Overview
The initial assessment domains
The initial assessment process recommended in this Guidance identifies eight domains domains that should be explored in assessment and considered when determining the next steps in a referral process for an adolescent who presents to primary care with a mental health need. The eight domains fall into two categories:
Primary Assessment Domains (Domains 1 to 4): These domains cover symptom severity and distress, harm, functioning and impact of co-existing conditions. Primary Assessment Domains represent the basic areas for an initial assessment that have direct implications for decisions about the selection of a level of care.
Contextual Domains (Domains 5 to 8): These domains cover service use and response history, social and environmental stressors, family and other supports, and engagement and motivation. Assessment on these domains provides essential context to moderate decisions indicated by the primary domains.
Initial assessment should consider the person’s current situation on all 8 domains. Each domain looks at specific factors relevant to making decisions about a level of care that is most likely suitable for the person’s mental health treatment needs. The selection of the domains, and factors covered in each domain, aims to capture a limited number of key areas that a clinician would consider when determining the most appropriate services for an adolescent needing referral for mental healthcare.
Rating the initial assessment domains
A rating system grades each domain on a 5-point rating scale of severity - while the terms vary in some domains, the rating scale for each domain follows the general format where:
0 = No problem1 = Mild problem2 = Moderate problem3 = Severe problem4 = Very severe problem
Specific criteria for assessing each domain, designed to serve as a checklist of factors to consider when judging the extent to which a problem is present.
General instructions for rating the domains
The initial assessment is undertaken across eight domains that describe clinical severity and service needs using a 5-point scale ranging from 0 to 4. Higher ratings indicate increased severity of the problem and the need for higher (more intensive) levels of care.
Each rating within each domain is defined by one or more descriptors designated by alpha characters (a, b, c, etc.). Only one of these descriptors need to be met for a rating to be selected for the adolescent.
Overarching rules
If there is uncertainty in the ratings for the primary assessment domains that impact on the level of care appropriate for the person, the IAR user may need to pause the IAR process and seek additional information that will allow rating of the domains with confidence.
Where uncertainty remains about ratings for the primary assessment domains even after the additional information is obtained, the person and family (where appropriate) should be supported to access an appropriate clinician or service for a more comprehensive assessment.
IAR does not indicate the urgency of the response a person might require. Users must still consider the urgency of the response required and activate urgent assessment and care pathways if needed (as per their service model and local system policies and procedures). Users of the IAR should be familiar with local urgent assessment and care pathways.
Unless otherwise stated, IAR users consider what has been ‘typical’ for the person over the past 30 days except where the person has experienced more recent or sudden changes or deterioration. Where this is the case, users should base their ratings on the more recent changes.
The IAR should not be used as a screening tool because it cannot be used without some form of personalised assessment.
Guides to rating each domain
If more than one descriptor applies to the person being assessed within each domain, the descriptor with the highest rating should be selected.
Example one: if 3-b, and 3-c apply, but 4-a is also present, the rating selected is 4.
Example two: if 2-a and 2-b apply, but 3-c is also present, the rating selected is 3.
Use all available information in making a rating. This should include clinical interviews and information gathered from the person, the person’s family, referrers, or other informants where possible. Consider all reliable perspectives when selecting a rating (e.g., including information provided by the person, family, or referrer).
The coding of ratings as numerals does not imply that an overall composite score can be used for making decisions about the person’s service needs. The numbers should be regarded as simply shorthand for summarising severity.
Guidance is given for each domain on examples of problems that should be considered for specific ratings (the ‘descriptors’). Consider these as examples only rather than an exhaustive list of all factors relevant to the domain. Therefore, referring to the underlying rating format at times may be helpful.