Child Behavioral/Emotional Needs Domain (Items 48-60)

These ratings identify the behavioral health needs of the child or adolescent. While the CANS is not a diagnostic tool, it is designed to be consistent with diagnostic communication. In DSM-IV a diagnosis is defined by a set of symptoms that is associated with either dysfunction or distress. This definition is consistent with the ratings of ‘2’ or ‘3’ as defined by the action levels below:

For Behavioral/Emotional Needs, the following categories and symbols are used:
0 | indicates a dimension where there is no evidence of any needs.
1 | indicates a dimension that requires monitoring, watchful waiting, or preventive activities.
2 | indicates a dimension that requires action to ensure that this identified need or risk behavior is addressed.
3 | indicates a dimension that requires immediate or intensive action.

NU Quick Tip

Many of the items in this section have clinical definitions. For additional information beyond what is offered here, please refer to the CANS glossary in the Resources and References Guides page.

48. Psychosis

This item is used to rate symptoms of psychiatric disorders with a known neurological base. DSM-IV disorders included on this dimension are Schizophrenia and Psychotic disorders (unipolar, bipolar, NOS). The common symptoms of these disorders include hallucinations, delusions, unusual thought processes, strange speech, and bizarre/idiosyncratic behavior.

0 | This rating indicates a child with no evidence of thought disturbances. Both thought processes and content are within normal range.

1 | This rating indicates a child with evidence of mild disruption in thought processes or content. The child may be somewhat tangential in speech or evidence somewhat illogical thinking (age inappropriate). This also includes children with a history of hallucinations but none currently. The category would be used for children who are sub-threshold for one of the DSM diagnoses listed above.

2 | This rating indicates a child with evidence of moderate disturbance in thought processes or content. The child may be somewhat delusional or have brief or intermittent hallucinations. The child’s speech may be at times quite tangential or illogical. This level would be used for children who meet the diagnostic criteria for one of the disorders listed above.

3 | This rating indicates a child with severe psychotic disorder. The child frequently is experiencing symptoms of psychosis and frequently has no reality assessment. There is evidence of ongoing delusions or hallucinations or both. Command hallucinations would be coded here. This level is used for extreme cases of the diagnoses listed above.

49. Attention Deficit/Impulse Control

Symptoms of Attention Deficit and Hyperactivity Disorder and Impulse Control Disorder would be rated here. Inattention/distractibility not related to opposition would also be rated here.

0 | This rating is used to indicate a child with no evidence of attention/hyperactivity problems.

1 | This rating is used to indicate a child with evidence of mild problems with attention/hyperactivity or impulse control problems. Child may have some difficulties staying on task for an age appropriate time period.

2 | This rating is used to indicate a child with moderate symptoms of attention/hyperactivity or impulse control problems. A child who meets DSM-IV diagnostic criteria for ADHD would be rated here.

3 | This rating is used to indicate a child with severe impairment of attention or dangerous impulse control problems. Frequent impulsive behavior is observed or noted that carries considerable safety risk (e.g. running into the street, dangerous driving or bike riding). A child with profound symptoms of ADHD would be rated here.

50. Depression

Symptoms included in this dimension are irritable or depressed mood, social withdrawal, sleep disturbances, weight/eating disturbances, and loss of motivation. This dimension can be used to rate symptoms of the following psychiatric disorders as specified in DSM-IV: Depressive Disorders(unipolar, dysthymia, NOS), Bipolar Disorder.

0 | This rating is given to a child with no emotional problems. No evidence of depression.

1 | This rating is given to a child with mild emotional problems. Brief duration of depression, irritability, or impairment of peer, family, or academic functioning that does not lead to gross avoidance behavior.

2 | This rating is given to a child with a moderate level of emotional disturbance. Any diagnosis of depression would be coded here. This level is used to rate children who meet the criteria for an affective disorder listed above.

3 | This rating is given to a child with a severe level of depression. This would include a child who stays at home or in bed all day due to depression or one whose emotional symptoms prevent any participation in school, friendship groups, or family life. Disabling forms of depressive diagnoses would be coded here. This level is used to indicate an extreme case of one of the disorders listed above.

51. Anxiety

This item describes the child’s level of fearfulness, worrying or other characteristics of anxiety.

0 | No evidence of any anxiety or fearfulness.

1 | History or suspicion of anxiety problems or mild to moderate anxiety associated with a recent negative life event. This level is used to rate either a mild phobia or anxiety problem or a sub-threshold level of symptoms for the other listed disorders.

2 | Clear evidence of anxiety associated with either anxious mood or significant fearfulness. Anxiety has interfered significantly in child’s ability to function in at least one life domain.

3 | Clear evidence of debilitating level of anxiety that makes it virtually impossible for the child to function in any life domain

52. Oppositional Behavior (Compliance with Authority)

This item is intended to capture how the child relates to authority. Oppositional behavior is different from conduct disorder in that the emphasis of the behavior is on non-compliance with authority rather than inflicting damage and hurting others.

0 | This rating indicates that the child/adolescent is generally compliant.

1 | This rating indicates that the child/adolescent has mild problems with compliance with some rules or adult instructions. Child may occasionally talk back to teacher, parent/caregiver; there may be letters or calls from school.

2 | This rating indicates that the child/adolescent has moderate problems with compliance with rules or adult instructions. A child who meets the criteria for Oppositional Defiant Disorder in DSM-IV would be rated here.

3 | This rating indicates that the child/adolescent has severe problems with compliance with rules or adult instructions. A child rated at this level would be a severe case of Oppositional Defiant Disorder. They would be virtually always noncompliant. Child repeatedly ignores authority.

53. Conduct

These symptoms include antisocial behaviors like shoplifting, lying, vandalism, cruelty to animals, and assault. This dimension would include the symptoms of Conduct Disorder as specified in DSM-IV.

0 | This rating indicates a child with no evidence of behavior disorder.

1 | This rating indicates a child with a mild level of conduct problems. The child may have some difficulties in school and home behavior. Problems are recognizable but not notably deviant for age, sex, and community. This might include occasional truancy, repeated severe lying, or petty theft from family.

2 | This rating indicates a child with a moderate level of conduct disorder. This could include episodes of planned aggressive or other anti-social behavior. A child rated at this level should meet the criteria for a diagnosis of Conduct Disorder.

3 | This rating indicates a child with a severe Conduct Disorder. This could include frequent episodes of unprovoked, planned aggressive or other anti-social behavior.

54. Substance Abuse

These symptoms include use of alcohol and illegal drugs, the misuse of prescription medications and the inhalation of any substance for recreational purposes. This rating is consistent with DSM-IV Substance-related Disorders.

0 | This rating is for a child who has no substance use difficulties at the present time. If the person is in recovery for greater than 1 year, they should be coded here, although this is unlikely for a child or adolescent.

1 | This rating is for a child with mild substance use problems that might occasionally present problems for the person (intoxication, loss of money, reduced school performance, parental concern). This rating would be used for someone early in recovery (less than 1 year) who is currently abstinent for at least 30 days.

2 | This rating is for a child with a moderate substance abuse problem that impairs his/her ability to function, but does not preclude functioning in an unstructured setting while participating in treatment.

3 | This rating is for a child with a severe substance dependence condition that consistently impairs his/her ability to function. Substance abuse problems may present significant complications to the coordination of care for the individual. A substance-exposed infant who demonstrates symptoms of substance dependence would also be rated here.

**LOOK OUT**

This item is not only scored for a child who is abusing substances, but also for substance exposed infants (SEI) who show signs of withdrawal.

55. Attachment Difficulties

This item should be rated within the context of the child’s significant parental or caregiver relationships.

0 | No evidence of attachment problems. Caregiver-child relationship is characterized by mutual satisfaction of needs and child’s development of a sense of security and trust. Caregiver appears able to respond to child cues in a consistent, appropriate manner, and child seeks age-appropriate contact with caregiver for both nurturing and safety needs.

1 | Mild problems with attachment. There is some evidence of insecurity in the child-caregiver relationship. Caregiver may at times have difficulty accurately reading child bids for attention and nurturance; may be inconsistent in response; or may be occasionally intrusive. Child may have mild 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.

2 | Moderate problems with attachment. Attachment relationship is marked by sufficient difficulty as to require intervention. Caregiver may consistently misinterpret child cues, act in an overly intrusive way, or ignore/avoid child bids for attention/nurturance. Child may have ongoing difficulties with separation, may consistently avoid contact with caregivers, and may have ongoing difficulties with physical or emotional boundaries with others.

3 | Severe problems with attachment. Child is unable to form attachment relationships with others (e.g., chronic dismissive/avoidant/detached behavior in caregiving 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 his/her attachment behaviors. A child who meets the criteria for an Attachment Disorder in DSM-IV would be rated here. 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.

56. Eating Disturbances

These symptoms include problems with eating including disturbances in body image, refusal to maintain normal body weight, recurrent episodes of binge eating and hoarding food. These ratings are consistent with DSM-IV Eating Disorders.

0 | This rating is for a child with no evidence of eating disturbances.

1 | This rating is for a child with a mild level of 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.

2 | This rating is for a child with a moderate level of eating disturbance. This could include a more intense preoccupation with weight gain or becoming fat when underweight, restrictive eating habits or excessive exercising in order to maintain below normal weight, and/or emaciated body appearance. This level could also include more notable binge eating episodes that are followed by compensatory behaviors in order to prevent weight gain (e.g., vomiting, use of laxatives, excessive exercising). This child may meet criteria for a DSM-IV Eating Disorder (Anorexia or Bulimia Nervosa).

3 | This rating is for a child with a more severe form of eating disturbance. This could include significantly low weight where hospitalization is required or excessive binge-purge behaviors (at least once per day).

57. Affect Dysregulation

These symptoms include difficulties modulating or expressing emotions, intense fear or helplessness, difficulties regulating sleep/wake cycle, and inability to fully engage in activities.

0 | This rating is given to a child with no difficulties regulating emotional responses. Emotional responses are appropriate to the situation.

1 | This rating is given to a child with some minor difficulties with affect regulation. This 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. This child may have some difficulty sustaining involvement in activities for any length of time.

2 | This rating is given to a child with moderate problems with affect regulation. This child may be unable to modulate emotional responses. This 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). This child may also exhibit persistent anxiety, intense fear or helplessness, or lethargy/loss of motivation.

3 | This rating is given to a child with severe problems with highly dysregulated affect. This child may have more rapid shifts in mood and an inability to modulate emotional responses (feeling out of control of their emotions). This child may also exhibit tightly contained emotions with intense outbursts under stress. Alternately, this 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”).

N/A | Not applicable due to child’s age; see section for children 0 to 5 years old.

58. Behavioral Regressions

These ratings are used to describe shifts in previously adaptive functioning evidenced in regression in behaviors or physiological functioning.

0 | This rating is given to a child with no evidence of behavioral regression.

1 | This rating is given to a child with some regressions in age-level of behavior (e.g., thumb sucking, whining when age inappropriate).

2 | This rating is given to a child with moderate regressions in age-level of behavior including loss of ability to engage with peers, stopping play or exploration in environment that was previously evident, or occasional bedwetting.

3 | This rating is given to a child with more significant regressions in behaviors in an earlier age as demonstrated by changes in speech or loss of bowel or bladder control.

N/A | Not applicable.

59. Somatization

These symptoms include the presence of recurrent physical complaints without apparent physical cause or conversion-like phenomena (e.g., pseudoseizures).

0 | This rating is for a child with no evidence of somatic symptoms.

1 | This rating indicates a child with a mild level of somatic problems. This could include occasional headaches, stomach problems (nausea, vomiting), joint, limb or chest pain without medical cause.

2 | This rating indicates a child with a moderate level of somatic problems or the presence of conversion symptoms. This could include more persistent physical symptoms without a medical cause or the presence of several different physical symptoms (e.g., stomach problems, headaches, backaches). This child may meet criteria for a somatoform disorder. Additionally, the child could manifest any conversion symptoms here (e.g., pseudoseizures, paralysis).

3 | This rating indicates a child with severe somatic symptoms causing significant disturbance in school or social functioning. This could include significant and varied symptomatic disturbance without medical cause.

N/A | Not applicable.

60. Anger Control

This item captures the youth’s ability to identify and manage their anger when frustrated.

0 | This rating indicates a child with no evidence of any significant anger control problems.

1 | This rating indicates a child with some problems with controlling anger. He/she may sometimes become verbally aggressive when frustrated. Peers and family members are aware of and may attempt to avoid stimulating angry outbursts. Child may have a history of physical aggression arising from inability to control anger, but none within the last 3 months.

2 | This rating indicates a child with moderate anger control problems. His/her temper has gotten him/her in significant trouble with peers, family, and/or school. This level may be associated with some physical violence, or increasing verbal outbursts. Others are likely quite aware of anger potential.

3 | This rating indicates a child with severe anger control problems. His/her temper is likely associated with frequent fighting that is often physical. Others likely fear him/her.

N/A | Not applicable due to child’s age.