A Trauma-Informed Approach to Diagnosing Children in Foster Care Gene Griffin, J.D., Ph.D. Northwestern University Medical School August 28, 2012 Critical Issues 1) Defining Child Trauma 2) Differential Diagnosis 3) Treatment Implications What is Childhood Trauma? The experience of an event by a child that is emotionally painful or distressful which results in lasting mental and physical effects.* Event Experience Effects * National Institute of Mental Health DSM IV Diagnostic Criteria for Posttraumatic Stress Disorder (PTSD) After experiencing the event, the person must exhibit: •Re-experiencing •Avoidance •Hyperarousal “Trauma” C o m p l e x i t y PTSD Trauma Symptoms Trauma Events Trauma in Child Welfare Per 1000 Children (Illinois Data) 0 - 17+ 1000 900 800 700 600 500 400 300 200 100 0 Any Event Trauma Symptoms PTSD Griffin et al, 2012 Critical Issues 1) Defining Child Trauma 2) Differential Diagnosis 3) Treatment Implications Differential Diagnosis Issue- We look at the same thing but call it by different names… • And it matters… 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 Mental Illness of Older Youth in Child Welfare McMillen et al., 2005, Journal of the American Academy of Child and Adolescent Psychiatry Table 3: Percentage of IL Children with Mental Health Symptoms vs. McMillen Mental Health Symptoms Depression Attention / Impulse Oppositional % of ChildrenAll Ages 16.68 12.50 Conduct Affect Dysregulation PTSD 5.54 9.67 9.97 2.88 (6.87 for older youth) McMillen Older Youth 18 10 17 (with Conduct Disorder) 6 (Mania) 8 American Academy of Child and Adolescent Psychiatry (2010) 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.’ Symptoms that Overlap with Child Trauma and Mental Illness- (AACAP, 2010) DSM Diagnosis Overlapping Symptoms Trauma 1. Anxiety Disorders avoidance of feared stimuli, physiologic and psychological hyperarousal upon exposure to feared stimuli, sleep problems, hypervigilance, and increased startle reaction 2. Attention Deficit / Restless, hyperactive, disorganized, and/or Hyperactivity agitated activity; difficulty sleeping, poor Disorder concentration, and hypervigilant motor activity Child Trauma 3. Bipolar Disorder Child Trauma Hyperarousal and other anxiety symptoms mimicking hypomania; traumatic reenactment mimicking aggressive or hypersexual behavior; and maladaptive attempts at cognitive coping mimicking pseudo-manic statements 4. Major Depressive Self-injurious behaviors as avoidant coping Disorder with trauma reminders, social withdrawal, affective numbing, and/or sleep difficulties Child Trauma Child Trauma Symptoms that Overlap with Child Trauma and Mental Illness- (AACAP, 2010) DSM Diagnosis Overlapping Symptoms Trauma 5. Oppositional Defiant Disorder A predominance of angry outbursts and irritability Child Trauma 6. Panic Disorder Striking 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 drugs and/or alcohol used to numb or avoid trauma reminders Child Trauma 8. Substance Abuse Disorder Child Trauma Average Number of Trauma and Mental Health Symptoms per Trauma Event 0 # of Significant Trauma Events (N) (N= 3412) Average # of Trauma Symptoms 0.06 Average # of Mental Health Symptoms 0.41 1 (N= 4081) 0.23 0.70 2 (N= 3039) 0.49 1.17 3 (N= 1792) 0.91 1.82 4 (N= 904) 1.23 2.42 5 (N= 489) 1.63 3.00 6 (N= 184) 1.93 3.67 7 (N= 73) 2.25 4.51 8 (N= 34) 2.85 5.53 9 (N= 10) 2.80 6.30 11* (N= 3) 2.33 9.33 13 (N= 17) 5.00 12.94 (*no subjects with 10 or 12 trauma events) Incident Rate Ratio= 1.410 Incident Rate Ratio = 1.342 Average Number of Mental Health Symptoms per Trauma Symptom # of Trauma Symptoms 0 Average # of Mental Health Symptoms 0.51 1 2.04 2 3.06 3 3.53 4 4.64 5 7.73 Incident Rate Ratio = 1.74 The Overlap of Trauma and Mental Health Symptoms Trauma and Mental Health Symptoms for Children Entering Care by Age 100% 90% 80% 70% 13.12% 7.11% BOTH Trauma and Mental Health 39.18% 11.76% 54.13% Symptoms 62.00% Mental Health Symptoms Only 60% 13.56% 50% 40% 30% Trauma 13.81% 21.92% 68.02% 20% 33.45% 10% Symptoms Only 15.75% 6.93% 6.00% 17.03% 16.25% NO Symptoms 0% 0 – 6 Year Olds 7 – 12 Year Olds 13 – 16 Year Olds Age Range 17 + Year Olds 17 Critical Issues 1) Defining Child Trauma 2) Differential Diagnosis 3) Treatment Implications …Call It By Different Names 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 …And It Matters Trauma-Informed Treatments place a greater focus on: • Safety • Adult Support • Resilience and Protective Factors Trauma-Informed Treatments focus less on medications Trauma-Informed Treatments are less stigmatizing 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