CDE Detailed Report

Disease: Sport Related Concussion
Sub-Domain: Mood/Anxiety
CRF: UCLA PTSD Reaction Index for Children

Displaying 1 - 50 of 127
CDE ID CDE Name Variable Name Definition Short Description Question Text Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guideline) Sub Domain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
C55079 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Violence community witness fear indicator UCLAPTSDRIDSM5VcCtyWtnsFearInd Indicator of whether the subject/participant has ever witnessed or feared violence in his or her neighborhood, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever witnessed or feared violence in his or her neighborhood, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Community Violence: Did you ever see a bad fight or shooting in your neighborhood, like between gangs? Were you afraid of getting badly hurt or killed? Have you seen someone mugged, robbed, stabbed or killed in your neighborhood? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 10:06:25.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55205 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Depersonalization observer frequency past month grade UCLAPTSDRIDSM5DprObsFqPMGrade Grade of frequency during the past month that the subject/participant has experienced depersonalization as though he or she were an outside observer, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has experienced depersonalization as though he or she were an outside observer, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I feel like I am seeing myself or what I am doing from outside my body (like watching myself in a movie). 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55119 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Assault physical trauma detail type UCLAPTSDRIDSM5AsltPhyTrmDtlTyp The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Physical Assault, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Physical Assault, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Physical Assault Trauma Details Punched;Kicked;Stabbed;Shaken;Weapon Used;Reported to CPS;Reported to police;Other Punched;Kicked;Stabbed;Shaken;Weapon Used;Reported to CPS (if a minor);Reported to police;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 14:15:09.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55153 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Suicide witness trauma detail type UCLAPTSDRIDSM5ScdWtnTrDtlTyp The type field for details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Attempted Suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Attempted Suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Witnessed Suicide Trauma Details Mother;Father;Brother;Sister;Other relative;Other;Close friend;Acquaintance/schoolmate;Stranger Mother;Father;Brother;Sister;Other relative;Other;Close friend;Acquaintance/schoolmate;Stranger Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:21:06.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55170 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Concentrate difficult frequency past month grade UCLAPTSDRIDSM5CntDfcFqPsMGrade Grade of frequency during the past month that the subject/participant has had difficulty concentrating, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has had difficulty concentrating, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I have trouble concentrating or paying attention 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55090 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Kidnap abduct suffer indicator UCLAPTSDRIDSM5KnpAbdctSfrInd Indicator of whether the subject/participant has ever been kidnapped or abducted, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been kidnapped or abducted, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Kidnapping/Abduction: Have you ever been stolen or kidnapped (taken somewhere against your will) by someone without the permission of your parent or legal guardian? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 11:21:24.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55230 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom increase difficulty do well school indicator UCLAPTSDRIDSM5SyInDfDoWlScInd Indicator of whether the subject/participant's PTSD symptom(s) increase(s) the difficulty he or she has in doing well at school, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's PTSD symptom(s) increase(s) the difficulty he or she has in doing well at school, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Do these reactions (thoughts and feelings) make it harder for you to do well in school? No;Yes No;Yes Alphanumeric

Clinician: Check whether the reactions (thoughts and feelings) above appear to cause clinically significant distress or functional impairment.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 13:38:45.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55132 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Rape assault sexual trauma detail perpetrator type UCLAPTSDRIDSM5RpAsSxTrDtPrTyp The type field for identifying details about the perpetrator related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Sexual Assault/Rape, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details about the perpetrator related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Sexual Assault/Rape, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Perpetrator Relative;Position of trust;Acquaintance;Stranger Relative;Position of trust (teacher, coach, minister);Acquaintance (neighbor etc);Stranger Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 15:13:35.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55195 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Thought intrusive frequency past month grade UCLAPTSDRIDSM5ThtIntFqPsMGrade Grade of frequency during the past month that the subject/participant has had intrusive thoughts about the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has had intrusive thoughts about the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I have upsetting thoughts, pictures or sounds of what happened come into my mind when I don't want them to. 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55101 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma event role type UCLAPTSDRIDSM5TrmaEvntRolTyp Type specifying the degree of involvement of the subject/participant with the traumatic event type specified in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Type specifying the degree of involvement of the subject/participant with the traumatic event type specified in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Role in Event Victim;Witness;Learned about Victim;Witness;Learned about Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 12:14:04.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55241 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Impairment functional clinically significant indicator UCLAPTSDRIDSM5FnImClnSigInd Indicator of whether the subject/participant's symptoms of PTSD cause clinically significant functional impairment, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's symptoms of PTSD cause clinically significant functional impairment, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Clinically Significant Functional Impairment False;True False;True Alphanumeric

check if functional impairment at home, at school, in peer relationships, in developmental progression

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 12:16:54.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55143 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - War violence political trauma detail other text UCLAPTSDRIDSM5WrVlcPolTrDtlOTH The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - War violence political trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - War violence political trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) War/Political Violence Trauma Details Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 08:29:51.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 30

Free-Form Entry

C55080 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Violence domestic witness indicator UCLAPTSDRIDSM5VlncDmstWitnsInd Indicator of whether the subject/participant has ever witnessed violence, or verbal or sexual abuse, between resident adults at home, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever witnessed violence, or verbal or sexual abuse, between resident adults at home, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Domestic Violence: Have you ever seen adults you live with get in a bad fight with each other, where someone got punched, kicked or hit with something? Have adults you live with threatened to hurt each other? Have you ever seen an adult you live with forced to do something sexual by another adult you live with? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 10:16:07.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55206 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Depersonalization detached self frequency past month grade UCLAPTSDRIDSM5DpDtSfFqPMGrade Grade of frequency during the past month that the subject/participant has experienced depersonalization as though he or she detached from him or herself, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has experienced depersonalization as though he or she detached from him or herself, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I feel not connected to my body, like I'm not really there inside 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55121 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Assault physical trauma detail other text UCLAPTSDRIDSM5AstPhyTrmDtlOTH The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Assault physical trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Assault physical trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Physical Assault Trauma Details Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 14:19:55.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 50

Free-Form Entry

C55154 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Suicide witness role type UCLAPTSDRIDSM5ScdWtnsRolTyp The type field for details about the subject/participant's degree of involvment related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Witnessed Suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for details about the subject/participant's involvment related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Witnessed Suicide, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Witnessed Suicide Role in Event Learned about;Witnessed Suicide;Witnessed body/scene Learned about;Witnessed Suicide;Witnessed body/scene Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:28:02.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55173 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Thought negative world frequency past month grade UCLAPTSDRIDSM5ThNgWlFqPsMGrade Grade of frequency during the past month that the subject/participant has had overly negative thoughts about the world, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has had overly negative thoughts about the world, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I have thoughts like, 'The world is really dangerous' 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55091 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Terrorism present for indicator UCLAPTSDRIDSM5TerismPsntFrInd Indicator of whether the subject/participant was ever present for an act of terrorism, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant was ever present for an act of terrorism, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Terrorism: Were you ever there when a terrorist attack happened, like a bombing, chemical attack or where people were taken hostage? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 11:23:35.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55231 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause problem other school indicator UCLAPTSDRIDSM5SyCsPrOtScInd Indicator of whether the subject/participant's PTSD symptom(s) cause him or her problems at school other than increasing the difficulty of doing well, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's PTSD symptom(s) cause him or her problems at school other than increasing the difficulty of doing well, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Do these reactions (thoughts and feelings) cause other problems at school? No;Yes No;Yes Alphanumeric

Clinician: Check whether the reactions (thoughts and feelings) above appear to cause clinically significant distress or functional impairment.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 13:38:45.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55133 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Rape assault sexual trauma detail type UCLAPTSDRIDSM5RpAstSxTrDtlTyp The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Sexual Assault/Rape, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Sexual Assault/Rape, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Sexual Assault/Rape Trauma Details Weapon Used;Drug used/suspected;Penetration occurred;Date/Acquaintance rape;Reported to police;Investigation conducted;Charges filed;Conviction;Other Weapon Used;Drug used/suspected;Penetration occurred;Date/Acquaintance rape;Reported to police;Investigation conducted;Charges filed;Conviction;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 15:28:13.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55196 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Blame self exagerrate frequency past month grade UCLAPTSDRIDSM5BlSfExFqPsMGrade Grade of frequency during the past month that the subject/participant has exagerratedly blamed him or herself for the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has exagerratedly blamed him or herself for the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I think that part of what happened was my fault 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55102 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma type experience age value UCLAPTSDRIDSM5TrmTypExpAgeVal Values(s) of the age(s) in years of the subject/participant at which he or she was involved with the type of trauma specified in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Values(s) of the age(s) in years of the subject/participant at which he or she was involved with the type of trauma specified in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type', as part of the UCLA PTSD Reaction Index DSM-5 (UCL Age(s) Experienced 1;3;2;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18 1;3;2;4;5;6;7;8;9;10;11;12;13;14;15;16;17;18 Numeric Values

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 12:19:53.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55242 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - DSM-5 symptom code UCLAPTSDRIDSM5DSM5SymptmCode Code identifying the DSM-5 symptom being scored, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Code identifying the DSM-5 symptom being scored, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) DSM-5 Symptom C1;A1;B1;D1;E1;A2;C2;B2;D2;E2;B3;B4;B5;D3;D4;D5;D6;D7;E3;E4;E5;E6 C1;A1;B1;D1;E1;A2;C2;B2;D2;E2;B3;B4;B5;D3;D4;D5;D6;D7;E3;E4;E5;E6 Alphanumeric Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 14:46:04.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55144 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Displacement forced trauma detail reason UCLAPTSDRIDSM5DsplcFrcTrDtlRsn The cause of displacement related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Forced Displacement, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The cause of displacement related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Forced Displacement, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Cause of Displacement War/Political Violence;Disaster;Other War/Political Violence;Disaster;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 08:33:22.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55081 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - School violence emergency indicator UCLAPTSDRIDSM5SchlVlncEmgcyInd Indicator of whether the subject/participant has ever been involved in or present for violence or an emergency at school, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been involved in or present for violence or an emergency at school, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) School Violence/Emergency: Were you ever at school when something really scary happened, like a shooting, a stabbing, a fire, where you or someone got badly beaten up or someone attempted or committed suicide? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 10:25:34.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55207 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Derealization distortion frequency past month grade UCLAPTSDRIDSM5DrlDstFqPMGrade Grade of frequency during the past month that the subject/participant has experienced derealization via distortion, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has experienced derealization via distortion, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I feel like things around me look strange, different, or like I am in a fog. 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55123 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Disaster trauma detail type UCLAPTSDRIDSM5DsastrTrmaDtlTyp The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Disaster, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Disaster, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Disaster Trauma Details Earthquake;Fire;Flood;Hurricane;Tornado;Chemical spill;Explosion;Other;Lost Home;Injured Earthquake;Fire;Flood;Hurricane;Tornado;Chemical spill;Explosion;Other;Lost Home;Injured Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 14:22:46.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55155 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma loss single type UCLAPTSDRIDSM5TrmaLossSglTyp The type of trauma to which the subject/participant was exposed if he or she was only exposed to one type, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type of trauma to which the subject/participant was exposed if he or she was only exposed to one type, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) If only one trauma/loss type is endorsed above, write in the trauma/loss type in this blank Serious Accidental Injury;Community Violence;Domestic Violence;War/Political Violence;School Violence/Emergency;Physical Assault;Sexual Assault/Rape;Disaster;Physical abuse;Psychological Maltreatment/Emotional Abuse;Neglect;Sexual abuse;Impaired Caregiver;Kidnapping/Abduction;Terrorism;Bereavement;Separation;Forced Displacement;Trafficking/Sexual Exploitation;Bullying;Attempted Suicide;Witnessed Suicide;Illness/Medical Trauma Serious Accidental Injury;Community Violence;Domestic Violence;War/Political Violence;School Violence/Emergency;Physical Assault;Sexual Assault/Rape;Disaster;Physical abuse;Psychological Maltreatment/Emotional Abuse;Neglect;Sexual abuse;Impaired Caregiver;Kidnapping/Abduction;Terrorism;Bereavement;Separation;Forced Displacement;Trafficking/Sexual Exploitation;Bullying;Attempted Suicide;Witnessed Suicide;Illness/Medical Trauma Alphanumeric Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:36:29.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55175 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Nightmare frequency past month grade UCLAPTSDRIDSM5NghtmrFqPsMGrade Grade of frequency during the past month that the subject/participant has had nightmares, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has had nightmares, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I have bad dreams about what happened, or other bad dreams 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55092 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Bereavement indicator UCLAPTSDRIDSM5BereavmntInd Indicator of whether the subject/participant has ever had someone to whom he or she was close die, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever had someone to whom he or she was close die, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Bereavement: Has someone you really cared about ever died? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 11:25:59.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55232 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause problem school describe text UCLAPTSDRIDSM5SymCsPrbScDscTxt The free-text field for describing problems at school caused by the subject/participant's PTSD symptoms, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field for describing problems at school caused by the subject/participant's PTSD symptoms, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Describe Alphanumeric

Clinician: Check whether the reactions (thoughts and feelings) above appear to cause clinically significant distress or functional impairment.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 13:30:05.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 255

Free-Form Entry

C55134 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Rape assault sexual trauma detail other text UCLAPTSDRIDSM5RpAstSxTrDtOTH The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Rape assault sexual trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Rape assault sexual trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Sexual Assault/Rape Trauma Details Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 15:33:13.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 30

Free-Form Entry

C55197 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Behavior self harm frequency past month grade UCLAPTSDRIDSM5BhSfHmFqPsMGrade Grade of frequency during the past month that the subject/participant has harmed him or herself, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has harmed him or herself, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I hurt myself on purpose 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55103 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma type experience age category UCLAPTSDRIDSM5TrmaTypExpAgCat Category(ies) of the age(s) selected in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma type experience age value', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Category(ies) of the age(s) selected in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma type experience age value', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Age(s) Experienced 1–5 years;6–12 years;13–18 years 1–5 years (blue);6–12 years (green);13–18 years (red) Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 12:25:43.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55244 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - DSM-5 symptom code high score UCLAPTSDRIDSM5DSM5SymCdHiScore Highest individual score among all symptoms belonging to the DSM-5 symptom code selected in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - DSM-5 symptom code', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Highest individual score among all symptoms belonging to the DSM-5 symptom code selected in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - DSM-5 symptom code', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Score (0–4) 0;1;2;3;4 0;1;2;3;4 Numeric Values

indicate highest score only for DSM-5 Symptom D2; indicate highest score only for DSM-5 Symptom D3; indicate highest score only for DSM-5 Symptom D4; indicate highest score only for DSM-5 Symptom E2

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 14:56:20.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55145 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Displacement forced trauma detail reason other text UCLAPTSDRIDSM5DpcFcTrDtRsnOTH The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Displacement forced trauma detail reason' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Displacement forced trauma detail reason' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Cause of Displacement Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 08:37:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 30

Free-Form Entry

C55156 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma loss most bothersome type UCLAPTSDRIDSM5TrLsMstBthrTyp The type of trauma or loss that most bothers the subject/participant at the present time if he or she has experienced more than one trauma or loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type of trauma or loss that most bothers the subject/participant at the present time if he or she has experienced more than one trauma or loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) If more than one trauma/loss type is endorsed, have the child/adolescent choose the trauma/loss experience that BOTHERS THEM THE MOST NOW and identify that trauma/loss type in this blank Serious Accidental Injury;Community Violence;Domestic Violence;War/Political Violence;School Violence/Emergency;Physical Assault;Sexual Assault/Rape;Disaster;Physical abuse;Psychological Maltreatment/Emotional Abuse;Neglect;Sexual abuse;Impaired Caregiver;Kidnapping/Abduction;Terrorism;Bereavement;Separation;Forced Displacement;Trafficking/Sexual Exploitation;Bullying;Attempted Suicide;Witnessed Suicide;Illness/Medical Trauma Serious Accidental Injury;Community Violence;Domestic Violence;War/Political Violence;School Violence/Emergency;Physical Assault;Sexual Assault/Rape;Disaster;Physical abuse;Psychological Maltreatment/Emotional Abuse;Neglect;Sexual abuse;Impaired Caregiver;Kidnapping/Abduction;Terrorism;Bereavement;Separation;Forced Displacement;Trafficking/Sexual Exploitation;Bullying;Attempted Suicide;Witnessed Suicide;Illness/Medical Trauma Alphanumeric Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:40:53.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55082 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Assault physical suffer witness indicator UCLAPTSDRIDSM5AsltPhySfrWtsInd Indicator of whether the subject/participant has ever been badly hurt by someone who is or was not a member of his or her family, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been badly hurt by someone who is or was not a member of his or her family, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Physical Assault: Have you ever been badly physically hurt (punched, kicked, stabbed, shaken) by someone outside of your family or who was not taking care of you? Have you ever been badly hurt (punched, kicked, stabbed) by someone outside your family, like someone in your neighborhood or a stranger? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 10:29:23.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55209 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Derealization unreality frequency past month grade UCLAPTSDRIDSM5DrlUrlFqPMGrade Grade of frequency during the past month that the subject/participant has experienced derealization via feelings of unreality, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has experienced derealization via feelings of unreality, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I feel like things around me are not real, like I am in a dream. 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55124 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Disaster trauma detail other text UCLAPTSDRIDSM5DstrTrmDtlOTH The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Disaster trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Disaster trauma detail type' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Disaster Trauma Details Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 14:35:41.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 30

Free-Form Entry

C55177 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Distress emotional reminder frequency past month grade UCLAPTSDRIDSM5DsEmRdFqPsMGrade Grade of frequency during the past month that the subject/participant has experienced emotional distress in response to reminders of the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has experienced emotional distress in response to reminders of the trauma/loss, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) When something reminds me of what happened I get very upset, afraid, or sad 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55093 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Separation familiar responsible adult indicator UCLAPTSDRIDSM5SepFamRspAdtInd Indicator of whether the subject/participant has ever been separated from a familiar adult who was responsible for him or her, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been separated from a familiar adult who was responsible for him or her, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Separation: Were you ever separated for a long time from someone you depend on, like a parent went to jail or was hospitalized, or you were placed in foster care? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 11:28:27.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55233 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Impairment functional school symptom cause indicator UCLAPTSDRIDSM5ImpFncScSyCsInd Indicator of whether the subject/participant's PTSD symptoms cause functional impairment at school, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant's PTSD symptoms cause functional impairment at school, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) School False;True False;True Alphanumeric

check if youth endorses #1 [UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom increase difficulty do well school indicator] or #2 [UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom cause problem other school indicator] below

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 13:33:01.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55135 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Kidnap abduct trauma detail perpetrator type UCLAPTSDRIDSM5KnpAbdcTrmDtlTyp The type field for identifying details about the perpetrator related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Kidnapping/Abduction, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details about the perpetrator related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Kidnapping/Abduction, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Perpetrator Relative;Position of trust;Acquaintance;Stranger;Other Relative;Position of trust (teacher, coach, minister);Acquaintance (neighbor etc);Stranger;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 15:35:30.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55198 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Sleep difficult frequency past month grade UCLAPTSDRIDSM5SlpDfcFqPsMGrade Grade of frequency during the past month that the subject/participant has had difficulty sleeping, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Grade of frequency during the past month that the subject/participant has had difficulty sleeping, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) I have trouble going to sleep, wake up often, or have trouble getting back to sleep. 0;1;2;3;4 None;Little;Some;Much;Most Numeric Values

Here is a list of problems people can have after bad things happen. Please think about the bad thing that happened to you that bothers you the most now. For each problem CIRCLE ONE of the numbers (0, 1, 2, 3 or 4) that tells how many days the problem happened to you in the past month, even if the bad thing happened a long time ago. Use the Frequency Rating Sheet to help you decide how many days the problem happened in the past month.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:53:38.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55104 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Serious accidental injury trauma detail type UCLAPTSDRIDSM5SrsAcIjTrmDtlTyp The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Serious Accidental Injury, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Serious Accidental Injury, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Serious Accidental Injury Trauma Details Motor vehicle;Fall;Dog bite;Hospitalized;Other Motor vehicle;Fall;Dog bite;Hospitalized;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 12:34:26.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55245 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - DSM-5 symptom category UCLAPTSDRIDSM5DSM5SymptomCat Category of DSM-5 symptom code scores being summed, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Category of DSM-5 symptom code scores being summed, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Symptom Category B;C;D;E B;C;D;E Alphanumeric Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 15:04:24.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

C55146 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Displacement forced trauma detail location UCLAPTSDRIDSM5DpcFcTrDtlLoc The type field for details about the site of displacement related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Forced Displacement, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The type field for details about the site of displacement related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Forced Displacement, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Site of Displacement Trailer;Refugee camp;Relocation center;Other Trailer;Refugee camp;Relocation center;Other Alphanumeric

TRAUMA/LOSS DETAILS: For each experience endorsed on the Trauma/Loss History Screening Questions form, place a check mark to indicate whether the specified trauma details were present, whether the child/adolescent was a victim, witness or learned about* the trauma, and the age(s) over which the trauma occurred. (Both of these forms may be updated over the course of treatment as additional information about trauma history is revealed or as additional traumas occur.) *Learned about only refers to indirect exposure in learning aversive details of violent personal assault, homicide, suicide, serious accident, or serious injury to a close relative or friend. It does not include learning about death due to natural causes.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 08:40:03.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Multiple Pre-Defined Values Selected

C55158 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma loss most bothersome describe text UCLAPTSDRIDSM5TrLsMstBthDscTxt The free-text field for describing the type of trauma or loss that most bothers the subject/participant currently (if more than one type experienced), or that the he or she experienced (if only one experienced), as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) The free-text field for describing the type of trauma or loss that most bothers the subject/participant currently (if more than one type experienced), or that the he or she experienced (if only one experienced), as part of the UCLA PTSD Reaction Index DSM Clinician: Provide a brief description of the trauma/loss type that is most bothersome now Alphanumeric Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-21 09:48:22.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points 4000

Free-Form Entry

C55083 UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Disaster involve witness present indicator UCLAPTSDRIDSM5DstrInvWtsPstInd Indicator of whether the subject/participant has ever been involved in, witness to, or present for a natural disaster or significant industrial accident, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Indicator of whether the subject/participant has ever been involved in, witness to, or present for a natural disaster or significant industrial accident, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) Disaster: Have you ever been in a natural disaster, like a hurricane, tornado, earthquake, flood or wildfire where you were hurt or could have been hurt or killed? Have you been in a natural disaster where you saw someone badly hurt or killed? Have you been in a place where there was a chemical spill or explosion? False;True False;True Alphanumeric

TRAUMA/LOSS HISTORY SCREENING QUESTIONS: Use the questions in the screening form provided below to ask about history of different types of trauma and loss. Place a check mark in the box on the left for each type of trauma /loss experience that has occurred. In interviewing the child/adolescent, you may ask: Sometimes people have scary or violent things that happen to them where someone could have been or was badly hurt or killed. I'm going to ask you some questions about whether any of these kinds of things have happened to you so that you can tell me if they did. [For those children/adolescents able to complete the form on their own, you may instruct them to place a check mark in the box on the left of the screening form to indicate that the trauma/loss has happened to them.] In either case, follow up on those items endorsed using the TRAUMA/LOSS DETAILS form provided in the next section.

Steinberg A, Brymer M, Decker K, Pynoos, R. The University of California at Los<br />Angeles Post-traumatic Stress Disorder Reaction Index. Curr Psych Rep.<br />2004;6:96&#8211;100. Pediatric Exploratory 1.00 2017-04-20 10:39:55.0 UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) Mood/Anxiety Outcomes and End Points

Single Pre-Defined Value Selected

CSV