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Article

Piloting the Implementation of Intake Assessment Tools and Caregiver Symptom Rating Tools in a Child and Adolescent Outpatient Psychiatry

by
Michèle Preyde
1,*,
Regina Markle
2,
Andre Watkis
2,
Melissa Aguto
2,
Shrenik Parekh
2 and
John Heintzman
3
1
Department of Family Relations and Applied Nutrition, College of Social and Applied Human Sciences, University of Guelph, Guelph, ON N1G 2W1, Canada
2
Waterloo Regional Health Network, Kitchener, ON N2G 1G3, Canada
3
The Sault Area Hospital, Sault St Marie, ON P6B 0A8, Canada
*
Author to whom correspondence should be addressed.
Psychiatry Int. 2026, 7(3), 135; https://doi.org/10.3390/psychiatryint7030135
Submission received: 27 February 2026 / Revised: 22 April 2026 / Accepted: 25 May 2026 / Published: 12 June 2026
(This article belongs to the Section Mental Health)
Versions Notes

Abstract

Background: The rising rate of referrals to outpatient psychiatry is difficult to manage. To explore intake and pre-assessment strategies to reduce strain related to the high volume of referrals, two intake tools and two caregiver symptom rating tools were trialled in a child and adolescent outpatient mental health clinic in Ontario, Canada. Methods: Intake personnel completed two tools in addition to the routine intake procedure in a feasibility study. Caregivers completed two symptom-rating tools, and feedback on the use of the tools was sought with a survey. Results: There were statistically significant differences between priority groups (i.e., determination as usual with high, medium, or low priority) on both intake tools, but no statistically significant differences between either caregiver rating tool were found. Conclusions: Standardizing the assessment process may facilitate care. Caregiver ratings did not align with triage priorities; however, these ratings may inform clinical assessments.

1. Introduction

In the fall of 2020, almost 20% of Canadians aged 12 years and older indicated a need for mental health care, though 45% of these Canadians reported that their mental health needs were unmet or only partially met [1]. Prevalence estimates for mental illness in children and youth range from 15% [2] to 22% [3], though 75% of Canadian children [4] and almost 80% of children in the U.S. [5] do not receive the type of specialized mental health care they need.
In Ontario, Canada, thousands of children wait months or even years to access specialized and community mental health services [6]. Children’s Mental Health Ontario has also reported “skyrocketing demands” for children’s mental health services and a dramatic rise in the severity of mental health problems [7,8]. These patterns are consistent with dramatic increases in referrals to child and adolescent outpatient psychiatry, especially for emotional disorders in girls [9,10]. The strategies utilized in outpatient services to manage wait times may assist families and staff in coping. For example, pre-waitlist strategies such as standardizing and centralizing the intake process may improve the chance of meeting the benchmarks created by the Canadian Psychiatric Association [11] and may be a complementary tool for the initial clinical assessment. However, it should be noted that currently there are no standardized tools required or mandated for use in children and youth mental health services, including outpatient psychiatry in Ontario, Canada [12]. Managers and clinicians are able to choose from an array of screening and intake tools, such as those reviewed by the Canadian Pediatric Society (CPS) [13]. For general mental health symptoms (as opposed to specific tools such as tools for depression or attention deficits), the CPS reviewed the Child Behaviour Checklist [14], the Pediatric Symptom Checklist [15] and the Strengths and Difficulties Questionnaire [16] that provide caregiver (parent) reported options.
The intake assessment and process may be key components in the care of children and adolescents, and an important opportunity to build rapport with families. The intake process for children and adolescents can take longer than for adults since it is more complex, involves gathering information from multiple people (e.g., caregivers, teachers), across different contexts and formats [17]. The accuracy of the assessment may be key to the treatment pathway, yet it is vulnerable to bias, particularly when standard tools are not used [18], though expertise may enhance this time-consuming intake process and reduce bias.
The intake process may also offer a critical opportunity to engage youth and their caregivers to foster retention in mental health services. Indeed, building a strong therapeutic alliance and trusting, supportive relationships with caregivers during intake and assessment have been shown to be associated with reduced attrition from clinical services [19,20,21]. Thus, the intake process permits an opportunity to form a trusting alliance with the patient and caregiver that might benefit retention and engagement during treatment.
Caregiver-reported symptom severity tools may also inform initial assessments. Caregiver ratings of the mental health symptoms of their child have been reported to facilitate communication in the initial assessment and permit clinicians to document change over time [22,23]. Thus, the use of standardized caregiver assessment tools may complement initial assessments.
The interconnected tension of a high volume of referrals and concern about timely access to care for those with the most severe mental illness has led to the development of tools designed to facilitate decision-making during the intake process and initial clinical assessments. The main purpose for the present study was to explore the feasibility and acceptance of two intake tools to assess priority for mental health care in children and adolescents referred to an outpatient clinic and to compare these tools with the intake determination used in usual/routine practice. If the standardized tools corroborate usual practice, could they replace an unstandardized process? Secondary purposes were to explore the use of caregiver ratings of patient symptoms to assist with initial assessments, and to explore the association between the intake assessment and the caregiver symptoms rating tool. If the caregiver ratings corroborate the usual intake assessment, could the standardized, parent-reported measures be used to augment the assessment? Consistent with the exploratory nature of the study, no hypotheses were generated.

2. Materials and Methods

A feasibility study was conducted to explore the acceptance and practicality of implementing standardized intake tools by comparing them to the usual intake process and eliciting comments from intake personnel on the standardized tools. A feasibility study was also conducted to explore the acceptance and practicality of implementing caregiver-rated symptom assessment tools to assist with initial assessments. The data were collected prospectively. Research ethics approval was obtained from the Tri-hospital Research Ethics Board (WRHN #: 2022-0750) and the University of Guelph (REB# 22-08-033) in accordance with the Declaration of Helsinki.

2.1. Setting

The Child and Adolescent Outpatient mental health clinic is situated in a community hospital providing regional care services for local cities and surrounding rural areas (serving a population of about 800,000). Patients (aged six to 17 years) are mainly referred from family physicians, inpatient psychiatry or emergency departments, pediatricians, or other specialists. Services include psychiatric consultation and multi-disciplinary care from nurses, social workers, an occupational therapist, and psychologists.
All patients referred to child and adolescent outpatient psychiatry and their caregivers with the ability to communicate in English were eligible for inclusion. To maintain privacy, the first point of contact for the study was a hospital staff member. At the time of scheduling the intake process, caregivers of children referred were asked if they would like to speak with a research assistant (RA) to learn about this study opportunity. For those who consented, the RA contacted the caregiver, fully described the study, and requested consent for the use of the intake tools and the completion of a caregiver survey by telephone. The RAs were stationed in the outpatient clinic and had a room with a hospital telephone to contact the caregivers and a door for privacy. The RA engaged the caregivers in the consent process and conducted the survey. The RA could provide assistance to the caregiver to complete the survey if needed. Caregivers could consent to all or only parts of the study. Caregivers were given a written copy of the consent at their child’s first appointment.
For caregivers who consented to the intake tools, the RA informed the intake workers of the consent, and the tools were completed by intake personnel after the intake process was completed as usual; the usual intake process is described below. Completing these tools after the intake process is consistent with instructions for use of these tools [24,25]. Caregiver surveys and intake tools were linked by a common identification number; no identifying information, such as names, was included in the survey (i.e., the surveys and intake forms were anonymized). Due to privacy legislation, the initial point of contact for the study had to be from hospital staff, and if consent to speak with a research team member was provided, then the RA could contact the caregiver.
Preliminary results from the intake tools and their comparison to the determinationas usual were presented to eight clinical staff members, including three intake personnel, during a regularly scheduled clinical meeting. Staff members were asked for their opinion of the intake tools and about using the tools (e.g., What did you think of the intake tools?). Their comments about the tools were manually recorded by an RA during the meeting.

2.2. Intake Measures

Two intake tools were used and completed by experienced intake personnel. The first tool was developed by members of the Western Canada Waitlist project and is a standardized tool to prioritize cases referred to children’s mental health. The Children’s Mental Health Priority Criteria Score (CMH-PCS) [25,26] was found to have good internal consistency [27] and could be used to identify levels of urgency [28,29] and has been used to suggest maximum wait times [30]. Total scores can range from 3 to 100; total scores less than 25 suggest the priority is low, between 26 and 50 is moderate, 51–75 is high, and 76–100 is very high. The User Manual for the CMH-PCS [25] was provided to the intake personnel to review before the study commenced.
The Home, Education and employment, Activities and peers, Drugs, Suicidality, Emotions, thoughts and behaviours, and Discharge resources (HEADS-ED) [24,31,32] was designed to capture these seven variables with three ordinal categories ranging from 0 (no action needed) to 2 (needs immediate action/severe functional impairment). Excellent inter-rater agreement has been reported [32]. The HEADS-ED has been successfully used in a variety of settings, including pediatric emergency departments [33], community settings [34], primary care [35], and a hospital-based centralized referral system [36]. A total score of eight, with a two for suicidality, indicates a need for immediate action. The HEADS-ED was designed to be easy to recall. Intake personnel were informed of the HEADS-ED website containing resources, including tutorials.

2.3. Caregiver Survey Questionnaire

The survey questionnaire included two caregiver-reported symptom severity measures (DSM-5 Cross-Cutting Symptom Measure; Strengths and Difficulties Questionnaire) and open-ended questions on their preferences and comments about these tools (i.e., Which tool did you prefer and why? Were any questions difficult to answer? Why?), yielding nominal data. These clinical tools were generally completed within two weeks after intake and before the child’s first clinical appointment.
The DSM-5-TR Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure (DSM-CR-CCSM) of children aged six to 17 years [37] was designed by the American Psychiatric Association for the assessment of patients’ symptoms across common potential areas of mental health concerns. Caregivers were asked to rate 25 items based on the past 2 weeks. Nineteen items were designed to assess 10 psychiatric domains, including depression, anger, irritability, mania, anxiety, somatic symptoms, inattention, psychosis, sleep disturbance, and repetitive thoughts and behaviours, rated on a 5-point scale from 0 (not at all) to 4 (Severe, nearly every day). Six items were designed to assess two domains, suicide attempt/ideation and substance use, and are rated on a “Yes, No, or Don’t Know” scale. The measure has been shown to be valid and reliable [37,38,39] and can be used serially to track changes over time.
Caregivers also completed the caregiver form of the Strengths and Difficulties Questionnaire (SDQ) [16]. The SDQ consists of 25 items to assess common psychiatric problems with five subscales, including emotional problems, hyperactivity, peer problems, conduct problems, and prosocial behaviours. Items are rated on a three-point scale ranging from 0 (not true) to 2 (certainly true) based on the last six months or past school year. A total score for difficulties can be computed by summing the first 4 subscales; the total difficulty score can range from 0 to 40. The SDQ has been shown to be valid and reliable [40,41,42].

2.4. Intake Process as Usual

All of the initial intake assessments were conducted by the intake personnel by telephone with the youth and caregiver, though some, especially older youth, may have completed the process independently. Intake assessments were completed by social workers and an occupational therapist with different clinical approaches. Since the usual intake assessment was not completely standardized, the exact differences between clinicians are not known. However, there were some common primary topics discussed when completing these initial assessments. How these topics were approached, the order of questions asked, the level of depth, and the specific framing of questions varied based on the clinician and patient needs. The topics generally included Family composition, School details (social and academic components), Peer relationships, Community/leisure, Stressors, Mood/affect, Coping strategies, Mental status (such as thought processes, behaviours, and cognitions), Alcohol/substance use, Trauma history, Physical health/medical history/allergies, Medication history, History of previous mental health interventions, Current mental health supports, Family mental health history, Sleep, Nutrition and screen for disordered eating, Risk (suicide risk and self-injury) and Patient’s mental health goals. A standardized scale to assess suicide risk (the Columbia Suicide Severity Rating Scale; CSSRS) [43] was also completed for each referral. Intake professionals also obtained parent feedback regarding the youth’s mood, behaviours, safety, and goals. The degree of caregiver involvement varied depending on the patient’s needs. After the initial intake assessment, youth referred to outpatient care were categorized as a high, moderate, or low level of need, and scheduling of initial psychiatry consultations was based on this level of need. Those considered high and medium levels of acuity are scheduled for psychiatric consult in accordance with acuity.
At the time of the study, youth deemed high priority could have been scheduled for an appointment in approximately 8 weeks from the time of intake assessment, while it could have been approximately 6 months, depending on psychiatry availability for youth considered medium priority. The available number of psychiatrists staffing the child and adolescent outpatient clinic fluctuates (e.g., psychiatrists relocate to a different region, go on vacation, or leave, new psychiatrists are given hospital privileges, and so forth), affecting wait times. After the initial consultation, the psychiatrist may connect the patient to other specialists within the clinic, hospital, or community. Those considered to have a low level of acuity may be seen eventually if a psychiatric opening becomes available; for a small number of youths, families, and clinicians may decide that other community services may serve the needs better than outpatient care. A small percentage of families decide to seek other community services rather than wait for an outpatient psychiatry appointment. Some patients, such as those referred from inpatient psychiatry, were directly seen by psychiatry (i.e., no intake process). All youth are provided with suggestions for support while they wait for their first clinical appointment.
Some patients arrived at the emergency department and were directly referred to the outpatient clinic (termed Rapid Response) for consultation and short-term treatment. For some of these patients, the initial intake assessment was completed in person, and if it was possible to obtain informed consent for the study, then the intake worker completed the tools after the intake assessment. The Mental Status Exam (MSE), a standardized method to assess a patient’s mental state, was also completed for clinical purposes (i.e., not part of this study). These patients are seen directly by a clinician (usually an MSW) who provides crisis intervention, assesses the mental health acuity of the patient, and determines if the patient will require psychiatry support or if other community supports would be helpful. If it is believed that psychiatric intervention is necessary, a conversation is had with the multi-disciplinary team to determine when a psychiatry appointment can be provided based on the individual’s mental health acuity and psychiatric availability.

2.5. Data Analysis

The Statistical Package for the Social Sciences (SPSS version 26) [44] was used for analyses. Demographic information was presented with descriptive statistics, including frequencies and measures of central tendency. A one-way Analysis of Variance (ANOVA) and Chi-square (X2) were used to explore differences in the age and sex/gender of patients and caregivers by priority group, as usually determined (i.e., high, medium, or low priority at intake). An ANOVA was used to explore whether the total mean scores of the two intake tools (CMH-PCS and the HEADS-ED) could be used to differentiate the high, medium, and low-priority groups as determined by the usual intake process. An ANOVA was also used to explore whether the total mean scores of the two caregiver clinical ratings (DSM-CR-CCSM; SDQ) could be used to distinguish between the high, medium, and low-priority groups. To account for the multiple analyses with usual determination, the Bonferroni correction was applied for the ANOVA analyses, with statistical significance set at p < 0.0125. Scheffé was used for post hoc testing with significance at p < 0.05. With alpha at 0.05, and 4 independent variables, the sample size estimate for medium effects is 84 participants [45].
Responses to the caregiver open-ended survey questions (e.g., Of the 2 Clinical tools, which did you prefer and why?) and the opinions provided by clinical staff on the intake tools were categorized with content analysis [46]. The caregiver responses were transcribed verbatim by the RA. The length of text varied from a few words to a few sentences by caregivers who responded to this item in the survey. Similar responses were grouped into a category. The responses were coded independently by an RA and the first author; there were no discrepancies. The clinical staff comments were typed into a Word document during the meeting by an RA without attributing comments to individuals. The clinical staff’s opinions were independently categorized by the RA and the first author; there were no discrepancies.
Since the main reasons for referral to urgent outpatient care often involve suicidal behaviour [47], the frequencies of the intake personnel responses to the items on the CMH-PCS and the HEADS-ED, and the caregiver responses on the DSM-CR-CCSM are presented. Suicidality is not captured by the SDQ. Chi-square was used to determine if there was a statistically significant difference in intake personnel ratings of no concerns (none) versus any concerns (including mild, moderate, severe on the CMH-PCS and ideation, plan/gesture on the HEADS-ED).

3. Results

From February 2023 to March 2024, hospital staff obtained caregiver consent to speak with an RA for 251 patients referred to the clinic, and RAs obtained informed consent from 134 caregivers (53.4%). Of the 134 patients included in this study, 115 caregivers completed baseline surveys (86%). Not all caregivers who provided consent to the use of the intake tools and consent to participate in the research were available to complete the baseline surveys. The main reason for incomplete surveys was scheduling difficulty (i.e., caregivers not having the time). The main reasons for declining to participate in the research were recorded by the RAs as being too busy, not interested, their child not wanting the caregiver to participate, not comfortable, and too overwhelmed. The aim was for the caregivers to complete the survey within two weeks of the intake process. Sixteen (14%) caregivers completed the survey on the same day the intake process was completed; 69 (60%) caregivers completed the survey within 1–19 days (mean 5 days) of the intake process, and 30 (26%) caregivers completed the survey more than 20 days after intake (mean 35 days).
Patients ranged in age from 6 to 18 years (mean age 14; SD 3.04), and 83 (62%) were identified as female at intake. The main reasons for referral were suicide ideation/self-harm/overdose (n = 69; 51.5%), anxiety including panic and fear (n = 30; 22%), mood disorder including depression, bipolar disorder (n = 30; 22%), behavioural problems including oppositional defiance, aggression (n = 22; 16%), emotion regulation difficulties (n = 16; 12%), ADHD (n = 16; 12%) and gender dysphoria (n = 13; 10%).
The mean age of caregivers was 44 years (SD 7.72), and most self-identified as female (n = 98, 85%). Most (n = 80, 69.6%) were in a coupled relationship, and of the 112 caregivers who responded, 86 (77%) reported completing college or university, 19 (17%) reported completing high school, and 7 (6%) reported completing middle school as their highest level of education. Of the 110 who responded, 90 (82%) reported being the mother of the patient, 14 (12.7%) reported being the father, 3 (2.7) reported being the grandmother, 2 reported being the sister, and one reported being the adoptive father.

Comparison Between Tools

There were no statistically significant differences between priority groups (i.e., high, medium, low) on patient age (F = 0.84, p = 0.43) and sex (X2 = 1.58, p = 0.45) as reported by intake workers or caregiver age (F = 0.91, p = 0.40), gender (X2 = 1.33, p = 0.86) or household income (F = 0.15, p = 0.86) as reported by caregivers.
There were statistically significant differences between priority groups (i.e., high, medium, and low) for the CMH-PCS (F = 41.1, p < 0.001) and the HEADS-ED (F = 20.7, p < 0.001; Table 1). Post hoc analyses indicated statistically significant differences between each of the three groups (i.e., high, medium and low priority) on both measures (i.e., CMH-PCS and the HEADS-ED); that is, the mean for the high priority group were statistically higher than the mean for the medium priority group, which in turn was higher than the mean for the low priority group suggesting that both intake tools successfully differentiated between the three priority groups.
Clinical staff reported that the intake tools included many areas in their usual process, particularly the CMH-PCS, though the following content areas were missing: guardedness or the patient not willing to talk, which may heighten safety concerns for some youth with high acuity, the patients’ trauma history, eating disorders, and gender dysphoria. Clinical staff also stated that the scoring of individual items on the CMH-PCS (i.e., the severity ratings) appeared “odd” or “arbitrary”. Clinicians expressly noted that for item 10 on harmful substance use, item 12 on school, and item 13 on social relationships, severe problems were rated as only 1. Clinicians noted that situations in these three items/areas “can really exacerbate symptoms” of patients and so should be given greater weight. An item on the services the patients were already accessing was missing from the CMH-PCS. The CMH-PCS was designed to be comprehensive and has a complicated scoring feature. Clinicians reported that the items not in HEADS-ED included danger to others; comorbidities; family history; prognosis without further intervention; degree of likely benefit of further intervention, in addition to those stated for the CMH-PCS.
There were no statistically significant differences between the three priority groups (i.e., high, medium, low) on the caregiver ratings of their children’s symptoms with either clinical rating tool (i.e., the DSM-CR-CCSM and the SDQ); that is, the caregiver rating tools did not differentiate between the three priority (high, medium, low) levels.
Seventy-one caregivers provided valuable comments on the symptom rating tools. Because the DSM-CR-CCSM contains items on suicidality, caregivers were asked the following: “Were any questions difficult to answer? Why?” Most of the caregivers (n = 42, 59%) did not have difficulties completing the DSM-CR-CCSM and thought the questions were “straightforward”. The main concerns were not knowing the answers (n = 6) and experiencing emotional discomfort for their child (n = 6); for example, one caregiver wrote “Yes, just painful to know she is hurting” and another stated “I am nervous about him. I feel bad that he is feeling down.” Some caregivers (n = 5) found it difficult to limit their responses for the DSM-CR-CCSM items to the past two weeks since this time frame did not map onto their experiences; it is not known if revising the DSM-CR-CCSM would better represent caregiver experiences while still being useful to psychiatrists. One topic concerned the questions/items on suicide in the DSM-CR-CCSM tool. Five caregivers noted difficulty regarding the item on suicide.
A total of 79 caregivers reported which tool they preferred; 34 (43%) preferred the SDQ, while 31 (39%) preferred DSM-CR-CCSM (X2 = 0.14, p = 0.71) and 14 (18%) indicated no preference. Caregivers who preferred the DSM-CR-CCSM stated that there were a greater number of response options, and it seemed more targeted than the SDQ. Caregivers who preferred the SDQ considered it easier than the DSM-CR-CCSM, and the ratings were based on the last six months as opposed to the last two weeks. Caregivers reported that rating the symptoms over the past six months (i.e., the SDQ) rather than the past two weeks (i.e., the DSM-CR-CCSM) was a more accurate time frame to convey what their child was experiencing, and it was difficult to recall how many days the symptoms were present. They also noted that the symptoms were different at home versus school, but it was not indicated in the tool in which context they should be rating their child’s symptoms. Example quotations from the caregivers who had no preference include: “No preference. They both capture our situation, and are easy to answer”, “Both are helpful for reflection”, and “Helped me feel helpful”.
There were considerable differences in frequencies in the responses to the items on suicidal behaviour (Table 2). There was a statistically significant difference in the intake personnel’s determination of the absence of concerns about danger to self (CMH-PCS) or suicidal thoughts/behaviours (HEADS-ED) (X2 = 4.78, p = 0.029).

4. Discussion

Ratings from both intake tools appeared to cohere well with the intake workers’ usual ratings of high, medium, and low priority. This finding lends support for implementing intake tools, which may facilitate standardizing the intake process. Neither of the caregiver-reported symptom assessment tools corresponded with the intake workers’ ratings of priority. Caregiver ratings do not appear to accurately reflect the assessment of case severity. The intake personnel and the caregivers provided insightful comments on the rating tools.
It is possible, though uncertain, whether implementing the CMH-PCS in the outpatient clinic would improve efficiencies. The CMH-PCS requires a well- structured interview and thorough knowledge of the patient, knowledge which is needed to complete any intake process. Despite comments regarding missing content on eating disorders or gender dysphoria, the CMH-PCS includes an item on “Comorbid psychiatric conditions” where these disorders could be specified/captured, or other comorbid conditions that might become common in the future could be identified. The CMH-PCS also has an item on comorbid medical conditions, which could be expanded to allow for specification of these medical conditions. The comorbidity of medical and psychiatric conditions has been identified as a main challenge in health and psychosocial care [48]. The use of the CMH-PCS or similar tool might lead to gains in efficiencies if clinicians used the completed tool to inform their initial consultations, though it is not known if clinicians would rely on it as a guide to know what issues had been raised or if they would gather their own history. However, updating an existing structured assessment (such as the CMH-PCS) may reduce the burden of repeated assessments on patients, caregivers, and clinical staff, especially if the intake/clinical assessment was contained in an electronic file [27,49] with software that permitted the insertion of updates on items of concern. Reliance on a standardized tool such as the CMH-PCS could improve interprofessional communication and could also permit clinicians to view change over time, especially for youth who are seen repeatedly in outpatient care. A clinical champion [50] may be needed to facilitate the adoption of a standardized priority tool, which can be adapted (Prof. Cawthorpe, email communication) for the local context.
Though the HEADS-ED has been successfully trialled as a hospital-based centralized referral system and deemed a useful tool for the mental health intake process [36], it may be too limited to inform the intake or clinical assessments in this child and adolescent outpatient clinic. Since there was significant correspondence with usual intake determination, the HEADS-ED might be a useful tool for use in primary care or other referral settings, and then forwarded to outpatient psychiatry along with the referral. It was designed to facilitate physician assessments [32] and has been shown to facilitate focused discussion when completed by a nurse for psychiatric consultation [33].
Suicidal behaviour is a key concern and is often the main reason for referral to adolescent specialized care [47], which was also the case for this report (n = 69, 51.5% of the sample was referred for suicidality). In the CMH-PCS, the item is phrased as ‘Danger to Self’, and response options range from none, minor, moderate, to severe. This score for danger to self is added to the other items, such that total scores of 51/100 or higher would be considered high or very high priority. In the HEADS-ED, the response options to the item on suicidality (Do you have any thoughts of wanting to kill yourself?) are none, ideation, or a plan/gesture. A score of two for suicidality or of eight or higher for the total HEADS-ED score would be considered a high priority, which aligns with the patient population. The differences in the phrasing of the item or question likely contributed to the differences in intake personnel responses; for example, Danger to Self (CMH-PCS) encompasses more than suicidal thoughts or plans (HEADS-ED). Therefore, consideration of which intake tool best captures this clinical symptom for this patient population is needed before a standardized tool can be adopted and implemented in routine clinical practice.
The caregiver ratings of their child’s symptom severity did not correlate with professional intake assessments of priority, so they are likely of little use during the intake process. However, it is not known if the caregiver ratings could inform the initial clinical consultations with the psychiatrist. According to the American Psychiatric Association, which developed the DSM-CR-CCSM, it is one of a suite of “emerging measures” expressly designed to be “administered at the initial patient interview and to monitor treatment progress” [51]. The SDQ is commonly used and has research evidence supporting its use to identify emotional and behavioural problems [52]. Because the DSM-CR-CCSM is based on the DSM-5TR and includes items on suicide and substance use, it would likely offer greater utility to clinicians than the SDQ. However, many caregivers did not seem to be aware of their children’s suicidal thoughts or behaviours, or were limited to the two- week time frame in which the question was posed in the DSM-CR- CCSM (Please see Table 2), so reliance solely on a caregiver’s perspective would likely miss many youth at-risk for suicidality. The question of whether asking about suicide can have adverse impacts may be a concern, though research suggests that adverse outcomes do not tend to follow such questions [53].

4.1. Implications for Practice and Research

Intake assessment tools may facilitate triage decision-making and treatment pathways for patients and families, and can be particularly valuable if they are designed to capture the appropriate information with ease [54]. They may even facilitate the tracking of changes in patients and families. Both intake tools explored in this study, the CMH-PCS and the HEADS-ED, were developed in Canada and validated to identify children and adolescents with mental health needs to prioritize those most in need. The CMH-PCS requires a thorough assessment, while the HEADS-ED was designed to be user-friendly. The interpretations of the scores from both tools were consistent with usual practice; however, screening tools may be of limited use if the tools are not tailored to the population and purpose, and if mental health professionals are resistant to adopting them. Clinician resistance to change or the adoption of new tools [55,56] has been identified as a barrier to evidence-based practice and knowledge translation. The intake assessment tool could be modified by intake workers to enhance its usefulness in particular settings; however, modifications may affect the psychometric properties. Any modifications should be examined in future research before incorporation into routine practice. Additionally, it may be difficult to balance the amount of detail needed with the perceived burden of completing a lengthy tool.
This study took place after the referral to mental health care was made. Future research efforts could be focused on exploring and improving the referral patterns to prioritize referral to outpatient care for those with severe mental illness by requesting the professionals who refer to the clinic to complete a brief standardized assessment, such as the HEADS-ED. It has been reported that lengthy wait times affect families’ help-seeking behaviours; lengthy waits have been associated with increased likelihood of seeking care at a different agency than the one to which the family was referred [57], leading to chaotic pathways to care, duplication of intake assessments, and fragmentation.
The timely and standardized input from caregivers was explored in the present study. It should be noted that 74% of caregivers were able to complete the child symptom rating tools within 20 days of the intake process; however, it was difficult for 26% of the sample to complete these tools within this time frame. This rate of caregiver completion is similar to other studies (e.g., 77% [58] and 85% [59]. The current study reflects real-world challenges at a stressful time for families (i.e., child referral to outpatient psychiatry) and in a resource-strained environment (i.e., outpatient psychiatry). Further exploration of implementing caregiver rating tools in child outpatient psychiatry is needed. In this study, RAs contacted caregivers by telephone to obtain informed consent and complete the tools, which provided an opportunity for reminders and clarifications if needed, but also may have reduced caregivers’ opportunity to complete the tools on their own time. Electronic technologies have been associated with improved completion rates, and parent reports have been shown to contribute distinct information to the measurement of outcomes [59]. In the future, investigators could explore the use of an online system for capturing caregiver input.

4.2. Limitations

The study makes important contributions to deliberations on how best to assess patients to prioritize mental health care for the growing number of children and adolescents who need it, though the study is not without limitations. This study was the first to be permitted in this hospital since the lockdown required to manage the COVID pandemic. There were several influences of the pandemic on the study, including some RAs becoming infected with COVID, requiring self-isolation and refraining from going to the hospital for varying periods of time. Hospital staff were required to be the first point of contact, and there were many times when staff were not able to make contact for the study due to leaves, already being overloaded with critical work, deciding that the study may not have been in the caregivers’ best interest (e.g., already too overwhelmed), and so forth. This study took place in a child and adolescent outpatient clinic, a setting known to be strained by resource issues and the complexity of the work. Consequently, some caregivers were not contacted for the study, affecting the response rate. Additionally, data were gathered at one hospital site, so the results may not apply to other settings. The sample size was adequate for analyses but was affected by missed opportunities for caregiver inclusion in the study. There may have been resistance by some intake personnel to completing the intake forms, with unknown impacts on the quality of completion. The caregiver-reported ratings may have been affected by social desirability and recall bias. Clinical staff opinions were verbally offered in a meeting and typed into a Word document by an RA; it is possible that some clinicians may have been affected by group dynamics. Asking clinical staff their opinions during a meeting was thought to be the least burdensome on them, though the method is less systematic than individually completed responses (e.g., in a survey). In future research, capturing the perspective of intake personnel in a systematic manner could advance practice research. The study was conducted in one child and adolescent outpatient unit. Lastly, the impacts of response bias are unknown.

5. Conclusions

Standardized intake tools were shown to correlate with the usual determination. Though the caregiver ratings of their children’s psychiatric symptoms did not cohere with usual determination, they may still be useful for informing assessments. The utilization of standardized intake tools expressly designed for child and adolescent psychiatric care may lead to efficiencies, though they may require adaptation to the specific setting/patients and require a champion to facilitate implementation. In an ideal world, everyone who needs mental health care would be able to access the appropriate level of care in a timely manner, and there would be a full spectrum of mental health care available to meet these needs. However, the process of identifying this need and aligning the severity of illness to the appropriate level of care is complex. The need for care is often greater than the available resources; thus, standardizing the process of prioritizing care may facilitate decisions.

Author Contributions

Conceptualization, M.P., S.P. and J.H.; methodology, M.P.; formal analysis, M.P.; investigation, M.P.; resources, M.P.; data curation, M.P.; writing—original draft preparation, M.P., R.M., A.W. and M.A.; writing—review and editing, M.P., R.M., A.W., M.A., S.P. and J.H.; supervision, M.P.; project administration, M.P.; funding acquisition, M.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research was partially funded by the Social Sciences and Humanities Research Council Institutional Grant—Explore Grant ($6998).

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Boards of the Tri-hospital Research Ethics Board (protocol code: WRHN #: 2022-0750; date of approval: 24 November 2022) and the University of Guelph (protocol code: REB# 22-08-033; date of approval: 24 November 2022).

Informed Consent Statement

Informed consent was obtained from all participants involved in the study.

Data Availability Statement

The data are not publicly available due to ethical/privacy issues.

Acknowledgments

The authors sincerely thank David Richard Leslie Cawthorpe for his careful review of a draft of the manuscript and comments. We also greatly appreciate the participants/caregivers of patients accessing psychiatric outpatient care for their time and willingness to contribute to this study, and the hospital staff and research assistants who provided invaluable support.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations were used in this manuscript:
CMH-PCSChildren’s Mental Health Priority Criteria Score
HEADS-EDThe Home, Education and employment, Activities and peers, Drugs, Suicidality, Emotions, thoughts and behaviours, and Discharge resources
CR-CCSM Caregiver reported Cross cutting symptom measure
SDQStrengths and Difficulties Questionnaire

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Table 1. Comparison of intake and caregiver tools to determination as usual by priority group, m (SD), (95% Confidence Interval), N = 134.
Table 1. Comparison of intake and caregiver tools to determination as usual by priority group, m (SD), (95% Confidence Interval), N = 134.
Intake Tool, m (SD)
(95%CI)		High Priority (n = 39)Medium Priority (n = 73)Low Priority (n = 22)p-Valueη2
CMH-PCS47.49 (17.0)
(41.8–53.2)		28.88 (10.74)
(26.4–31.4)		19.59 (8.84)
(15.7–23.5)		<0.001 *0.35
HEADS-ED6.79 (2.4)
(6.0–7.6)		4.97 (1.6)
(4.6–5.3)		3.68 (1.9)
(2.9–4.5)		<0.001 *0.24
Caregiver tool,
m (SD)
DSM-CR-CCSM28.25 (13.8)
(23.6–32.9)		24.74 (12.29)
21.5–28.0)		27.32 (12.3)
(21.0–33.7)		 0.42
SDQ15.89 (7.7)
(13.3–18.5)		17.11 (6.9)
(15.3–19.0)		15.68 (7.1)
(12.0–19.3)		 0.65
Note: CMH-PCS = The Children’s Mental Health Priority Criteria Score; HEADS-ED = The Home, Education and Employment, Activities and peers, Drugs, Suicidality, Emotions, thoughts and behaviours, and Discharge resources (intake screening tool); DSM-CR-CCSM = DSM-5-TR Caregiver-Rated Level 1 Cross-Cutting Symptom Measure; SDQ = Strengths and Difficulties Questionnaire (Caregiver-rated); * Post hoc analyses (Scheffé) indicated there were statistically significant differences on total mean scores of both intake tools between each of the three priority groups (High, Medium, Low) as determined by usual intake process.
Table 2. Responses to items on self-harm/suicide on three different measures, n (%).
Table 2. Responses to items on self-harm/suicide on three different measures, n (%).
MeasureNoneMinorModerateSevere
CMH-PCS: Danger to Self
(n = 123)		19 (15.4)55 (44.7)40 (32.5)9 (7.3)
HEADS-ED: Suicidality * (n = 123)NoneIdeationPlan or gesture
33 (27)85 (69)5 (4)
DSM-CR-CCSM (n = 113)ItemNoYesI do not know
In the past two weeks, has your child talked about wanting to kill themselves?78 (51.3)32 (21.1)3 (2.7)
Has your child EVER tried to kill themselves?85 (77)20 (18)6 (5)
* Note. Sample suicide item from HEADS-ED: “Do you have any thoughts of wanting to kill yourself?”
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Preyde, M.; Markle, R.; Watkis, A.; Aguto, M.; Parekh, S.; Heintzman, J. Piloting the Implementation of Intake Assessment Tools and Caregiver Symptom Rating Tools in a Child and Adolescent Outpatient Psychiatry. Psychiatry Int. 2026, 7, 135. https://doi.org/10.3390/psychiatryint7030135

AMA Style

Preyde M, Markle R, Watkis A, Aguto M, Parekh S, Heintzman J. Piloting the Implementation of Intake Assessment Tools and Caregiver Symptom Rating Tools in a Child and Adolescent Outpatient Psychiatry. Psychiatry International. 2026; 7(3):135. https://doi.org/10.3390/psychiatryint7030135

Chicago/Turabian Style

Preyde, Michèle, Regina Markle, Andre Watkis, Melissa Aguto, Shrenik Parekh, and John Heintzman. 2026. "Piloting the Implementation of Intake Assessment Tools and Caregiver Symptom Rating Tools in a Child and Adolescent Outpatient Psychiatry" Psychiatry International 7, no. 3: 135. https://doi.org/10.3390/psychiatryint7030135

APA Style

Preyde, M., Markle, R., Watkis, A., Aguto, M., Parekh, S., & Heintzman, J. (2026). Piloting the Implementation of Intake Assessment Tools and Caregiver Symptom Rating Tools in a Child and Adolescent Outpatient Psychiatry. Psychiatry International, 7(3), 135. https://doi.org/10.3390/psychiatryint7030135

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