Preventing and Healing Stress Related Depression, Anxiety and Childhood Behavior
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Child & Adolescent Trauma History Questionnaire

 

INSTRUCTIONS FOR MENTAL HEALTH WORKERS
Taking a Child or Adolescent Trauma History

Increasing research indicates that traumatic experience may be at the root of a wide range of problems, from physical symptoms (such as headaches, allergies, pains) to emotional symptoms (depression, anxiety, panic attacks, etc.) to difficult behaviors (substance use, self-injury, acting out, verbal/emotional outbursts, suicidal thoughts or attempts, etc.). Many DSM diagnoses may eventually be determined to have their roots in trauma.

Trauma is defined as the person's experience of a situation, not the situation itself. Not all traumatic events or experiences are recognized, especially if they are not the obvious, dramatic kind. This checklist will help you recognize some possible sources of emotional trauma that might otherwise be overlooked.

This is not an exhaustive list, but a guide for exploration. It is not intended to be used as a top to bottom questionnaire. Use these points to stimulate a conversation, listening for each type of issue as you ask general questions, and leading to more specific questions. You will probably need to elicit information over a period of time, not all at one session. There is a value in hearing what events or experiences arise for the child before you ask about particulars.

 

CHILD / ADOLESCENT TRAUMA HISTORY
(depending on age, can have child draw or act out information)

What is a scary thing that has happened to you or in your life?
(ask for one example before getting into other questions - notice what comes up first)

 

BIRTH

How many children are in your family? Full/half/step sibs? Where are you in the line-up?


Do you know if your parents planned for you, or if you were a surprise?


What stories have you heard about your birth? (listen for/elicit information about prematurity, difficult birth, unwanted, adopted, separated from mother at birth, hospitalization, physical or emotional problems mother was having during pregnancy)

 

FAMILY

How many places have you lived? Were you separated from either parent or siblings?

Who took care of you when you were little? How many babysitters or nannies?

Who do you live with? Who else sleeps in your room?

Are your parents together? Are there other adults in your home?

Do your parents yell at you? At each other? Do they hit you? Each other?

How do you get along with your siblings?

Has anyone ever touched you in a way that was scary or uncomfortable?

Does anyone in your family have a problem with alcohol or drugs?

 

HEALTH

What time do you usually go to sleep? What time do you get up?

When you get up, do you feel rested or still tired?

What do you usually have for breakfast? For dinner? Who fixes your meals?

Did you ever have a serious accident (burn, fall, broken bone, auto, etc.)?

Were you ever in the hospital? Did you have any surgeries?

Did you have any scary or upsetting experiences with a doctor, nurse, or hospital?

Do you get sick often? With what?

(older kids/teens) Have you ever injured yourself intentionally (cutting, banging head, etc.)

(older kids/teens) Have you ever thought about killing yourself? Have you ever tried?

 

SCHOOL

Do you feel teased, picked on, bullied or threatened?

Do you feel left out?

Do you think people are mean to you?

 

FRIGHTENING EVENTS

What's another scary thing that has happened to you?

What's a scary thing that has happened to someone you know?

 

LOSSES

Did anyone close to you die? How?

Did you ever lose a pet? How? Did a special friend move away?

Did you ever lose something else that was special to you? What? How?

(teens) Did you ever have a relationship break up? How?

 

 

 

 

   
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