CDE Detailed Report
Sub-Domain: Mood/Anxiety
CRF: UCLA PTSD Reaction Index for Children
Displaying 51 - 100 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| C55125 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Abuse sexual trauma detail type | UCLAPTSDRIDSM5AbsSxlTrmDtlTyp | The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Sexual Abuse, 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 Abuse, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | Sexual Abuse Trauma Details | Forced sexual behavior;Watch something sexual;Penetration occurred;CPS report filed;Investigation conducted;Charges filed;Conviction;Perpetrator removed from home | Forced sexual behavior;Watch something sexual;Penetration occurred;CPS report filed;Investigation conducted;Charges filed;Conviction;Perpetrator removed from home | 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;6:96–100. | Pediatric | Exploratory | 1.00 | 2017-04-20 14:38:13.0 | 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 |
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| 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;6:96–100. | 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 |
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| 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;6:96–100. | 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 |
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| C55210 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom bother upset subject participant indicator | UCLAPTSDRIDSM5SxBthUpsSjPtInd | Indicator of whether the subject/participant's symptoms of PTSD bother him or herself, 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 bother him or herself, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | Do these reactions (thoughts and feelings) bother or upset you a lot? | 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;6:96–100. | Pediatric | Exploratory | 1.00 | 2017-04-21 12:13:43.0 | 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 |
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| C55136 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Terrorism trauma detail type | UCLAPTSDRIDSM5TerismTrDtlTyp | The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Terrorism, 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 Terrorism, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | Terrorism Trauma Details | Shooting;Suicide bombing;Bombing;Biological agent;Chemical agent;Radiological agent;Hostages taken;Other | Shooting;Suicide bombing;Bombing (package, vehicle);Biological agent;Chemical agent;Radiological agent;Hostages taken;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;6:96–100. | Pediatric | Exploratory | 1.00 | 2017-04-20 15:40:48.0 | 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 |
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| C55179 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Affect positive difficult experience frequency past month grade | UCLAPTSDRIDSM5AfPDExFqPsMGrade | Grade of frequency during the past month that the subject/participant has had difficulty experiencing positive affect, 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 experiencing positive affect, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | I have trouble feeling happiness or love | 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;6:96–100. | 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 |
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| C55094 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - War violence political presence witness indicator | UCLAPTSDRIDSM5WrVcPolPscWtsInd | Indicator of whether the subject/participant has ever lived in a country experiencing, or seen someone injured or killed in, war or political violence, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | Indicator of whether the subject/participant has ever lived in a country experiencing, or seen someone injured or killed in, war or political violence, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | War/Political Violence: Have you lived in a country where a war or armed conflict was happening (like soldiers or armed groups were fighting)? Did you see people who had been badly hurt or killed in a war or armed conflict? | 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;6:96–100. | Pediatric | Exploratory | 1.00 | 2017-04-20 11:32:37.0 | 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 |
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| C55234 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Symptom increase difficulty make get along friend indicator | UCLAPTSDRIDSM5SyInDfMkGAFrInd | Indicator of whether the subject/participant's PTSD symptom(s) increase(s) the difficulty he or she has in making or getting along with friends, 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 making or getting along with friends, 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 get along with your friends or make new friends? | 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;6:96–100. | 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 |
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| C55246 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - DSM-5 symptom category total score | UCLAPTSDRIDSM5DSM5SyCaTotScore | Total score of all DSM-5 symptom code high scores for the DSM-5 symptom category selected in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - DSM-5 symptom category', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | Total score of all DSM-5 symptom code high scores for the DSM-5 symptom category selected in 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - DSM-5 symptom category', as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | Symptom Category Summative Score | Numeric Values |
Category B Total: Sum scores for symptoms B1-B5; Category C Total: Sum scores for symptoms C1 and C2; Category D Total: Sum scores for symptoms D1-D7; Category E Total: Sum scores for symptoms E1-E6 |
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;6:96–100. | Pediatric | Exploratory | 1.00 | 2017-04-21 15:09:10.0 | UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) | Mood/Anxiety | Outcomes and End Points |
Free-Form Entry |
0 | 28 | ||||||||
| C55147 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Displacement forced trauma detail location other text | UCLAPTSDRIDSM5DpcFcTrDtlLocOTH | The free-text field related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Displacement forced trauma detail location' 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 location' specifying other text, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | Site 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;6:96–100. | Pediatric | Exploratory | 1.00 | 2017-04-21 08:44:07.0 | UCLA PTSD Reaction Index for Children/Adolescents - DSM-5 (UCLA PTSD-RI DSM-5) | Mood/Anxiety | Outcomes and End Points | 30 |
Free-Form Entry |
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| C55199 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Affect negative self frequency past month grade | UCLAPTSDRIDSM5AfNgSfFqPsMGrade | Grade of frequency during the past month that the subject/participant has had negative affect about 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 had negative affect about him or herself, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | I feel ashamed or guilty about some part of what happened | 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;6:96–100. | 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 |
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| C55105 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Illness medical trauma detail person type | UCLAPTSDRIDSM5IlMdTrDtlPsnTyp | The type field for identifying the person involved in the trauma, related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Illness/Medical Trauma, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | The type field for identifying the person involved in the trauma, related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Illness/Medical Trauma, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | Illness/Medical Trauma Trauma Details | Self;Family;Friend | Self;Family;Friend | 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;6:96–100. | 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 |
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| C55126 | UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Abuse physical trauma detail type | UCLAPTSDRIDSM5AbsPhyTrmDtlTyp | The type field for identifying details related to 'UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) - Trauma detail type' specifying Physical Abuse, 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 Abuse, as part of the UCLA PTSD Reaction Index DSM-5 (UCLA PTSD-RI DSM-5) | Physical Abuse Trauma Details | Punched;Kicked;Stabbed;Shaken;Weapon Used;Reported to CPS;Reported to police;Badly physically hurt | Punched;Kicked;Stabbed;Shaken;Weapon Used;Reported to CPS (if a minor);Reported to police;Badly physically hurt | 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;6:96–100. | Pediatric | Exploratory | 1.00 | 2017-04-20 14:46:58.0 | 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 |
