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Office of Mental Health

CANS-NY CODING DEFINITIONS FOR THE RATINGS

Note: Rate each for the prior 30 days unless otherwise specified.

CHILD/YOUTH STRENGTHS DOMAIN

Check FAMILY This item describes to degree to which positive and supportive relationships exist within the family
0 Family has strong relationships and excellent communication.
1 Family has some good relationships and good communication.
2 Family needs some assistance in developing relationships and/or communication.
3 Family needs significant assistance in developing relationships and communication or child/youth has no identified family.
Notes:
Check INTERPERSONAL This item describes the ability to make and maintain positive relationships.
0 Child/Youth has well-developed interpersonal skills and friends.
1 Child/Youth has good interpersonal skills and has shown the ability to develop healthy friendships.
2 Child/Youth needs assistance in developing good interpersonal skills and/or healthy friendships.
3 Child/Youth needs significant help in developing interpersonal skills and healthy friendships.
Notes:
Check RELATIONSHIP STABILITY This rating refers to the stability of significant relationships in the child or youth's life. This likely includes family members but may also include other individuals.
0 This level indicates a child/youth who has stable relationships. Family members, friends, and community have been stable for most of his/her life and are likely to remain so in the foreseeable future.
1 This level indicates a child/youth who has had stable relationships but there is some concern about instability in the near future due to such things as transitions or illness.
2 This level indicates a child/youth who has had at least one stable relationship over his/her lifetime but has experienced other instability through factors such as divorce, moving, removal from home, and death within the past year.
3 This level indicates a child/youth who does not have stability in relationships.
Notes:
Check OPTIMISM Please rate the highest level from the past 30 days.
0 Child/Youth has a strong and stable optimistic outlook on his/her life.
1 Child/Youth is generally optimistic.
2 Child/Youth has difficulties maintaining a positive view of him/herself and his/her life; child/youth may vary from overly optimistic to overly pessimistic.
3 Child/Youth has difficulties seeing any positives about him/herself or his/her life.
Notes:
Check PROBLEM SOLVING This rating should be based on the individual's ability to identify and use external/environmental strengths in managing his/her life.
0 Child/Youth is quite skilled at finding the necessary resources required to aid him/her in managing challenges.
1 Child/Youth has some skills at finding necessary resources required to aid him/her in a healthy lifestyle but sometimes requires assistance in identifying or accessing these resources.
2 Child/Youth has limited skills for finding necessary resources required to aid in achieving a healthy lifestyle and requires temporary assistance both with identifying and accessing these resources.
3 Child/Youth has no skills for finding the necessary resources to aid in achieving a healthy lifestyle and requires ongoing assistance with both identifying and accessing these resources.
Notes:
Check CULTURAL IDENTITY Cultural identity refers to the child/youth's view of him/herself as belonging to a specific cultural group. Culture may be defined by factors including race, religion, ethnicity, geography or lifestyle.
0 Child/youth has clear and consistent cultural identity and is connected to others who share his/her cultural identity.
1 Child/youth is experiencing some confusion or concern regarding cultural identity.
2 Child/youth has significant struggles with his/her own cultural identity; child/youth may have cultural identity but is not connected with others who share this culture.
3 Child/youth has no cultural identity or is experiencing significant problems due to conflict regarding his/her cultural identity.
Notes:
Check SPIRITUAL/RELIGIOUS This item describes the child/youth involvement in spiritual and religious practices and communities. Particularly for children, family involvement in these activities can be rated as a strength.
0 Child/youth receives comfort and support from religious and/or spiritual beliefs and practices.
1 Child/youth is involved in a religious community whose members provide support.
2 Child/youth has expressed some interest in religious or spiritual belief and practices.
3 Child/youth has neither identified religious or spiritual beliefs nor interest in these pursuits.
Notes:
Check COMMUNITY LIFE This item describes the child/youth's degree of connection to his/her community.
0 Child/youth is well-integrated into his/her community. He/she is a member of community organizations and has positive ties to the community.
1 Child/youth is somewhat involved with his/her community.
2 Child/youth has an identified community but has only limited ties to that community.
3 Child/youth has no identified community to which he/she is a member.
Notes:
Check TALENTS/INTEREST This item describes a broad array of possible activities that the child/youth may enjoy and use to help in development. Included are athletic, artistic, hobbies, etc.
0 Child/Youth has a talent that provides him/her with pleasure and/or self esteem.
1 Child/Youth has a talent, interest, or hobby with the potential to provide him/her with pleasure and self esteem.
2 Child/Youth has identified interests but needs assistance converting those interests into a talent or hobby.
3 Child/Youth has no identified talents, interests or hobbies.
Notes:
Check EDUCATIONAL This item rates the degree of partnership between the school and others in meeting the child/youth's educational needs.
0 School works closely with child/youth and family to identify and successfully address child's/youth's educational needs OR child/youth excels in school.
1 School works with child/youth and family to identify and address educational needs.
2 School currently unable to adequately identify and/or address child's/youth's needs.
3 School unable and/or unwilling to work to identify and address child's/youth's needs.
N/A Child is not in school due to age under 5.
Notes:
Check VOCATIONAL This item describes the degree of job/career related skills possessed by the youth. Most children would be rated a '3' or NA.
0 Youth has vocational skills and work experience.
1 Youth has some vocational skills or work experience.
2 Youth has some prevocational skills.
3 Youth needs significant assistance developing vocational skills.
N/A Child is under age 14 .
Notes:
Check RESILIENCY This rating should be based on the individual's ability to identify and use internal strengths in managing their lives.
0 Child/Youth is able to both identify and use internal strengths to better her/himself and successfully manage difficult challenges.
1 Child/Youth is able to identify most of his/her internal strengths and is able to partially utilize them.
2 Child/Youth is able to identify internal strengths but is not able to utilize them effectively.
3 Child/Youth is not yet able to identify internal personal strengths.
Notes:

PRIMARY CAREGIVER AND SECONDARY INVOLVEMENT (SI) STRENGTHS DOMAIN

Use these definitions for the strengths of the primary caregiver and for the strengths of the secondary perspective, when indicated.

Check SUPERVISION This item describes the caregivers' ability to monitor and discipline the child/youth in all the ways that are required.
0 Caregiver/SI has good monitoring and discipline skills.
1 Caregiver/SI provides generally adequate supervision; may need occasional help or technical assistance.
2 Caregiver/SI reports difficulties monitoring and/or disciplining child/youth. Caregiver needs assistance to improve supervision skills.
3 Caregiver/SI is unable to monitor or discipline the child/youth. Caregiver requires immediate and continuing assistance. Child is at risk of harm due to absence of supervision.
Notes:
Check CARE INVOLVEMENT This item describes the degree to which the caregiver is involvement in seeking and supporting care to address the needs of their child.
0 Caregiver/SI is able to act as an effective advocate for child/youth.
1 Caregiver has history of seeking help for their children. Caregiver is open to support, education, and information.
2 Caregiver/SI reports difficulties monitoring and/or disciplining child/youth. Caregiver needs assistance to improve supervision skills.
3 Caregiver/SI wishes for child/youth to be removed from their care.
Notes:
Check KNOWLEDGE This item seeks to identify whether the caregiver requires further information in order to best advocate for their child.
0 Caregiver/SI is knowledgeable about the child's/youth's needs and strengths.
1 Caregiver/SI is generally knowledgeable about the child/youth but may require additional information to improve their parenting capacity.
2 Caregiver/SI reports difficulties monitoring and/or disciplining child/youth. Caregiver needs assistance to improve supervision skills.
3 Caregiver/SI lack of knowledge places the child/youth at risk of significant negative outcomes.
Notes:
Check ORGANIZATION This item describes the ability of the caregiver to organize and manage the household.ORGANIZATION This item describes the ability of the caregiver to organize and manage the household.
0 Caregiver/SI has good monitoring and discipline skills.
1 Caregiver/SI has minimal difficulties with organizing and maintaining a household that supports needed services, i.e., caregiver may now and then be forgetful about appointments or occasionally fail to return case manager calls.
2 Caregiver/SI reports difficulties monitoring and/or disciplining child/youth. Caregiver needs assistance to improve supervision skills.
3 Caregiver/SI is unable to organize a household that supports needed services.
Notes:
Check NATURAL SUPPORTS This item describes the presence of unpaid others to support raising the child.
0 Caregiver/SI has good monitoring and discipline skills.
1 Caregiver/SI has some family, friend or social network that actively helps with raising the child/youth.
2 Caregiver/SI has some family, friend or social network that may be able to help with raising the child/youth.
3 Caregiver/SI is unable to monitor or discipline the child/youth. Caregiver requires immediate and continuing assistance. Child is at risk of harm due to absence of supervision.
Notes:
Check RESIDENTIAL STABILITY This item describes the housing stability of the caregiver.
0 Caregiver/SI has good monitoring and discipline skills.
1 Caregiver/SI has relatively stable housing but either has moved in the past three months or there are indications of housing problems that might force them to move in the next three months.
2 Caregiver/SI has moved multiple times in the past year. Housing is unstable.
3 Caregiver/SI has experienced periods of homelessness in the past six months.
Notes:
Check PROBLEM SOLVING Please rate the highest level from the past 30 days. This rating should be based on the individual's ability to identify and use external/environmental strengths in managing his/her live
0 Caregiver/SI has good monitoring and discipline skills.
1 Caregiver/SI has some skills in finding necessary resources that are useful in aiding him/her and the family including, the child/youth, in achieving and maintaining safety and well-being but sometimes requires assistance in identifying or accessing resources
2 Caregiver/SI has limited skills in finding necessary resources that are useful in aiding him/her and the family, including the child/youth, in achieving and maintaining safety and well-being and requires temporary assistance both with identifying and accessing these resources.
3 Caregiver/SI has no skills in finding the necessary resources that are useful in aiding him/her and the family, including the child/youth, in achieving and maintaining safety and well-being and requires ongoing assistance with both identifying and accessing resources.
Notes:
Check CULTURAL IDENTITY This refers to the caregiver’s view of his/herself as belonging to a specific cultural group. Culture may be defined by factors including race, religion, ethnicity, geography or lifestyle.
0 Caregiver/SI has clear, consistent cultural identity and is connected to others who share his/her cultural identity.
1 Caregiver/SI provides generally adequate supervision; may need occasional help or technical assistance.
2 Caregiver/SI has significant struggles with his/her own cultural identity. The caregiver may have cultural identity but is not connected with others who share this culture.
3 Caregiver/SI has no cultural identity or is experiencing significant conflict regarding cultural identity.
Notes:

PRIMARY CAREGIVER AND SECONDARY INVOLVEMENT (SI) NEEDS DOMAIN

Use these definitions for the needs of the primary caregiver and, for the needs of the secondary perspective.

Check LEGAL This item describes the caregiver involvement in courts based on his/her behavior
0 Caregiver/SI has no known legal difficulties.
1 Caregiver/SI has a history of legal problems but currently is not involved with the legal system.
2 Caregiver/SI has some legal problems and is currently involved in the legal system.
3 Caregiver/SI has serious current or pending legal difficulties that place him/her at risk for a court ordered out of home placement.
Notes:
Check PHYSICAL This item describes the presence of any medical or physical challenges to caregiving.
0 Caregiver/SI is in recovery from medical/physical problems.
1 Caregiver/SI has medical/physical problems that interfere with his/her capacity to parent.
2 Caregiver/SI has medical/physical problems that make it impossible for him/her to parent at this time.
3 Caregiver/SI has good monitoring and discipline skills.
Notes:
Check MENTAL HEALTH This item describes the presence of any mental health challenges to caregiving.
0 Caregiver/SI has no mental health needs.
1 Caregiver/SI is in recovery from mental health difficulties.
2 Caregiver/SI has some mental health difficulties that interfere with his/her capacity to parent.
3 Caregiver/SI has mental health difficulties that make it impossible for him/her to parent at this time.
Notes:
Check SUBSTANCE USE This item describes the presence of any substance use challenges to caregiving.
0 Caregiver/SI has no substance use needs.
1 Caregiver/SI is in recovery from substance use difficulties.
2 Caregiver/SI has some substance use difficulties that interfere with his/her capacity to parent.
3 Caregiver/SI has substance use difficulties that make it impossible for him/her to parent at this time.
Notes:
Check DEVELOPMENTAL This item describes the presence of any developmental challenges to caregiving.
0 Caregiver/SI has good monitoring and discipline skills.
1 Caregiver/SI has developmental challenges but they do not currently interfere with parenting.
2 Caregiver/SI reports difficulties monitoring and/or disciplining child/youth. Caregiver needs assistance to improve supervision skills.
3 Caregiver/SI has severe developmental challenges that make it impossible for her/him to parent at this time.
Notes:
Check SAFETY This item describes the need for child protective interventions.
0 Household is safe and secure. Child/Youth is at no risk from others.
1 Household is safe but concerns exist about the safety of the child/youth due to history or others in the neighborhood that might be abusive. 
2 Child/Youth is in some danger from one or more individuals with access to the household.
3 Child/Youth is in immediate danger from one or more individuals with unsupervised access..
Notes:
Check ACCULTURATION/LANGUAGE This item includes both spoken and sign language.
0 Caregiver/SI has good monitoring and discipline skills.
1 Caregiver/SI provides generally adequate supervision; may need occasional help or technical assistance.
2 Caregiver(s)/SI does not speak English A translator or native language speaker is needed for successful intervention and a qualified individual can be identified within natural supports.
3 Caregiver(s) /SI does not speak English A translator or native language speaker is needed for successful intervention and no such individual is available from among natural supports.
Notes:

CHILD/YOUTH LIFE FUNCTIONING DOMAIN

Check PRIMARY CAREGIVER The caregiver may be a family member or non-family member for this rating category.
0 Caregiver/SI has good monitoring and discipline skills.
1 Child/Youth is doing adequately in relationships with primary caregiver(s) and others in the living environment although some problems may exist.
2 Caregiver/SI reports difficulties monitoring and/or disciplining child/youth. Caregiver needs assistance to improve supervision skills.
3 Child/Youth is having severe problems with primary caregiver or others in the living environment (including siblings, and/or other family members). This would include problems of domestic violence, constant arguing, etc.
Notes:
Check FAMILY Complete this category only if family (biological or adoptive) is NOT the primary caregiver but has contact/involvement with the child.
0 Child/Youth is doing well in relationships with family.
1 Caregiver/SI provides generally adequate supervision; may need occasional help or technical assistance.
2 Child/Youth is having moderate problems with family including siblings and/or other family members.
3 Child/Youth is having severe problems with family including siblings, and/or other family members. This would include problems of domestic violence, constant arguing, etc.
N/A Family is current primary caregiver and has been rated in the above Caregiver category.
Notes:
Check ACCULTURATION/LANGUAGE This item includes both spoken and sign language.
0 Child/youth speaks and understands English well.
1 Child/youth speaks some English but potential communication problems exist due to limits on vocabulary or understanding of the nuances of the language.
2 Caregiver/SI reports difficulties monitoring and/or disciplining child/youth. Caregiver needs assistance to improve supervision skills.
3 Child/youth does not speak English. A translator or native language speaker is needed for successful intervention and no such individual is available from among natural supports.
Notes:
Check LIVING SITUATION This item describes the child/youth functioning in their current living environment.
0 No evidence of problem with functioning in current living environment.
1 Mild problems with functioning in current living situation; caregivers are concerned about child's/youth's behavior in living situation.
2 Moderate to severe problems with functioning in current living situation; child/youth has difficulties maintaining his/her behavior in this setting, creating significant problems for others in the residence.
3 Caregiver/SI is unable to monitor or discipline the child/youth. Caregiver requires immediate and continuing assistance. Child is at risk of harm due to absence of supervision.
Notes:
Check SLEEP This item describes any challenges for the child/youth or his/her environment with regards to his/her pattern of sleeping.
0 Child/Youth gets a full night's sleep each night
1 Caregiver/SI provides generally adequate supervision; may need occasional help or technical assistance.
2 Child/ Youth is having problems with sleep. Sleep is often disrupted and youth seldom obtains a full night of sleep.
3 Caregiver/SI is unable to monitor or discipline the child/youth. Caregiver requires immediate and continuing assistance. Child is at risk of harm due to absence of supervision.
Notes:
Check SEXUALITY This item describes any challenges in the area of sexuality or sexual development.
0 Child/Youth has healthy sexual development.
1 Child/Youth has some issues with sexual development but these do not interfere with his/her functioning in other life domains.
2 Child/Youth has problems with sexual development that interfere with his/her functioning in other life domains.
3 Child/Youth has severe problems with sexual development.
Notes:
Check KNOWLEDGE OF SEXUALITY This item describes any developmentally appropriate need the child/youth may have in terms of knowledge about sexual relations.
0 Child/Youth has developmentally appropriate level of knowledge about sex and sexuality.
1 Child/Youth may be more knowledgeable about sex and sexuality than would be indicated by their age.
2 Child/Youth has significant deficits in knowledge about sex or sexuality. These deficits interfere with the child's/youth's functioning in at least one life domain.
3 Child/Youth has significant deficits in knowledge about sex and /or sexuality that places him/her at risk for significant physical or emotional harm.
Notes:
Check SOCIAL FUNCTIONING This item describes the presence of any need in the child/youth's relational world.
0 Child/Youth is on a healthy social development pathway.
1 Child/Youth is having some minor problems with his/her social development.
2 Child/Youth is having some moderate problems with his/her social development.
3 Child/Youth is experiencing severe disruptions in his/her social development.
Notes:
Check RECREATIONAL This item describes any needs in the child/youth's use of leisure time.
No evidence of any problems with recreational functioning. Child/Youth has access to sufficient activities that he/she enjoys
.
0 Child/Youth is participating in recreational activities although some problems may exist.
1 Caregiver/SI provides generally adequate supervision; may need occasional help or technical assistance.
2 Child/Youth is having moderate problems with recreational activities. Child/Youth may experience some problems with effective use of leisure time.
3 Child/Youth has no access to or interest in recreational activities. Child/Youth has significant difficulties making use of leisure time.
Notes:
Check JOB FUNCTIONING This item should only be rated in the youth is employed.
0 Youth has some mild problems at work (e.g. tardiness, conflict).
1 Youth has moderate problems at work.
2 Youth has severe problems at work in terms of attendance, performance or relationships; youth may have recently lost a job.
3 Youth is not currently or recently employed or is under age 14.
Notes:
Check SCHOOL BEHAVIOR This item describes behavior when attending school.
0 Child/Youth is behaving well in school.
1 Child/Youth is behaving adequately in school although some behavior problems exist.
2 Child/Youth is having moderate behavioral problems at school. He/she is disruptive and may have received sanctions including suspensions.
3 Child/Youth is having severe problems with behavior in school. He/she is frequently or severely disruptive. School placement may be in jeopardy due to behavior.
N/A Child/youth is not in school due to age.
Notes:
Check SCHOOL ACHIEVEMENT This item is rated based on developmental age rather than chronicological age.
0 Child/Youth is doing well in school.
1 Child/Youth is doing adequately in school although some problems with achievement exist.
2 Child/Youth is having moderate problems with school achievement. He/she may be failing some subjects.
3 Child/Youth is having severe achievement problems. He/she may be failing most subjects or is more than one year behind same age peers in school achievement.
N/A Child is not in school due to age.
Notes:
Check SCHOOL ATTENDANCE This item describes any challenge with regard to be physically present at school.
0 Child/Youth has some problems attending school but generally goes to school; may miss up to one day per week on average OR may have had moderate to severe problem in the past six months but has been attending school regularly in the past month.
1 Child/Youth is having problems with school attendance. He/she is missing at least two days each week on average.
2 Child/Youth is generally truant or refusing to go to school.
3 Child/Youth is not in school due to age.
Notes:
Check JUVENILE JUSTICE/LEGAL This item describes the child/youth's involvement in the court system due to his/her own behavior (i.e. juvenile justice involvement).
0 Child/Youth has no known legal difficulties.
1 Child/Youth has a history of legal problems but currently is not involved with the legal system.
2 Child/Youth has some legal problems and is currently involved in the legal system.
3 Child/Youth has serious current/pending legal difficulties that create risk of court ordered out of home placement.
Notes:
Check DEVELOPMENTAL Note: A score of 1, 2, or 3 indicates need to complete the Developmental Domain.
0 Child/Youth has no developmental problems.
1 Child/Youth has some problems with immaturity or there are concerns about possible developmental delay. Child/Youth may have low IQ.
2 Child/Youth has developmental delays or mild mental retardation.
3 Child/Youth has severe and pervasive developmental delays or profound mental retardation.
Notes:
Check MEDICAL Note: A score of 1, 2, or 3 indicates need to complete the Medical Health Domain.
0 Child/Youth is healthy.
1 Child/Youth has some medical problems that require medical treatment.
2 Child/Youth has chronic illness that requires ongoing medical intervention..
3 Child/Youth has life threatening illness or medical condition.
Notes:
Check BEHAVIORAL HEALTH Note: A score of 1, 2, 3, also indicates need to complete the Behavioral Health Domain.
0 Child/Youth has no emotional or behavioral difficulties.
1 Child/Youth has some emotional or behavioral difficulties but these challenges do not interfere with current functioning.
2 Child/Youth has notable emotional or behavioral difficulties that currently interfere with the child/youth, family or community functioning.
3 Child/Youth has dangerous or disabling emotional or behavioral difficulties.
Notes:
Check ADJUSTMENT TO TRAUMA Note: If rating is 1, 2, or 3, OMH must complete the Trauma Module.
0 No evidence of traumatic events.
1 History or suspicion of problems associated with traumatic life event/s.
2 Clear evidence of adjustment problems associated with traumatic life event/s; adjustment is interfering with child's functioning in at least one life domain within the past 30 days.
3 Clear evidence of symptoms of Post Traumatic Stress Disorder which may include flashbacks, nightmares, significant anxiety, and intrusive thoughts of trauma experience within the past 30 days.
Notes:
Check SUBSTANCE EXPOSURE This dimension describes the child's exposure to substance use and abuse before birth.
0 Child/Youth had no in utero exposure to alcohol or drugs.
1 Child/Youth had mild in utero exposure (e.g. mother ingested alcohol or tobacco in small amounts fewer than four times during pregnancy).
2 Child/Youth was exposed to significant alcohol or drugs in utero. Any ingestion of illegal drugs during pregnancy (e.g. heroin, cocaine), or significant use of alcohol or tobacco, would be rated here.
3 Child/Youth was exposed to alcohol or drugs in utero and evidenced symptoms of substance withdrawal at birth (e.g. crankiness, feeding problems, tremors, weak and continual crying).
Notes:
Check SUBSTANCE USE Note: A score of 1,2, or 3, indicates the need to complete the Substance Use Module.
0 No evidence of substance use.
1 History or suspicion of substance use.
2 Clear evidence of substance use that interferes with functioning in any life domain.
3 Child requires detoxification OR is addicted to alcohol and/or drugs (include here a child/youth who is intoxicated at time of the assessment, e.g., currently under influence).
Notes:

CHILD/YOUTH RISK BEHAVIORS DOMAIN

Check SUICIDE RISK This item describes any circumstances involving thought or efforts of the child./youth to kill him/herself.
0 No evidence of suicide risk.
1 History but no recent ideation or gesture.
2 Within the past 30 days, has evidenced ideation or gesture but not in the past 24 hours.
3 Current ideation and intent OR command hallucinations that involves self-harm.
Notes:
Check SELF-INJURIOUS BEHAVIOR This item describes repetitive self harm, non-suicidal self injury that is generally serving a self-soothing purpose.
0 No evidence of self-injurious behavior.
1 History of self-injurious behavior.
2 Within the past 30 days has engaged in self injurious behavior that does not require medical attention.
3 Within the past 30 days has engaged in self injurious behavior that requires medical attention
Notes:
Check OTHER SELF HARM This item describes reckless behavior other than suicide or self injury that places the child/youth at risk of physical harm.
0 No evidence of behaviors other than suicide or self-mutilation that place the child/youth at risk of physical harm.
1 History of behavior other than suicide or self-mutilation that places child/youth at risk of physical harm; this includes reckless and risk-taking behavior that may endanger the child/youth.
2 Within the past 30 days, has engaged in behavior other than suicide or self-mutilation that places him/her in danger of physical harm; this includes reckless behavior or intentional risk-taking behavior.
3 Within the past 30 days engaged in behavior other than suicide or self-mutilation that places him/her at immediate risk of death; this includes reckless behavior or intentional risk-taking behavior.
Notes:
Check DANGER TO OTHERS This item describes the level of physical risk to others from the child/youth's behavior.
0 No evidence of danger to others.
1 History of homicidal ideation, physically harmful aggression or fire setting that put self or others in danger.
2 Homicidal ideation, physically harmful aggression, or dangerous fire setting within the past 30 days but not in the past 24 hours.
3 Within the past 30 days, acute homicidal ideation with plan, physically harmful aggression OR command hallucinations that involve harm of others; or child/youth set a fire that placed others at significant risk of harm.
Notes:
Check SEXUAL AGGRESSION This item describes the perpetration of sexually aggressive behavior.
No evidence of any history of sexually aggressive behavior; no sexual activity with younger children, non-consenting others, or children not able to understand consent
.
0 History of overtly sexually aggressive behavior prior to one year ago OR within the past year sexually non-aggressive but inappropriate behavior that troubles others such as harassing talk or excessive masturbation
1 History of behavior other than suicide or self-mutilation that places child/youth at risk of physical harm; this includes reckless and risk-taking behavior that may endanger the child/youth.
2 Child/youth has engaged in sexually aggressive behavior in the past year but not in the past 30 days
3 Child/youth has engaged in sexually aggressive behavior in the past 30 days
Notes:
Check DELINQUENT BEHAVIOR This item describes behavior that could get the child/youth arrested.
0 No evidence.
1 History of delinquency.
2 Acts of delinquency within the past 30 days.
3 Severe acts of delinquency that place others at risk of significant loss or injury or place child/youth at risk of adult sanctions within the past 30 days.
Notes:
Check EXPLOITATION Please rate the highest level. This item examines the history and level of current risk of exploitation of the child/youth by others within the past year
0 No evidence of exploitation against the child/youth within the past 30 days and no significant history of child/youth being exploited within the past year; the child/youth may have been robbed or bullied on one or more occasions in the past, but no pattern of exploitation exists; child/youth is not presently at risk for re-exploitation.
1 Child/youth has a history of being exploited but has not been exploited, bullied or victimized in the past year and is not presently at risk of re-exploitation.
2 Child/youth has been exploited within the past year but is not currently in acute risk of re-exploitation; this might include physical or sexual abuse, significant psychological abuse by family or friend, extortion or violent crime.
3 Child/youth has been recently exploited and is in acute risk of re-exploitation; examples include working as a prostitute, being forced into parentified roles and responsibilities and living with an abusive relationship.
Notes:
Check FIRE SETTING This item describes behavior related to setting fires whether intentional or accidental.
0 No evidence of fire setting.
1 History of fire setting but not in the past six months
2 Setting a fire in the past six months but not of the type that has endangered the lives of others OR repeated non-endangering fire-setting behavior over a period of the past two years including in the past six months.
3 Current acute threat of fire setting or has set fire that endangered others (i.e., tried to burn down a house).
Notes:
Check RUNAWAY This item describes behavior related to attempts to escape an environment by leaving without permission.
0 No evidence of runaway behavior.
1 History of running away from home or other settings involving at least one overnight absence within 30 days.
2 Recent runaway behavior or ideation but not in the past 7 days.
3 Acute runaway risk as manifest by either recent attempts OR significant ideation about running away; OR child/youth is currently a runaway.
Notes:
Check INTENTIONAL MISBEHAVIOR This item refers to behavior in which the child or youth is intentionally trying to force adults to sanction him/her. Children and youth often attempt to force one sanction in order to avoid a different one. This item was formerly called "Social Behavior".
0 No evidence of problematic social behavior; child/youth does not typically engage in behavior that forces adults to sanction him/her .
1 Mild level of problematic social behavior which might include intentional or unintentional occasional inappropriate social behavior that forces adults to sanction the child/youth; infrequent inappropriate comments to strangers or infrequent unusual behavior in social settings.
2 Moderate level of problematic social behavior: Intentional or unintentional social behavior that is causing problems in the child's/youth's life at home and/or in the community or school.
3 Severe level of problematic social behavior: Frequent serious intentional or unintentional inappropriate social behavior that forces adults to seriously and/or repeatedly sanction the child/youth; or inappropriate social behaviors that are sufficiently severe that they place the child at risk of significant sanctions (e.g. expulsion, removal from the community).
Notes:
Check DECISION MAKING This item describes the child or youth's ability to anticipate consequences of choices use developmentally appropriate judgment.
0 No evidence of problems with judgment or poor decision making that result in harm to development and/or well-being.
1 History of problems with judgment in which the child/youth makes decision that are in some way harmful to his/her development and/or well-being; for example, this could include a child/youth who has a history of hanging out with other children who shoplift.
2 Within the last 30 days, problems with judgment in which the child/youth makes decisions that are in some way harmful to his/her development and/or well-being.
3 Within the last 30 days, problems with judgment that place the child/youth at risk of significant physical harm.
Notes:
Check PSYCHOSIS The key symptoms of psychosis include hallucinations, delusions (consider age), very bizarre thoughts, or very bizarre behavior.
0 No evidence of psychosis
1 History or suspicion of hallucinations, delusions or bizarre behavior that might be associated with some form of psychotic disorder.
2 Clear evidence of hallucinations, delusions or bizarre behavior that might be associated with some form of psychotic disorder within the past 30 days.
3 Clear evidence of dangerous hallucinations, delusions, or bizarre behavior that might be associated with some form of psychotic disorder which places the child/youth or others at risk of physical harm within the past 30 days.
Notes:
Check IMPULSIVITY/HYPERACTIVITY This key aspect of impulsivity is evidence of the loss of control of the behavior (any behavior can be impulsive but no behavior is always impulsive).
0 No evidence of impulsivity/hyperactivity.
1 Some problems with impulsive, distractible or hyperactive behavior that places the child/youth at risk of future functioning difficulties.
2 Clear evidence of problems with impulsive, distractible, or hyperactive behavior that interferes with the child's/youth's ability to function in at least one life domain.
3 Clear evidence of a dangerous level of impulsive behavior that can place the child/youth at risk of physical harm.
Notes:
Check DEPRESSION With children and youth the mood state might be irritable rather than sad.
0 No evidence of depression.
1 History or suspicion of depression; or within the past 30 days, mild to moderate depression associated with a recent negative life event with minimal impact on life domain functioning at this time.
2 Within the last 30 days, clear evidence of depression associated with either depressed mood or significant irritability which has interfered significantly in child's/youth's ability to function in at least one life domain.
3 Within the last 30 days, clear evidence of disabling level of depression that makes it virtually impossible for the child/youth to function in any life domain.
Notes:
Check ANXIETY This item describes worries or fearfulness that interfere with functioning.
0 No evidence of anxiety.
1 History or suspicion of anxiety problems; or within the past 30 days, mild to moderate anxiety associated with a recent negative life event with minimal impact on life domain functioning at this time.
2 Within the last 30 days, clear evidence of anxiety associated with either anxious mood or significant fearfulness that interferes significantly in child's/youth's ability to function in at least one life domain.
3 Within the last 30 days, clear evidence of debilitating level of anxiety that makes it virtually impossible for the child/youth to function in any life domain.
Notes:
Check OPPOSITIONAL This item describes a deviance of or non-compliance with authority figures.
0 No evidence of Oppositional Disorder.
1 History of problems with judgment in which the child/youth makes decision that are in some way harmful to his/her development and/or well-being; for example, this could include a child/youth who has a history of hanging out with other children who shoplift.
2 Clear evidence within the past 30 days of oppositional and/or defiant behavior towards authority figures, which is currently interfering with the child's/youth's functioning in at least one life domain; behavior may cause emotional harm to others.
3 Clear evidence within the past 30 days of a dangerous level of oppositional behavior involving the threat of physical harm to others.
Notes:
Check CONDUCT This item describes antisocial behavior.
0 No evidence of Conduct Disorder.
1 History or suspicion of problems associated with antisocial behavior including but not limited to lying, stealing, manipulating others, sexual aggression, violence towards people, property or animals.
2 Clear evidence of antisocial behavior including but not limited to lying, stealing, manipulating others, sexual aggression, violence towards people, property, or animals.
3 Evidence of a severe level of conduct problems as described above that places the child/youth or community at significant risk of physical harm due to these behaviors.
Notes:
Check ANGER CONTROL This item describes problems associated with anger, it may or may not be associated with loss of control of behavior.
0 No evidence of any significant anger control problems.
1 Some problems with controlling anger; child/youth may sometimes become verbally aggressive when frustrated; peers and family may be aware of and may attempt to avoid stimulating angry outbursts.
2 Moderate anger control problems; child/youth's temper has gotten him/her in significant trouble with peers, family and/or school; anger may be associated with physical violence; others are likely quite aware of anger potential.
3 Severe anger control problems; child/youth's temper is likely associated with frequent fighting that is often physical; others likely fear him/her.
Notes:
Check ATTACHMENT This item describes the child or youth's ability to form relationships in an age appropriate way.
0 No evidence of attachment problems; parent-child relationship is characterized by satisfaction of needs and child/youth's development of a sense of security and trust.
1 Mild problems with attachment; this could involve either mild problems with separation or mild problems of detachment.
2 Moderate problems with attachment; child/youth is having problems with attachment that require intervention; child/youth who meet the criteria for an Attachment Disorder in DSM-IV would be rated here.
3 Severe problems with attachment; child/youth who is unable to separate or a child/youth who appears to have severe problems with forming or maintaining relationships with caregivers would be rated here.
Notes:

CHILD/YOUTH DEVELOPMENTAL DOMAIN

Check COGNITIVE
0 Child's/Youth's intellectual functioning appears to be in normal range; there is no reason to believe that the child has any problems with intellectual functioning.
1 Child/Youth has low IQ (70 to 85) or has identified learning challenges.
2 Child/Youth has mild mental retardation. IQ is between 55 and 70.
3 Child/Youth has moderate to profound mental retardation. IQ is less than 55.
Notes:
Check AGITATION
0 Child/youth does not exhibit agitated behavior.
1 Child/youth becomes agitated on occasion but can be calmed relatively easily.
2 Child/youth becomes agitated often and/or can be difficult to calm.
3 Child/youth exhibits a dangerous level of agitation. He/she becomes agitation often and easily and becomes aggressive towards self and/or others.
Notes:
Check SELF STIMULATION This rating includes self-stimulation (pacing, rocking, gesticulating, and some verbalizations, this rating does not include masturbation), and agitation related to the over or under stimulation of the sensory environment. This rating also includes ability of the child/youth to use all of the senses.
0 No evidence of self-stimulation; no agitation when exposed to sensory stimuli; no impairment of sensory functioning.
1 Mild level of agitation or self-stimulation including such behaviors as periodic pacing or rocking; sensitive to touch or texture or to loud or bright environments; or seeks out stimulation. This dimension can also apply to a child/youth with a mild impairment of a single sense (i.e. vision or hearing).
2 Moderate to severe level of agitation and/or self-stimulation. Examples may include frequent rocking, odd behaviors, pacing, etc;. easily agitated/distressed by stimulation of senses (touch, taste, texture, noise, lights). This dimension can include a moderate impairment on a single sense or mild impairment on multiple senses.
3 Profound level of agitation that is disruptive to any environment; self stimulation causes physical harm to patient; unable to tolerate stimulation of senses. This dimension may include significant impairment on one or more senses (visually, hearing impaired).
Notes:
Check SELF-CARE DAILY LIVING SKILLS
0 Child's/Youth's self-care and daily living skills appear developmentally appropriate; there is no reason to believe that the child/youth has any problems performing daily living skills.
1 Child/Youth requires verbal prompting on self-care tasks or daily living skills.
2 Child/Youth requires physical prompting on self-care tasks or attendant care on one self-care task (e.g. eating, bathing, dressing, and toileting).
3 Child/Youth requires attendant care on more than one of the self-care tasks, bathing, dressing, toileting, etc.
Notes:
Check COMMUNICATION
0 Child's/Youth's receptive and expressive communication appears developmentally appropriate; there is no reason to believe that the child has any problems communicating.
1 Child/Youth has receptive communication skills but limited expressive communication skills..
2 Child/Youth has both limited receptive and expressive communication skills.
3 Child/Youth is unable to communicate.
Notes:
Check DEVELOPMENTAL DELAY
0 Child's/Youth's development appears within normal range; there is no reason to believe that the child/youth has any developmental problems.
1 Evidence of a mild developmental delay.
2 Evidence of a pervasive developmental disorder including Autism, Tourette's, Down's Syndrome or other significant developmental delay.
3 Severe developmental disorder.
Notes:
Check MOTOR This rating describes the child/youth's fine (e.g. hand grasping and manipulation) and gross (e.g. walking, running) motor functioning. This includes DSMIV diagnosis of motor disorders
0 No evidence of problems with motor functioning.
1 Mild to moderate fine or gross motor skill deficits.
2 Moderate to severe motor deficits; a non-ambulatory child/youth with fine motor skills or an ambulatory child/youth with significant fine motor deficits would be rated here; a child/youth who meets criteria for a motor disorder would be rated here.
3 Severe or profound motor deficits; for instance, a non-ambulatory child/youth with fine motor skill deficits would be rated here.
Notes:
Check SENSORY This rating describes the child's ability to use all senses including vision, hearing, smell, touch, and kinesthetics.
0 The child's/youth's sensory functioning appears normal. There is no reason to believe that the child/youth has any problems with sensory functioning.
1 The child/youth has mild impairment on a single sense (e.g. mild hearing deficits, correctable vision problems).
2 The child/youth has moderate impairment on a single sense or mild impairment on multiple senses (e.g. difficulties with sensory integration, diagnosed need for occupational therapy).
3 The child/youth has significant impairment on one or more senses (e.g. profound hearing or vision loss).
Notes:

CHILD/YOUTH MEDICAL DOMAIN

Check LIFE THREATENING
0 Child's/Youth's medical condition has no implications for shortening his/her life.
1 Child's/Youth's medical condition may shorten life but not until later in adulthood.
2 Child's/Youth's medical condition places him/her at some risk of premature death before he/she reaches adulthood.
3 Child's/Youth's medical condition places him/her at eminent risk of death.
Notes:
Check CHRONICITY
0 Child/Youth is expected to fully recover from his/her current medical condition within the next six months.
1 Child/Youth is expected to fully recover from his/her current medical condition after at least six months but less than two years.
2 Child/Youth is expected to fully recover from his/her current medical condition but not within the next two years.
3 Child's/Youth's medical condition is expected to continue throughout his/her lifetime.
Notes:
Check DIAGNOSTIC COMPLEXITY
0 The child's/youth's medical diagnoses are clear and there is no doubt as to the correct diagnoses; symptom presentation is clear.
1 Although there is some confidence in the accuracy of child's/youth's diagnoses, there also exists sufficient complexity in the child's/youth's symptom presentation to raise concerns that the diagnoses may not be accurate.
2 There is substantial concern about the accuracy of the child's/youth's medical diagnoses due to the complexity of symptom presentation.
3 It is currently not possible to accurately diagnose the child's/youth's medical condition(s).
Notes:
Check EMOTIONAL RESPONSE
0 Child/Youth is coping well with his/her medical condition.
1 Child/Youth is experiencing some emotional difficulties related to his/her medical condition but these difficulties do not interfere with other areas of functioning.
2 Child/Youth is having difficulties coping with his/her medical condition. His/her emotional response is interfering with functioning in other life domains.
3 Child/Youth is having a severe emotional response to his/her medical condition that is interfering with treatment and functioning.
Notes:
Check IMPAIRMENT IN FUNCTIONING
0 Child's/Youth's medical condition is not interfering with his/her functioning in other life domains.
1 Child's/Youth's medical condition has a limited impact on his/her functioning in at least one other life domain.
2 Child's/Youth's medical condition is interfering with functioning in more than one life domain or is disabling in at least one.
3 Child's/Youth's medical condition has disabled him/her in most other life domains.
Notes:
Check TREATMENT INVOLVEMENT
0 Child/Youth and family are actively involved in treatment.
1 Child/Youth and/or family are generally involved in treatment but may struggle to stay consistent.
2 Child/Youth and/or family are generally uninvolved in treatment although they are sometimes compliant to treatment recommendations.
3 Child/Youth and/or family are resistant to all efforts to provide medical treatment.
Notes:
Check INTENSITY OF TREATMENT
0 Child's/Youth's medical treatment involves taking daily medication or visiting a medical professional no more than weekly.
1 Child's/Youth's medical treatment involves taking multiple medications or visiting a medical professional multiple times per week.
2 Child's/Youth's treatment is daily but non-invasive; treatment can be administered by a caregiver.
3 Child's/Youth's medical treatment is daily and invasive and requires either a medical professional to administer or a well trained caregiver.
Notes:
Check ORGANIZATIONAL COMPLEXITY
0 All medical care is provided by a single medical professional.
1 Child's/Youth's medical care is generally provided by a coordinated team of medical professionals who all work for the same organization.
2 Child's/Youth's medical care requires collaboration of multiple medical professionals who work for more than one organization but current communication and coordination is effective.
3 Child's/Youth's medical care requires the collaboration of multiple medical professionals who work for more than one organization and problems currently exist in communication among these professionals.
Notes:
Check FAMILY STRESS Please rate the highest level from the past 30 days.
0 Child's/Youth's medical condition is not adding any stress to the family.
1 Child's/Youth's medical condition is a mild stressor on the family.
2 Child's/Youth's medical condition is a stressor on the family and is interfering with healthy family functioning.
3 Child's/Youth's medical condition is a severe stressor on the family and is resulting in significant functioning problems in a number of dimensions in the family domain.
Notes:

CHILD/YOUTH ADJUSTMENT TO TRAUMA DOMAIN

Check SEXUAL ABUSE Please rate within the lifetime.
0 There is no evidence that child/youth has experienced sexual abuse.
1 Child/youth has experienced one episode of sexual abuse or there is a suspicion that child/youth has experienced sexual abuse but no confirming evidence.
2 Child/youth has experienced repeated sexual abuse.
3 Child/youth has experienced severe and repeated sexual abuse which may have caused physical harm and/or significantly impacts his/her functioning.
Notes:
Check PHYSICAL ABUSE Please rate within the lifetime.
0 There is no evidence that child/youth has experienced physical abuse.
1 Child/youth has experienced one episode of physical abuse or there is a suspicion that child/youth has experienced physical abuse but no confirming evidence.
2 Child/youth has experienced repeated physical abuse.
3 Child/youth has experienced severe and repeated physical abuse that causes sufficient physical harm to necessitate hospital treatment.
Notes:
Check EMOTIONAL/VERBAL ABUSE Please rate within the lifetime.
0 There is no evidence that child/youth has experienced emotional abuse.
1 Child/youth has experienced mild emotional abuse.
2 Child/youth has experienced repeated emotional abuse.
3 Child/youth has experienced severe and repeated emotional abuse that has significantly impacted his/her functioning.
Notes:
Check MEDICAL TRAUMA Please rate within the lifetime.
0 There is no evidence that child/youth has experienced any medical trauma .
1 Child/youth has experienced mild medical trauma including minor surgery (e.g. stitches, bone setting).
2 Child/youth has experienced moderate medical trauma including major surgery or injuries requiring hospitalization.
3 Child/youth has experienced life threatening medical trauma.
Notes:
Check NATURAL DISASTER Please rate within the lifetime.
0 There is no evidence that child/youth has experienced any natural disaster.
1 Child/youth has been indirectly affected by a natural disaster.
2 Child/youth has experienced a natural disaster which has had a notable impact on his/her well-being.
3 Child/youth has experienced a life threatening natural disaster.
Notes:
Check WITNESS TO FAMILY VIOLENCE Please rate within the lifetime.
0 There is no evidence that child/youth has witnessed family violence.
1 Child has witnessed one episode of family violence.
2 Child/youth has witnessed repeated episodes of family violence but no significant injuries (i.e. requiring emergency medical attention) have been reported.
3 Child/youth has witnessed repeated and severe episodes of family violence; significant injuries have occurred as a direct result of the violence.
Notes:
Check WITNESS TO COMMUNITY VIOLENCE Please rate within the lifetime
0 There is no evidence that child/youth has witnessed violence in the community.
1 Child/youth has witnessed fighting or other forms of violence in the community.
2 Child/youth has witnessed the significant injury of others in his/her community.
3 Child/youth has witnessed the death of another person in his/her community
Notes:
Check WITNESS/VICTIM TO CRIMINAL ACTIVITY Please rate within the lifetime.
0 There is no evidence that child/youth has been victimized or has witnessed significant criminal activity.
1 Child/youth has witnessed significant criminal activity.
2 Child/youth is a direct victim of criminal activity or witnessed the victimization of a family member or friend.
3 Child/youth has been a victim of criminal activity that was life threatening or caused significant physical harm or child/youth witnessed the death of a loved one.
Notes:
Check AFFECT DYSREGULATION These symptoms include difficulties modulating or expressing emotions, intense fear or helplessness, difficulties regulating sleep/wake cycle, and inability to fully engage in activities.
0 Caregiver/SI has good monitoring and discipline skills.
1 This rating is given to a child with some minor difficulties with affect regulation. This child could have some difficulty tolerating intense emotions and become somewhat jumpy or irritable in response to emotionally charged stimuli, or more watchful or hyper-vigilant in general. This child may have some difficulty sustaining involvement in activities for any length of time.
2 This rating is given to a child with moderate problems with affect regulation. This child may be unable to modulate emotional responses. This child may exhibit marked shifts in emotional responses (e.g., from sadness to irritability to anxiety) or have contained emotions with a tendency to lose control of emotions at various points (e.g., normally restricted affect punctuated by outbursts of anger or sadness). This child may also exhibit persistent anxiety, intense fear or helplessness, or lethargy/loss of motivation.
3 This rating is given to a child with severe problems with highly dysregulated affect. This child may have more rapid shifts in mood and an inability to modulate emotional responses (feeling out of control of their emotions). This child may also exhibit tightly contained emotions with intense outbursts under stress. Alternately, this child may be characterized by extreme lethargy, loss of motivation or drive, and no ability to concentrate or sustain engagement in activities (i.e., emotionally "shut down").
Notes:
Check RE-EXPERIENCING These symptoms consist of difficulties with intrusive memories or reminders of traumatic events, including nightmares, flashbacks, intense reliving of the events, and repetitive play with themes of specific traumatic experiences. These symptoms are part of the DSM-IV criteria for PTSD.
0 This rating is given to a child with no evidence of intrusive symptoms.
1 This rating is given to a child with some problems with intrusions, including occasional nightmares about traumatic events.
2 This rating is given to a child with moderate difficulties with intrusive symptoms. This child may have recurrent frightening dreams with or without recognizable content or recurrent distressing thoughts, images, perceptions or memories of traumatic events. This child may exhibit trauma-specific reenactments through repetitive play with themes of trauma or intense physiological reactions at exposure to traumatic cues.
3 This rating is given to a child with severe intrusive symptoms. This child may exhibit trauma-specific reenactments that include sexually or physically traumatizing other children or sexual play with adults. This child may also exhibit persistent flashbacks, illusions or hallucinations that make it difficult for the child to function.
Notes:
Check AVOIDANCE These symptoms include efforts to avoid stimuli associated with traumatic experiences. These symptoms are part of the DSM-IV criteria for PTSD.
0 This rating is given to a child with no evidence of avoidance symptoms.
1 This rating is given to a child who exhibits some avoidance. This child may exhibit one primary avoidant symptom, including efforts to avoid thoughts, feelings or conversations associated with the trauma..
2 This rating is given to a child with moderate symptoms of avoidance. In addition to avoiding thoughts or feelings associated with the trauma, the child may also avoid activities, places, or people that arouse recollections of the trauma.
3 This rating is given to a child who exhibits significant or multiple avoidant symptoms. This child may avoid thoughts and feelings as well as situations and people associated with the trauma and have an inability to recall important aspects of the trauma.
Notes:
Check NUMBING These symptoms include numbing responses that are part of the DSM-IV criteria for PTSD. These responses were not present before the trauma.
0 This rating is given to a child with no evidence of numbing responses.
1 This rating is given to a child who exhibits some problems with numbing. This child may have a restricted range of affect or an inability to express or experience certain emotions (e.g., anger or sadness).
2 This rating is given to a child with moderately severe numbing responses. This child may have a blunted or flat emotional state or have difficulty experiencing intense emotions or feel consistently detached or estranged from others following the traumatic experience.
3 This rating is given to a child with significant numbing responses or multiple symptoms of numbing. This child may have markedly diminished interest or participation in significant activities and sense of a foreshortened future.
Notes:
Check DISSOCIATION Symptoms included in this dimension are daydreaming, spacing or blanking out, forgetfulness, fragmentation, detachment, and rapid changes in personality often associated with traumatic experiences. This dimension may be used to rate dissociative disorders (e.g., Dissociative Disorder NOS, Dissociative Identity Disorder) but can also exist when other diagnoses are primary (e.g., PTSD, depression).
0 This rating is given to a child with no evidence of dissociation.
1 This rating is given to a child with minor dissociative problems, including some emotional numbing, avoidance or detachment, and some difficulty with forgetfulness, daydreaming, spacing or blanking out.
2 This rating is given to a child with a moderate level of dissociation. This can include amnesia for traumatic experiences or inconsistent memory for trauma (e.g., remembers in one context but not another), more persistent or perplexing difficulties with forgetfulness (e.g., loses things easily, forgets basic information), frequent daydreaming or trance-like behavior, depersonalization and/or derealization. This rating would be used for someone who meets criteria for Dissociative Disorder Not Otherwise Specified or another diagnosis that is specified "with dissociative features."
3 This rating is given to a child with severe dissociative disturbance. This can include significant memory difficulties associated with trauma that also impede day to day functioning. Child is frequently forgetful or confused about things he/she should know about (e.g., no memory for activities or whereabouts of previous day or hours). Child shows rapid changes in personality or evidence of distinct personalities. Child who meets criteria for Dissociative Identity Disorder or a more severe level of Dissociative Disorder NOS would be rated here.
Notes:
Check SOMATIZATION These symptoms include the presence of recurrent physical complaints without apparent physical cause or conversion-like phenomena (e.g., pseudo-seizures).
0 This rating is for a child with no evidence of somatic symptoms..
1 This rating indicates a child with a mild level of somatic problems. This could include occasional headaches, stomach problems (nausea, vomiting), joint, limb or chest pain without medical cause.
2 This rating indicates a child with a moderate level of somatic problems or the presence of conversion symptoms. This could include more persistent physical symptoms without a medical cause or the presence of several different physical symptoms (e.g., stomach problems, headaches, backaches). This child may meet criteria for a somatoform disorder. Additionally, the child could manifest any conversion symptoms here (e.g., pseudo-seizures, paralysis).
3 This rating indicates a child with severe somatic symptoms causing significant disturbance in school or social functioning. This could include significant and varied symptomatic disturbance without medical cause.
Notes:

CHILD/YOUTH SUBSTANCE USE DOMAIN

Check SEVERITY OF USE
0 Child/Youth is currently abstinent and has maintained abstinence for at least six months.
1 Child/Youth is currently abstinent but only in the past 30 days or child/youth has been abstinent for more than 30 days but less than 6 months.
2 Child/Youth actively uses alcohol or drugs but not daily within the past 30 days.
3 Child/Youth has used alcohol and/or drugs on a daily basis within the past 30 days.
Notes:
Check DURATION OF USE
0 Child/youth has not begun use in the past year.
1 Child/youth has been using alcohol or drugs for at least one year but has had periods of at least 30 days where he/she did not have any use.
2 Child/Youth has been using alcohol or drugs for at least one year (but less than 5 years), but not daily.
3 Child/Youth has been using alcohol and/or drugs on a daily basis for more than the past year or intermittently for at least 5 years.
Notes:
Check PEER INFLUENCES
0 Child's/Youth's primary peer social network does not engage in alcohol or drug use.
1 Child/Youth has peers in his/her primary peer social network who do not engage in alcohol or drug use but has some peers who do.
2 Child/Youth predominately socializes with peers who frequently engage in alcohol or drug use.
3 Child/Youth identifies with/is a member of a peer group that consistently engages in alcohol or drug use.
Notes:
Check STAGE OF RECOVERY
0 Child/youth is in the maintenance stage of recovery. He/she is abstinent and able to recognize and avoid risk factors for future alcohol or drug use.
1 Child/youth is actively trying to use treatment to remain abstinent.
2 Child/youth is in contemplation phase, recognizing a problem but not willing to take steps for recovery.
3 Child/youth is in denial regarding the existence of any substance use problem.
Notes:

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.