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June 2010

done in a sporadic nature. Some of the assessments contained in the files were incomplete, thus complicating analysis.

In reviewing case materials, Fellows were asked to record the presenting problems (DSM-IV diagnoses, Global Assessment of Functioning, IQ scores), medications, assessment results, and treatment recommendations contained in both the earliest and the most recent psychological assessment located in the DFCS case file. Ninety-two percent (92%) of cold case children had a mental health diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV) criteria. This would make sense, as abuse and neglect are DSM- IV diagnoses and all of the children were removed from the home for abuse and neglect. On average, the children had two diagnoses on their early assessment and three diagnoses on their most recent assessment. The most common diagnoses included: Attention Deficit/Hyperactivity Disorder (ADHD), Post Traumatic Stress Disorder (PTSD), Oppositional Defiant Disorder (ODD), and various cognitive issues (e.g., borderline intellectual functioning, various learning disorders). Table 7 shows the most frequent mental health diagnoses. Table 7. Most Frequent Mental Health Diagnoses % of Children with Diagnosis Attention Deficit/Hyperactivity Disorder (ADHD) Post Traumatic Stress Disorder (PTSD) Oppositional Defiant Disorder (ODD) Various Cognitive Issues Bipolar Disorder Various Depressive Issues Conduct Disorder Reactive Attachment Disorder (RAD) Psychotic Disorder or Features 51% 27% 23% 23% 20% 19% 17% 14% 7%

A key area of interest was the extent of stability or change in mental health over time during the foster care experience. However, the young average age of removal (eight years old on average) requires extreme caution with this type of analysis. Young children present unique diagnostic challenges for a number of reasons. Disorders often manifest themselves differently in children than in adults. Children are also constantly changing and developing, each at their own pace. They are learning how to adjust to the many changes they are experiencing. Finally, they are learning how to process and express emotions and other experiences, while at the same time learning how to interact with others. Differential diagnosis, the process of arriving at an accurate diagnostic picture by ruling out other, competing diagnoses, is especially difficult with young children. For example, a child with depression may present to the clinician as a child with ADHD. In addition, many children received their initial assessment near the time of their entry into the foster care system, when the nature of their trauma was acute and perhaps complicated the diagnostic process. Other factors can account for differences across assessments, particularly differences in training and perspectives of clinicians. It is also important to note the limitations of assessment and diagnosis, in that they represent the observation and recording of a sample of behavior during a typically limited window of time. Arriving at a clear diagnostic impression for children is challenging, potentially leading to a phenomenon known as “diagnostic drift” in which children present differently during subsequent psychological assessments, resulting in “drifting” diagnoses over time. Therefore, the fact that cold case children had more diagnoses on average during later periods of their stay does not conclusively point to deteriorating mental health.


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