Scales for Assessing Posttraumatic Responses of Children

We are finally beginning to see the development of child- specific measures of children's exposure to and reactions to traumatic events. I myself have developed several of these measures. I have four different measures of Childhood PTSD. Each measures consists of approximately 95 items (it varies with the version) that assess both DSM-IV criteria for PTSD (63 items) and Associated Symptoms (32 items) as well. I have some preliminary psychometric data on the measures for those who are interested. At least two questions are asked for each DSM-IV symptom. These measures have been used with children, adolescents, and young adults from the ages of 6 to 24. They have also been used with MR adults. They are currently being used at several locations in the USA, Canada, and around the world (e.g., Latin America, Europe, and Japan). All of the measures ask essentially the same questions, except the parents are not asked some questions having to do with internal processes and they are asked additional behavioral questions. These scales have been revised several times.

  1. The Childhood PTSD Interview:
    A semi- structured interview that can be administered by paraprofessionals.
    The questions are written at the third-grade reading level, but it has been used with younger children.
  2. The When Bad Things Happen scale:
    A paper-and-pencil self-report for children. It has a third-grade reading level.
  3. The Childhood PTSD Interview -- Parent Form:
    A semi-structured interview of the parent about the child's reactions.
  4. The Parent's Report of the Child's Reaction to Stress:
    A paper-and-pencil report for the parent or guardian about the child's reactions.
  5. Several life-time stressor scales for different age groups of children -- school-aged, teens, and young adults -- and parents about their children's life-time exposure to 65 different stressors, which vary from such things as moving or problems in school, to exposure to violence and traumatic experiences. All but the young adults ask about the exact same questions. On all but the young adult measure there are no direct questions about physical or sexual abuse (I can't get these questions past IRBs or therapists). However, the Young Adult Upsetting Times Checklist asks very explicit and detailed questions about such abuse before and after the age of 18, with different family members, with people outside the family, and with strangers. I have interesting information on the clustering (factors) of college students' answers to this measure. On all but the measure for the very youngest, respondents are asked to rate each potential stressor as never occurring, occurring but not upsetting, occurring and moderately upsetting, or occurring and very upsetting. Also for all but the youngest, each event is rated for the past year and for anytime previous to the past year. The youngest children just check each event that has ever happened to them.
  6. The Dimensions of Stressful Events (DOSE) scale:
    A unique measure that rates a stressful event, or series of related events, on characteristics or dimensions that the literature indicates can lead to increased traumatization.
  7. The World View Survey:
    A measure of basic beliefs that may be affected by exposure to traumatic events. See the article on the development and psychometrics of The World View Survey for more information.
Be sure to see the article on the Revised Version 4 of the four PTSD measures as well as the DOSE. You can also see more about these scales, along with example items (and the full DOSE) in Stamm (1996 -- see reference at the end of this article). But if you would like more information now, please contact me at Kenneth.Fletcher@umassmed.edu. You can also write me at Kenneth E. Fletcher, University of Massachusetts Medical Center, Department of Psychiatry, 55 Lake Avenue North, Worcester, MA 01655-0001 USA. Or call me at (508) 856-3329.

Philip Saigh, Ph.D., with the help of a multitude of colleagues, has developed the Children's PTSD Inventory on the basis of DSM-IV criteria for PTSD. The initial psychometrics he and his colleague Anastasia Yasik, Ph.D., presented at the November, 1998, ISTSS conference in Washington, D.C., suggest that this structured interview is promising indeed, with very good reliablity and validity. An article published in the Journal of Traumatic Stress (Saigh et al., 2000) describes the development and the reliability of the measure. This appears to be an excellent interview that takes a trained interviewer 15-20 minutes to administer to children with trauma histories (and about 5 for those with no trauma history). Examples of traumatic ("scrary") experiences are described, and then the child is asked if he or she has ever experienced a scary event. If yes, the child is asked 1) if the event scared the child, 2) if the child felt upset when it happened, and/or 3) the child felt he or she could do nothing to stop it from happening. If answers indicate either a traumatic stressor did not occur or if the child did not react negatively to it even if it did happen, the interview is terminated, and the child is diagnosed with no PTSD. If the interview is not terminated several additional yes/no questions are asked: 11 concerning reexperiencing symptoms, 16 concerning numbing and avoidance, and 7 concerning arousal. Questions related to duration of symptoms are also asked. The instrument yields the following diagnoses: Negative PTSD, Acute PTSD, Chronic PTSD, Delayed Onset PTSD, and No Diagnosis (i.e., insufficient information).For more information, write Dr. Saigh at CUNY, Graduate Center, 33 W. 42nd Street, New York, NY 10036, or e-mail him.

Those of you in the Childhood PTSD Research Group know that I am using a children's version of the Impact of Events Scale (IES; see Stamm, 1996), the Child's Reaction to Traumatic Events Scale (CRTES).. It is a 15-item paper-and-pencil self-report scale. Six of the items are derived from the original IES. The child indicates on a 4-point rating scale the frequency of occurrence of each item in the past week, from rarely to often. Information about the scale's psychometric properties are currently being collected. A study of the reactions of children and adolescents to Hurricane Hugo in the USA indicated good internal consistency for the scale and its two subscales, using Cronbach's alpha: .84 for the Intrusion subscale, .72 for the Avoidance subscale, and .85 for the total scale. More will be published about this scale in a later newsletter and an article to be added to this website. Meanwhile see the review of the scale in Stamm (1996). This scale was written by Russell Jones, who can be contacted at the Department of Clinical Psychology, Virginia Polytechnic University, Stress and Coping Lab, 4102 Derring Hall, Blacksburg, VA 24601-0436 USA, USA; e-mail: ptl@vt.edu; telephone: (703) 231-5934.

Speaking of the Impact of Events Scale, an 8-item version has been suggested by Dyregrov and Yule (1995) as a reliable and valid screening device. I personally think it might work best with adolescents. The Intrusion scale is composed of the following items:

The Avoidance scale is composed of these items:

If you regularly administer the parent form of the Child Behavior Checklist (Achenbach, 1991), you might be interested in a post-hoc PTSD scale used by Wolfe et al. (1989) and myself (information to be posted in the future). I belief this "scale" of 20 items at best represents a general screening device. Parents appear to be rating their kids for general dysphoria and/or behavioral problems even more than they are for posttraumatic stress responses. The 20 items (for which Wolfe et al., 1989, found a Cronbach's alpha of .89 based on a sample of 68 sexually abused children; and I found an alpha of .83 based on a sample of 30 school-aged kids, 10 of whom were seeking treatment for exposure to traumatic events and 20 of whom were from the community) are as follows:

Ricky Greenwald has a 30-item paper-and-pencil PTSD screener in a parent and a child version -- Reports on Post- traumatic Symptoms (PROPS and CROPS). Items are from the CBCL, and each is rated similarly to Saxe's items (see below). Validation and translation information on his instruments is available on his site. You can contact him by writing to Ricky Greenwald, Psy.D., 483 Belknap Rd., Framingham, MA 01701 USA. Or, you can e-mail him at rickygr@childtrauma.com The measures are now being distributed by The Sidran Foundation

John March (919-684-4950; e-mail:jsmarch@acpub.duke.edu) has a self-report children's PTSD screener called the Kiddie Post-Traumatic Symptoms (K-PTS) Scale that uses 13 Yes/No responses about exposure to common stressors of children, and it is followed by 13 PTSD questions rated on a 4-point Likert scale. The current version has undergone 3 iterations in community samples. March stresses that this is still "clearly a work in progress," and that it is "psychometrically sound with respect to internal validity as a scale, but we know relatively less about external validity or whether or not it is sensitive to change." (These are cautions that could well be taken into consideration for all of the childhood PTSD scales of which I am aware, including my own.) March considers his scale a research tool, and he will only give it to "researchers with clearly defined protocols...who are willing to return the K-PTS and demographic data" (a professional courtesy that should be extended to everyone mentioned in this article). He does not want to give it out to others yet because he's "not yet comfortable with the science" of it.

Roger Hamada (who can be reached at Kapiolani Medical Center, 1319 Punahou St., Honolulu, HI 96826 USA; 808-973-8368; but it is best to e-mail him at hamadar@jabsom.biome d.hawaii.edu) and his colleagues have created the Kauai Recovery Index (KRI), a 24-item self- report for children and adolescents. The scale has been used with children as young as second graders. Items are substantially revised from the Reaction Index. With the addition of 4-6 exposure items, including questions about exposure to a trauma and degree of fear, the items reflect the diagnostic criteria of PTSD in DSM-IV. The KRI is designed to be used as a screening device to help identify children suffering substantial traumatic reactions to large-scale critical incidents such as natural disasters of large magnitude. Therefore, the guiding principles in its development were brevity and ease of administration, while preserving reliability and validity. Children rate their reactions to the disaster by marking each item on a 3-point scale of No, Sometimes, or Almost all the time.

Psychometric analyses are underway for data collected on 3,860 2nd through 6th graders who experience Hurricane Iniki (and were presented at the 1996 ISTSS conference in SF; I may present more information on them in a future issue of the newsletter). Ratings were taken about 2 years after the hurricane. When subscales are rationally derived based on the DSM-IV diagnostic criteria, the Cronbach alphas are .78 for Criterion B, .51 for C, and .47 for D. Test-retest for 43 students over a 4-week period was .77 for the total score and .44, .29, and .64 for Criteria B, D, and D. Validity data were presented at the ISTSS conference. The scale is currently suggested for children exposed to Type I (acute) traumas only.

Glenn Saxe, M.D. (Women's Health Services Division, National Center for PTSD, VAMC 116B-3, 150 S. Huntington Ave., Boston, MA 02130 USA; 617-232-9500; e-mail: Saxe.Glenn@Boston.VA.Gov ) has created a Child Stress Reaction Checklist that he uses with pediatric burn victims. This is parent paper- and-pencil report that asks how much the event upset the child (rated from Not at all to Extremely upsetting) followed by 30 PTS Reaction items that the parent circles either Not True, Somewhat or Sometimes True, or Very True, a format that mimics the Child Behavior Checklist. Dr. Saxe recently presented preliminary psychometrics on the scale at the November, 1998, ISTSS conference in Washington, D.C. They suggest that the measure has promising reliability and validity.

Good news! The venerable Child PTSD Reaction Index (CPTSD-RI), written by Fredericks, Pynoos, Nader, et al., and one of the mostly widely used measures in childhood PTSD research is being rewritten -- this time with children in mind (the original was based on Fredericks' adult Reaction Index). It is now called the UCLA PTSD Index for DSM IV, and as it's new name implies it now allows preliminary screening for DSM diagnosis. The items are actually child-friendly. Psychometrics are still being collected, however. For more information, contact the UCLA Trauma Psychiatry Service, 300 Medical Plaza, Los Angeles, CA 90095-6968. Their phone is 310-206-8973. Or you can e-mail them.

If you are interested in obtaining an in-depth assessment of a child's early trauma history, you might be interested in the Early Trauma Interview or its companion Inventory. If so, contact Dr. J. Douglas Bremmer, Yale Psychiatric Institute, P.O. Box 208038, New Haven, CT 06520-8038.

The venerable CHILD PTSD REACTION INDEX (CPTSD-RI), written by Fredericks, Pynoos, Nader, et al., and one of the mostly widely used measures in childhood PTSD research. This is probably the most frequently used measure to date, but it is also one I do not recommend, for several reasons. It is based on Fredericks' adult Reaction Index, which was never properly tested for its psychometrics. The CPTSD-RI may consequently not always be easily understood by children. It does not cover all DSM-IV symptoms, nor does it allow a DSM diagnosis to be made. It's psychometrics do not appear to have ever been properly studied either. The latest version is probably available from Pynoos's group at .

The VA has been using a measure called the Clinician-Administered PTSD Scale (CAPS) for years now. They have also been working on a child version, the CAPS-C for years. They have had the usual problems of getting research subjects, however, and I don't know how much progress they have made on assessing the psychometrics. Kathleen Nader and Robert Pynoos, who helped create the CPTSD-RI, apparently had a hand in creating this measure as well (Nader, Kriegler, Blake, Pynoos, Newman, & Weather, 1996). I have some problems with this measure, however. It is a long and involved and complicated interview that tries to do everything. It tries to assess both frequency and intensity of symptoms during the past month. I think this would be a challenging task for most teens (and some adults), let alone younger children.

Some people have used Briere's TRAUMA SYMPTOM CHECKLIST FOR CHILDREN (TSC-C) (Briere, 1989). It is designed to assess trauma-related psychological symptoms: Anxiety, Depression, Posttraumatic Stress, Sexual Concerns, Dissociation, and Anger. It was originally designed for trauma symptoms related to sexual abuse, but people have been using it for other traumas as well (a questionable practice, in my view). I'm not sure whether or not this is listed in Stamm's (1996) book. I've seen a copy somewhere but was not too impressed. "Acceptable internal consistency and convergent validity" have been reported, however (in an unpublished manuscript).

I am always being asked if I know of any assessment tools for kids younger than 6 or 7. Besides the parent reports, there is only one that I am aware of. This is the Angie/Andy Child Rating Scales, a cartoon-based measure, for kids 6-12. It is designed to assess symptoms of PTSD in kids exposed to prolonged, chronic stress. In addition to symptoms of PTSD, the scale measures symptoms of disregulation of affect and impulses, amnesia and dissociation, self-perception impairment, alterations in relations with others, somatization, guilt and self-blame, despair and hopelessness, and loss of sustaining beliefs. Based on a sample of 208 kids (6-12 years old, 43% hispanic, 43% black, 49.6% exposed to multiple traumas; 65 with no known type of extreme stressor exposure), internal consistency for the PTSD scale of 22 items were high (alpha = .90), and alphas for the other six associated-symptom scales ranged from .70 to .88. Good indications of validity have also been found. The scale is by Frances Praver, Ph.D. (5 Marseilles Drive, Locust Valley, NY 11560 USA; 516-676-1594) and David Pelcovitz (Dept. of Psychiatry, 400 Community Drive, Manhasset, NY 11030 USA; 516- 562-3176). The scale comes in a boys form and a girls form. I'm going to try to write up more on this for the next issue of the newsletter. For now see the review in Stamm (1996).

More established, comprehensive measures (usually interviews) have begun to include PTSD modules. I believe either the DICA or the DISC (or both) now have such modules. The K-SADS-E (Orvaschel et al., 1981, 1982) also has one that people are beginning to use (Orvaschel, unpublished, 1988).

The Dartmouth Child Trauma Research Group and The National Center for PTSD in White River Junction, VT, have a child and a parent version of a screener interview that they call the TESI (see Stamm, 1996, for more information). The interview asks if any of 16 different kinds of traumatic events have ever happened to the child (e.g., bad accident, death of important other, witness to violence, death of pet, kidnapping, physical abuse, natural disaster, etc.). If any did happen to the child, additional information is elicited regarding the particulars of the event. I understand that the scale has been refined since this article first appeared in the Spring of 1996. For more information contact Julie Thomas, Division of Child Psychiatry, Dartmouth Hitchcock Medical Center, Lebanon, NH 03764 USA; 603-650-7073; e- mail: Julie.Thomas@Dartmouth.Edu .

I have seen a reference to something called THE TRAUMATIC EVENTS QUESTIONNAIRE-ADOLESCENT version (TEQ-A), but I know nothing about it other than it is a 46-item self-report questionnaire designed to elicit details about 5 types of traumatic experiences. These include witnessing home violence, witnessing community violence, and being a victim of community violence, physical abuse, and sexual abuse. Each of the events is purportedly consistent with DSM-IV criteria for a traumatic event (which may or may not be a recommendation). Details of each event include the age at onset, duration, frequency, use of force, type of injury, and identity of perpetrator(s) (Lipschitz et al., 1999). There is an adult version available as well.

References

Achenbach, T.M. (1991). Manual for the Child Behavior Checklist/4-18 and 1991 Profile. Burlington: University of Vermont Department of Psychiatry.

Briere, J. (1989). The trauma symptom checklist for children. Odessa, FL: Psychological Assessment Resources.

Carlson, E.B. (1997). Trauma assessments: A clinician's guide. NY: The Guilford Press.

Dyregrov. A., & Yule, W. (November, 1995). Screening measures -- the development of the UNICEF screening battery. The 9th Annual Meeting of the International Society of Stress Studies, Boston, MA, USA.

Lipschitz, D.S., Winegar, R.K., Hartnick, E., Foote, B., Southwick, S.M. (1999). Perceived abuse and neglect as risk factors for suicidal behavior in adolescent inpatients. Journal of Nervous and Mental Disease, 187, 32-39.

Nader, K., Kriegler, J.A., Blake, D.D., Pynoos, R.S., Newman, E., & Weather, F.W. (1996). Clinician Administered PTSD Scale, Child and Adolescent Version. White River Junction, VT: National Center for PTSD

Orvaschel, H., Puig-Antich, J., Chambers, W., Tabirizi, M.A., Johnson, R. (1982). Retrospective assessment of child psychopathology with the Kiddie-SADS-E. Journal of the American Academy of Child Psychiatry, 21, 392-397.

Orvaschel, H., Weisman, M.M., Padier, W., Lowe, T. (1981). Assessing psychopathology in children of psychiatrically disturbed parents: A pilot study. Journal of the American Academy of Child Psychiatry, 20, 112-122.

Saigh, P., Yaski, A.E., Oberfield, R.A., Green, B.L., Halamandaris, Ph.V., Rubenstein, H., Nester, J., Resko, J., Hetz, B., & McHugh M. (2000). The Children's PTSD Inventory: Development and reliability. Journal of Traumatic Stress, 30, 369-380.

Skidmore, G.L., & Fletcher, K.E. (November, 1997). Assessing Trauma's Impact on Beliefs: The World View Survey. A paper presented at the Thirteenth Annual Meeting of the International Society for Traumatic Stress Studies, Montreal, Quebec, Canada.

Stamm, B. H. (1996). Measurement of Stress, Trauma and Adaptation. Lutherville, MD: Sidran Press.

Wolfe, V.V., Gentile, C., & Wolfe, D.A. (1989). The impact of sexual abuse on children: A PTSD formulation. Behavior Therapy, 20, 215-228.


Table of Contents .

Disclaimer: This is an unofficial UMMS page.