ISSUE 96 JANUARY 2007 CONTENTS HOME PAGE
Need and risk and how to tell the difference
Need and risk and how to tell the difference
Sibylle Artz, Diana Nicholson, Elaine Halsall, Susan Larke and Sonya Boya
This article discusses the role of assessment in child and youth care practice and presents a model for differentiating between two kinds of assessment--needs assessment and risk assessment. After introducing the definitions and complications of needs mid risk assessment, we provide an overview research project that culminated in the development of a guidebook entitled Guide for Needs Assessment for Youth.1 We then discuss risk assessment and its appropriate use in child and youth care, especially as such assessment relates to suicide.
Assessment is central to good child and youth care practice and key to engaging in a focused and helpful way with clients. To respond effectively, workers need to know when circumstances call for a focus on need and when they call for a focus on risk. But differentiating between these two kinds of assessment is not nearly as tidy and easily dealt with as one might anticipate, and effective assessment presents workers with considerable practice challenges.
A search of the literature on risk and need assessment reveals that neither research nor practice draw clear and distinct lines between the two. While the meaning of assessment is generally agreed upon [e.g., the systematic gathering and synthesizing of information about and with a client in a manner that serves to promote effective treatment (Cohen, Swerdlik, & Smith, 1992; Hepworth & Larsen, 1990; Plake & Conoley 1995), the literature shows that when discussing risk assessment and need assessment, risk and need are frequently collapsed (see Henderson, Aydlett, & Bailey, 1994; Hodges, 1999; Kroll, Woodham, Rothwell, Bailey Tobias, et al., 1999; Ottenbacher, Taylor, Msall, & Braun, 1996; Towberman, 1992).
Such collapsing is detrimental to effective child and youth practice. Needs assessment that is collapsed into risk assessment tends to be deficit-focused, that is, concerned with problematic conditions and behaviors rather than with strengths and potential (Ernst, 2000; Henderson, et al., 1994; Hodges, 1999; Kroll et al., 1999; Ottenbacher et al., 1996; Towberman, 1992). Deficit-based approaches mask the ability of individuals to thrive even in adversity, and do not create a basis for the kind of strengths-based assessment that was suggested by Wolin, Wolin and Wieczorek (1999) as preferable to "narrow models that emphasize people's vulnerability, the power of disease processes, and professional expertise" (p. 3).
Even on its own, the term need has changing and competing definitions and numerous difficulties exist in operationalizing concepts of need (Colton, Drury & Williams, 1995). Like risk and resiliency, need is not a static construct and is best viewed as dynamic and evolving (Bradshaw; 1972; Johnson, Meiller, Miller, & Summers, 1987; Wright, Williams, & Wilkinson, 1998).
A further complication is introduced into the discussion by findings that indicate that assessing for risk does not necessarily assist workers in determining who needs services and what kinds of services might be of most benefit, nor does it assist in predicting what will happen in a client's future (Garmazy, 1971; Mangham, McGrath, Reid, & Stewart, 1995; Masten,1999; Werner & Smith, 7992). This suggests that, while identification of at-risk children and youth is of vital importance, a narrow focus on risk factors alone will not help researchers or workers to predict or to determine outcome, nor will it help with selecting the most appropriate services. This also suggests that, to facilitate appropriate service provision, accurate needs assessment is a must. However, shifting the focus exclusively to needs assessment brings another challenge with it: some risks, especially the risk of harm to self and others, must take precedence over any other call for service and intervention. Therefore, both need and risk must be understood contextually and procedurally without collapsing one into the other or ignoring one in favor of the other.
To develop a broader understanding of needs assessment, we (Artz, Nicholson, Halsall, & Larke, 2001) embarked on a participatory, action-based project (see Guba & Lincoln, 1989; Maguire, 2001; Reason & Bradbury, 2001; Stringer, 1999) to develop a youth- and worker-friendly need assessment. As well, we consulted with our colleague Sonya Boya, from Project Alive (a British Columbia Ministry of Children and Family Development program for children and youth at risk of suicide) to help us understand those instances when risk assessment very definitely must be our starting point (see the "Widening the Lens: Including Risk Assessment" section of this article).
Creating a user-friendly guide for needs
In Phase I, 27 youth workers (14 female, 7 male), who work in a variety of roles, shared their perspectives on the theoretical and practical issues with respect to needs assessment. This provided the foci and questions for the interviews with counselors and youth and also assisted with recruiting the youth and youth workers to be involved in Phases II and III.
In Phase II, seven youth and eight youth workers participated in semi-structured interviews. Youth were asked for their perceptions about, and experiences with, being assessed and counseled, and their views on optimal assessment and the provision of services. Youth workers were asked for their experiences and views on practice with respect to assessing and responding to youth needs. Participants' responses were used to develop typologies of perceptions and experiences with respect to understanding and responding to need (Goetz & LeCompte, 1984). While we conducted the focus groups and interviews, the research team also embarked on an extensive literature search that resulted in a review of 108 publications focusing on youth needs assessment.
The information generated by the interviews and the literature review was then combined, analyzed, and organized into categories and spheres of interest relevant to needs assessment, and used as the basis for a Draft Guide for Needs Assessment for Youth. After sharing the first draft with participants from Phases I and II, some changes were made to the draft guide before the pilot test began.
The guide was pilot-tested by all the participants from Phases I and II, eight new youth workers (four male, four female) and their youth clients (eight male, three female), and reviewed by three academics from three Canadian universities who were themselves conducting research on needs assessment.
Relationship as the foundation for assessment work. Workers and youth noted that, in order to determine what is 'needed,' that is, if there is anything missing, absent or required in a young person's life, first a trusting relationship must be established. Workers and youth told us that, to build trust, they need to be afforded the time to develop long-term relationships and "really get to know" one another (Artz, Nicholson, Halsall, & Larke, 2001). As one worker noted, "You have to earn the right to ask question,." Youth told us repeatedly that they do not cooperate with workers with whom they have no established connections or with assessments that they believe are disrespectful, intrusive, irrelevant, and/or demeaning. One critical aspect of developing trust identified by both youth and their workers is the inclusion of youth in all aspects of the assessment process. This inclusion was identified as central to success and underlined in our development of the guide.
Approach assessment holistically. Workers and youth reported that a youth's whole world needs to be considered if one is to understand effectively what needs he or she might have. Youth complained about workers, not really knowing who they were "as a person" and about the propensity of many workers to focus on just the things the youth has done (i.e., their behavior). Workers and youth also noted that over-generalizing the shared experiences of a group such as adolescent poses a serious obstacle to effective assessment. We understood that we needed to take an ecological approach to assessment that would consider all the systems within an individual's life: intrapersonal, family, peer, social, cultural, and community so that a space could be created for each person's unique way of being.
Highlight youth’s strengths and abilities. Workers, youth, and the academics whom we consulted in our final phase all pointed to the importance of recognizing youth's strength,, and abilities.
All our consultants noted that workers and youth can benefit from not focusing on "what is wrong and what a person cannot do" and that, instead, close attention should be paid to young people's capacities and capabilities, how they think about themselves and their lives, and what they are willing to try. This suggested to us that we must be sure to include a clear focus on' strengths and capabilities in our assessment guide and refrain from focusing exclusively on what appears to be missing in the lives of the young people in question.
Offer a process that facilitates continual assessment. Our conversations with youth and workers and our review of the literature highlighted the active and generative nature of youth (c.f., Clark, 2001). Workers stressed that no single approach, assessment instrument, or any "one-time-only" assessment can adequately capture youth's needs. Rather, workers wanted a guide that would assist them in conducting ongoing assessment that would shed light on the constant changes in the severity, magnitude, and frequency of problems faced by their clients. This would assist them in avoiding "freeze frame" approaches to assessment and include a means by which workers and youth could record changes within the youth's world and in the youth's behaviors.
A guidebook emerges. The final version of the guide (developed as outlined through pilot testing and evaluation in Phase III) was designed to include five sections that reflect the key themes highlighted in the literature and discussed with youth and workers. We named these sections Context, Connectedness, Care, Capability, and Change, and prefaced each with a statement of objectives, the assumptions that support these objectives, and a series of questions that will assist workers and youth in clarifying the youth's needs. A vital aspect of the guide is the reciprocal nature of the posing of the questions and the inclusion of questions that the youth can ask the worker. In formulating the guide in this way, we took seriously all the data that we had gathered that pointed to the central importance of an emphasis on youth inclusion and youth strength. We then constructed an approach that integrates youth participation and balances the power between youth and their workers. The tool, the background literature review, and the project report can be accessed on-line at http://web.uvic.ca/cyc/naty
Widening the lens: Including risk assessment
Project Alive responds, on an urgent basis, to children and youth who are suicidal in hospital, school, home, office, and community settings. The initial goal of intervention is the assessment of current suicide or self harm risk. A number of risk-assessment tools have been developed: see Westefeld, Range, Rogers, Maples, Bromley, and Alcorn, (2000) for a discussion of the Hopelessness Scale, the Beck Depression Inventory, the Scale for' Suicide Ideation, the Suicidal Ideation Scale, the Suicide Behaviours Questionnaire, the Reasons for Living inventory, the Suicide Probability Scale, the Suicide Ideation Questionnaire, the Multi-attitude Suicide Tendency Scale, the Fairy Tales test, and others; and Jobes (2000) for a discussion of the Collaborative Assessment and Management of Suicidality. While risk assessment tools are helpful in conjunction with the clinical interview, in eliciting relevant factors that may aid in assessing an individual, or in designing an intervention, their use in crisis intervention is questionable.
For Project Alive clinicians, avoiding the use of a paper tool eliminates a perceived barrier to establishing a therapeutic relationship fairly quickly. A thorough, comprehensive clinical interview elicits similar information, and more, while establishing a strong relationship with the child or youth, which is essential to facilitating the development of a plan.
A youth referred to Project Alive is assessed for suicide or self-harm risk, and appropriate intervention follows. Project Alive clinicians tend to adopt the guidelines for assessment and management of suicidal youth as outlined in Practice Principles: A Guide for Mental Health Clinicians Working with Suicidal Children and Youth (Ministry of Children and Family Development, 2001). The principal tool for assessment is the clinical interview, conducted mostly in a narrative, collaborative way. The risk assessment aims to reveal the level of risk associated with the youth's suicide attempt, self-harm behavior or suicide ideation. The areas of focus include: primary risk factors (affective disorders, previous suicide attempts, hopelessness); secondary risk factors (substance abuse, personality disorders); situational risk factors (family functioning, social relationships, exposure to suicide, life stressors, sexual orientation); and protective factors or strengths (individual, family, social, and community resources). Formulating the intervention plan in situations of low to moderate risk involves safety planning as well as an assessment of current and future needs that, once addressed, could potentially reduce the youth's level of distress and the risk of self-harm. This dynamic plan is based upon assessed risk factors balanced with identified protective factors, including the youth's strengths. Continuous assessment of risk levels throughout the intervention (i.e., involvement with the child or youth)-for which the time-period is not predetermined-is crucial, as situational factors may change, increasing or reducing the level of risk for suicide.
In the case of suicide crisis intervention, assessing risk is a vital first step that continues throughout the intervention with a youth. Assessing need occurs inherently in the risk assessment, as well as more intentionally, to determine interventions that would serve to reduce the risk of suicide. In our work with youth, the ability to move fluidly between need and risk assessment and back again emerges as a vital competency. We must be able to recognize the distinctions between risk and need to understand how and when to focus on one or the other and to engage youth in this dynamic process. As Clark (2001) notes, "Expertise continues to be vital and required; but only to guide and raise the three critical ingredients-the tactical triad--of a youth's resources, perceptions and participation" (p.26). In working with youth on the delicate undertaking of creating relationships that make it possible for them to reveal to us their needs and risks, it is ultimately our ability to create a rapport and deepen our communication that will make the difference.
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1. The project described in this paper was supported by a grant from the National Crime prevention Center Partnership Program, Department of Justice, Canada, to the first author.