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