Infants/children/or adolescents’ exposure multiple traumatic events, of an invasive, interpersonal nature, and The wide-ranging, long-term impact of this exposure The nature of the traumatic events: Often is severe and pervasive, such as abuse or profound neglect; Usually begins early in life; Can be disruptive of the development and the formation of a health sense of self (with self-regulatory, executive functioning, self-perceptions, etc.); Often occur in the context of the child’s relationship with a caregiver; and Can interfere with the child’s ability to form a secure attachment bond, which is considered a prerequisite for health social-emotional functioning. Many aspects of a child’s healthy physical and mental development rely on this secure attachment, a primary source of safety and stability Wide-ranging, long-term adverse effects can include impairments in: Physiological responses and related neurodevelopment, Emotional responses, Cognitive processes including the ability to think, learn, and concentrate, Impulse control and other self-regulating behavior, Self-image, and Relationships with others. AND/OR HIV/AIDS (single qualifying condition) AND Appropriateness Criteria; check all that apply. At risk for adverse event (i.e. death, disability, inpatient or nursing home admission, mandated preventative services or out of home placement): Has inadequate social/family/housing support, or serious disruption in family relationships Has inadequate connectivity with healthcare system Does not adhere to treatments or has difficulty managing medications Has recently been released from incarceration, placement, detention or psychotic hospitalization Has deficits in activities of daily living, learning or has cognition issues Is concurrently eligible or enrolled, along with either their child or caregiver, in a health home Preventive Services Connectivity Is the Child/Youth currently receiving preventive services? Yes; please identify if known: No Unknown Is the Child/Youth currently receiving services from a Care Management Agency? Yes; please identify if No Unknown
Infants/children/or adolescents’ exposure multiple traumatic events, of an invasive, interpersonal nature, and The wide-ranging, long-term impact of this exposure The nature of the traumatic events: Often is severe and pervasive, such as abuse or profound neglect; Usually begins early in life; Can be disruptive of the development and the formation of a health sense of self (with self-regulatory, executive functioning, self-perceptions, etc.); Often occur in the context of the child’s relationship with a caregiver; and Can interfere with the child’s ability to form a secure attachment bond, which is considered a prerequisite for health social-emotional functioning. Many aspects of a child’s healthy physical and mental development rely on this secure attachment, a primary source of safety and stability Wide-ranging, long-term adverse effects can include impairments in: Physiological responses and related neurodevelopment, Emotional responses, Cognitive processes including the ability to think, learn, and concentrate, Impulse control and other self-regulating behavior, Self-image, and Relationships with others. AND/OR HIV/AIDS (single qualifying condition) AND Appropriateness Criteria; check all that apply. At risk for adverse event (i.e. death, disability, inpatient or nursing home admission, mandated preventative services or out of home placement): Has inadequate social/family/housing support, or serious disruption in family relationships Has inadequate connectivity with healthcare system Does not adhere to treatments or has difficulty managing medications Has recently been released from incarceration, placement, detention or psychotic hospitalization Has deficits in activities of daily living, learning or has cognition issues Is concurrently eligible or enrolled, along with either their child or caregiver, in a health home Preventive Services Connectivity Is the Child/Youth currently receiving preventive services? Yes; please identify if known: No Unknown Is the Child/Youth currently receiving services from a Care Management Agency? Yes; please identify if No Unknown