Coordinated Services Team Initiative (Cst) (Page 6 of 7) in pdf

APPENDIX A

(Complete if the Child has a Mental Health Diagnosis)

Severe Emotional Disturbance (SED) Criteria Checklist

The child must meet all of the criteria, 1. through 4. below.

Please check all criteria that apply to the child or adolescent you are referring.

1. The child/adolescent must meet all three of the following:

____ be a child or adolescent under the age of 21; and

____ have an emotional disability that has persisted for at least 6 months; and

____ that same disability must be expected to persist for a year or longer.

2. The child/adolescent has an emotional and/or behavioral disability that has been diagnosed by a board certified

psychiatrist or clinical psychologist (PhD) under the classification system in the American Psychiatric

Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) from the following list:

Name of diagnosing psychiatrist or clinical psychologist: __________________________

Adult diagnostic categories appropriate for children and adolescents include:

____ Substance-Related Disorders (303.90 – 305.90, not to include caffeine or

nicotine-related disorders)

____ Schizophrenia and Other Psychotic Disorders (293.81, 293.82, 295.10 –

295.90, 297.1, 297.3, 298.9)

____ Mood Disorders (293.83, 296.00 – 296.90, 300.4, 301.13, 311)

____ Anxiety Disorders (293.89, 300.00 – 300.02, 300.16 – 300.3, 300.7,

308.3, 309.81)

____ Somatoform Disorders (300.11, 300.81)

____ Sexual and Gender Identity Disorders (302.2 – 302.6, 302.85, 302.89, 302.9)

____ Impulse-Control Disorders (312.30, 312.33, 312.34)

____ Adjustment Disorders (309.0, 309.24 – 309.4, 309.9)

____ Personality Disorders (coded on Axis II: 301.0, 301.20 – 301.9)

Disorders usually first diagnosed in infancy, childhood, or adolescence include:

____ Pervasive Developmental Disorders (299.00, 299.10, 299.80)

____ Attention-Deficit and Disruptive Behavior Disorders (312.8, 312.9, 313.81,

314.00 – 314.9)

____ Tic Disorders (307.20, 307.22, 307.23)

____ Feeding and Eating Disorders (307.1, 307.51, 307.52, 307.53, 307.59)

____ Other Disorders of Infancy, Childhood, or Adolescence (307.3, 309.21,

313.23, 313.89)

3. The child/adolescent shows either A. Symptoms or B. Functional Impairments.

A. Symptoms – the child/adolescent must have one of the following

Psychotic symptoms – serious mental illness (e.g. schizophrenia)

____

characterized by defective of lost contact with reality, often with hallucinations or delusions.

____

Danger to self, others and property as a result of emotional disturbance. The

individual is self destructive, e.g., at risk for suicide, runaway, promiscuity, and/or at risk for

causing injury to persons or significant damage to property.

Module 2

Page 23

Coordinated Services Team Initiative (Cst) Page 6

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