1. A Trauma-Informed Approach to Diagnosing Children in Foster Care Gene Griffin, J.D., Ph.D.Northwestern University Medical SchoolAugust 28, 2012

2. 1) Defining Child Trauma 2) Differential Diagnosis 3) Treatment Implications Critical Issues

3. The experience of an event by a child that is emotionally painful or distressful which results in lasting mental and physical effects.* EventExperienceEffects What is Childhood Trauma? * National Institute of Mental Health

4. DSM IV Diagnostic Criteria for Posttraumatic Stress Disorder (PTSD) Re-experiencing Avoidance Hyperarousal After experiencing the event, the person must exhibit:

5. “Trauma” PTSD Trauma Symptoms Trauma Events ComplexityComplexity

6. Trauma in Child Welfare Per 1000 Children (Illinois Data) Griffin et al, 2012

7. 1) Defining Child Trauma 2) Differential Diagnosis 3) Treatment Implications Critical Issues

8. Issue- We look at the same thing but call it by different names… And it matters… Differential Diagnosis

9. We Look at the Same Thing But… A 16-year-old male does not sit still, does not pay attention, overreacts to slights, mistrusts adults, runs away and repeatedly gets into fights. An adult should refer the youth to: A. Juvenile Justice B. Mental Health C. Childhood Trauma

10. Mental Illness of Older Youth in Child Welfare  McMillen et al., 2005, Journal of the American Academy of Child and Adolescent Psychiatry

11. Mental Health Symptoms % of Children- All Ages McMillen Older Youth Depression16.6818 Attention / Impulse 12.5010 Oppositional9.9717 (with Conduct Disorder) Conduct5.54 Affect Dysregulation 9.676 (Mania) PTSD2.88 (6.87 for older youth) 8 Table 3: Percentage of IL Children with Mental Health Symptoms vs. McMillen

12. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder ‘The Psychiatric Assessment Should Consider Differential Diagnoses of Other Psychiatric Disorders and Physical Conditions That May Mimic PTSD.’ American Academy of Child and Adolescent Psychiatry (2010)

13. DSM Diagnosis Overlapping SymptomsTrauma 1. Anxiety Disordersavoidance of feared stimuli, physiologic and psychological hyperarousal upon exposure to feared stimuli, sleep problems, hypervigilance, and increased startle reaction Child Trauma 2. Attention Deficit / Hyperactivity Disorder Restless, hyperactive, disorganized, and/or agitated activity; difficulty sleeping, poor concentration, and hypervigilant motor activity Child Trauma 3. Bipolar DisorderHyperarousal and other anxiety symptoms mimicking hypomania; traumatic reenactment mimicking aggressive or hypersexual behavior; and maladaptive attempts at cognitive coping mimicking pseudo-manic statements Child Trauma 4. Major Depressive Disorder Self-injurious behaviors as avoidant coping with trauma reminders, social withdrawal, affective numbing, and/or sleep difficulties Child Trauma Symptoms that Overlap with Child Trauma and Mental Illness- (AACAP, 2010)

14. DSM Diagnosis Overlapping SymptomsTrauma 5. Oppositional Defiant Disorder A predominance of angry outbursts and irritability Child Trauma 6. Panic DisorderStriking anxiety and psychological and physiologic distress upon exposure to trauma reminders and avoidance of talking about the trauma Child Trauma 7. Psychotic Disorder severely agitated, hypervigilance, flashbacks, sleep disturbance, numbing, and/or social withdrawal, unusual perceptions, impairment of sensorium and fluctuating levels of consciousness Child Trauma 8. Substance Abuse Disorder drugs and/or alcohol used to numb or avoid trauma reminders Child Trauma Symptoms that Overlap with Child Trauma and Mental Illness- (AACAP, 2010)

15. # of Significant Trauma Events (N) Average # of Trauma Symptoms Average # of Mental Health Symptoms 0 (N= 3412)0.060.41 1 (N= 4081)0.230.70 2 (N= 3039)0.491.17 3 (N= 1792)0.911.82 4 (N= 904)1.232.42 5 (N= 489)1.633.00 6 (N= 184)1.933.67 7 (N= 73)2.254.51 8 (N= 34)2.855.53 9 (N= 10)2.806.30 11* (N= 3)2.339.33 13 (N= 17)5.0012.94 (*no subjects with 10 or 12 trauma events) Incident Rate Ratio= 1.410Incident Rate Ratio = 1.342 Average Number of Trauma and Mental Health Symptoms per Trauma Event

16. # of Trauma Symptoms Average # of Mental Health Symptoms 00.51 12.04 23.06 33.53 44.64 57.73 Incident Rate Ratio = 1.74 Average Number of Mental Health Symptoms per Trauma Symptom

17. 17 The Overlap of Trauma and Mental Health Symptoms

18. 1) Defining Child Trauma 2) Differential Diagnosis 3) Treatment Implications Critical Issues

19. It is the adults who decide how to interpret the behaviors and symptoms of youth These interpretations will drive the treatment Treatment for child trauma can take a very different focus than treatment for mental illness …Call It By Different Names

20. Safety Adult Support Resilience and Protective Factors Trauma-Informed Treatments place a greater focus on: Trauma-Informed Treatments focus less on medications Trauma-Informed Treatments are less stigmatizing …And It Matters

21. Policy Recommendations Our study recommends child welfare agencies adopt policies requiring: mental health screenings and assessments of all children in child welfare include measures of traumatic events and trauma-related symptoms; evidence-based, trauma-focused treatment begin when a child in child welfare demonstrates a trauma-related symptom; and a clinician not diagnose a child in child welfare with a mental illness without first addressing the impact of trauma