Overview
The initial assessment domains
The initial assessment process recommended in this Guidance identifies eight domains that are assessed when determining the next steps in the referral process for a child referred to a mental health service. The eight domains fall into two categories:
Primary Assessment Domains (Domains 1 to 4): These domains cover symptoms severity and distress, risk of 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 child’s current situation on all eight domains. Each domain looks at specific factors relevant to making decisions about a level of care that is most likely suitable for the child’s mental health treatment needs. The selection of the domains, and factors covered in each domain, aims to capture key areas that a clinician should consider when determining the most appropriate services for a child 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 child.
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.
Unless otherwise stated, IAR users should 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.
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.
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 child, the child’s family, referrers, or other informants where possible. Consider all reliable perspectives when selecting a rating (e.g., including information provided by the child, 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 child’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.
PRACTICE POINT - Informed Consent
Clinicians have legal and ethical obligations to obtain informed consent before performing any healthcare intervention. To give informed consent, a person (or the person making decisions for them if they cannot make decisions for themselves) should be sufficiently informed of the risks and benefits of any treatment (including, where relevant, the risk associated with no treatment).
The process of gaining consent for the treatment of children and adolescents (under the age of 18) differs significantly from that of adults and is more complex and varied. In some instances, consent must be given by the relevant parent or guardian, whereas in others, it may be possible for a person under 18 who is a ‘mature minor’ to give consent. A mature minor is a child or adolescent assessed as having the capacity to make specific decisions based on various factors, including the nature of the treatment, age, maturity, medical/social history, degree of independence, understanding, and intelligence. If a child or adolescent is a mature minor, consent for treatment is not required from a parent or guardian.
Depending on the circumstances, involvement of both the parent/guardian and a child/adolescent in providing consent for assessment, referral and intervention can be preferable.
Where, on balance, the risk of engagement of the parent will lead to a potential negative impact on the child or adolescent, consideration may need to be given to the involvement of an alternative guardian if the child or adolescent is not a mature minor and cannot make treatment decisions for themselves.
Some states or territories have specific legislation governing the informed consent of children and adolescents in healthcare. It is the responsibility of all healthcare providers to know and understand their legal obligations in whichever state or territory they are practising. For further information, consult your state/territory legislation and/or consult your professional indemnity insurer or professional association.