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CLTS FS Instructions Module 4 - Mental Health


4.1 Does the Child Need More than Outpatient Counseling to Address their Mental Health or Substance Use Disorder Needs?
4.2 Duration of Mental Health Diagnosis
4.3 Duration of Diagnosed Emotional Disability
4.4 Mental Health Services
4.5 Rare and Extreme Conditions

Mental Health Diagnoses Summary

The information listed here is directly from the Diagnoses page. This provides the screener an opportunity to confirm that they have selected the correct mental health conditions for the child. The rest of the questions on this page refer to symptoms or needs directly related to these mental health diagnoses.

4.1 Does the Child Need More than Outpatient Counseling to Address their Mental Health or Substance Use Disorder Needs?

Wisconsin Administrative Chapter DHS 36, specifically DHS 36.14, indicates criteria for determining the need for psychosocial rehabilitation services shall be available to individuals who are determined to require more than outpatient counseling.

The question cited above would be answered “No” if the child’s needs are being met through outpatient counseling and/or medication related appointments which are addressing the medical necessity and need related to a mental health and/or substance use disorder.

The answer to the question cited above would be answered “Yes” if the child has functional impairments that interfere with or limit one or more major life activity, therefore needing more than outpatient counseling and/or medication related appointments, such as coordination of services and any psychosocial rehabilitation service to address the medical necessity and need related to a mental health and/or substance use disorder.

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4.2 Duration of Mental Health Diagnosis

If the child has a clinical Mental Health diagnosis, has the diagnosis or related symptoms persisted for at least six months?

  • Yes
  • No
  • Child does not have a Mental Health Diagnosis

If the child has a clinical Mental Health diagnosis, is the diagnosis expected to last a year or longer?

  • Yes
  • No

Many of the questions on this Children's Long-Term Support Functional Screen (CLTS FS) page reflect current duration requirements for a psychiatric level of care.  

Note: Autism spectrum disorders, (attention-deficit/hyperactivity disorder (ADHD), and attention deficit disorder (ADD) are mental health diagnoses. While many people identify these diagnoses as developmental in nature, they are clinical mental health diagnoses and, therefore, require an answer to this question for appropriate functional eligibility determination.

Complete the Mental Health section for every child. If a child does not have a mental health diagnosis but is exhibiting symptoms or receiving mental health services, the screener can indicate that on this page. Every question on this page relates directly to mental health issues or concerns.

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4.3 Mental Health Symptoms/Minimum Frequency

The minimal frequency of mental health and behavioral symptoms is lower than the criterion used for ADLs and IADLs. For anorexia/bulimia, psychosis, and violence, the screener should check the box if one of the following is true:

  • The child currently has symptoms as defined.
  • The child had the symptoms as defined at least once in the past three months.
  • The child had the symptoms as defined at least twice in the past year.

For suicidality, the screener should check the box if the child has had a suicide attempt, significant suicidal ideation, or developed a plan in the past 12 months.

Does the child have any of the following symptoms? (Check all that apply and enter notes below)

  • Anorexia/bulimia–Life-threatening symptomology.
  • Psychosis–Serious mental illness with delusions and/or hallucinations.
  • Suicidality–Suicide attempt or significant suicidal ideation (both passive and active) within the past 12 months.
  • Violence–Life-threatening acts.

For Anorexia/Bulimia–Life-threatening symptomology including at least one of the following:

  • Malnutrition diagnosed by a physician.
  • Electrolyte imbalances diagnosed by a physician. Electrolytes are body salts like sodium, potassium, and chloride.
  • Body weight or development below 20th percentile due to the eating disorder as determined by a physician.

For anorexia/bulimia and psychosis, there should be a corresponding diagnosis in the diagnosis table of the CLTS FS.

Psychosis occurs only with severe mental conditions resulting in loss of contact with reality through delusions or hallucinations. A delusion is defined to be a pathological belief (the result of an illness or illness process) held despite evidence to the contrary. A hallucination, in the broadest sense of the word, is perception in the absence of a stimulus. Hallucinations can occur in any sensory modality—visual, auditory, olfactory, and tactile.

Suicidality involves both passive and active measures. Passive involves caregiver report that the child has spoken/written of harming self and this is believed to be a serious threat. An active measure involves a plan to act upon self-harm. Both the active and passive suicidality look-back period is 12 months from the time of screen begin date.

Violence is defined as life-threatening acts that endanger another person’s life. This life-threatening act must result in one of the following:

  • An injury seeking medical attention.
  • Use of weapons against someone (for example, gun, knife, chains, switchblade).
  • Arson (purposeful fire setting) or bomb threats.

If the behavior does not meet this requirement, the screener may be able to check one of the behaviors listed under the category Aggressive or Offensive Behaviors on the Behavior Page of the CLTS FS.

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4.4 Mental Health Services

Does the child currently require services from any of the following? (Check all that apply)

  • Clinical Case Management and Service Coordination across Systems, this is specifically for services rendered through the mental health system. 
  • Criminal Justice System, including juvenile and adult justice systems and police involvement.
  • Mental Health Services (check all that apply): 
    • Psychiatric Medication with Psychiatrist or other Physician 
    • Counseling Sessions 
    • Inpatient Psychiatric Treatment
    • Day Treatment—either partial or full day
    • Behavioral Treatment for Children with Autism Spectrum Disorders under the supervision of a mental health professional
    • In-Home Psychotherapy under the supervision of a mental health professional
      • If a child is participating in ongoing treatment, once they have completed the intensive program it is only listed as mental health services if a psychiatrist or psychologist oversees the specific intervention. 
      • This excludes treatment for substance abuse only, which is captured below.
  • Substance Abuse Services, including day treatment and outpatient services.
  • In-school Supports for Emotional and/or Behavioral Problems 
    • “In-school supports” includes special education classes, one-on-one assistance, informal supports or a behavioral intervention plan (BIP) in an individualized educational plan (IEP). This is for emotional or behavioral problems; do not check it for children with only cognitive and/or physical disabilities.
    • This item is checked in the following situations:
      • Child has an IEP for emotional/behavioral disorders (EBD) programming. This is not applicable for supports only related to focusing, staying on task, or organization.
      • Child has an active BIP in an IEP.
      • Informal supports can include sensory breaks, added support during peer/social interactions, and classroom accommodations to aid behavior.

“Require” is based on a professional’s recommendation that a specific service is essential to address the identified mental health need. The professional recommendation must have been made within the past year. If the parent or child has not accessed recommended services for over 12 months, then this recommendation is no longer valid.

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4.5 Rare and Extreme Conditions

The three rare and extreme conditions identified in the following three questions (requiring redirection, having nightmares or night terrors, and inability to perform routine cares) usually don’t cause physical harm to the child or others. They are directly associated with mental health disorders and inhibit the child’s ability to function throughout their day, every day. They are usually not overt behaviors and are better described as a lack of behavior or action. There are limited interventions because the condition appears to be a direct result of their mental health status. Consideration needs to be given to these rare and extreme conditions as a measure of the severity of a child’s mental health condition. The following three questions address these unique situations:

Does this child exhibit disruptive behaviors in structured settings on a daily basis that require redirection from an adult at a frequency of every three minutes or more often and this behavior has been demonstrated consistently for the past six months? Disruptive behaviors may include sliding around a room in a chair, screaming out inappropriate words or phrases or sitting in the center of a room and refusing to move.

  • Yes
  • No

This question will only be answered “Yes” in rare situations. It is imperative that the screener confirm that the frequency of this disruptive behavior occurs “every three minutes or more often” all day, every day.

Does this child experience nightmares or night terrors at least four times a week and this sleep interruption has been consistent for the past six months? These nightmares or night terrors must be characterized by repeated frightening episodes of intense anxiety that may be accompanied by screaming, crying, confusion, agitation, and/or disorientation.

  • Yes
  • No

All children have nightmares or even the occasional night terror. This question is intended for the child who has these intense experiences at least four nights a week, for six months or more. If the condition does not meet this frequency, then check “no” and describe the situation in the note section.

Is this child unable to complete routine events (hygiene tasks, leaving the house, walking on certain pavements, or sharing community equipment with others) throughout the day, every day, consistently for the past six months due to an obsession? An obsession is a thought, a fear, an idea, an image, or words that a child cannot get out of his/her mind. It does not include self-stimulating or compulsive behaviors. The child experiencing the obsession must be aware of the obsession but not be able to control the influence of his/her own thought patterns.

  • Yes
  • No

In general, this question will be most appropriately answered “Yes” if the child has a diagnosis of a severe obsessive compulsive or anxiety disorder. This does not apply to a child with sensory needs that cause them to engage in repetitive behaviors. Keep in mind that the question indicates that the child would be able to express their awareness and desire to stop this behavior but is unable to due to their mental health condition.

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Last revised February 2, 2022