CRITERIA CHECKLIST. Serious Mental Illness (SMI)
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1 Serious Mental Illness (SMI) SMI determination is based on the age of the individual, functional impairment, duration of the disorder and the diagnoses. Adults must meet all of the following five criteria: Age: Diagnoses: Functional Impairment: Functional Domain: Duration: 1
2 Major Depression and Bipolar Disorder Requires a GAF of 50 or below to qualify as SMI Major Depression 296.xx (all except Mood Order NOS ) Bi-Polar Disorders 296.xx (all except Bi-Polar NOS ) Other Mood Disorders Requires a GAF of 50 or below to qualify as SMI Cyclothymic Disorder Anxiety Disorders Requires a GAF of 50 or below to qualify as SMI Panic Disorder w/out Agoraphobia Generalized Anxiety Disorder Phobic Disorder Panic Disorder w/agoraphobia Social Phobia Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Eating Disorders Requires a GAF of 50 or below to qualify as SMI Anorexia Nervosa Bulimia Nervosa Somatoform Disorders Requires a GAF of 50 or below to qualify as SMI Conversion Disorder Dissociative Disorders Requires a GAF of 50 or below to qualify as SMI Dissociative Amnesia Dissociative Fugue Dissociative Identity Disorder Factitious Disorders Requires a GAF of 50 or below to qualify as SMI Factitious Disorder with Psychological Signs and Symptoms
3 Person must meet SMI criteria and at least one of the following: A. Symptom Severity and Other Risk Factors Significant current danger to self or others or presence of active symptoms of a SMI as evidenced by a GAF score of 40 or below. Three or more emergency room visits or psychiatric hospitalizations within the last year. Individuals must meet the ASAM Placement Criteria for Level III or IV services and must have a High Score on the following dimensions: intoxicated/withdrawal potential, bio medical condition, emotional/behavior/cognitive conditions. Person is experiencing trauma symptoms related to sexual assault, domestic violence or other traumatic event. Severe impairment in at least one Axis IV functional domain or moderate functional impairment in multiple domains. B. Co-Occuring Disorders Substance Dependency diagnosis and any mental illness that affects functionality. SMI or Substance Dependency and potentially life-threatening medical condition (e.g., diabetes, HIV/AIDS, hepatitis). SMI or Substance Dependency and Developmental Disability. 3
4 Severe Emotional Disturbance (SED) SED determination is based on the age of the individual, functional impairment or symptoms, diagnoses and duration of the disorder. The child/adolescent must meet all of the following four criteria: Age: Functional Impairment or Symptoms: Functional Impairment in two of the following capacities (compared with expected developmental level): 4
5 Symptoms the child/adolescent must have 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. 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. 3. Diagnoses: The child/adolescent has an emotional and/or behavioral disability that has been diagnosed by a licensed psychiatrist, licensed psychologist, LISW, LMFT, or LPCC under the classification system in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) from the following list: Adult diagnostic categories appropriate p for children and adolescents Substance Dependence Disorders ( ) Schizophrenia and Other Psychotic Disorders (293.81, , , 297.1, 297.3, 298.9) Mood Disorders (293.83, , 300.4, , 311) Anxiety Disorders (293.89, , , 300.7, 308.3, ) Somatoform Disorders (300.11, ) Sexual and Gender Identity Disorders ( , , , 302.9) Impulse Control Disorders (312.30, , ) Disorders usually first diagnosed in infancy, childhood, or adolescence Attention-Deficit and Disruptive Behavior Disorders (312.8, ) Tic Disorders (307.20, , ) Feeding and Eating Disorders (307.1, , , , ) Reactive Attachment Disorder of Infancy or Early Childhood (313.89) 4. Duration: has an emotional disability that has persisted for at least six months; AND that same disability must be expected to persist for a year or longer. 5
6 Child/adolescent meets SED criteria and at least two of the following six: 1. Multi-system involvement: The youth is currently involved with two or more public child-serving divisions or agencies including mental health, juvenile justice, or child welfare (e.g., they have case workers/case managers in two or more systems). 2. At risk of out-of-home placement due to SED: Current evaluation indicates child meets level of care for the following out-of-home placements: Residential facility for severe behavioral, psychiatric issues (ARTC, RTC, Group home). Residential treatment program for youthful sexual offenders. OR Child has multiple failed attempts in intensive outpatient services (IOP) and family is unable to maintain the child in the home without significant support. 3. Hospitalization: Current hospitalization in an inpatient psychiatric facility or two psychiatric admissions within the past 12 months. 4. Recent (within last six months) or pending discharge from a: Residential facility for severe behavioral, psychiatric issues. Residential treatment program for youthful sexual offenders. OR Two or more placements in a residential program for severe behavioral, psychiatric or sexual offending issues within the past 12 months. 5. Suicide attempts: A history of two or more suicide attempts within the past 12 months resulting in medical intervention. 6. History of significant trauma. 6
7 At-Risk Severe Emotional Disturbance (SED) At-risk SED determination is based on the age of the individual, involvement in children s services systems, and psychosocial stressors. The child/adolescent must meet all of the following three criteria: Age: System Involvement: Psychosocial Stressors: 7
8 Chronic Substance Dependency (CSD) CSD determination is based on the age of the individual, diagnoses, functional impairment, and duration of the disorder and the diagnoses. Adults must meet all of the following criteria: Age: Diagnoses: Functional Impairment: Functional Domain: Duration: 8
9 Co-Occurring Disorder (COD) Adult COD is defined as the following: 9
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