"Kentucky Determination Criteria Checklist for Severe Emotional Disability (Sed)" - Kentucky

Kentucky Determination Criteria Checklist for Severe Emotional Disability (Sed) is a legal document that was released by the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities - a government authority operating within Kentucky.

Form Details:

  • Released on February 28, 2020;
  • The latest edition currently provided by the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities.

ADVERTISEMENT
ADVERTISEMENT

Download "Kentucky Determination Criteria Checklist for Severe Emotional Disability (Sed)" - Kentucky

Download PDF

Fill PDF online

Rate (4.6 / 5) 23 votes
Kentucky Determination Criteria Checklist
for Severe Emotional Disability (SED)
Relates to KRS 200.503(3) and 907 KAR 15:060, 15:065, 15:050, and 15:055,
and 908 KAR 2:260. Per KRS 200:501 – Children with a SED who are receiving
institutional care or are at risk of institutional placement shall be given priority for services
pursuant to KRS 200:501–200.509.
___________________________ _______________________ _______________________________
Individual’s Name
Identification Number
Diagnostic Code(s)
The following table illustrates the criteria that shall be met for an individual to be designated as SED. In
order to make an SED designation, Sections 1, 2 and 4 are required and at least two of five in Section 3.
YES NO
Criteria
Section 1: Age
Is a person under age 18 or under age 21 who was receiving services prior to eighteenth birthday and that must
be continued for therapeutic benefit.
Section 2: Diagnosis
 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 and Statistical Manual of Mental Disorders.
 Excludes those children who are singularly diagnosed an intellectual disability.
AND
Section 3: Limitations
Presents substantial limitations in at 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 the 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 effective 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 pattern 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 other 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.
2/28/2020
Kentucky Determination Criteria Checklist
for Severe Emotional Disability (SED)
Relates to KRS 200.503(3) and 907 KAR 15:060, 15:065, 15:050, and 15:055,
and 908 KAR 2:260. Per KRS 200:501 – Children with a SED who are receiving
institutional care or are at risk of institutional placement shall be given priority for services
pursuant to KRS 200:501–200.509.
___________________________ _______________________ _______________________________
Individual’s Name
Identification Number
Diagnostic Code(s)
The following table illustrates the criteria that shall be met for an individual to be designated as SED. In
order to make an SED designation, Sections 1, 2 and 4 are required and at least two of five in Section 3.
YES NO
Criteria
Section 1: Age
Is a person under age 18 or under age 21 who was receiving services prior to eighteenth birthday and that must
be continued for therapeutic benefit.
Section 2: Diagnosis
 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 and Statistical Manual of Mental Disorders.
 Excludes those children who are singularly diagnosed an intellectual disability.
AND
Section 3: Limitations
Presents substantial limitations in at 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 the 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 effective 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 pattern 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 other 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.
2/28/2020
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., failing 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 with supervisor and other workers, hostile
behavior on the job).
e) Functioning in Self-Direction: Impairment in self-direction is manifested by an inability to control behavior
and make decisions in a manner appropriate to his or her 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 exhibited by:
Rarely or minimally seeking comfort in distress
Limited positive affect and excessive levels of irritability, sadness or 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
Inability to make and keep friends
Inability to share
AND
Section 4: Duration
Presents substantial limitations or symptomology in the areas above that have persisted for at least one (1) year or
are judged by a mental health professional to be at high risk of continuing for one (1) 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 compact;
OR
DCBS Out of Home Placement:
The Department for 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.
This 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 by a qualified, licensed behavioral health professional.
______________________________/_____________________________
___________________
Print Name/Credentials
Signature
Date
2/28/2020
Page of 2