Standards of payment for foster care of children

APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET
INSTRUCTION BOOKLET
(Use in Conjunction with Self-Survey Questionnaire)
The following instructions provide specific guidelines, definitions and examples for use in completing theself-survey questionnaire. It is recommended that the questionnaire be completed by the staff member whois most familiar with the child. In order to achieve consistency, it is necessary that the following directionsand definitions be carefully read and applied by each individual filling out the questionnaire. Beforeanswering each question, it is essential to read the instructions pertaining to that question.
The questionnaire itself is divided into six sections: I. Program and Child identifying information II. Behavior problems III. Mental illness and psychiatric symptoms IV. Developmental disabilities V. Skills in activities of daily living VI. Physical disabilities and health problems Before beginning, it would be helpful to read the entire self-survey questionnaire through carefully to get asense of the type of information that will be collected and to determine the appropriate sections in which tocode certain items. It should be noted that most children will NOT require all sections to be completed.
The instructions will follow the questionnaire exactly. General instructions are given for each section andindividual instructions are provided for each question, with definitions and/or examples given ifappropriate.
A few general notes or reminders before beginning: • It will be necessary to use the child's case record to complete a number of items on the questionnaire.
• Fill out only one answer sheet per child.
• Either a pen or pencil may be used but be careful to be legible.
• Do not leave blanks in any boxes unless instructed to do so.
• Take particular care to enter the appropriate legible numbers or text within the boxes where asked.
• A number of items require specific documentation in the case record. Read instructions carefully in each section and each question to determine exactly which choices require such documentation.
• In most cases, the questions ask for the frequency or severity of a given problem in the past 90 days only. Be sure to include only information from that time period unless otherwise indicated.
• Record those behaviors that occur at the facility or while the child is on a home visit.
• If there are any questions in completing the questionnaire after reviewing the form and the instructions, Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET

SPECIFIC INSTRUCTIONS:

I. PROGRAM AND CHILD IDENTIFYING INFORMATION

(Case #)
Enter a unique case number for each child in the review. You could use your agency’s
internal case number or have your agency coordinator create a unique set of case numbers
for this project. Check with your agency coordinator for instructions.

(Agency Code)
Enter the OCFS-assigned code for your agency. Check with your agency coordinator
for instructions.

(Program Code)
Enter the OCFS-assigned program code for your agency. Check with your agency
coordinator for instructions.

(Reviewer)
Enter the name of the person completing the questionnaire.

(Reviewer’s Title)
Enter the title of the person completing the questionnaire.

(Review Date)
Enter the date on which this questionnaire is completed. Do NOT omit this item as it is
critical in verifying other information given. Use only one date for this project review,
even if the review is completed over a period of days. Check with your agency
coordinator for instructions.


(Child’s DOB)
Enter the child's exact date of birth using 6 numbers. For example, if the birth date is June8, 1964, enter:
(Child’s Initials)
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APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET

(County)
Enter the code for the county that is paying for the cost of care from the list providedbelow. This is generally the county where the child's family resides.
Unless the child is being paid for privately, be aware that, regardless of the type ofplacement (voluntary, CSE, court), the county that placed the child does have somefinancial responsibility.
If the child is being paid for privately, indicate the county in which the parents reside.

(Placement Date)
Enter the date that the child was placed in the specific program in which he/she iscurrently placed.
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For instance, if the agency has more than one program, and the child was originally placedat the institution and subsequently moved to the group home where he/she currentlyremains, enter the date of placement in the group home.
Similarly, if the child was transferred from one of the agency's group homes to anotheragency group home, enter the date of the placement in the group home where he/shecurrently resides.

(Placement Code)
Enter the code that specifies the most recent placement mechanism from the list.
Be sure to note the most recent mechanism. For instance, the child may have originallybeen placed with the agency by the Family Court following an adjudication of neglect.
Since that time, the court placement may have lapsed and the child is now on voluntarystatus. Check carefully to accurately code the current status.
There may be children in the agency that are in OCFS (formerly DFY) custody. If so, useChoices 6 or 7.

(Other Placement) Other Placement mechanism
If Choice 8 is selected for Placement Code, specify the mechanism.

(IQ Score)
If the child has been tested by a standardized IQ test within the past three years, indicate the score. A mental age or grade equivalent score should NOT be entered here. Onlyscores from a standardized IQ test are acceptable.
Enter only the full scale IQ in the box provided. A performance or verbal score alone isnot acceptable.
If there is a statement in the record that the child is untestable, enter"888."
(IQ Test Name)
If the child has been tested by a standardized IQ test within the past three years, indicatethe name of the test. Examples of standardized IQ tests are: o Cattell o Bayley o Gesell o McCarthy o Leiter
(IQ Test Date)
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APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET
If the child has been tested by a standardized IQ test within the past three years, indicatethe date, e.g., month (00) and year (00) it was administered.

(School Placement) Current School Placement Code
Code
Enter the code that indicates where the child is attending school.

(Other School)
If Choice 5 is selected for the Current School Placement Code, specify the other type ofschool where the child is attending school.

II. BEHAVIOR SECTION

This section of the questionnaire is divided into two parts: those behaviors that the child has manifested 6
months prior to placement and the current behaviors that have been observed 90 days prior to completion of
this self-survey.
A. Prior to Placement Behavior Problems:
This series of questions focuses on describing selected significant behaviors occurring prior to thechild's placement in this specific program. Consider behaviors that have occurred only in the 6 monthperiod prior to placement in this program. If the child has been transferred to a program within theagency, consider only behaviors that are documented in the case record during the 6 months beforetransfer. If the child was not present in the agency, use only external-from-agency documentation, i.e.,local DSS, probation, police reports contained in the case record. The following items contain examplesof behaviors to be used as guidelines. The child does not need to display all the examples in a particularchoice.

(Q11) Question 11. Major assaults
This item must be substantiated by documentation in the case record.

A major assault is a physical attack on another person in which serious harm resulted (e.g., the
victim required serious medical attention) or would have resulted had there not been immediate
physical restraint or intervention. Do NOT count incidents which are entirely self defense.
Examples of major assaults are:
o Murder or attempted murder
o Rape
o An assault with a dangerous weapon or object
o A serious attack on an individual much weaker
o Particularly vicious fighting
A major assault is NOT:
o Fist fighting between physical equals
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET
o Slapping, pushing, shoving, scratching, biting o Throwing a book at someone Use common sense. An 8-year old is unlikely to cause an adult serious harm if he/she fights withthe adult. Similarly, in general, throwing a chair in someone's direction does not generally result inserious harm. However, it could be done with such great velocity and at such close range that itcould conceivably hurt someone badly. Consider the circumstance carefully.
Also, the intent (i.e., not by accident) to harm someone should be present. If a child loses controland starts throwing things around the room and someone walks in and accidentally gets hit by aflying object, the behavior should not be considered a major assault.
(Q12) Question 12. Major vandalism
This item must be substantiated by documentation in the case record.

Major vandalism or serious destruction of property is defined as an incident in which damage of
more than $50 occurred. This is not limited to a single object that has a value greater than $50.
One incident on a given day wherein a number of smaller items were destroyed that, taken
together, amount to greater than $50 is considered a major vandalism. However, if a lot of small
items were destroyed over a number of days, that cannot be considered as an incident of major
vandalism.
Intent to destroy should be evident. A child who goes on a joy ride and accidentally cracks up the
car is not guilty of vandalism.
(Q13) Question 13. Major theft
This item must be substantiated by documentation in the case record.

This is an incident of theft totaling more than $50 value. If a child goes out one day to a neighbor's
house and steals their TV set, stereo and bicycle, this should be coded as "one incident" and not
three.
"One incident" is also the correct choice if the child goes into a store on a given occasion and
shoplifts a hair dryer, two pairs of jeans and other smaller items that total over $50.
(Q14) Question 14. Robbery
This item must be substantiated by documentation in the case record.

A robbery is theft that involves confrontation with the victim. It generally includes a weapon
and/or threat of serious harm to the victim. If in the act of the robbery, the victim is seriously hurt,
code the incident BOTH as a robbery and as a major assault.
(Q15) Question 15. Major firesetting
This item must be substantiated by documentation in the case record.

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APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET
This includes firesetting in which damage of more than $50 occurred or in which someone wasphysically in danger. This would include setting a mattress or car on fire. Playing with matches orlighting a fire in a steel wastepaper basket away from the possibility of the fire spreading or asmall, isolated grass fire, are not considered major firesetting incidents. (These items may becoded in Question 17, Other Behavior Problems.) (Q16) Question 16. Hard drug use/excessive alcohol consumption
Code use of these drugs for other than approved medical reasons.
Excessive alcohol consumption is drinking to the point of being inebriated and habitual.
Hard drug use and/or excessive alcohol consumption must be habitual and to the degree that itinterferes with the child's daily functioning.
(Q17) Question 17. Other significant behavior problems
This item is available to capture any other significant management problem that has not beencaptured in previous items. If there is more than one problem, select the more severe issue.
Code only the behavior that seriously affects the child's ability to function normally in his/hercommunity or, if the child was previously placed in another program, behavior that was disruptiveto the program. Do NOT code behaviors that were merely irritating or petty.

B. Current Behavior Problems:

This section is concerned with actual observable behaviors such as assaultiveness, stealing, etc.
Consider only what the child actually does, not feelings, emotional problems, interpretations orinferences about how the child might behave in a different setting or why the child behaves in aparticular manner. (Some of these issues will be dealt with in the Mental Illness section.) For example, hostility is not a behavior; however, verbal abusiveness or bullying are behaviors.
For questions 18 to 34, code only those behaviors that have occurred in the past 90 days. If the childhas been in placement at this specific facility for less than 90 days, include only those incidents thathave occurred since the child was placed in the facility even if the child has only been in placement for one day.
Example: Today's date is November 1, 1982. The child was placed at the facility on September 15, 1982. Codeonly those problems which occurred from 9/15/82 to 11/1/82.
Today's date is November 1, 1982. The child was placed at the facility on April 3, 1981. Code onlythose problems which occurred from 8/1/82 to 11/1/82.
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET
Do NOT code the same behavior in more than one item. Consider the behavior carefully, look at all thechoices, and decide which ONE item most accurately describes that particular behavior. There arecertain exceptions to this rule that are described in the appropriate sections below.
Questions 18 through 23 require documentation in the case record.

(Q18) Question 18. Major assaults
This item must be substantiated by documentation in the case record.

A major assault is a physical attack on another person in which serious harm resulted (e.g., the
victim required serious medical attention) or would have resulted had there not been immediate
physical restraint or intervention. Do NOT count incidents which are entirely self defense.
Examples of major assaults are:
o Murder or attempted murder
o Rape
o An assault with a dangerous weapon or object
o A serious attack on an individual much weaker
o Particularly vicious fighting
A major assault is NOT:
o Fist fighting between physical equals
o Slapping, pushing, shoving, scratching, biting
o Throwing a book at someone
Use common sense. An 8-year old is unlikely to cause an adult serious harm if he/she fights with
the adult. Similarly, in general, throwing a chair in someone's direction does not generally result in
serious harm. However, it could be done with such great velocity and at such close range that it
could conceivably hurt someone badly. Consider the circumstance carefully.
Also, the intent (i.e., not by accident) to harm someone should be present. If a child loses control
and starts throwing things around the room and someone walks in and accidentally gets hit by a
flying object, the behavior should not be considered a major assault.
(Q19) Question 19. Major vandalism
This item must be substantiated by documentation in the case record.

Major vandalism or serious destruction of property is defined as an incident in which damage of
more than $50 occurred. This is not limited to a single object that has a value greater than $50.
One incident on a given day wherein a number of smaller items were destroyed that, taken
together, amount to greater than $50 is considered a major vandalism. However, if a lot of small
items were destroyed over a number of days, they cannot be considered as an incident of major
vandalism. (They may, instead, be coded in Question 30, Minor vandalism.)
Intent to destroy should be evident. A child who goes on a joy ride and accidentally cracks up the
car is not guilty of vandalism.
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APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET

(Q20) Question 20. Major theft
This item must be substantiated by documentation in the case record.

This is an incident of theft totaling more than $50 value. If a child goes out one day to a neighbor's
house and steals their TV set, stereo and bicycle, this should be coded as "one incident" and not
three.
“One incident” is also the correct choice if the child goes into a store on a given occasion and
shoplifts a hair dryer, two pairs of jeans and other smaller items that total over $50.

(Q21) Question 21. Robbery
This item must be substantiated by documentation in the case record.

A robbery is theft that involves confrontation with the victim. It generally includes a weapon
and/or threat of serious harm to the victim. If in the act of the robbery, the victim is seriously hurt,
code the incident BOTH as a robbery and as a major assault.

(Q22) Question 22. Major firesetting
This item must be substantiated by documentation in the case record.

This includes firesetting in which damage of more than $50 is likely or in which someone is
physically in danger. This would include setting a mattress or car on fire. Playing with matches or
lighting a fire in a steel wastepaper basket away from the possibility of the fire spreading or a
small, isolated grass fire, are not considered major firesetting incidents. (These items may be
coded in Question 34, Other Behavior Problems.)

(Q23) Question 23. Running away
This item must be substantiated by documentation in the case record.

This includes running away from the residential program or from home on home visits. The
incident must be overnight and/or necessitate return by authorities (police, facility staff).
If the child runs away during the day and returns on his/her own volition that same day, do NOT
code this as running away. Such behavior may be reflected in Question 34, Other Behavior
Problems.
If the child is a few hours late in returning to the facility from a home visit, do NOT code this as
running away. However, if the child does not return for a day or more without a legitimate excuse,
this may be coded as running away.
Length of absence is not considered in this item. An overnight absence and a two-month absence
are each coded as "one incident."
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APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET
Questions 24 to 34 deal with the general frequency of a particular behavior during the past
90 days (unless the child has been in placement for less than 90 days; if so, code only those
behaviors that have occurred since the child was placed in this specific facility).

Code the choice that is the most accurate average for the entire 90 day period. If, for
example, in the first month, the child had tantrums more than once a week and, in the
remaining two months, had only an occasional tantrum, the most appropriate response
would be Choice 3 - "Twice a month to once a week."

(Q24) Question 24. Truancy
In order to be coded as truant, the child must be deliberately cutting the majority of the school daywithout a valid excuse. Skipping one or two classes, even if this happens daily, should NOT becounted here. It can, however, be coded in Question 34, Other Behavior Problems.
DO NOT include absences in school that are the result of running away from the residentialprogram.

(Q25) Question 25. Alcohol or soft drug use
Alcohol consumption is drinking to the point of being inebriated or inappropriate alcoholconsumption.
Soft drugs are such drugs as marijuana or hashish. Excessive use is smoking to the extent that itinterferes with normal functioning (such as in school).
Do NOT include here incidents of alcohol or drug use simply because they are a violation offacility rules. This item is only concerned with excessive use.
(Q26) Question 26. Hard drug use/excessive alcohol consumption
Code use of these drugs for other than approved medical reasons.
Excessive alcohol consumption is drinking to the point of being inebriated and habitual.
Hard drug use and/or excessive alcohol consumption must be habitual and to the degree that itinterferes with child's daily functioning.

(Q27-1) Question 27-1. Verbal abusiveness - Code
Use this to code the frequency of verbal abusiveness.
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APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET
This includes hostile swearing, name calling and the like which is directed towards others and isabusive in tone. It does NOT include swearing which is simply a part of the child's culture andwhich is not hostile or verbal outbursts that are not specifically directed toward another person(s).
(Q27-2) Question 27-2. Verbal abusiveness - Describe Problem
Use this space to specify the type of verbal abusiveness.

(Q28) Question 28. Physical fighting or minor assault
Use this item to code physical fighting between persons of approximately equal ability which isunlikely to result in serious harm. This is also the appropriate item to use to code minor assaultslike biting, scratching, punching or use of an object (book, cup, brush, broom) that is unlikely tocause serious harm.

(Q29) Question 29. Minor theft
Minor theft is stealing an item or items of less than $50 value such as shoplifting a minor item orstealing records or clothes from other children in the facility.
Intent to steal must be apparent. A child who takes other children's toys because he/she doesn'tunderstand that they do not belong to him/her is not a thief. (If this is a significant problem,however, it may be coded in Question 34, Other Behavior Problems, as a minor incident.)
(Q30) Question 30. Minor vandalism
This includes the destruction of minor items of property with a value of less
than $50.
Examples:

(Q31) Question 31. Tantrums
A tantrum is defined as a severe anger outburst in which, for example, the child may be screaming,slamming doors, and throwing clothes or books around, resulting in a disruption of the presentactivity.
If a child's tantrum consists wholly of verbal abuse toward another person(s), code it as eitherverbal abusiveness or a tantrum but NOT both.
In general, do not code minor incidents like pouting, whining and stamping feet here. It should bea severe enough incident to be disruptive to programming.
(Q32) Question 32. Threatening others or bullying
Code here behaviors wherein the child is verbally threatening others with bodily harm or bullying(pushing, shoving). The child should be perceived as a threat by the target of the bullying. Idle Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
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threats not directed to someone in particular or threatening by a youngster who is so small that noone takes the threat seriously should NOT be coded.

(Q33) Question 33. Resistance to authority
In answering this question, exclude behaviors that are reflected in other questions in this sectionlike truancy, running away, etc. Consider here items like refusal to comply with a request by astaff member and violation of minor rules.

(Q34-1) Question 34-1. Other significant behavior problems - Code
Use this to code the frequency of other significant behavior problems.
This item is available to capture any other significant management problem that has not beencaptured in previous items. If there is more than one problem, select the more severe issue.
Code only the behavior that is a significant management issue, that is, a behavior that is disruptiveto the program or would seriously affect the child's ability to function normally in his/hercommunity. Do NOT code behaviors that are merely irritating or so petty that they do not requireany significant staff attention.
Before noting any problem here, scan the Mental Illness section to be sure that the behavior won'tbe picked up there.

(Q34-2) Question 34-2. Other significant behavior problems – Describe Problem
Use this space to specify the type of behavior problem.
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APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET
III. MENTAL ILLNESS AND PSYCHIATRIC SYMPTOMS

This section deals with psychiatric and emotional disorders or problems of the child that significantly
interfere with his or her ability to function normally. These disturbances must be evidenced by actual
observable symptoms such as a suicide threat, toewalking, mood swings and the like. Do not make
interpretations or inferences about how the child might be feeling, etc.
For purposes of this survey, we make a distinction between behavior problems and emotional problems.
Thus, behavior problems or inferences about the possible cause of behavior problems should NOT be coded
in this section. For example, if a child's tantrums are caused by underlying depression, but the child does
not display other symptoms of depression, do NOT mark depression in this section. Review the items in
this section carefully to determine if the child has any observable psychiatric symptoms.
If the child displays psychiatric symptoms, code them regardless of assumptions as to why they may exist.
Children that are retarded may display symptoms like head-banging, lack of responsiveness, lability, etc. It
is appropriate to code those symptoms in this section because, regardless of the possible reason for their
presence, they constitute management or treatment issues for the agency.
A. MENTAL ILLNESS AND PSYCHIATRIC SYMPTOMS PRIOR TO PLACEMENT

(Q35) Question 35. Mental illness and psychiatric symptoms prior to placement
Consider only those symptoms that occurred in the 6 month period prior to placement in thisfacility.
Consider only those symptoms that are documented in the case record or referral material aboutthat time period.
If the case record indicates that there were some psychiatric problems in that period, but there isnot enough specific information to determine the severity of the problem, use Choice 5.
(Q36) Question 36.

Indicate whether the child has been hospitalized in a psychiatric facility or a Residential TreatmentFacility (RTF).
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APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
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B. CURRENT MENTAL ILLNESS AND PSYCHIATRIC SYMPTOMS

For Questions 37 to 50 Code only those symptoms that have existed in the past 90 days (unless the child has
been in placement with you for less than 90 days; if so, consider only those symptoms present since the
child was placed here). Do NOT include the existence or severity of a problem prior to this time period.
If there are no significant psychiatric symptoms, skip the entire section.
Be careful not to code the same problem twice. For example, slicing one's wrist may be coded as a suicide
attempt or as self-abuse but not both. Talking to trees could be coded as either bizarre behavior or bizarre
language but not both.
Documentation in the case record is required in order to select certain choices in all of the following
questions in this section. Specifically, documentation is required when selecting choices:

Thus, with the exception of Questions 37, 38 and 49, it is the last two choices in each question for which
documentation is required.
Sufficient documentation consists of at least a detailed description and indication of the frequency or
severity of the specific psychiatric symptom exhibited by the child in the 90 day period in question. A mere
statement in the record that the child exhibits one or any of the following symptoms does not constitute
sufficient documentation for selecting the choices indicated above. For example, if the record states that the
child is suicidal, or exhibits bizarre behavior, or is depressed, or is hyperactive, etc. without describing how
and to what extent he/she exhibits these symptoms, then there is NOT enough evidence to select the above
indicated choices in these questions.
(Q37) Question 37. Suicide threats or attempts
Code here only overt suicide threats, gestures or attempts. Suicidal ideation or talking generally
about death or wishing to be dead are NOT to be coded in this item. They may be considered in
Question 45,Depression.
If the child makes a threat that is clearly an attention- getting behavior and not taken seriously at
all, do NOT code it as a threat.
If the child exhibits more than one of these symptoms (threat, gesture, attempt) code the more
severe (they are listed in order of increasing severity).
Choices 4, 5, and 6 must be substantiated by documentation in the case record.

The record must describe the suicidal behavior so as to distinguish whether it would be considered
a gesture or an attempt. The number of times that the child exhibits such behavior must be
indicated.
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(Q38) Question 38. Self-mutilation or self-abuse
This refers to physical actions that are of physical harm to the child. Do NOT code incidents that
have already been coded in Question 37.
Examples of self-abuse are:
o slapping or hitting self
o headbanging
o hairpulling
o scratching or biting self
o putting fist through a window with the intent of causing self harm
Self-abuse does NOT include:
o overeating or undereating
o taking drugs for experimental purposes or drinking to excess
o promiscuity or masturbation
o walking at night in a dangerous neighborhood
o "risk-taking" behavior
Choices 3, 4, and 5 must be substantiated by documentation in the case record.
The record must describe exactly what the child does that is self-abusive. In order to mark Choices
4 or 5, this behavior must be likely to cause the child physical harm. "Occasional incidents" are
two incidents per month or less. "Frequent incidents" are more than two incidents per month.

(Q39) Question 39. Bizarre behavior
Code here only incidents of exceptionally abnormal, unusual or peculiar behavior. This item doesNOT include behavior that is merely annoying or unacceptable, such as typical adolescentattention getting behavior. It is intended only to capture clinically bizarre actions that would stigmatize the child.
Be sure not to code behavior here that you have already coded elsewhere or that is captured inother questions, such as self-abuse, echolalia or bed-wetting.
Examples of bizarre behavior are:• Oddities of motor movement such as finger flapping, toewalking, tics and other peculiarposturing that are not the result of a physical disability• Growling or barking • Autistic-type self-stimulatory behavior like continual spinning or rocking or an unusualpreoccupation with or attachment to objects Bizarre behavior is NOT:• Fighting, swearing, running away • Sleepwalking or other sleep disorders Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
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Choices 3 and 4 must be substantiated by documentation in the case record.
The record must describe the particular behavior and how much it interferes with daily livingactivities or attracts attention.
(Q40) Question 40. Bizarre language
It is important to distinguish bizarre language from speech disorders. Lisping, stuttering, mumblingand other speech disorders should not be marked in this section. Additionally, swearing, profanityor babytalk are not to be coded as bizarre language.
o Echolalia - Repetition or echoing of the words or phrases of others, such as when a staff personsays to the child, "I'd like to see you for a few minutes" and the child says, "Like to see you for afew minutes. Like to see you for a few minutes." o Perseveration - Persistent repetition of words, ideas or subjects so that, once the child beginsspeaking about a particular subject or uses a particular word, it continually recurs. For example,"I think I'll put on my hat, my hat, my hat." o Neologisms - New words invented by the child, distortions of words, or standard words towhich the child has given new, highly idiosyncratic meaning.
o Elective mutism - Continuous refusal to speak by a child who has the ability to understandspoken language and to speak.
Choices 3 and 4 must be substantiated by documentation in the case record. The particular
language peculiarity should be described in the record. To use Choice 3, the record must indicate
that this language peculiarity interferes with the child's oral communication on a daily basis. For
Choice 4, the record must indicate that the child hardly communicates because of his/her muteness
or total preoccupation with bizarre language.
Questions 41 to 48 are concerned only with the extent to which a given symptom has interferedwith normal daily functioning in the past 90 days. "Normal functioning" is defined as the ability toadequately perform the normal activities of daily living for the child's age group: getting up in themorning, bathing, dressing, eating, participating in school activities, doing chores, interacting withothers, and participating in play activities.
A response of 3 or 4 on any item for Questions 41 to 48 must be substantiated by documentation inthe case record. The case record must describe the extent to which the following items interferewith the child's daily living activities. In order to select Choice 3, the symptom must interfere withseveral of the activities on a continual basis. In order to select Choice 4, the symptom mustprevent the child from performing most or all of these daily living activities.
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APPENDIX C2: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
INSTRUCTION BOOKLET
(Q41) Question 41. Hyperactivity and/or attention deficits
Hyperactivity is excessive or frenzied physical activity; the child appears to be in constant motionthat seems not to be goal-directed.
o Running about or climbing on things excessively o Inability to sit still o Extreme restlessness or fidgeting An attention deficit is a substantially impaired ability to pay attention as evidenced by: o Extreme distractibility o Difficulty concentrating on schoolwork or other tasks requiring sustained attention o Often failing to complete a task (Q42) Question 42. Withdrawal, extreme passivity, lack of responsiveness to surroundings
This item addresses the child's relatedness to and interaction with his/her environment.
Use Choice 2 if the child functions relatively normally, but is often in a fog, is "spacey," seems tobe in a dream world, isolates him/herself from others, and spends a lot of time doing nothing.
Use Choice 3 if the child has obvious thought disorders or is so "out of it" that sometimes he/shedoes not respond to direct questions.
Use Choice 4 if the child is completely out of touch and is almost completely unresponsive toothers or to the environment.
(Q43) Question 43. Psychotic thought disorders
Code here indications of gross impairment in reality testing that are not attributable to mentalretardation, such as: o Hallucination - The child sees things or hears voices that aren't there o Bizarre delusions - A false belief whose content is patently absurd and has no possible basis infact, such as the child who thinks he is Christ or has delusions of being controlled or having noinsides o Marked loosening of associations - Thinking in which ideas shift from one subject to anotherthat is completely unrelated without any awareness that the topics are unconnected o Marked illogical thinking not attributed to mental retardation - Thinking that contains clearinternal contradictions or in which conclusions are reached that are clearly erroneous, given theinitial premise. For example, "Parents are the people that raise you. Parents can be anything-material, vegetable, or mineral - that has taught you something. A person can look at a rock andlearn something from it, so a rock is a parent." (Q44) Question 44. Nonpsychotic thought disorders
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This is a disturbance in thought that is a serious distortion of reality but not so gross that it ispsychotic. Examples of nonpsychotic thought disorders include: o Magical thinking - A belief that one's thoughts, words or actions might cause or prevent acertain outcome that defies the normal laws of cause and effect such as the mother who believesher child will become ill if she has an angry thought; clairvoyance, telepathy, "others can feel myfeelings," thought broadcasting o Recurrent illusions that are inappropriate for the child's age - e.g., "I felt as if my dead motherwere in the room with me." o Ideas of reference- An idea, held less firmly than a delusion, that events, objects, or otherpeople in the child's immediate environment have a particular and unusual meaning specifically forhim or her o Grandiosity - An inflated appraisal of one's worth, power, knowledge, importance or identity (Q45) Question 45. Depression
Do NOT include here normal periods of "the blues" or normal grief or sadness that is associatedwith a specific event (such as the recent death of a loved one).
In order to be coded here, the depression must be characterized by one or more of the followingobservable symptoms: o Loss of interest or pleasure in usual activities o Poor appetite or significant weight loss or increased appetite or significant weightgain o Difficulty sleeping or excessive sleeping o Feelings of worthlessness, self-reproach, or excessive inappropriate guilt o Recurrent thoughts of death, suicidal ideation or wish to be dead (Q46) Question 46. Lability or emotional instability
Code here sharp swings or repeated, rapid and abrupt shifts in interpersonal behavior, mood, self-image or attitude that appear to have little or no appropriate relationship to environmentalcircumstances.
For example, if a child seems elated one moment and then, suddenly and inexplicably, flies into arage, this behavior may be coded as lability.
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(Q47) Question 47. Other affective or emotional disorders
Code here only those disturbances in affect or emotion that have not been captured elsewhere inthis section.
o Flat affect - Consistently shows little or no emotional expression; the voice may bemonotonous and the face may be immobile o Blunted or constricted affect- Marked by a severe reduction in the intensity, expression or rangeof affective expression o Inappropriate affect - Affect is clearly discordant with the content of the speech or thought(smiling and laughing when discussing demons that are persecuting the child) o Extreme anxiety - The child is exceptionally fearful or anxious for no apparent reason (Q48-1) Question 48-1. Other psychiatric symptoms – Code
Use this to code the frequency of other psychiatric symptoms.
Include a symptom that has not been coded elsewhere either in this section or the behavior section.
If there is more than one symptom, select the more severe.
o Encopresis - soiling after an age at which continence is expected that is not due to a physicaldisorder.
o Pica - child eats nonfoods like crayons, paper clips, leaves o Bulimia - serious binge eating accompanied by episodes of starving, induced vomiting, etc.
o Anorexia Nervosa - serious self-starvation to the extent that life may be threatened o Phobias - excessive and unusual specific fears. In coding phobias, consider carefully how theyinterfere with daily functioning. An excessive fear of dogs is unlikely to interfere with mostfunctioning and should be coded as a 2. On the other hand, agoraphobia (fear of being in open orin public places) may interfere significantly with normal functioning and may (depending upon theindividual child) warrant a coding of 3 or 4.
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(Q48-2) Question 48-2. Other psychiatric symptoms – Describe Problem
Use this space to specify the type of other psychiatric symptoms.
(Q49) Question 49. Bedwetting (enuresis)
This is defined as repeated involuntary voiding of urine that is not due to a physical disorder afteran age at which continence is expected.
(Q50-1) Question 50-1. Ability to relate to peers - Code
This item is concerned with the child's ability to interact with others. Do NOT code hostility,aggressiveness or the like here as these behaviors are picked up in the behavior section.
If Choice 5 is selected, be sure to specify in Q50-2 what the disorder is.
Choices 3 and 4 must be substantiated by documentation in the case record. For choice 3,
there must be discussion in the case record about the child's lack of interaction with peers. For
Choice 4, the case record must describe the child's unresponsiveness to human beings. For
example, if the child is autistic and spends all of his/her time engaged in rocking and is mute and
does not substantially respond to conversation from others, then this choice would be selected.
(Q50-2) Question 50-2. Ability to relate to peers – Describe Problem
Use this space to specify the disorder if Choice 5 is selected in Question 50-1.
(Q51-1) Question 51-1. Primary psychiatric diagnosis – Code
Specify the code for the most recent formal diagnosis as it is written in the case record, only if oneexists, and only if: o It was made by a psychiatrist or psychologist o It is a current diagnosis (made within the past 2 to 3 years) If there is no formal diagnosis, leave this question blank.
The primary diagnosis is generally the main focus of attention or treatment and will generally bethe first diagnosis listed on Axis I (these classifications onto axes are made by the DSM-III) unlessotherwise indicated in the psychiatric report.
If there are multiple Axis II diagnoses, and there are no indications as to which is the primary andsecondary diagnosis, use the first Axis I diagnosis listed as the primary diagnosis (Question 51)and the first Axis II diagnosis listed as the secondary diagnosis (Question 52).
In the absence of a clear diagnosis, a written Diagnostic Impression made by the psychiatrist orpsychologist is acceptable.
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(Q51-2) Question 51-2. Primary psychiatric diagnosis – Write Diagnosis
Use this space to write out the primary psychiatric diagnosis where there is one that meets theconditions specified above in Q51-1.
(Q52-1) Question 52-1 Secondary psychiatric diagnosis - Code
Specify the code for a secondary diagnosis if it exists. This may be: o a second Axis I diagnosis where no Axis II diagnosis is made (Q52-2) Question 52-2 Secondary psychiatric diagnosis – Write Diagnosis
Use this space to write out the secondary psychiatric diagnosis where there is one that meets theconditions specified above in Q52-1.
(Q53) Question 53. Psychotropic or anticonvulsant medication
This item will be used solely for planning purposes and will not be considered for rate setting.
Indicate if the child does or does not currently receive prescribed psychotropic (mood altering) oranticonvulsant (anti-seizure) medication.
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IV. DEVELOPMENTAL DISABILITIES
There are five accepted developmental disabilities in New York State Mental Hygiene Law: If the child has indications of any one of these, complete the entire section.
(Q54) Question 54. Mental Retardation
If the child has a diagnosis that is a range of levels, such as Mild to Moderate Mental Retardationor Moderate to Severe Mental Retardation, use Choice 6.
If the child has more than one diagnosis, select the most recent one.
In order to use Choices 2, 3, 4, 5, or 6, a written diagnosis by a psychiatrist or psychologist mustbe in the case record.
(Q55) Question 55. Epilepsy/Seizure Disorder
In the absence of a formal diagnosis of epilepsy or seizure disorder, if the child is on anti-convulsant medication (see Question 53 for a list) for reasons other than to control the side effectsof psychotropic medication, you may code the child under 2 on the scale.
If there is no diagnosis and the child is NOT on anticonvulsant medication, but it appears that thechild may be having seizures, use Choice 6.
Choices 2, 3, 4, and 5 require a diagnosis and documentation in the case record.
(Q56) Question 56. Cerebral palsy
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There must be a formal diagnosis in the case record of cerebral palsy (this would include adiagnosis of spasticity, athetosis, or ataxia) to use choices 2, 3, or 4.
(Q57-1) Question 57-1. Other neurological impairments
Specify the code for any other major impairments affecting the central nervous system.
Do not code epilepsy, cerebral palsy or causes for mental retardation (such as Down's Syndrome,hydrocephalus or microcephaly). Also, do not code Organic Brain Syndrome or learningdisabilities.
Specify in Q57-2 what the neurological impairment is.
If the record indicates Minimal Brain Damage or "soft signs”, use Choice 3.
(Q57-2) Question 57-2. Other neurological impairments
Use this space to specify the type of other neurological impairment.
(Q58) Question 58. Autism
o There is a diagnosis of Atypical Pervasive Developmental Disorder o There is a diagnosis of Childhood Onset Pervasive Developmental Disorder o There is a diagnosis of Childhood Schizophrenia that appears to be a proxy forAutism o The record documents indications of autistic symptoms or autistic-like features butthere is no formal diagnosis of Autism Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
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V. SKILLS IN ACTIVITIES OF DAILY LIVING
This section should be completed only if one or more items were checked in the DEVELOPMENTALDISABILITIES SECTION and there are deficits in ADL skills relative to what is expected for that child'sage group. Persons should be rated on present, not future anticipated, ability. Rate persons on what theyare capable of doing, not on what they may or may not be permitted to do as a result of the facility'spolicies.
Responses 2, 3, 4 and 5 must be substantiated by documentation in the case record. This
documentation can consist of a description of how the child's disability interferes with his/her ability to
perform the following activities and/or the activities performed by staff in assisting or training the child
in performing these activities.
(Q59) Question 59. Eating
Consider the child's ability to eat a complete meal with little or no spilling using all normal dishesand utensils. Do NOT code any deficit here if the child is a "junk food" eater or is a sloppy eaterdue to laziness or apathy.
(Q60) Question 60. Dressing and grooming
Consider the child's ability to dress him/herself completely with no assistance in buttoning, puttingshoes on correct feet, tying shoe laces, etc. He or she should also be able to bathe unaided, brushhis/her teeth, and wash his/her hair.
Do NOT code any deficit here if the child knows how to dress and groom but is merely a sloppydresser due to laziness or apathy.
(Q61) Question 61. Toileting
To be completely independent, the child should have bowel and bladder control, go to thebathroom independently and be able to choose the correct restroom in a public place.
(Q62) Question 62. Uses telephone
The child should be able to dial the number correctly and carry on a conversation.
(Q63) Question 63. Uses stove to prepare meals
Consider the child's current ability to use a stove, whether or not the program permits the childrento cook for themselves. The child should be able to prepare simple meals like hot dogs, soup oreggs or bake something simple like a TV dinner in the oven with little or no help.
(Q64) Question 64. Uses neighborhood stores for shopping
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Consider the child's ability to use the community regardless of facility norms. The child should beable to follow simple directions concerning where to go, cross streets obeying lights and signals,make the correct purchase, and make the correct change. Do NOT code a deficit here if the childis not trustworthy in the community because he/she is a shoplifter, etc.
(Q65) Question 65. Uses laundry to wash clothes
This item should also be completed to reflect the child's skill rather than whether or not the facilityprovides for children to do their own laundry. The child should be able to use a washing machineand dryer to wash a simple load of clothing.
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VI. HEALTH PROBLEMS AND PHYSICAL DISABILITIES
Complete this section if the child has any significant physical disabilities or major chronic health problems.
(Q66) Question 66. Vision
Consider the child's vision with correction (glasses or contact lenses).
(Q67) Question 67. Hearing
If the child uses a hearing aid, consider the degree of hearing impairment with the use of a hearingaid.
(Q68) Question 68. Mobility
Code here mobility problems. Consider use of support devices other than wheelchairs underchoice 2.
(Q69) Question 69. Speech
Code here speech disorders such as lisping, stuttering or other articulation problems. DO NOTcode language problems (echolalia, perseveration, etc.) (Q70-1) Question 70-1. Other Serious Chronic Health Problem - Code
Use this to code any other serious chronic health problem (for example, a broken leg is not achronic health problem) that may interfere with the child's normal functioning or require ongoingspecialized medical attention. Exclude epilepsy or cerebral palsy.
Choices 3 and 4 must be substantiated by documentation in the case record.
(Q70-2) Question 70-2. Other Serious Chronic Health Problem - Describe Problem
Use this space to specify the type of other serious chronic health problem.
(Q71-1) Question 71-1. Other Serious Chronic Health Problem - Code
Use this to code any other serious chronic health problem (for example, a broken leg is not achronic health problem) that may interfere with the child's normal functioning or require ongoingspecialized medical attention. Exclude epilepsy or cerebral palsy.
Choices 3 and 4 must be substantiated by documentation in the case record.
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(Q71-2) Question 71-2. Other Serious Chronic Health Problem - Describe Problem
Use this space to specify the type of other serious chronic health problem.
(Q72) Question 72. Specialized health care
This question is available to indicate if the child receives any specialized health care.
Specialized health includes only those procedures that must be performed by a trained healthprofessional (e.g., doctor, nurse, nurse's aide, physical therapist).
o services for conditions which will be cured within 60 days o routine custodial care including - annual or periodic checkups or evaluations - taking blood samples or temperature checks - applying salves to burns or skin problems - feeding, changing, dressing - diagnostic testing o speech therapy, recreation therapy, occupational therapy o tube feeding, postural drainage, or suctioning (Q73) Question 73. Additional Comments
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Source: http://www.ocfs.state.ny.us/main/rates/FosterCare/SelfSurvey/InstBook.pdf