UCLA PTSD INDEX FOR DSM-IV (Parent Version, Revision 1) © Page 1 of 5
Child's Name ________________________________ Age _______ Sex (Circle): Girl Boy
Name of Person Completing this Form ________________ Relationship to Child
____________
Today s Date (write month, day and year) ____________________ Grade in School
____________
School ________________ Teacher _____________________ Town __________________
Below is a list of VERY SCARY, DANGEROUS OR VIOLENT things that sometimes happen to children.
These are times where someone was HURT VERY BADLY OR KILLED, or could have been. Some children
have had these experiences, some children have not had these experiences. Please be honest in answering if the
violent thing happened to your child , or if it did not happen to your child.
___________________________________________________________________________________________
FOR EACH QUESTION: Check "Yes" if this scary thing HAPPENED TO YOUR CHILD
Check "No" if it DID NOT HAPPEN TO YOUR CHILD_____
1) Being in a big earthquake that badly damaged the building your child was in. Yes [ ] No [ ]
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2) Being in another kind of disaster, like a fire, tornado, flood or hurricane. Yes [ ] No [ ]
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3) Being in a bad accident, like a very serious car accident. Yes [ ] No [ ]
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4) Being in place where a war was going on around your child. Yes [ ] No [ ]
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5) Being hit, punched, or kicked very hard at home.
(DO NOT INCLUDE ordinary fights between brothers & sisters). Yes [ ] No [ ]
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6) Seeing a family member being hit, punched or kicked very hard at home.
(DO NOT INCLUDE ordinary fights between brothers & sisters). Yes [ ] No [ ]
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7) Being beaten up, shot at or threatened to be hurt badly in your town. Yes [ ] No [ ]
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8) Seeing someone in your town being beaten up, shot at or killed. Yes [ ] No [ ]
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9) Seeing a dead body in your town (do not include funerals). Yes [ ] No [ ]
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10) Having an adult or someone much older touch your child's
private sexual body parts when your child did not want them to. Yes [ ] No [ ]
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11) Hearing about the violent death or serious injury of a loved one. Yes [ ] No [ ]
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12) Having painful and scary medical treatment in a hospital when your child
was very sick or badly injured. Yes [ ] No [ ]
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13) OTHER than the situations described above, has ANYTHING ELSE ever happened
to your child that was REALLY SCARY, DANGEROUS OR VIOLENT? Yes [ ] No [ ]
Please write what happened: ______________________________________________________________
1998 Robert Pynoos, M.D., Ned Rodriguez, Ph.D., Contact: UCLA Trauma Psychiatry Service/ 300 UCLA Medical Plaza, Ste 2232
UCLA PTSD INDEX FOR DSM-IV (Parent Version, Revision 1) © Page 2 of 5
Alan Steinberg, Ph.D., Margaret Stuber, M.D., Calvin Frederick, M.D. Los Angeles, CA 90095 -6968
ALL RIGHTS RESERVED/DO NOT duplicate or distribute without permission (310) 206-8973/ EMAIL: rpynoos@mednet.ucla.edu
14) a) If you answered "YES" to only ONE thing in the above list of questions #1 to #13, place the
number of that thing (#1 to #13) in this blank. # ____________
b) If you answered "YES" to MORE THAN ONE THING, place the number of the thing that
BOTHERS YOUR CHILD THE MOST NOW in this blank. #___________
c) About how long ago did this bad thing (your answer to a or b ) happen to your child? __________
d) Please write what happened: _________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
FOR THE NEXT QUESTIONS, please CHECK "Yes, No, or Don't know" to answer HOW YOUR CHILD
FELT during or right after the experience happened that you just wrote about in Question 14. Only check
"Don't Know" if you absolutely cannot give an answer.
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15) Was your child afraid that he/she would die? Yes [ ] No [ ] Don't know [ ]
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16) Was your child afraid that he/she would
be seriously injured? Yes [ ] No [ ] Don't know [ ]
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17) Was your child seriously injured? Yes [ ] No [ ]
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18) Was your child afraid that someone
else would die? Yes [ ] No [ ] Don't know [ ]
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19) Was your child afraid that someone else
would be seriously injured? Yes [ ] No [ ] Don't know [ ]
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20) Was someone else seriously injured? Yes [ ] No [ ]
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21) Did someone die? Yes [ ] No [ ]
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22) Did your child feel terrified? Yes [ ] No [ ] Don't know [ ]
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23) Did your child feel intense helplessness? Yes [ ] No [ ] Don't know [ ]
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24) Did your child feel horrified; was what
he/she saw disgusting or gross? Yes [ ] No [ ] Don't know [ ]
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25) Did your child get hysterical or run around? Yes [ ] No [ ] Don't know [ ]
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26) Did your child feel very confused? Yes [ ] No [ ] Don't know [ ]
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27) Did your child feel like what was happening did not seem real in some way, like it was going on in a
movie instead of real life? Yes [ ] No [ ] Don't know [ ]
1998 Pynoos, Rodriguez, Steinberg , Stuber & Frederick
UCLA PTSD INDEX FOR DSM-IV (Parent Version, Revision 1) © Page 3 of 5
Here is a list of problems children sometimes have after very stressful experiences. Please think about your child's stressful
experience that you wrote about in Question #14. Then, read each problem on the list carefully. CIRCLE one of the
numbers (0, 1, 2, 3, 4 or 5) that tells how often the problem has happened to your child in the past month. Refer to the
Rating Sheet (on page 5) to help you decide how often the problem has happened. Note: If you are unsure about how often
your child has experienced a particular problem, then try to make your best estimation. Only circle "Don't Know" if you
absolutely cannot give an answer. PLEASE BE SURE TO ANSWER ALL QUESTIONS
None Little Some Much Most Don't
Know
1D4 My child watches out for danger or things that
he/she is afraid of. 0 1 2 3 4 ?
2B4 When something reminds my child of what
happened he/she gets very upset, scared or sad. 0 1 2 3 4 ?
3B1 My child has upsetting thoughts, pictures or sounds
of what happened come into his/her mind when
he/she does not want them to. 0 1 2 3 4 ?
4D2 My child feels grouchy, angry or mad.
0 1 2 3 4
?
5B2 My child has dreams about what happened or other
bad dreams 0 1 2 3 4 ?
6B3 My child has flashbacks of what happened; he/she
feels like he/she is back at the time when the bad
thing happened living through it again. 0 1 2 3 4 ?
7C4 My child feels like staying by him/her self and not
being with his/her friends. 0 1 2 3 4 ?
8C5 My child feels alone inside and not close to other
people. 0 1 2 3 4 ?
9C1 My child tries not to talk about, think about, or have
feelings about what happened. 0 1 2 3 4 ?
10C6 My child has trouble feeling happiness or love. 0 1 2 3 4 ?
11 C6My child has trouble feeling sadness or anger. 0 1 2 3 4 ?
12D5 My child feels jumpy or startles easily, for example,
when he/she hears a loud noise or when something
surprises him/her. 0 1 2 3 4 ?
13D1 My child has trouble going to sleep or wakes up
often during the night. 0 1 2 3 4 ?
14AF My child feels that some part of what happened is
his/her fault. 0 1 2 3 4 ?
1998 Pynoos, Rodriguez, Steinberg , Stuber & Frederick
UCLA PTSD INDEX FOR DSM-IV (Parent Version, Revision 1) Page 4 of 5
None Little Some Much Most Don't
Know
15C3 My child has trouble remembering important parts of
what happened. 0 1 2 3 4 ?
16D3 My child has trouble concentrating or paying 0 1 2 3 4 ?
attention.
17C2 My child tries to stay away from people, places, or
things that make him/her remember what happened. 0 1 2 3 4 ?
18B5 When something reminds my child of what happened,
he/she has strong feelings in his/her body like heart
beating fast, head aches, or stomach aches. 0 1 2 3 4 ?
19C7My child thinks that he/she will not live a long life. 0 1 2 3 4 ?
20AFMy child is afraid that the bad thing will happen 0 1 2 3 4 ?
again.
21B1My child plays games or draws pictures that are like
some part of what happened. 0 1 2 3 4 ?
1998 Pynoos, Rodriguez, Steinberg , Stuber & Frederick
UCLA PTSD INDEX FOR DSM-IV (Parent Version, Revision 1) Page 5 of 5
FREQUENCY RATING SHEET
HOW OFTEN OR HOW MUCH OF THE TIME
DURING THE PAST MONTH, THAT IS SINCE
____________________,
DOES THE PROBLEM HAPPEN?
0 1 2 3 4
NONE LITTLE SOME MUCH MOST
S M T W H F S S M T W H F S S M T W H F S S M T W H F S S M T W H F S
X X X X X X X X X X X X X
X X X X X X X X
X X X X X X X X X
X X X X X X X X X X X X
NEVER TWO TIMES 1-2 TIMES 2-3 TIMES ALMOST
A MONTH A WEEK EACH WEEK EVERY DAY
