Young Child PTSD Checklist (YCPC) Caregiver 20210506 Young Child PTSD Checklist (YCPC) CaregiverClient Name* First Last Client Date of Birth* MM slash DD slash YYYY Today's Date* MM slash DD slash YYYY For child under 7 years old. Below is a list of symptoms that children can have after life-threatening events. When you think of ALL the life-threatening traumatic events select the response that best describes how often the symptom has bothered you in the LAST 2 WEEKS.1. Does your child have intrusive memories of the trauma? Does s/he bring it up on his/her own?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 2. Does your child re-enact the trauma in play with dolls or toys? This would be scenes that look just like the trauma. Or does s/he act it out by him/herself or with other kids?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 3. Is your child having more nightmares since the trauma(s) occurred?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more time a week/Almost always Everyday 4. Does your child act like the traumatic event is happening to him/her again, even when it isn't? This is where a child is acting like they are back in the traumatic event and aren't in touch with reality. This is a pretty obvious thing when it happens.* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 5. Since the trauma(s) has s/he had episodes when s/he seems to freeze? You may have tried to snap him/her out of it but s/he was unresponsive.* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 6. Does s/he get upset when exposed to reminders of the event(s)? For example, a child who was in a car wreak might be nervous while riding in a car now. Or, a child who was in a hurricane might be nervous when it is raining. Or, a child who saw domestic violence might be nervous when other people argue. Or, a girl who was sexually abused might be nervous when someone touches her.* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 7. Does your child get physically distressed when exposed to reminders? Like heart racing, shaking hands, sweaty, short of breath, or sick to his/her stomach? Think of the same type of examples as in #6* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 8. Does your child try to avoid conversations that might remind him/her of the trauma(s)? For example, if other people talk about what happened, does s/he walk away or change the topic?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 9. Does your child try to avoid things or places that remind him/her of the trauma(s)? For example, a child who was in a car wreak might try to avoid getting into a car. Or, a child who was in a flood might tell you not to drive over a bridge. Or, a child who saw domestic violence might be nervous to go in the house where it occured. Or, a girl who was sexually abused might be nervous about going to bed because that's where she was abused before.* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 10. Does your child have difficulty remembering the whole incident? Has s/he blocked out the entire event?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 11. Has s/he lost interest in doing things that s/he used to like to do since the trauma(s)?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 12. Since the trauma(s), does your child show a restricted range of positive emotions on his/her face compared to before?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 13. Has your child lost hope for the future? For example, s/he believes will not have fun tomorrow, or will never be good at anything.* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 14. Since the trauma(s) has your child become more distant and withdrawn from family members, relatives, or friends?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 15. Has s/he had a hard time falling asleep or staying asleep since the trauma(s)?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 16. Has your child become more irritable, or had outbursts of anger, or developed extreme temper tantrums since the trauma(s)* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 17. Has your child had more trouble concentrating since the trauma(s)?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 18. Has s/he been more "on the alert" for bad things to happen? For example, does s/he look around for danger?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 19. Does your child startle more easily than before the trauma(s)? For example, if there's a loud noise or someone sneaks up behind him/her, does s/he jump or seem startled?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 20. Has your child become more physically aggressive since the trauma(s)? Like hitting, kicking, biting, or breaking things.* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 21. Has s/he become more clingy to you since the trauma(s)?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 22. Did the night terrors start to get worse after the trauma(s)? Night terrors are different from nightmares: in night terrors a child usually screams in their sleep, they don't wake up, and they don't remember it the next day.* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 23. Since the trauma(s), has your child lost previously aquired skills? For example, lost toliet training? Or lost language skills? Or, lost motor skills working snaps, buttons, or zippers?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 24. Since the trauma(s), has your child developed any new fears about things that don't seem related to the trauma(s)? What about going to the bathroom alone? Or, being afraid of the dark?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday Functional Impairment: Do the symptoms that you endorsed above get in the way of your child's ability to function in the following areas?25. Do (symptoms) substantially "get in the way" of how s/he gets along with you, interfere in your relationship, or make you feel upset or annoyed?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 26. Do these (symptoms) "get in the way" of how s/he gets along with brothers or sisters, and make them feel upset or annoyed?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 27. Do (symptoms) "get in the way" of how s/he gets along with friends at all – at daycare, school, or in your neighborhood?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 28. Do these (symptoms) "get in the way" with the teacher or the class more than average?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 29. Do (symptoms) make it harder for you to take him/her out in public than it would be with an average child? Is it harder to go out with your child to places like the grocery store? Or to a restaurant?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday 30. Do you think that these behaviors cause your child to feel upset?* Not at all Once a week/Once in a while 2 to 4 times a week/Half the time 5 or more times a week/Almost always Everyday Please click SUBMIT when complete
