TBH: CHILD & ADOLESCENT VERSION (with scoring)

TRAUMATIC EVENTS for 7-18 year-old children and adolescents

(Adapted from the Child PTSD Checklist, © Michael Scheeringa, MD, MPH, 2010, Tulane University, New Orleans, LA)

Youth TIPS #: __ __ __ __ __ __ __ __ __ Today’s Date: _____/______/______

Youth Name: __________________________ Age of Child: ______

For 7-18 Year-Olds to fill out about themselves:

TO COUNT AN EVENT, YOU MUST HAVE FELT ONE OF THESE:
(1) Felt like you might die
(2) Had a serious injury or felt like you might get a serious injury, or
(3) Saw (1) or (2) happen to another person, or saw someone die.

0 = Did not happen Circle your age when Circle your age when Circle how many
to me. this happened to you this happened to you times this has
1 = Did happen to the first time. the last time. happened to you.
me.
1. Crash in automobile, plane, or 0 1 Not sure 0-6 7-12 13-18 0-6 7-12 13-18 1 2–5 6-9 >10
boat.
2. Attacked by an animal. 0 1 Not sure 0-6 7-12 13-18 0-6 7-12 13-18 1 2–5 6-9 >10

3. Disasters (flood, hurricane, 0 1 Not sure 0-6 7-12 13-18 0-6 7-12 13-18 1 2–5 6-9 >10
tornado, house fire, war, etc.).
4. Unusually scary medical 0 1 Not sure 0-6 7-12 13-18 0-6 7-12 13-18 1 2–5 6-9 >10
procedures or hospitalization.
5. Physical abuse. 0 1 Not sure 0-6 7-12 13-18 0-6 7-12 13-18 1 2–5 6-9 >10

6. Sexual abuse, sexual assault, or 0 1 Not sure 0-6 7-12 13-18 0-6 7-12 13-18 1 2–5 6-9 >10
rape.
7. Life-threatening injuries (burns, 0 1 Not sure 0-6 7-12 13-18 0-6 7-12 13-18 1 2–5 6-9 >10
falls, near drowning, etc.).
8. Witnessed another person 0 1 Not sure 0-6 7-12 13-18 0-6 7-12 13-18 1 2–5 6-9 >10
being beaten, raped,
threatened with serious harm,
shot at, seriously wounded,
or killed.
9. Other: 0 1 Not sure 0-6 7-12 13-18 0-6 7-12 13-18 1 2–5 6-9 >10

10. If more than one event happened to you, write the number of the event that you think caused the most
distress:
This form may be reproduced and used for free, but not sold, without further permission from the author.

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For 7-18 Year-Olds:
Below is a list of problems that kids sometimes have after experiencing events from the previous page. Read each one carefully and
circle the number (0-3) that best describes how often that problem has bothered you IN THE LAST 2 WEEKS. Fill this out even if no
events were experienced on the previous page.

(0) (1) (2) (3)

Not at all/ Once a week or 2 to 4 times a week/ 5 or more times a
only once less/ once in a while half the time week/almost always

11. Having upsetting thoughts or images about the event that came into my head when I didn’t 0 1 2 3
want them to

12. Having bad dreams or nightmares 0 1 2 3

13. Acting or feeling as if the event was happening again 0 1 2 3

(e.g., hearing something or seeing a picture about it, and feeling as if I was there again)
14. Feeling upset when I think or hear about the event 0 1 2 3
(e.g., feeling scared, angry, sad, guilty, etc.)
15. Having feelings in my body when thinking about or hearing about the event 0 1 2 3
(e.g., breaking out into a sweat, heart beating fast)

16. Trying not to think about, talk about, or have feelings about the event 0 1 2 3

17. Trying to avoid activities, people, or places that remind me of the traumatic event 0 1 2 3

18. Having much less interest in doing things I used to do 0 1 2 3

19. Not feeling close to people around me 0 1 2 3

20. Not being able to have strong feelings 0 1 2 3

(e.g., being unable to cry or unable to feel happy)
21. Feeling as if my future plans or hopes will not come true 0 1 2 3
(e.g., feeling as if I will not have a job, or get married, or have kids)

22. Having trouble falling or staying asleep 0 1 2 3

23. Feeling irritable or having fits of anger 0 1 2 3

24. Being overly careful 0 1 2 3

(e.g., checking to see who is around and what is around)
25. Being jumpy or easily startled 0 1 2 3
(e.g., jumping when someone walks up behind me)
(Items 11-25 are from the Child PTSD Symptom Scale (CPSS), Caregiver Version [Foa et al., 2001])

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For 7-18 Year-Olds:

Please circle the number under the heading that best describes you:
(0) (1) (2)
Never Sometimes Often
26. Feel sad, unhappy 0 1 2
27. Feel hopeless 0 1 2
28. Down on myself 0 1 2
29. Worry a lot 0 1 2
30. Seem to be having less fun 0 1 2
31. Fidgety, unable to sit still 0 1 2
32. Daydream too much 0 1 2
33. Get distracted easily 0 1 2
34. Have trouble concentrating 0 1 2
35. Act as if driven by a motor 0 1 2
36. Fight with other children 0 1 2
37. Do not listen to rules 0 1 2
38. Do not understand other people’s feelings 0 1 2
39. Tease others 0 1 2
40. Blame others for my troubles 0 1 2
41. Refuse to share 0 1 2
42. Take things that do not belong to me 0 1 2
43. Worry about things working out for me 0 1 2
44. Worry about being as good as other kids 0 1 2
45. Feel afraid to be alone at home 0 1 2
(Items 26-42 are from the Pediatric Symptom Checklist [Murphy et al., 1989])
(Items 43-45 are from the SCARED [Birmaher et al., 1999])

No or Unknown Yes
46. In the last 90 days, have you had suicidal ideas or attempted suicide? 0 1
47. Have you heard voices or seen things that other people don’t hear or see? 0 1

For 13-18 Year-Olds ONLY:

No or Unknown Yes
48. In the last 90 days, have you abused alcohol and/or drugs? 0 1
(Items 46-48 are from the Behavioral Health Screening Form [DCFS])

Thank you.
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TBH SCORING
Cut-off Scores that Indicate Clinical Concern and Cause for Referral to Clinicians.
Items Cut-off
PTSD score (15 items) #11-25 10 or higher
Internalizing score (8 items)* #26-30 + #43-45 8 or higher
ADHD score (5 items) #31-35 7 or higher
Externalizing score (7 items) #36-42 7 or higher