OLDER CHILDREN AGES 7+
Strengths and Difficulties Questionnaire
(Self-report)
For each item, please mark the box for Not True, Somewhat True or Certainly True box. Please answer all items as best you can even if you are not absolutely certain. Give your answers based on how things have been for you over the last month.
Child's name ______Male/Female Child’s date of birth ______
CPS/JJPO ______Today’s date ______
Completed by: ______Relationship to child ______
Location: ______
Not Somewhat Very
True True True
I try to be nice to other people, I care about their feelings □ □ □
I am restless, I cannot stay still for long □ □ □
I get a lot of headaches, stomach-aches or sickness □ □ □
I usually share with others, for example CD’s, games, food □ □ □
I get very angry and often lose my temper □ □ □
I would rather be alone than with people of my age □ □ □
I usually do as I am told □ □ □
I worry a lot □ □ □
I am helpful if someone is hurt, upset or feeling ill □ □ □
I am constantly fidgeting or squirming □ □ □
I have one good friend or more □ □ □
I fight a lot, I can make other people do what I want □ □ □
I am often unhappy, depressed or tearful □ □ □
Other people my age generally like me □ □ □
I am easily distracted, I find it difficult to concentrate □ □ □
I am nervous in new situations, I easily lose confidence □ □ □
I am kind to younger children □ □ □
I am often accused of lying or cheating □ □ □
Other children or young people pick on me or bully me □ □ □
I often offer to help others (parents, teachers, other children) □ □ □
I think before I do things □ □ □
I take things that are not mine from home, school or elsewhere □ □ □
I get along better with adults than with people my own age □ □ □
I have many fears, I am easily scared □ □ □
I finish the work I’m doing, My attention is good □ □ □
Upsetting Events Survey
1. Have you ever been in a natural disaster such
as a flood, fire, mudslide, hurricane or earthquake?
2. Have you ever been in a bad motor vehicle or car accident? By bad accident, we mean an accident that was bad enough so you had to get medical care or that badly injured or killed someone else?
3. Have you ever been in any other kind of accident where you or someone else was badly hurt? By accident, we mean something like a plane crash, an explosion or fire, or someone almost drowning?
4. Did a close friend or someone you loved die suddenly (when you didn't expect it) because of an accident, illness, suicide or murder?
5. Have you ever been robbed or been there during a robbery where the robber(s) used or showed a weapon?
6. Have you ever been hit or beaten up and badly hurt by a stranger or by someone you didn't know very well?
7. Did you ever see a stranger, or someone you didn't know very well, attack, beat up, badly hurt or kill someone?
8. Has anyone ever threatened to kill you or badly hurt you?
9. Have you ever been badly hurt or punished by a parent, teacher, or caretaker? By badly hurt we mean in a way that caused you to have bruises, burns, cuts, or broken bones?
10. Did you see or hear family fighting? By family fighting we mean any
family member beating up or causing bruises, burns or cuts on another
family member.
11. Have you ever been slapped, punched, kicked, beaten up, or otherwise badly hurt by a friend, acquaintance, boyfriend or girlfriend?
12. Before your 16th birthday, did anyone touch or stroke your body in a sexual way when you did not want them to? Or did they make you touch or stroke their body in a sexual way when you did not want them to?
13. Before your 16th birthday, did anyone who was at least 5 years older than you touch or stroke your body in a sexual way? Or did they make you touch or stroke their body in a sexual way?
14. After your 16th birthday, did anyone touch your sexual parts or make you touch their sexual parts against your will?
15. Has anyone stalked you, in other words, followed you or kept track of you in a way that made you feel scared or worried about being safe?
16. Did you go through any other events that were life threatening, caused a bad injury, or were very upsetting to you? Did you see any other events that were life threatening, caused bad injury, or were very upsetting? We are talking about events like being lost, tortured, kidnapped or held captive.
17. Have you had a great shock because one of the events on this list happened to someone close to you (parent, close relative, close friend)?
If you checked yes for questions number 16 or 17, please write down what event you were thinking of when you answered. ______
Child PTSD Symptom Scale
(Self-report)
Below is a list of problems that kids sometimes have after an upsetting event. Read each one carefully and circle the number (0-3) that best describes how often that problem has bothered you in the last month.
0 / 1 / 2 / 3Not at all or only at one time / Once a week or less/once in a while / 2 to 4 times a week/ half the time / 5 or more times a week/almost always
1. / 0 / 1 / 2 / 3 / Having upsetting thoughts or images about the event that came into your head when you didn’t want them
2. / 0 / 1 / 2 / 3 / Having bad dreams or nightmares
3. / 0 / 1 / 2 / 3 / Acting or feeling as if the event was happening again (hearing something or seeing a picture about it and feeling as if I am there again)
4. / 0 / 1 / 2 / 3 / Feeling upset when you think about it or hear about the event (for example, feeling scared, angry, sad, guilty, etc)
5. / 0 / 1 / 2 / 3 / Having feelings in your body when you think about or hear about the event (for example, breaking out into a sweat, heart beating fast)
6. / 0 / 1 / 2 / 3 / Trying not to think about, talk about, or have feelings about the event
7. / 0 / 1 / 2 / 3 / Trying to avoid activities, people, or places that remind you of the traumatic event
8. / 0 / 1 / 2 / 3 / Not being able to remember an important part of the upsetting event
9. / 0 / 1 / 2 / 3 / Having much less interest or doing things you used to do
10. / 0 / 1 / 2 / 3 / Not feeling close to people around you
11. / 0 / 1 / 2 / 3 / Not being able to have strong feelings (for example, being unable to cry or unable to feel happy)
12. / 0 / 1 / 2 / 3 / Feeling as if your future plans or hopes will not come true (for example, you will not have a job or getting married or having kids)
0 / 1 / 2 / 3
Not at all or only at one time / Once a week or less/ once in a while / 2 to 4 times a week/ half the time / 5 or more times a week/almost always
13. / 0 / 1 / 2 / 3 / Having trouble falling or staying asleep
14. / 0 / 1 / 2 / 3 / Feeling irritable or having fits of anger
15. / 0 / 1 / 2 / 3 / Having trouble concentrating (for example, losing track of a story on the television, forgetting what you read, not paying attention in class)
16. / 0 / 1 / 2 / 3 / Being overly careful (for example, checking to see who is around you and what is around you)
17. / 0 / 1 / 2 / 3 / Being jumpy or easily startled (for example, when someone walks up behind you)