with regard to the recommended services and other key decisions made in the life of a case. Thus, one implementation challenge of the CANS approach is the time required of providers from the outset, in order for the assessment process to have maximum benefit. Yet, gaining a broader understanding of the child and family, despite the time involvement, is intended to ultimately improve the quality of services for children and families.

Another potential implementation challenge is helping staff at all levels of a system understand the value of the CANS-Trauma, how it is different from other commonly used measures, and how it was designed to enhance real-world practice. The CANS tools are not designed as traditional psychometric tools and do not offer a total score or clinical cutoff score, such as tools designed for use in research, but rather serve as a communication strategy. Additionally, the CANS allows for a certain degree of “subjectivity” in its scoring. For instance, the person completing the CANS-Trauma may at times receive inconsistent or even contradictory information from various sources regarding a child’s functioning in a particular area. These instances require the clinical judgment of the caseworker or clinician to determine the most accurate rating.

Finally, as is the case with any trauma-informed assessment approach that requires providers to discuss trauma experiences and reactions with families, it is possible that caseworkers themselves may experience secondary traumatic stress. Thus, when completing the CANS-Trauma with children and families, it is important for caseworkers to be trained and supported in attuning to their own potential secondary traumatic stress reactions and related self-care strategies to support them in their work.

Evidence for Success

One of the strongest pieces of evidence for the effectiveness of the CANS tools is that different versions of the CANS have been widely adopted across multiple child-serving systems and are used in various ways across every state in the U.S. While the CANS-Trauma is a relatively newer version of the CANS (with the updated version developed in 2013), research and evidence to support the success of the CANS-Trauma is still in its early stages. That being said, the CANS-Trauma has been shown to effectively guide service planning and placement decisions to support youth and families involved in child welfare as described above. Using the CANS-Trauma in practice can offer a structured and successful way for providers to engage youth and families in order to foster collaborative relationships and support the intervention process. Further, utilization of the CANS-Trauma can ultimately bolster the three pillars of child welfare: safety, permanency, and well-being, both at the individual and at systems levels.

The CANS-Trauma provides an effective way of engaging youth and families in the service delivery process. This upfront engagement enables collaboration between service providers and the family, which is an aspect of care that is desired by and beneficial to caregivers. Initial qualitative data collected from both birth and foster parents indicated a unanimous desire to be involved in the assessment process, but confirmed that oftentimes the CANS, like many other assessment instruments, are completed without the caregiver’s knowledge or involvement. For instance, sharing the CANS manual and scores with the family, and offering to complete the tool together, can facilitate a more comprehensive understanding of the youth and caregiver’s strengths and needs for both the family and provider. Additionally, this process demonstrates to families that their input is both needed and respected, but it is also being utilized to inform service recommendations. Further, qualitative feedback indicates that caregiver involvement in the CANS assessment process offers them increased insight into the needs and strengths of youth, so that they are better able to support their children in care (N. St. Jean & L. Davis, focus groups, March 17/April 9, 2015).

In the national BSC focused on the meaningful use of the CANS-Trauma and FANS-Trauma with youth and families, child welfare and mental health agencies sought to enhance their use of these tools with families. Data from participating teams demonstrated that family engagement strategies used during the assessment process (such as those described above) helped caregivers better understand the value of the assessment and its benefits to their child; it also resulted in caregivers’ increased understanding of both the child and family’s strengths and needs and enhanced the assessment process overall (Davis, Torgersen, & Kisiel, 2016).

Increased understanding of the youth and family’s strengths and needs by the provider, caregiver, and youth, as a result of a collaborative assessment process, can also enable the development of more effective and meaningful treatment and service plans (Caliwan & Furrer, 2009). The identification and assessment of strengths, in addition to needs, facilitates service planning that is both strengths-based and trauma-informed, which allows for services to focus on bolstering protective factors that may already exist within the individual or family system.

In addition to service planning, the CANS tools more broadly have also shown success in supporting safety and permanency by informing placement decisions for youth entering into the child welfare system. The CANS helps shift placement decisions away from what may be easiest or most cost effective for the agency, with a focus on strengths and needs of the child (Hirsch et al., 2009). Further, increasing awareness of trauma-related needs through the CANS-Trauma assessment process can help inform placement decisions and secure needed resources to ensure the youth’s safety and involvement in trauma-informed care. The youth’s strengths and needs can help guide the type of living arrangement that may be most beneficial for the youth, and facilitate placement in the least restrictive environment possible (Hirsch et al., 2009).

Developing decision support algorithms for the CANS tools has also proven effective for making more successful placement recommendations. Such decision algorithms have been used across several states, including Pennsylvania, Illinois, Tennessee, and Alaska (Epstein, Schlueter, Gracey, Chandrasekhar, & Cull, 2015; Lyons, 2004). The goal of the CANS, when used this way, is to identify the least restrictive level of care that will be adequate to meet the youth’s current needs. Research indicates that youth placed in residential treatment at the recommendation of this algorithm showed more positive change in emotional and behavioral symptoms than youth assigned to residential placement against the advisement of the algorithm (Chor, McClelland, Weiner, Jordan, & Lyons, 2012). Decreases in symptoms have also been documented across placements at differing levels of restrictiveness when informed by both a multidisciplinary team and the CANS algorithm (Chor, McClelland, Weiner, Jordan, & Lyons, 2015). It has also been shown that youth placed in settings that are consistent with this algorithm have a decreased risk of disruption than peers placed in settings that are not informed by the algorithm (Epstein et al., 2015).

In addition to these benefits, the CANS tools overall have been successful in monitoring outcomes of youth in the child welfare system on a macro-level. Aggregate CANS data have shown to be beneficial for tracking agency outcomes through state-wide provider databases that collect CANS information; tracking agency outcomes identifies provider agencies that may be more successful at addressing particular needs as compared to other agencies (Hirsch et al., 2009). Systemic knowledge of these service achievements can inform service referrals based on individualized youth needs, in turn promoting safety and permanency.

At a federal level, the Administration on Children, Youth and Families (ACYF) has placed increased emphasis on measuring well-being as a way to better address child welfare outcomes (Samuels & Anderson, 2014). As the CANS-Trauma incorporates strengths into the evaluation of well-being, which many current assessments do not, it provides a unique opportunity for child welfare systems to track outcomes across the four recognized domains of well-being (cognitive functioning, physical health and development, behavioral/emotional functioning, and social functioning) (Administration for Children and Families [ACYF], 2012). Use of the CANS-Trauma to measure well-being individually and in the aggregate is an emerging area of success that has promising implications, as data can be used to inform future practices and policies, especially those that may recommend enhancing strengths as one approach for supporting the well-being of youth in child welfare.

Summary and Conclusion

The CANS is one of the most widely used tools within child-serving systems across the United States, with several applications in child welfare settings. It is a well-established and structured tool that is multi-purpose in nature with demonstrated utility across various levels of a system. In particular, the CANS-Trauma is a trauma-informed assessment strategy that is designed to address some of the existing challenges in the field. It assesses a wide array of trauma experiences, trauma-related needs and strengths of the child and caregiving system; effectively identifying the range of complex needs of youth within child welfare settings is a critical first step in the assessment process. The CANS-Trauma also minimizes the potential burden of assessment on providers, by allowing them to incorporate several sources of information about the child and family and integrating this information in a centralized way into a single tool.

The CANS-Trauma lends itself to many trauma-informed practice components which are directly relevant to child welfare providers, including comprehensive assessment, support for service and treatment planning, family engagement, and collaboration and communication across providers. These practice components are supported by initial evidence and feedback from provider agencies along with several accompanying resources that highlight the benefits of this approach. As outlined in this chapter, “meaningful use” of assessment is a framework that can be used to support the building of competencies in effective use of assessment in trauma-informed child welfare practice; these competencies can be readily implemented in conjunction with the CANS-Trauma tool. When the CANS-Trauma is integrated in child welfare systems in a meaningful way, with support for the effective use of the tool in practice, this process can help caseworkers and other child welfare providers build competencies that will enhance safety, permanency, and well-being, and improve the overall quality of services provided to children and families served within child welfare systems across the country.