Free Screening for Severe Emotional Disturbance - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20851G (Rev. 08/2008)

STATE OF WISCONSIN

G. SCREENING FOR SEVERE EMOTIONAL DISTURBANCE (ALL AGES) The child must meet all of the criteria, 1 through 4 below. 1. The child meets all three of the following: Is under the age of 21 or is attending high school; and Has an emotional disability that has persisted at least 6 months; and That same disability is expected to persist for a year or longer. 2. The child has an emotional and / or behavioral problem that has been diagnosed by a board certified psychiatrist or clinical psychologist (Ph. D.) under the classification system in the American Psychiatric Assn. Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). Adult diagnostic categories appropriate for children and adolescents are: Organic mental syndromes and disorders (292.00* - 292.90*, 294.80) Psychoactive substance use disorders (303.90, 304.00 - 304.90*, 305.00, 305.20* - 305.90*). Use codes for abuse only. Schizophrenia (395.1x, 295.2x, 295.3x, 295.6x, 295.9x) Schizoaffective disorders (295.70) Mood disorders (296.2x - 296.70, 300.40, 301.13, 311.00) Somatoform disorders (300.11, 300.70*, 300.81, 307.80) Dissociative disorders (300.12 - 300.15, 300.60) Sexual disorders (302.20 - 302.40, 302.70 - 302.79, 302.81 - 302.84, 302.89, 302.90, 306.51) Intermittent explosive disorder (312.34) Pyromania (312.33) Adjustment disorder (309.00, 309.23, 309.90) Personality disorders (coded on Axis II: 301.00, 301.20 - 301.50, 301.60 - 301.90) Psychological factors affecting physical condition (316.00 - and specify physical conditions on Axis III) Disorders often evident in infancy, childhood and adolescence include: Pervasive developmental disorders (coded on Axis II: 299.00, 299.80) Disruptive behavior disorders (312.00, 312.20, 312.90, 313.81, 314.01) Anxiety disorders of childhood or adolescence (309.21, 313.00, 313.21) Eating disorders (307.10, 307.50, 307.51, 307.52, 307.53) Gender identity disorders (302.50, 302.60, 302.85*) Tic disorders (307.20 - 307.23) Reactive attachment disorder of infancy or early childhood (313.89) 3. The child shows either a. Symptoms or b. Functional Impairments a. Symptoms - the child has at least one of the following: Psychotic symptoms - Serious mental illness (e.g. schizophrenia) characterized by defective or lost contact with reality, often with hallucinations or delusions. Suicidality - The child must have made an attempt within the last three months or have significant ideation about or have a plan for suicide within the past month.

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20851G (Rev. 08/2008)

STATE OF WISCONSIN Page 2

Violence - The child is at risk for causing injury to persons or significant damage to property as a result of emotional disturbance (significant injury / damage as in fire setting, punching holes in walls; e.g., lack of appropriate impulse controls). Anorexia Nervosa - Weight loss of at least 25% of original body weight, signs of electrolyte imbalance, cardiac arrhythmias or congestive heart failure. b. Functional Impairments in two of the following capacities, compared with expected developmental level and at a level that would place the child at risk of removal from family or its equivalent. Functioning in self care - Impairment in self care is manifested by a child's consistent inability to take care of age appropriate personal grooming, hygiene, clothes and meeting of nutritional needs. Functioning in community - Impairment in community function is manifested by a consistent lack of age appropriate behavioral controls, decision-making, judgment and value systems which results in potential involvement or involvement with the juvenile justice system. Functioning in social relationships - Impairment of social relationships is manifested by the consistent inability to develop and maintain satisfactory relationships with peers and adults. Functioning in the family - Impairment in family function is manifested by a pattern of significantly disruptive behavior exemplified by repeated and / or unprovoked violence to siblings and / or parents, disregard for safety and welfare of self or others, i.e. - fire setting, serious and chronic destructiveness, inability to conform to reasonable limitations / expectations. Functioning at school - Manifested by any one of the following: The inability at school to pursue educational goals in a normal time frame; e.g. consistently failing grades, repeated truancy, expulsion, property damage or violence toward others; or Meeting the definition of "child with exceptional educational needs" under ch. Pl 11 and 115.76(3), Wis. Stats. 4. The child is receiving services from two* or more of the following service systems. Mental Health (services of a Medicaid certifiable provider) Special Education (ED placement) Juvenile Justice (children adjudicated delinquent are not eligible for FSP) Child Protective Services (voluntary or involuntary) * Exceptions: Children with anorexia nervosa can be determined eligible when actively receiving services from only one service system such as Mental Health.