Although screening and assessment are on-going and dynamic processes (as discussed further in Question Six), our efforts to identify tools focused on those that are currently being used, or that can be used, by TANF agency staff. Additionally, it bears repeating that this review of tools is not intended to be an exhaustive review of screening, assessment, or identification tools used in all states.56 It is also not intended to suggest the use of particular tools. Instead the objective was to identify examples of tools used in TANF agencies and to expand thinking by states and localities that have not established or are considering changes to their screening or assessment approaches. Overall, there are few studies and even fewer evaluations of these tools' effectiveness, particularly when used in welfare to work programs.57
Appendix A provides profiles of the screening and assessment tools we identified. The actual instruments are not included because many tools are copyrighted or, in some cases, our state contacts were not comfortable with the distribution of their state-developed tool.58 For each instrument identified, the profile notes the following key features:
number and types of questions (form and content);
notes about implementation (i.e., time required, self-administered, administered in an interview setting);
cost (of purchasing necessary tools);
source or publisher; and
states known to be using.
While the profiles describe key features of the instruments, they do not fully capture the variation in wording of the questions, perhaps one of the more distinctive features of each instrument. Some questions carefully inquire about the experiences considered characteristic of an individual with a particular barrier. Others simply ask whether or not a barrier exists. Still others do not include questions at all. Instead, they provide a topical interview guide, leaving it to the interviewer to determine appropriate questions given the client and the ensuing conversation. Such a guide may or may not be considered a screening or assessment tool by its users and other observers but is included here.
The tools we identified also vary in how they are administered. The majority are designed as paper and pencil instruments and are meant to be self-administered (with some offering computer administration options). Others are meant to be completed in an interview setting, where a staff person poses questions and records responses. The paper and pencil tools often include 'yes' or 'no' or scaled questions ranging in length from one question to more than 75 questions. Tools designed to be completed in an interview setting may be 'yes' or 'no' or scaled questions but are also more likely to be short-answer, open-ended questions. We also identified a couple of tools that are notifications to clients about their rights that require an affirmative acknowledgement of a barrier and, in so doing, serve as a screening tool.
Each state or locality must determine which tool best meets their needs.
We present this diverse set of tools to document the array of screening and assessment tools that exist and so that states may consider which approach best meets their needs. Although, as illustrated in this section, some tools are more widely used than others, this should not be considered an endorsement of a particular tool or approach. Each state or locality must determine which particular barrier (or combinations of barriers) they wish to identify and consider tools or approaches that best meet the needs of their clients and capacity of their staff.
56 The American Public Human Services Association has undertaken a 50-state survey that includes identifying the screening and assessment tools in use in TANF agencies.
57 We also present a few screening and assessment tools that were recommended for use with TANF recipients by subject matter experts, although like the examples of tools used by states, little is known about their ability to accurately identify barriers among TANF clients.
58 In some cases, this was because the state is in the process of revising its tool.
What tools are used to identify multiple barriers to work?
Because many clients face multiple barriers to employment, some states have developed tools intended to identify several barriers.
Although TANF agencies have always screened for barriers, there is now greater interest in tools to assist in identifying a wider range of barriers to employment than might have been included in existing assessment tools. Because many welfare clients do not face a single barrier to work, some states have developed a single tool that is intended to identify several different barriers. In some cases, states are adding questions that probe for the existence of a possible barrier to employment but do not go so far as to incorporate questions from a targeted screening tool or questions commonly used by experts in a specific field. Other states are incorporating questions from a separate, targeted screening instrument into their existing employability assessment tool.
For example, Rhode Island's "Family Needs Assessment" collects information about immediate subsistence needs (i.e., housing, utilities, food, health-care needs). This tool also includes an item requiring the Social Caseworker to indicate whether or not a client uses alcohol or drugs and if such use prevents successful participation in required activities (in this case the worker is instructed to refer the client for professional/medical evaluation to determine the best treatment plan). As discussion points, this document lists the four questions from the CAGE, a well-known substance abuse screening tool. The Family Needs Assessment also has discussion questions
regarding the need for mental health services.
Montana also uses a single assessment tool to collect information on a variety of different barriers to employment including substance abuse and mental health problems, learning disabilities, limited English proficiency, legal issues, health conditions, availability of transportation and child care, and existence of an employment goal.59 Although this tool collects information about employment experience and the client's ability to search for work, it differs from Rhode Island's tool in that it is much shorter and collects responses to only 'yes' or 'no' questions, not detailed information about past employment or educational levels.
Washington uses a combination of tools that address a range of issues. During the initial intake interview with Department of Social and Health Services (DSHS) WorkFirst case managers, clients not only complete eligibility related requirements, but are also asked a number of questions regarding their ability to participate in Washington's WorkFirst program. Questions range from basic employment and education histories and child care and transportation needs, to questions about physical, emotional, or behavioral barriers to obtaining and maintaining a job. Barriers might include health conditions, domestic violence (discussed under the heading of "Family Support"), substance abuse problems, and literacy or learning problems. Based on responses to these questions, the case manager offers follow up questions and can also choose to involve a DSHS social worker.60 Social workers use a different tool that covers many of the same issues and is also administered in an interview setting. This "Intensive Services Assessment" is divided into 16 sections that collect information ranging from basic information about the client, how to contact her, and her education and employment history to detailed questions about her health, family planning, parent-child relationships, domestic violence, and other issues.
59 As of March 2000, Montana was in the process of revising this tool.
60 "Social worker" is the term that is used; however, individuals are not required to be licensed social workers or hold Master's of Social Work degrees.
What tools are used to identify substance abuse?
By far, the most commonly noted specialized tools used to identify substance abuse problems are the CAGE and the Substance Abuse Subtle Screening Inventory (SASSI). These tools were most commonly mentioned by both TANF agencies screening for substance abuse problems as well as substance abuse experts. The CAGE's popularity is likely due to its ease of administration. A short tool, it consists of only four questions that require no training to administer. Not surprisingly, the CAGE was found to be used widely both as a stand-alone tool and incorporated into tools designed to identify multiple barriers to employment. Originally developed for individuals already known to be drinking, the CAGE is designed to assess whether alcohol use is a problem. The CAGE is currently being used more broadly in welfare offices and by others to identify whether or not an individual is using alcohol or drugs. Some in the substance abuse field expressed concern about TANF agencies using the CAGE this way, given this was not its intended purpose.
The SASSI is also popular for its ease of administration. Although the SASSI (78 questions) is a longer tool than the CAGE (four questions), it can be administered quickly and easily. Unlike the CAGE, administration of the SASSI requires training and comes at a cost to agencies.
Despite the popularity of the CAGE and SASSI, there are a number of other tools that can be used to identify substance use. The U.S. Department of Health and Human Services, Center for Substance Abuse Treatment created the Simple Screening Instrument for Alcohol and Other Drug Abuse.61 The Simple Screening Instrument is 16 'yes' or 'no' questions regarding consumption, problem recognition, experience with adverse consequences, and awareness of a past or present problem with alcohol and other drugs, among other things. According to the implementation guidelines, it can be used by a diverse group of outreach workers, paraprofessionals, and professionals in the fields of both alcohol and drug abuse and infectious diseases.
According to the recent report by the National Center on Addiction and Substance Abuse (CASA), the State of North Carolina is actively attempting to identify substance abusers from among the TANF population. The North Carolina Department of Social Services has entered into a process of using both TANF staff and Qualified Substance Abuse Professionals62 to assist with the identification of substance abuse problems. All TANF applicants and recipients are supposed to be screened for alcohol and substance abuse problems. County offices determine which staff will conduct the initial screening (either Department of Social Services staff or Qualified Substance Abuse Professionals) and the procedures that work best for their office. The initial screen can be conducted using one of two other types of substance abuse tools: the Alcohol Use Disorder Identification Test (AUDIT) or the Drug Use Questionnaire (DAST-10). If either of these tools indicates a problem, the client is referred to the QSAP for in-depth assessment using the Substance Use Disorder Diagnostic Schedule (SUDDS-IV).63
61 More recently, the Center for Substance Abuse Treatment has undertaken an effort to prepare a Technical Assistance Publication addressing screening and assessing for substance abuse problems among TANF clients (forthcoming).
62 Qualified Substance Abuse Professionals are employed by local mental health authorities but in some cases are located in DSS offices.
63 National Center on Addiction and Substance Abuse August 1999, pp. 39-40.
What tools are used to identify learning disabilities?
Washington and Kansas stand on the forefront of state efforts to develop and rigorously test screening tools that can be used to identify the possibility of a learning disability among TANF clients.64 The Kansas tool has been validated for use with TANF clients, and, although it contains more questions than the Washington tool, it requires relatively little time to implement and score. In Kansas, all TANF clients who are work program participants are screened for learning disabilities. If the screen indicates the likelihood of a learning disability, the individual is referred for further assessment, often by the Vocational Rehabilitation program or in some cases through a local mental health or education provider.
We identified two tools designed to screen for learning disabilities among TANF clients.
The Washington tool is a short, 13-item screen that was validated for use with TANF clients. It is intended to identify individuals who potentially have a learning disability but is neither an assessment nor a diagnostic tool. A number of states have adopted Washington's tool due to its ease of administration. For example, Minnesota was attracted to Washington's tool because it had been rigorously tested and would be easy for contractors to implement. Services in Minnesota, including case management, employability planning, and screening for learning disabilities, are provided through a number of decentralized service contractors.65
64 The National Institute for Literacy (NIFL) has also undertaken an effort to assist literacy programs enhance services to adults with learning disabilities. Although not specifically targeted for TANF recipients, NIFL's series Bridges to Practice offers a review of tools used to identify learning disabilities and offers a training curriculum for literacy professionals.
65 However, TANF officials in Minnesota indicated problems with inconsistent implementation of the tool, given the number of service contractors and their varying processes. This is but one challenge associated with working with partners, discussed further in Question Seven.
What tools are used to identify victims of domestic violence?
Many states are developing tools and other methods to screen for domestic violence, perhaps in part due to prevalence estimates regarding domestic violence and the adoption of the Family Violence Option.66 However, our review did not identify any non state-developed tools intended to screen or assess for the existence of a domestic violence situation in a TANF family.
For example, Louisiana uses a one-page document to notify welfare recipients of their right to claim "good cause" due to domestic violence. In claiming good cause, TANF recipients not only disclose their domestic violence situation but can then receive an exemption from work requirements. Filling out the form is voluntary and confidential. The form also gives examples of abuse and tells the client to ask the case manager for more information about services.
Montana requires clients to fill out a multi-barrier tool (described earlier) and if the results of this screen are positive, they are asked to complete a more detailed tool - the Domestic Violence Screening Questionnaire. This tool was developed by the state's Domestic Violence Coalition for use in TANF offices and focuses specifically on domestic violence. If a welfare client answers 'yes' to one or more questions on this specialized tool, they are referred to a DVC counselor for appropriate services.
Oregon's system of identifying domestic violence is quite extensive and Oregon was called a "model state" by one expert. Oregon has a comprehensive system including several tools that utilize different approaches to screen and assess welfare clients for domestic violence issues - three are profiled here.67 Domestic violence is discussed several times throughout the application process and each of the tools has a different purpose and is used at a different point in the process. There is a Reference Card for the caseworkers to use with brief information about how and where to screen a client, safety questions, the referral services available, and behavioral clues to observe. An Interview Questions tool provides caseworkers with suggested questions to ask at each stage of a conversation regarding how to: establish trust, broach the subject, identify patterns of abuse, assess the level of risk to the children, and establish the woman's history of seeking help. Finally, an optional Safety Assessment was designed to make a general determination about the safety of the client and her children. It provides caseworkers with suggested questions meant to be asked in the office when the abuser is not around.
Domestic violence experts emphasized the importance of the environment in which screening is conducted.
Domestic violence experts interviewed did not recommend any tools for use with TANF clients but emphasized that the environment in which screening is done is very important. One expert said that the environment in which domestic violence issues are addressed should be a safe environment where clients are informed about what happens if they decide to disclose domestic violence. Caseworkers, in turn, need to know what to do if a client confides that they are a victim of domestic violence.
66 For additional information on state approaches to identifying and addressing domestic violence, see Burt, Martha, Janine M. Zweig and Kathryn Schlichter. Strategies for Addressing the Needs of Domestic Violence Victims within the TANF Program. Washington, DC: U.S. Department of Health and Human Services, June 2000.
67 Virginia is working to publish a collection of screening tools including Oregon's. See State of Virginia, Department of Human Services. Compendium of Screening Tools (Draft), undated.
What tools are used to identify mental health problems?
Several states screen welfare clients for mental health problems as part of a multi-barrier screening tool. Among the states reviewed, we found only two states or localities using separate, targeted tools to screen for mental health problems. Mental health experts we interviewed identified several standard tools that are used by trained, clinical professionals to assess people for mental health problems.However, none of the mental health experts we interviewed believed these tools should be used by laypersons in a TANF agency. In fact, experts said that standard tools should only be used by clinically trained professionals. Examples of these may include, but are not limited to the Beck's Depression Inventory-II (BDI-II), the Posttraumatic Stress Diagnostic Scale, and the Zung Depression Scale.
Some mental health tools must be administered by trained professionals.
The BDI-II has 21 scaled questions, must be administered by someone with a Master's degree, and be scored and interpreted by someone with a Ph.D./Ed.D. The Zung Depression Scale is 20 scaled questions and also requires a clinical professional or licensed social worker to administer. The Posttraumatic Stress Diagnostic Scale, on the other hand, is 49 'yes' or 'no' and scaled questions and requires only that it be administered by someone with a Bachelor's degree in psychology or education or a closely related field.
In New Jersey the Divisions of Family Development and Mental Health Services within the Department of Human Services, have initiated a pilot program funded with TANF dollars to identify TANF recipients in one county who have mental illnesses and need related services to help them enter the workforce. The pilot program involves the county welfare agency and two mental health providers who work as a team to identify TANF recipients who have mental illnesses, assess their clinical needs, and to link them to mental health services and a supported employment program to facilitate entry into the workforce. A twelve-item instrument was developed for use by county welfare case managers to assist them in identifying customers who could benefit from the pilot program.
In Portland, Oregon all new TANF applicants screened for mental health and substance abuse problems through participation in an "Addiction Awareness Class." During this class, TANF clients are asked to complete the Zung Depression Scale. The results of the Zung are scored by an onsite alcohol and drug clinical assessment specialist. The specialist informs both the client and the client's caseworker in writing about the test results and the next steps to take.68
68 National Center on Addiction and Substance Abuse 1999.
What are the DSM IV and the Asam Criteria and How are They Used?
In our review of screening and assessment tools, we found two diagnostic criteria manuals - the Diagnostic and Statistical Manual - IV (DSM IV) and the American Society of Addiction Medicine (ASAM) Patient Placement Criteria - 2. The DSM IV and the ASAM criteria are not tools per se and are applicable to both mental health and substance abuse problems. Experts indicated that the DSM IV and ASAM criteria should only be used by a trained clinician and not by a layperson.
The DSM IV is a descriptive classification system published by the American Psychiatric Association and, as a system, is used to assess clients (but it is not an assessment tool per se). It provides clinical guidelines to tell the clinician whether symptoms are present and provides a list of symptoms. Clinicians rely on these guidelines in making diagnoses, often for medical insurance purposes. However, the application of these guidelines may vary their application by clinicians.
The ASAM criteria provides two sets of guidelines, one for adults and one for adolescents, and five levels of service for each group. The levels of service are:
Intensive Outpatient/Partial Hospitalization Services
Medically-Managed Intensive Inpatient Services69.
For each level of care, a brief overview of the services available by severity of addiction/illness and related problems is presented. Also presented is a structured description of the settings, staff and services, admission, continued service, and discharge criteria. The terminology used in ASAM has been updated to be consistent with the most recent language of the American Psychiatric Association's DSM IV.
In some states, the DSM IV and ASAM criteria are being used in relation to TANF either onsite or offsite. Clinically trained professionals - such as staff holding Masters of Social Work degrees - co-located onsite in TANF offices may use the DSM IV or ASAM criteria after clients have positively screened for mental health or substance abuse problems using one of the multi-barrier tools. Alternatively, a TANF client who is referred for services may receive a further diagnosis from an offsite clinical professional using the DSM IV and ASAM. Finally, the DSM IV or ASAM could be used as the foundation or guidelines for developing screening or assessment tools.
Officials in Utah specifically mentioned the use of DSM IV and ASAM criteria when the initial, multi-barrier screening tool suggests the possibility of a mental health problem. If a TANF client screens positive for mental health issues from the multi-barrier tool, the client is referred to a credentialed social worker. Social workers are located throughout the state in TANF offices and apply the DSM IV and the ASAM criteria. If a client is diagnosed as positive for substance abuse or a mental health disorder, they are referred to an offsite provider for further assessment and treatment.
69 American Society of Addiction Medicine (ASAM). Second Edition of Patient Placement Criteria, Annapolis Junction, MD, 1996.