1. Navigating Uncertainty
Diagnostic Challenges in Youth Affected by Trauma

2. Presenters
Julia K. Hoke, Ph.D., Director of Psychological Services, Austin Child Guidance Center,
May Matson Taylor, Ph.D., Staff Psychologist, Austin Child Guidance Center,
JULIA
We are both psychologists at the Austin Child Guidance Center. Approximately ??% of the children we see at the center have been experienced at least once incidence of trauma. May and I see clients for therapy, but the bigger piece of what we do at ACGC is conducting psychological assessments. Over the years, I’ve lost count of the number of assessment referrals we’ve received that include questions related to trauma exposure. Therapists may refer a child with a trauma history for assessment due to aggression, impulsivity, and poor academic performance. The underlying question is often something like, “Is this ADHD, ODD, [insert diagnosis here] or are the child’s symptoms related to trauma?” Unfortunately, questions like these oversimplify the challenges inherent in reaching valid diagnostic conclusions with this vulnerable population. Questions like these set up a false dichotomy. Children with a trauma history often show behaviors and experience emotions related to their exposure to trauma AND they may also carry other diagnoses.
In developing this presentation, we encountered information that challenged some of our assumptions, and we have made changes to our practices based on what we’ve learned.

3. Objectives:
Greater awareness of the complexity of diagnostic decision-making in children with adverse events
Increased recognition of importance of routine screening for trauma, as well as effective screening strategies
Understanding of the various ways that traumatic exposure can impact children’s functioning and common diagnostic patterns seen in children exposed to trauma
Strategies for working within the (often inadequate) DSM-5 system to describe the functioning of children affected by trauma
Assessment strategies for children with trauma (and when to refer for more in-depth psychological assessment)
Strategies for diagnostic decision-making in children with trauma histories
JULIA
Poll audience members on professional background – acknowledge that with regard to #5, we will be discussing general guidelines more than specific assessment strategies. If those of you who do psychological assessment are interested in talking more specifically about PA strategies, contact us or talk to us afterwards.
A caveat: We want to recognize the resilience of children who are exposed to trauma—that not all children will end up experiencing significant distress or functional impairment and that for some children with trauma-exposure, there will not be any psychiatric diagnosis.

4. Case studies
“Alex” - 7-year-old boy who lives with his mother, stepfather, and sister.  He was referred due to disruptive behavior, noncompliance, inattention, and fighting with peers.  He witnessed domestic violence between his mother and a previous partner on several occasions between ages 3 and 5.
“Karla” - 11-year-old girl who lives with her maternal aunt, aunt's partner, and her 2 younger cousins.  Karla was removed from her mother's care at age 4 and spent about a year in foster care before being placed with her aunt.  Between birth and age 4, Karla was exposed to parents who were heavy drug users, inconsistent supervision, witnessing domestic violence, witnessing her mother's arrest, and possible sexual abuse.   Karla has previous diagnoses of ADHD, ODD, and a mood disorder.  Current concerns include emotional and behavioral outbursts/meltdowns, limited peer relationships, inattention, and struggling academically.
MAY

5. Trauma Prevalence Data
2011 – 12 National Survey of Children’s Health – 47.9% of children had experienced at least one adverse childhood event (ACE)
2011 SAMHSA report – 26% of children in the US witness or experience a traumatic event before turning 4
National Survey of Children’s Exposure to Violence (2015) – nearly 60% of youth surveyed had been exposed to violence in last year
JULIA
Challenges in determining prevalence: This is data on the experience of potentially traumatic events; it is much more difficult to collect data re: the percentage of children who experience the event as traumatic. In addition, national surveys often confound difficult or stressful events with trauma. More broadly, there is confusion as well as ongoing discussion in the field about specific events that “qualify” as traumatic. The key point here is that a great number of children—in some studies most—are exposed to at least one PTE during childhood. If we expand the definition of trauma somewhat, the rates are even higher.
Other challenges: time period being examined (first four years, before age 17, within past year), how questions are asked, who is asked (child or caregiver), sample being surveyed, screening method
A review of methodologically rigorous studies of trauma prevalence found that 8 – 10% of American youth have experienced at least 1 sexual assault with; higher rates among girls than boys; around 70% experience at least one incident of physical abuse or assault during childhood;

6. Understanding the Impact of Trauma
Acute trauma vs. Chronic Trauma
Moderated by developmental variables
Perception and appraisal
Relational context of trauma
Normal reactions to abnormal circumstances
“Trauma specific” symptoms vs. non-specific symptoms
Short-term vs. longer-term impacts
MAY
Trauma, including one-time, multiple, or long-lasting repetitive events, affects everyone differently. Some individuals may clearly display criteria associated with posttraumatic stress disorder (PTSD), but many more individuals will exhibit resilient responses or brief subclinical symptoms or consequences that fall outside of diagnostic criteria. The impact of trauma can be subtle, insidious, or outright destructive. How an event affects an individual depends on many factors, including characteristics of the individual, the type and characteristics of the event(s), developmental processes, the meaning of the trauma, and sociocultural factors.
We discuss these domains as if they are discrete, when of course they are not—cognitive development impacts language and academics and emotional and behavioral regulation. We focus on findings that have diagnostic implications.
Much of the research on trauma consequences focuses on children with chronic, developmental trauma
Single incidence of trauma (e.g., natural disaster, car accident): short-term distress and for most children, a return to typical functioning
Previous trauma leaves children more susceptible to impact of subsequent trauma

7. Cognitive
Reduced cerebral cortex size in children with chronic developmental trauma has impact on many complex functions
Lower IQ
Memory problems
Slowed academic progress
Poor problem-solving skills
Deficits in receptive/expressive language
MAY
IQ – effects as dramatic as lead poisoning, one study of 200 children found that children who experienced or witnessed trauma during the first 2 years had IQ’s on average 7 points lower than matched group of children who had not experienced trauma

8. Relational/Attachment
Complex array of attachment difficulties not adequately captured by DSED or RAD
Difficult trusting others, making friends
Clinginess with caregivers
Social withdrawal
Relating to parents/caregivers like a younger child
Intense preoccupation with safety of caregiver
Lack of reciprocity in relationships
Inappropriate attempts to get physical affection or closeness
Difficulty regulating empathic arousal
MAY
Difficulty regulation empathic arousal – evidenced by lack of empathy or by excessive reactivity to others’ distress

9. Behavior Regulation/Executive Functioning
Conduct problems: aggression, reckless behavior, substance use/abuse, oppositional-defiant behaviors
Executive Functioning: Poor attention, impulsivity, difficulty initiating and sustaining goal directed behavior
Repetitive or compulsive behaviors
MAY
Repetitive or compulsive behaviors may represent maladaptive attempts at self-soothing

10. Emotional Functioning
Excessive temper or tearfulness
Difficulty recovering from extreme emotional states
Startle easily
Fearfulness and worrying
Phobias
Separation anxiety
Guilt and shame
Irritability
Depression
MAY

11. Physiological Sleep disturbances
Problems with feeding, appetite and weight gain
Toileting problems
Sensory difficulties (over or under awareness)
MAY
Common physical disorders and symptoms include somatic complaints; sleep disturbances; gastrointestinal, cardiovascular, neurological, musculoskeletal, respiratory, and dermatological disorders; urological problems; and substance use disorders.

12. Step 1: Universal Trauma Screening

13. Rationale for Universal Screening
High prevalence of ACE in youth presenting for care
To identify imminent danger requiring urgent response
Determine appropriate follow-up and need for trauma-specific services
Communicate to clients recognition of role of trauma and openness to talking about trauma
May set the stage for later disclosure
JULIA
By the fact that you are here, I know that you are all probably at least somewhat convinced that universal trauma screening is important. So with the knowledge that I am preaching to the choir, I won’t spend a lot of time on this. A complete consideration for trauma screening is beyond the scope of this presentation. We have some resources at the end of the powerpoint for those interested in learning more .
We include trauma screenings because failing to identify that a client or family has a trauma history increase the risk of misdiagnosis, inappropriate treatment plan, re-traumatization, and more negative mental health outcomes. Individuals may feel more understood and are better able to engage in collaboration when we ask about their trauma backgrounds. Simply asking directly about trauma experiences also communicates that “it is o.k. to talk about what happened,” and this is a message many children and adults need to hear.
Should child-serving practices/agencies also screen parents?

14. Barriers to Screening Time constraints
Not part of standard procedure in some settings
Belief that treatment should focus solely on presenting symptoms
Lack of training and/or feelings of incompetence in responding to and addressing trauma
Fear that it will be too disturbing to client or client is not ready
Assumption that screening has already occurred
JULIA
Audience participation: What are reasons that we don’t screen for trauma?
This seems straightforward but we know that many primary care providers are not screening for trauma. Discomfort with asking intrusive questions, time, assumption that screening has already happened. We know that children and parents do not always disclose trauma when first asked, so it is important to include trauma screening at multiple levels of care. Some professionals may avoid thorough screening because of child-abuse reporting laws.  
2012 study - Most (82%) of the clinicians indicated that they did not have adequate time to address either psychosocial or mental health issues with patients. Less than 5% indicated that they are “very comfortable” addressing trauma-related issues
One study found that only 28% of PCP’s routinely screen for trauma (2012)

15. Screening vs. Assessment
Screening: brief, focused inquiry to determine whether an individual has experienced specific, potentially traumatic events
Assessment: more in-depth exploration of the nature and severity of the traumatic events, the sequelae of those events, and current trauma-related symptoms.
JULIA
Trauma-informed screening refers to a brief, focused inquiry to determine whether an individual has experienced specific traumatic events
Trauma assessment is a more in-depth exploration of the nature and severity of the traumatic events, the sequelae of those events, and current trauma-related symptoms.
A note here about the difference between PTE (which is usually what we are screening for) and the actual experience of trauma. The event itself is potentially traumatic. It is the individual’s experience of that event that identifies it as traumatic or not.)  
When we talk about screening, the implication is that a more in-depth assessment of trauma symptoms will take place for some subset of those screened and we will talk more about trauma assessment after highlighting some important considerations in trauma screening.

16. Best Practices in Trauma Screening
Informed consent
Creating a safe environment
Ask about a range of specific trauma types
Screen at outset of treatment/evaluation
Use unambiguous, straightforward language
Consider using a screening tool
Multiple informants
Repeated screening
JULIA
Ask participants to raise hands if they or someone at their site routinely screens for trauma.
Informed consent – let client/parent know what you’re going to be asking about and that it is their choice to answer, could mention risks/benefits
Creating a safe environment – seems obvious but some of us may practice in settings in which children or parents may be easily overheard during an intake interview, this does not create psychological safety
Ask about a range of trauma types – just asking whether the child has experienced something scary or dangerous is often not sufficient; children may not categorize their experiences in this way so it helps to ask about a range of PTE’s
Do as early as possible in treatment – some of us may be reluctant to ask about trauma at the first visit, wanting instead to build rapport, because exposure to trauma may necessitate trauma-specific treatment, it is important to ask as early in treatment
Use unambiguous language – Examples from UCLA Index “did someone touch the private parts of your body when you did not want them to?” “Were you hit, punched, or kicked very hard at home?”
Consider using a screening tool – it can be hard to include all of these aspects without using some sort of standardized tool, we recommend a tool that can be used as a semi-structured interview bc interviews tend to produce higher rates of disclosure than a self-report survey
Multiple informants - especially important because trauma symptoms are relatively more abstract than other symptoms and may be harder for children to report on, also combining parent + child reports results in more children being diagnosed with PTSD than only counting symptoms upon which there is agreement
Ongoing assessment – For settings in which you see a child more than once, such as ours, we ask about trauma history at each level of care using a combination of phone interviewing, checklist, and in-person interviewing
For instance, at our agency, our intake specialist asks parents over the phone about their children’s trauma history. Then, our developmental questionnaire asks this question again and provides a list of common adverse childhood experiences and traumatic events for parents to choose from. Providing a list (either in writing or through an interview) has been found to increase sensitivity of trauma screening (need reference here). Then, therapists ask about trauma at the initial therapy appointment. If a child participates in a psychological assessment or psychiatric evaluation, screeners for trauma are included here as well.
Personal interviews produce higher prevalence estimates than self-report surveys
Multiple informants –

17. Step 2: Selective Trauma Assessment

18. To Refer or Not to Refer
If trauma exposure is indicated, your next step depends on setting, profession/training, and purpose of encounter.
Make referral to more appropriate professional for additional assessment of trauma symptoms
Do brief assessment of trauma symptoms and if present, make referral to more appropriate professional
Complete in-depth trauma assessment and refer for treatment
Complete in-depth trauma assessment and begin treatment
JULIA
Whether you will do additional assessment if trauma exposure is indicated is dependent on setting, professional background/training, and purpose of encounter- For those of you who will end up doing more in-depth trauma assessment, we will include strategies for this type of assessment later in our presentation
Trauma assessment for those who need trauma assessment

19. Referring for Psychological Assessment
Seek out referral sources that are trained in the assessment of trauma
Prepare client and parent for possibility of uncertainty in diagnosis
Be mindful of time frame: referral for assessment during period shortly following trauma may produce a “snapshot” of current functioning (and treatment recommendations) but is less likely to yield clear diagnostic information
JULIA
How do find referral sources trained in the assessment of trauma?
Currently there are no established standards for a trauma-informed assessment – at our center, we use a collaborative approach to assessment in which the parent and client are active participants in shaping the assessment process. This is consistent with trauma-informed care standards which call for maximizing collaboration and increasing opportunities for empowerment and choice. Ask questions about the psychologist’s experience assessing youth exposed to trauma, assessment tools used. If you are employed in a setting that sees many children exposed to trauma (and frequently refers for assessment), consider developing a referral network with other professionals who have similar experience.
If you are the therapist or other treatment provider, it may be helpful to prepare the parent for the possibility that there may not be a clear diagnostic conclusion at this time.
There are some good reasons to refer a child for a psychological assessment even when trauma has occurred recently. In some situations, it is useful to get a snapshot of the child’s current functioning to identify what level of care and treatment is needed. Diagnostic uncertainty is likely to be high in these situations, though.

20. Careful Assessment of Trauma History and Symptoms
Get a timeline and a thorough developmental history
With acute trauma – pay attention to correspondence between traumatic events and onset of symptoms
Consider using a trauma assessment tool
Multiple informants – parent and child
Use educational interviewing
Asking only about trauma symptoms connected to “worst trauma” may underestimate total symptoms
Pay attention to avoidance – may lead to underreporting
What interventions and supports have been tried
Risk and protective factors
-Why is this important
-What decisions are we making based on this info (diagnosis, treatment plan, etc)
So you’ve screened for trauma, and your client has reported some specific, potentially traumatic events and you’ve determined that the next step is trauma assessment and that you are the appropriate individual to begin that assessment. Remember the role of resiliency—not all children who’ve experienced ACE develop symptoms. In one study, approx 14% of children who experienced trauma went on to develop PTSD.
We recommend using a standardized tool, preferably one that can be used as an interview for younger children, to assess trauma-specific symptoms, as well as other symptoms that can be associated with trauma. This should be a piece of your overall diagnostic process rather than a distinct stand-alone assessment. Depending on your setting (i.e., primary care vs. behavioral health), you may see varying rates of trauma symptoms in trauma exposed youth. Keep in mind that not all youth who experience trauma develop significant symptoms.
Timeline – of traumatic events, changes in caregiver, onset of symptoms
Educational interviewing – provide psychoeducation about effects of trauma while asking about symptoms
Avoidance – can lead to underreporting by child OR parent; may get a better sense of avoidance from observing reaction to asking about the trauma rather than by asking client to report directly on avoidance symptoms. “I don’t think about [the trauma]” can mean anything.

21. Step 3: Typical Diagnostic Practices
This is not really what we’re talking about, but it’s important to note. Depending on your setting, you collect the typical data you would normally collect on a range of domains of functioning. For instance, if there are questions about learning, you collect information on academic achievement, etc.

22. Step 4: Trauma-Informed Diagnostic Practices
Or in other words, so what can we do as clinicians to be more trauma-sensitive in our diagnostic processes?

23. Rationale for Diagnostic Decision-Making
Setting-specific requirements (e.g., eligibility, insurance billing)
Provides important information for treatment planning
Aids in parent or caregiver’s understanding of presenting difficulties and rationale for treatment
Parents and teachers develop more realistic expectations
Clients gain more adaptive understanding of themselves
When clients understand the impact of trauma it gives them a chance to develop healthier and less shame-based understandings of themselves, starts healing process

24. DSM-5 Trauma Specific Syndromes
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Other Specified/Unspecified Trauma- and Stressor-Related Disorder
Let’s start with an overview of different diagnoses we may be considering. This is a bit of a misnomer but we will borrow this distinction from the DSM for ease of discussion. The DSM-5 lists these diagnoses as trauma or stressor-related disorders.
How much detail should we discuss here? What about differentiating how trauma symptoms present at different ages?
Trauma-specific syndromes are not the only or even the most common way in which trauma impacts functioning. The concept of Developmental Trauma Disorder of Childhood, although not included in the most recent DSM, provides a good framework for understanding the various ways that trauma exposure can show up in children. (except I didn’t actually use this framework!) Consider re-organizing by DTD framework? This leaves out cognitive and learning impacts. Chronic developmental trauma places children at-risk for developmental deficits in all domains.

25. Other Common Diagnoses
Attention-Deficit/Hyperactivity Disorder
Disruptive Mood Regulation Disorder
Oppositional Defiant Disorder
Bipolar Disorder
Depressive Disorders
Anxiety Disorders
Psychotic disorders
Other neurodevelopmental disorders: Intellectual Disability, SLD, ASD
The brief overview of trauma effects in various domains sets the stage for many of the diagnoses we see in children impacted by trauma. Some recent research suggests that dysregulation is the primary mechanism by which trauma impacts the development of psychopathology and you can see that many of the disorders listed have emotional or behavioral dysregulation as a primary feature.
These can be disorders that are comorbid with PTSD or other trauma-related diagnoses. In some trauma-affected children, trauma exposure may manifest in other diagnoses. Research has found that trauma increased the prevalence of ADHD, DMDD, ODD, Bipolar, Depression, and Anxiety.
Specific trends in comorbidity: In preschoolers, ODD and separation anxiety are the most common comorbidities, social difficulties and conduct problems are also frequently seen
Maltreated school-age children – common co-morbidities include ADHD, anxiety disorders, psychotic symptoms, ODD
In adolescence – all of the above, plus an increase in substance use disorders

26. Potential Pitfall 1: Making Diagnosis Without Adequate Awareness of Trauma
Case Study 1, “Alex”
Door 1: ADHD only
Door 2: ADHD + a trauma-related diagnosis
Door 3: Trauma-related diagnosis only
If impact of trauma is not fully considered, child could miss out on receiving appropriate trauma-informed interventions
What happens when diagnoses are made without awareness of a child’s trauma experiences? This could be due to missed opportunities to adequately screen for trauma, lack of follow-up on reports of trauma (screening but no assessment), individual’s reluctance to report trauma, or simply discounting the impact of trauma in diagnostic formulations
Doors 1 – 3 represent diagnostic hypotheses that would inform a careful assessment of this child.
Careful assessment of the role of trauma in a child’s functioning allows providers to better educate parents and teachers about the effects of trauma, appropriate expectations, and effective support strategies
In each scenario, there is the possibility of a false positive and a false negative

27. Potential Pitfall 2: Failing to Consider Relevant Diagnoses
Trauma-related disorders have a high rate of comorbidity
Missing part of the diagnostic picture may limit treatment effectiveness, prevent the child from receiving some appropriate support services
Trauma is part of the etiology of several other psychiatric diagnoses
This seems to be the less common outcome, but it is one we want to recognize
Trauma as part of the clinical picture doesn’t preclude you from considering other diagnoses
We often find this easier to do with certain diagnoses but more difficult with others – this variability is likely due at least somewhat to our understanding of the role of trauma in the etiology of other psychiatric diagnoses
Could talk about Case Study #2 – what if she has a LD in addition to trauma-related symptoms

28. Potential Pitfall 3: It’s not always one or the other
Disorders that are clearly trauma linked
Disorders that can have trauma as part of their etiology
Disorders for which trauma is not a recognized developmental pathway
Emerging research will likely shift our understanding
Treatment implications – recognizing when trauma is part of developmental pathway
Muddy, murky middle ground, trauma increases the risk of certain diagnoses.
We accept that trauma can be part of the developmental pathway for certain disorders beyond those identified by the DSM as being “trauma or stressor-related): for instance, anxiety disorders that develop following trauma or depression. Then there are some disorders such as DMDD for which emerging research suggests a link between trauma exposure and the diagnoses. There are other disorders that we consider “neurodevelopmental” and many of us are hesitant to diagnose these conditions in youth with chronic developmental trauma.
In children with acute stressors, it can be easier to determine whether symptoms predated the traumatic occurrence, but with chronic, developmental trauma, we are unlikely to be able to make this distinction. Some leaders in the field of child trauma (Bruce Perry) contend that ADHD, clearly a neurodevelopmental disorder, is better understood as a neurobiological response to trauma. It seems likely that the neurophysiological impact of trauma on the developing brain represents one pathway by which neurodevelopmental disorders (such as ADHD) may develop; however, there is not sufficient research, yet, for us to feel confident attributing neurodevelopmental disorders to the impact of trauma.
Instead, when we make a diagnoses of a neurodevelopmental disorder such as ADHD in a child with chronic or complex trauma, we are likely to communicate the possibility or even the likelihood that the child’s trauma history has played a role in the development of ADHD symptoms.

29. Strategy 1: Be appropriately cautious in initial diagnosis
Consider initial assessment as “snapshot” and recommend re-evaluation after period of intervention and/or stability
Use “Provisional” and Other Specified and Unspecified diagnoses to signal less diagnostic certainty
Consider listing “Rule-Out” diagnoses when symptoms are more likely attributable to trauma
Use T codes for child abuse and neglect

30. Strategy 2: Be Mindful of Research
Awareness of common responses to trauma and the range of possible responses
Recognizing impact of trauma on neurodevelopment and how this can manifest in behavior
Prevalence rates for various diagnoses can be used as a “check” on your diagnostic practices or those at your agency

31. Strategy 3: Stay Curious
Abandon the perspective of “all-knowing” clinician
Acknowledge uncertainty
Keep learning

32. Selected Resources
National Child Traumatic Stress Network (
American Psychological Association (
National Center for MH Promotion and Youth Violence Prevention (

33. Selected Resources
Trauma Screening Guidelines (
Post-traumatic stress disorder diagnosis in children: challenges and promises (