Screening and Assessment Tools to Assess Impact of Trauma
Trauma-informed Care for Afghan Refugee Children

Traumatic experiences may contribute to both internalizing (anxiety, depression) and externalizing (hyperactivity, opposition/defiance, aggression) or both. The provider should synthesize the results to help determine the optimal option for retesting and/or referral. A referral to a therapist who is adept at trauma-informed care and with working with refugee children is certainly appropriate.

Screening for Stress

There may be a need to screen for stressful life events and trauma experienced by refugee families and their children as a precursor to other psychological conditions.  This screening is not necessarily undertaken on an initial intake visit but is more appropriate in follow-up visits. This of course may need to be earlier if there is clearly evidence of trauma related concerns.

• The Stressful Life Events (SLE) Checklist ¹ is a survey of thirteen questions identifying different traumatic events that an adolescent might have been exposed. This survey can be used to assess if an adolescent meets the first criteria (A1-experienced a traumatic event) in the DSM-IV, for a diagnosis of post-traumatic stress disorder (PTSD). The instrument is scored by adding the number of experienced Stressful Life Events as endorsed by a yes/no answer.
  • SLE in Dari: Stressful Life Events Screening Questionnaire (PDF)
  • SLE in Pashto: Stressful Life Events Screening Questionnaire (PDF)

Screening for Anxiety, Depression, Sleep Disorders, and Other Conditions

There is a broad body of research that has shown that trauma and stressful events experienced by refugee children can be associated with internalizing behaviors such as anxiety and depression. There are no consistent prevalence rates of psychiatric symptoms in minor refugees for depression, anxiety, sleeping problems and depression. However, they are the most common and are believed to be higher than in the general minor population. In addition, children often present with a mixture of the symptoms listed and do not necessarily fulfilling a single diagnostic category. For example, a child may present with a mixture of post-traumatic and depressive symptomatology. ²

Derluyn and colleagues identified that adolescent refugees who had been separated from their parents had significantly higher depression scores based on the Hopkins Symptom Checklish-37 (HSCL-37) scale. ³ Externalizing problems are less likely in unaccompanied refugee youths than internalizing problems. ⁴

• The Hopkins Symptom Checklist-37A (HSCL-37A) is a self-administered questionnaire designed to measure both anxiety and depression symptoms. It has been validated in various clinical and community samples and has also been utilized in a number of refugee studies with minors. ⁵
  • HSCL37A in Dari: Hopkins Symptom Checklist-37A (PDF)
  • HSCL37A in Pashto: Hopkins Symptom Checklist-37A (PDF)
• The Harvard Trauma Questionnaire (HTQ-5) is a more in-depth survey tool. It has been updated to be consistent with the DSM-5 criteria for PTSD and other trauma related mental health problems. The tool provides graded responses to questions as well as a diagnostic score and a total numeric score. It was developed to assess potentially traumatic experiences, and a rich variety of post-traumatic symptoms in different cultural settings. ⁶ 
  Jackoben and colleagues using the Harvard Trauma Questionnaire found a major depression rate of 9.4% and anxiety disorder of 3.9%. ⁷  Sanchez-Cao revealed that even with high rates of depression unaccompanied refugee minors were frequently not in contact with mental health services. ⁸ Both the Jackoben and Sanchez-Cao teams included Afghan refugee minors as part of their assessments.
  • The HTQ-5 has not been translated at this time.
• The Mini-International Neuropsychiatric Interview for Children and Adolescents (M.I.N.I. Kid) is a relatively short structured diagnostic interview for DSM-IV and ICD-10 psychiatric disorders. The measure assesses the current prevalence of child and adolescent psychiatric diagnoses (major depressive episode, suicidality, dysthymia, (hypo)manic episode, panic disorder, agoraphobia, separation anxiety disorder, social phobia, specific phobia, obsessive compulsive disorder, PTSD, alcohol abuse, alcohol dependence, substance abuse, substance dependence, Tourette’s disorder, motor tic disorder, vocal tic disorder, transient tic disorder, ADHD (combined; inattentive; hyperactive/impulsive), conduct disorder, oppositional defiant disorder, psychotic disorders, mood disorder with psychotic features, anorexia nervosa, bulimia nervosa, generalized anxiety disorder, adjustment disorder).
  • The M.I.N.I. Kid has not been translated at this time.

Screening and Assessment Tools for PTSD

There are a numerous screening and assessment tools for PTSD in children and adolescents. However, a number of them may require additional training by the primary care provider or be administered by other health personnel such as psychologists, social workers, psychiatrists, etc. Below is a listing with a brief description of a number of the most frequently used tools for the screening of PTSD.

• The Children’s Revised Impact of Event Scale (CRIES-13) (PDF) is a self-report tool of eight questions that has been used for screening during routine health check-ups. Younger children may have difficulties completing the questionnaire by themselves and may be assisted by their parents. ⁹
  • CRIES-13 in Dari: Children’s Revised Impact of Event Scale (PDF)
• The Reactions of Adolescents to Traumatic Stress questionnaire (RATS) is a 22-item, self-report screening tool. The items were derived from the  core symptoms of the DSM-IV that contribute to the diagnosis of PTSD. The RATS has demonstrated good validity for use with young refugee populations. ¹⁰
  • RATS in Dari: Reactions of Adolescents to Traumatic Stress (PDF)
  • RATS in Pashto: Reactions of Adolescents to Traumatic Stress (PDF)
• The Child and Adolescent Trauma Scale (CATS) is a longer measurement tool to assess for potential traumatic events and of posttraumatic stress symptoms (PTSS) based on the DSM-5. The CATS can be administered as a self-report or as an interview and is appropriate for preschoolers, children, and adolescents. There is a self-report and caregiver version for 7-17 years of age. There are caregiver interview versions: for children 3-6 years of age and one for 7-17 year olds. The interview format may be preferable with younger children or youth with reading comprehension challenges. The CATS is a more in-depth tool and requires that the provider has reviewed the clinical guide training manual. ¹¹
  • The Child and Adolescent Trauma Scale (CATS) (PDF)
  • CATS in Dari: Child and Adolescent Trauma Screen (PDF)
  • CATS in Pashto: Child and Adolescent Trauma Screen (PDF)

There are a number of good screening tools that have previously been used with Afghan refugees but are presently not available in Dari and/or Pashto.

• The Child Post Traumatic Stress Disorder Symptom Scale (CPSS) is a 17-item self-report questionnaire developed for children and youth between 10–18 years of age, examining PTSD symptoms. ¹²
• Posttraumatic Stress Disorder Checklist (PCL-5) is a 20-item self-report screening tool to assess PTSD within the last month. It covers four symptom clusters of PTSD according to DSM-5, rated on a five-point Likert scale (0 = “not at all”; 1 = “a little bit”; 2 = “moderately”; 3 = “quite a bit”; 4 = “extremely”). Sum scores of 33 and more indicate the presence of PTSD. ¹³
• The UCLA PTSD Reaction Index (RI) ¹⁴ is a tool designed to assess posttraumatic stress symptoms in children and adolescents.
• The Clinician Administered PTSD Scale for DSM-5 Child/Adolescents (CAPS-CA-5) is a 30-item clinician-administered PTSD scale based upon DSM-5 criteria for children and adolescents ages 7 and above. In addition, questions target the onset and duration of symptoms, subjective distress, impact of symptoms on social functioning, impairment in development, overall response validity and overall PTSD severity. The CAPS-CA-5 was designed to be administered by clinicians and clinical researchers who have a working knowledge of PTSD but can also be administered by appropriately trained paraprofessionals.