Kentucky Determination Criteria Checklist for Severe Emotional Disability (SED) by Teri Lloyd | May 16, 2022 Name of Client First Last Medicaid NumberDiagnostic Codes and DescriptionSection 1Age: Is the person under age 18 or under age 21 who was receiving services prior to eighteenth birthday and that must be continued for therapeutic benefit. Yes No Section 2Diagnosis: * Individual with a clinically significant disorder of thought, mood, perception, orientation, memory or behavior that is listed in the current edition of the APA's Diagnostic an dStatistical Manual of Mental Disorders. * Excldues those children who are singularly diagnosed with intellectual disability. Yes No Section 3Limitations: Presents substantial limitation in a least 2 of the following 5 areas that have persisted for at least 1 year or are judged by a behavioral health professional to be at high risk of continuing for 1 year without professional intervention: a) Functioning in Self-Care: Impairment in self-care is manifested by a person's consistent inability to provide, sustain and protect his or herself at a level appropriate to his or her age. (e.g., significant basic hygiene or self-care needs, pattern of self-injurious behavior, pattern of physically reckless decision-making, eating disorders, failure to address serious health, nutrition, safety, or medical needs, threatens or attempts suicide) b) Functioning in Interpersonal Relationships: Impairment of interpersonal relationships (including community relationships) is manifested by a consistent inability to develop and maintain satisfactory relationships with peers and adults. Children and adolescents exhibit constrictions in their capacities for shared attention, engagement, initiation of two-way communication, and shared social problem solving. Inability to maintain safety without assistance; a consistent lack of age-appropriate behavioral controls, decision-making, judgment and value systems which result in potential out-of-home placement. (e.g., repeated or serious aggressive interactions with peers or adults in the community, isolated or withdrawn much of the time, behavior which consistently alienates peers.) c) Functioning in Family Life: Impairment in family function is manifested by the inability to live in a family or family type environment. This can include a patten of emotional or disruptive behavior exemplified by repeated and /or unprovoked aggravating or violent behaviors aimed at others in the home (siblings and/or parents and/or caretakers such as relative caregivers, foster parents) and seriously disrupts the home; disregard for safety and welfare of self or others in the home (e.g., fire setting, serious and chronic destructiveness, self-injurious behavior, inability to conform to reasonable expectations that may result in removal from the family or its equivalent). Child-caregiver and family characteristics do not include developmentally based adaptive patterns that support social-emotional well-being. d) Functioning at School/Work: Impairment in school/work function is manifested by an inability to pursue educational goals in a normal time frame (e.g., consistently failing grades, repeated truancy, expulsion, property damage, or violence toward others); the ability to learn social and intellectual skills from teachers in available educational settings (e.g., falling most courses - or some courses, if performance is significantly below ability, dropped out of school without alternative academic or vocational involvement or has serious attendance problems, behavior problems result in frequent intervention or suspensions, special class placement or expulsion); or inability to be consistently employed at a self-sustaining level (e.g., inability to conform to work schedule, poor relationships wih supervisor and other workers, hostile behavior on the job). e) Functioning in Self-Direction: Impaiarment in self-direction is manifested by an inability to control behavior and make decisions in a manner appropriate to his age. (e.g., repeated or serious violations of the law or community norms; lacks confidence or competence to perform routine age-appropriate functions in the community such as running an errand; behavior is repeatedly disruptive or inappropriate in community settings; requires adult supervision in community well after age when should have more autonomy.) NOTE: For early childhood functioning, major impairments undermine the fundamental foundation of healthy functioning by: Rarely or minimally seeking comfort in distress; Limited positive affect and excessive levels of irritability, sadness ore fear: Disruptions in feeding and sleeping patterns; Failure, even in unfamiliar settings, to check back with adult caregivers after venturing away; Willingness to go off with an unfamiliar adult with minimal or no hesitation; Regression of previously learned skills; keep friends; Inability to share Section 4AND Duration: Presents substantial limitation or symptomology in the areas above that have persisited for at least one (1) year or are judged by a mental health professional to be at risk of continuing for one 91) year without professional Intervention: OR: Interstate Compact (per KRS Chapter 615): Is a Kentucky resident and is receiving residential treatment for emotional disability through the interstate compadt; OR: DCBS Out of Home Placement: The Department of Community Based Services has removed the child from the child's home and has been unable to maintain the child in a stable setting due to emotional disturbance. Consent The individual meets the criteria for the designation of Severe Emotional Disability (SED). Documentation of the existence of these criteria of Age, Diagnosis, disability and Duration is present in the individual's medical record and assessment has been conducted bya qualified licensed behavioral health professional.Print Name /Credentials SignatureDate MM slash DD slash YYYY Submit a Comment Cancel replyYou must be logged in to post a comment.
