How do I assess for trauma and PTSD-related concerns?

Trauma exposure and trauma-related symptoms may affect safety, functioning, emotional regulation, treatment engagement, and treatment outcomes.

When clinically appropriate, exploring trauma history and current trauma-related symptoms can help you better understand a client's clinical needs and inform treatment planning.

Assessment should be trauma-informed, taking into account the client's readiness, clinical stability, and therapeutic rapport.

What should I consider?

Trauma exposure and history

Consider relevant past or recent experiences that may be contributing to the client's current presentation.

Current trauma-related symptoms

Consider symptoms such as:

  • Intrusive symptoms
  • Avoidance
  • Dissociation
  • Changes in mood or cognitive ability
  • Hyperarousal
  • Sleep disturbances
  • Other trauma-related responses
Safety and risk

Consider concerns that may be associated with the client's current situation, circumstances, or symptoms, including:

  • Suicidal ideation
  • Self-harm
  • Substance use
  • Interpersonal violence
  • Exploitation
Functioning

Consider the impact on:

  • Relationships
  • Work
  • School
  • Daily functioning, including sleep, hygiene, motivation, concentration, and appetite
Coping and protective factors

Consider the client's current strengths, supports, coping strategies, and other factors that promote stability.

Readiness and pacing

Consider the client's current ability and willingness to discuss trauma-related experiences without causing significant distress or destabilization.

Impact on treatment

Consider whether the client's current symptoms, functioning, or risk factors indicate that changes are needed to the current treatment plan.

Trauma and PTSD screening and assessment tools

The source material identifies several tools that may support trauma and PTSD screening and assessment:

  • PCL-5: A 20-item, self-report measure for adults used to assess PTSD symptoms and severity, monitor changes, screen for PTSD, and support a provisional PTSD diagnosis.
  • CAPS-5: A structured interview for adults that can be used to assess current and lifetime PTSD diagnoses and symptoms. CAPS-CA-5 is available for children and adolescents ages 7+.
  • ACEs: An adult questionnaire that gathers information about exposure to difficult childhood experiences. It helps identify risk factors but does not assess current symptoms, functioning, or clinical severity.
  • PEARLS: A screener for children and adolescents ages 0–19 that includes an ACE screen and screening for social determinants. Different versions are available based on age and whether the caregiver or adolescent completes the tool.

 

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