Original Research

Using the Child and Adolescent Service Intensity Instrument (CASII) as an Outcome Measure



From the Jewish Family and Children’s Service, Phoenix, AZ (Dr. Henderson) and Consult-Stat, Macungie, PA (Ms. Wasser, Dr. Wasser).


  • Background: The reliability and validity of the Child and Adolescent Service Intensity Instrument (CASII) as a tool to help determine needed level of care for children with behavioral health needs has previously been established.
  • Objective: To determine the utility of the CASII as an outcome measure.
  • Methods: A sample consisting of all clients (n = 8465) admitted to service at an outpatient behavioral health facility from 2013 through 2016 were studied. CASII was administered at admission and discharge and ratings were compared with paired t-tests within demographic and diagnosis groups.
  • Results: Mean CASII composite ratings decreased between admission and discharge in the entire cohort as well as within gender, age group, and multiple diagnosis groups tested.
  • Conclusion: CASII was useful as an outcome measure in our relatively low to moderate acuity population.

Keywords: outcomes, evidence based practice, child psychology, outpatient research.

The primary goal of mental health services is to provide interventions that result in a reduction of problematic symptomatology [1]; therefore, evaluation of those interventions is important for both the client as well as the stakeholders of the organization providing them. Health care payment reforms require tracking quality measures, and such measures directly influence the development, administration, and monitoring of mental health programs as well as specific treatment modalities [2,3]. Organizations are more likely to benefit when outcomes measures are relayed quantitatively [4]. In addition, clients are becoming more informed regarding the quality of care, and outcomes assessments can inform clients that programs are delivering the most efficacious therapies based on current evidence-based practice standards.

Developing outcomes assessments in behavioral health is challenging [5–7]. There are numerous potential outcome domains that can be assessed as well as different ways of measuring them. Futher, evaluating treatment can be expensive, with components including developing a tool, training staff to administer the tool, ensuring the necessary technical support to store and process the data, interpretation of the data, compiling reports, and communicating results to clients and providers [5]. Being mindful of these components and their associated costs, our organization considered whether a tool we currently use to assess the appropriate intensity of service needed for an individual could also be used as an outcome measure.

Therapeutic methods for children in our organization consist of a “system of care” approach designed by a treatment team that incorporates varied methods depending on the needs of the child. The primary goal is to prevent children with traumatic-based disorders from developing continuing disorders associated with their experiences, such as substance use and chronic health and mental health disorders. Our organization currently uses the CASII (Child and Adolescent Service Intensity Instrument) to assess the appropriate level of intensity of service needed by the child. The CASII incorporates holistic information on the child, within the context of his/her family and social ecology, assessing across 6 dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services.

In order to comply with the call to consider outcomes measurement and evidence based practice as an integral component of children’s mental health services, this study was performed. It examines the use of the CASII as an outcomes measure based on the rationale that a decreased level of care upon discharge would correlate with a positive outcome by proxy.


CASII Instrument

The CASII is a decision support tool to help the service provider determine the intensity of services that a child should have to adequately address their behavioral health needs. The CASII has a strong evidence base supporting its reliability and validity [8], and has gained wide usage in a range of health care settings over the past 13 years [9–11].

As mentioned, the CASII assesses the client across 6 key dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services. Each dimension is scored along a 5-point rating scale, and a total or composite rating is calculated by adding the scores for each dimension. The composite rating corresponds with the level of service intensity needed. There are 7 levels of service intensity, ranging from Level 0 (corresponding with a composite rating of 9 or less) to Level 6 (corresponding with a composite rating of 28 or more) (Table 1).

Study Sample

The sample consisted of all clients (n = 8465) admitted to service from 2013 through 2016 to our facility. Our facility is an outpatient facility offering counseling, mental health assessment and treatment, early childhood trauma assessment, child crisis interventions and rehabilitation for domestic violence, child abuse and neglect, and substance abuse. All clients between the ages of 6 and 17 are assessed with the CASII on admission and then at 6-month intervals until discharge from the program. Being discharged from the program of care prompts the completion of the discharge CASII. If the client had been rated within the 30 days prior to discharge the most recent CASII is used as the discharge measure.

Next Article: