The objective of the current study was to develop a very short, reliable, and valid measure that assesses risk for traumatic stress symptoms in youth following a medical trauma. The resultant 4-item Child Stress Disorders Checklist-Short Form (CSDC-SF) was derived from the 36-item Child Stress Disorders Checklist (CSDC). The CSDC-SF evidenced psychometric properties equivalent to those of the previously validated CSDC, including comparable reliability and concurrent, discriminant, and predictive validity.
Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD) can have long-term negative consequences on child mental and physical health and development if left untreated [11
]. Experiencing a medical trauma has been identified as a significant risk factor for the development of ASD and PTSD, leading some to conclude that routine psychological assessment and treatment should become standard practice in pediatric trauma care [28
]. The first step to obtaining appropriate treatment is identification of symptomatic and at-risk youth. However, recent data suggest that pediatric emergency care providers [29
] and primary care pediatricians [30
] infrequently assess for traumatic stress in their patients, citing time constraints as a major barrier. The short length of the CSDC-SF may help to address this barrier and increase the likelihood that physicians will incorporate measurement of traumatic stress into their clinical assessments, though this remains to be tested empirically. Importantly, screening for traumatic stress should only be implemented in settings where suitable referral procedures are established to provide appropriate follow-up care for identified youth.
The CSDC-SF complements a growing body of instruments available for frontline healthcare clinicians to assess PTSD symptoms in children (e.g. CTSQ [31
], CTSQ-HR [32
], STEPP [33
]) and adults [34
] (see Brewin [37
] for general review of PTSD screens). Whereas currently available child measures utilize self-report (CTSQ) or a mixture of self- and parent-report and medical record information (CTSQ-HR; STEPP), the CSDC-SF relies solely on observer report. Therefore, the CSCD-SF may be particularly useful when self-report and/or medical record data are not available and/or when the accuracy of the child's report of symptoms is in question (e.g. due to lack of understanding, insight, or ability or willingness to report symptoms accurately). The CSDC-SF may be most useful when utilized in conjunction with a self-report measure. A number of studies indicate that parent-child agreement regarding child ASD/PTSD symptoms following an acute medical injury is relatively poor in the immediate aftermath of the trauma, with increasing agreement over time [28
]. These patterns have led many to conclude that children and parents offer different clinical information and to recommend the use of data from multiple reporters to assess child ASD/PTSD [28
Of note, there is some evidence that assessing a few key traumatic stress symptoms in the immediate aftermath of a medical trauma may be as effective in predicting the development of PTSD as conducting a full diagnostic interview [40
]. Therefore, a measure such as the CSDC-SF may prove as accurate as a clinical interview without the time or expertise demands. Also, while the CTSQ, CTSQ-HR, and STEPP were designed to predict the development of PTSD symptomatology, the CSDC-SF was demonstrated to be useful in assessing current ASD or PTSD symptoms as well as predicting the development of PTSD symptoms. The CSDC-SF offers some benefits over the original CSDC, most notably its considerably shorter length. Moreover, the items included in the CSDC-SF are all fairly easily observable, whereas the CSDC contains a number of items that are highly relevant to a diagnosis of PTSD but also more challenging to observe (e.g. “child seems numb or distant from his/her emotions”) or difficult to assess in the acute setting (e.g. “child avoids places that remind him or her of the injury”) and therefore more vulnerable to reporting inaccuracies.
Though this study examined the psychometric properties of the CSDC-SF in a larger and more varied sample than the study examining the psychometric properties of the original CSDC, the current sample size was relatively small. Larger sample sizes would allow for a detailed examination of any age, gender, race, or ethnicity effects on the psychometric properties of the measure. Such work is necessary to determine if the items perform differently across various demographic groups. The current sample included youth from 6 to 17 years of age but was skewed toward older children and adolescents. Younger children may express their traumatic stress symptoms differently than older children [16
]. Therefore, the performance of the CSDC-SF should specifically be tested in different age groups. Of note, data from the National Center for Injury Prevention and Control indicate that the ratio of male to female participants in the current samples reflects the gender distribution among youth hospitalized for injuries [1
]. Studies that recruit a more balanced ratio of male to female participants may be better positioned to examine potential gender differences in the psychometric properties of the CSDC-SF. Also, while the current study assessed a wider variety of traumatic injuries than the original CSDC study, the current study sample was restricted to youth who had experienced a burn or injury. The current results do not indicate whether the CSDC-SF would be valid among children who have experienced other types of traumatic events.
This study is the first step in the development and validation of a 4-item observer measure to assess presence of or risk for ASD/PTSD in children. Due to the ease of use, the CSDC-SF has potential for more widespread utility, and future work should continue to explore the psychometric properties of the measure so that its validity in various settings among different populations may be established. Specifically, as noted above, the measure should be tested in larger, demographically diverse samples that will allow for an examination of possible developmental, race/ethnicity, and gender effects in the functioning of the instrument. Future work should also include one or more control samples of children who have not experienced a traumatic event to further examine the measure's validity. The CSDC-SF should also be tested in other traumatized populations (e.g. due to maltreatment, witnessing violence), in different settings (e.g. pediatric clinics, schools, outpatient clinics), and with reporters other than parents who may be able to report on child symptoms (e.g. teachers, therapists) to determine if the measure may have broader utility. These steps may be accomplished through a multi-site trial that assesses the psychometric properties of the CSDC-SF, independent from the original CSDC, among a diverse sample of traumatized youth. A large, randomized control trial may evaluate whether the CSDC-SF can be used to effectively screen for present or emergent traumatic stress and whether referrals and treatment for youth identified at risk decrease later psychological morbidity. Such a study may also examine whether the predictive value of the CSDC-SF is increased when used in conjunction with other relevant clinical material (e.g. child self-report of symptoms, medical data, child's prior psychological functioning, degree of family support). As with the original CSDC, there is no clinical cutoff score with the CSDC-SF; rather, higher scores suggest greater risk. Larger studies may examine whether the efficiency of identifying at-risk children is aided by use of a cutoff score by examining the measure's sensitivity and specificity with different cutoff scores. By increasing the availability of valid, user-friendly assessment tools for ASD and PTSD symptoms in children and adolescents, the likelihood that at-risk youth will be evaluated early and referred for treatment to prevent the long-term negative sequelae of trauma exposure may be increased.