Trauma Assessment
Clinical Approach
1.
Start with a knowledge that something happened or suspect that something may have happened
2.
Meet parents in the absence of the child and perform a clinical interview a.
Ask specific questions about the history of child with focus on developmental milestones, achievement, and socialization b.
Inquire about exposure to traumatic events. Get a description of the event. c.
Inquire about changes in behavior pre and post trauma d.
Review all academic, medical, police, and agency records e.
Take notes and quotes from records reviewed. Be sure to indicate source, date, and exact statements from your review.
3.
Perform DSM parent clinical interview for PTSD, MD, Phobia, and separation anxiety disorder.
4.
Meet the child privately
5.
Explain purpose of evaluation
6.
Establish rapport
7.
Administer CPTSDI
8.
Do DSM-IV child clinical interview for PTSD phobia, MD, CD, separation anxiety disorder, substance abuse/dependence,
9.
Administer RCMAS and CDI ( note: BE SURE to Review Suicide Question
BEFORE You Allow the Child to Leave )
11. Follow up with clinical questions as indicated by responses to any of the aforementioned test administrations.

Epidemiological Approach
1.
Give a global nondiagnostic PTSD symptoms self report
2.
Then follow the clinical model
Report Format
Name, DOB, date,
Measures -List
Reason for Referral “ He was referred for testing because his parents reported that he was hit by a bus. His parents also indicated that he his academic achievement has declined since the accident.”
Background Information
A. Pre-Trauma functioning . Be sure to report information regarding academic achievement, socialization, school attendance, parental observations and or teacher comments before traumatization.
B. Objective Information About Trauma Exposure . Include verbatim reports from parents, hospital records, police documents, and or agency records.
Test Results .
A.
Diagnostic.
1) Start by saying “As based on an administration of the Children’s PTSD
Inventory, the child met or did not meet criteria for PTSD.” Then report positive and negative symptoms. Be sure to directly quote from CPTSDI re.
Criterion A1 child statement. Go through each section and provide examples of items that were positive and negative.
2) Report results of child clinical interview for PTSD and indicate if child meet or did not meet criteria
3) Report results of parent SCID PTSD module.
4) Report results for parent clinical PTSD interview.
5) Report diagnostic child SCID findings for comorbid disorders. Simply indicate if the child met or did not meet criteria.
B. Nondiagnostic
1) Report results in terms of percentiles for CDI and RCMAS.

Summary
One Paragraph
DSM-IV Axes
Axis I
Axis II
Axis III (Deferred)
Axis IV
Axis V (Report GAF)
Type your name, degree
Title
Sign