me. If the needs / functioning fall within a shaded box, explain why: child’s I-12. Behavioral Regression are Child has some regression in Child has moderate Child has significant Child’s behaviors consistent and age age-level behavior (e.g. regression in age-level regression in behaviors as appropriate or this thumb sucking, whining when behavior including loss of demonstrated by significant information is unknown to age inappropriate). ability to engage with peers, periods of changes in me. stopping play or exploration, speech or loss of bowel or or occasional bedwetting. bladder control. If the needs / functioning fall within a shaded box, explain why: child’s A. EMOTIONAL CHARACTERISTICS (Ages 5 to 21) (Continued) I-13. Affect Dysregulation / Emotions Are Not Appropriate to the Situation (PAST 30 DAYS) No evidence of inappropriate Child has mild to moderate Child has severe problems emotional response Child’s emotional response, any problems demonstrating with appropriate emotional to situations are mostly concerns are age emotional responses that are response but is able to inappropriate and interfere appropriate or this appropriate to a given control affect at times. in several areas of life. information is unknown to situation. Interferes with functioning in me. some areas of life. If the needs / functioning fall within a shaded box, explain why: child’s I-14. Suicide Risk Do Not Include Cutting Behaviors in This Category (PAST 30 DAYS) – No evidence of suicidal History but no recent ideation Recent ideation or gesture Current ideation or intent thoughts or actions or this or gesture. but not in the past 24 hours. OR command information is unknown to hallucinations that involve me. (Cutting behavior is not self-harm. a suicidal action). If the needs / functioning fall within a shaded box, explain why: child’s I-15. Self-Injurious Behavior (PAST 30 DAYS) No evidence of self-injurious History of self-mutilation. Engaging in self-mutilation Engaging in self mutilation behavior or this information is that does not require medical that requires medical
me. If the child’s needs / functioning fall within a shaded box, explain why: I-12. Behavioral Regression Child’s behaviors are consistent and age appropriate or this information is unknown to me. Child has some regression in age-level behavior (e.g. thumb sucking, whining when age inappropriate). Child has moderate regression in age-level behavior including loss of ability to engage with peers, stopping play or exploration, or occasional bedwetting. Child has significant regression in behaviors as demonstrated by significant periods of changes in speech or loss of bowel or bladder control. If the child’s needs / functioning fall within a shaded box, explain why: A. EMOTIONAL CHARACTERISTICS (Ages 5 to 21) (Continued) I-13. Affect Dysregulation / Emotions Are Not Appropriate to the Situation (PAST 30 DAYS) No evidence of inappropriate emotional response, any concerns are age appropriate or this information is unknown to me. Child has mild to moderate problems demonstrating emotional responses that are appropriate to a given situation. Child has severe problems with appropriate emotional response but is able to control affect at times. Interferes with functioning in some areas of life. Child’s emotional response to situations are mostly inappropriate and interfere in several areas of life. If the child’s needs / functioning fall within a shaded box, explain why: I-14. Suicide Risk – Do Not Include Cutting Behaviors in This Category (PAST 30 DAYS) No evidence of suicidal thoughts or actions or this information is unknown to me. (Cutting behavior is not a suicidal action). History but no recent ideation or gesture. Recent ideation or gesture but not in the past 24 hours. Current ideation or intent OR command hallucinations that involve self-harm. If the child’s needs / functioning fall within a shaded box, explain why: I-15. Self-Injurious Behavior (PAST 30 DAYS) No evidence of self-injurious behavior or this information is History of self-mutilation. Engaging in self-mutilation that does not require medical Engaging in self mutilation that requires medical
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