Elsevier

General Hospital Psychiatry

Volume 32, Issue 3, May–June 2010, Pages 321-327
General Hospital Psychiatry

The Child Stress Disorders Checklist-Short Form: a four-item scale of traumatic stress symptoms in children

https://doi.org/10.1016/j.genhosppsych.2010.01.009Get rights and content

Abstract

Objective

To develop a user-friendly scale that measures traumatic stress responses in injured children. Though injured youth are at high risk for traumatic stress reactions and negative sequelae, there are limited options available for assessing risk, particularly in acute settings.

Method

Participants were children and adolescents (ages 6–18) hospitalized with burns or acute injuries (N=147). During hospitalization, parents and nurses completed the Child Stress Disorders Checklist (CSDC), a 36-item observer-report measure of traumatic stress symptoms. Other established measures of child traumatic stress were completed by parents and children during hospitalization and 3 months postinjury. A brief version of the CSDC was created using standard psychometric scale development techniques. The psychometric properties of the resultant scale were compared to those of the original CSDC.

Results

A four-item scale (CSDC-Short Form, CSDC-SF) emerged that demonstrated internal, interrater, and test–retest reliability and concurrent, discriminant, and predictive validity comparable to that of the full scale.

Conclusions

The CSDC-SF assesses traumatic stress reactions in injured children. Because the measure is very short and does not require specialized training for administration or interpretation, it may be a useful tool for providers who treat injured youth to identify those at risk for traumatic stress reactions.

Introduction

Each year, millions of youth in the United States experience a medical trauma. In 2008, more than 8 million children and adolescents under the age of 18 were seen in hospital emergency rooms for injuries [1]. Numerous studies have demonstrated that medical trauma results in a range of psychological sequelae, with acute stress disorder (ASD) or posttraumatic stress disorder (PTSD) reportedly arising in 6–35% of cases, and subsyndromal ASD/PTSD developing in an additional 10–20% [2], [3], [4], [5], [6]. Both full and subsyndromal diagnoses are associated with substantial clinical distress and functional impairment [7].

Evidence suggests that untreated traumatic stress symptoms in childhood may persist for years, even into adulthood [8], often having debilitating consequences on development. For example, PTSD has been associated with decreased total and cerebral brain volume and attenuated frontal lobe asymmetry in children [9], [10]. Furthermore, PTSD has been associated with increased risk for a variety of physical and mental disorders, including circulatory, endocrine, musculoskeletal and digestive diseases; chronic health conditions (e.g., chronic fatigue); and substance abuse, eating disorders and depression [11]. Though there are a number of empirically supported interventions that have been shown to significantly reduce PTSD symptoms in traumatized children and adolescents [8], [12], their effectiveness may be diminished as time from trauma exposure increases [13].

These data indicate a considerable need for tools that can accurately assess traumatic stress symptoms in at-risk children, particularly in the immediate aftermath of trauma exposure. Furthermore, these tools need to be accessible to providers working in settings where medically injured children are treated (e.g., emergency rooms, medical inpatient units, outpatient clinics). Specifically, measures need to (a) be short enough to be easily incorporated into busy acute clinical settings, (b) rely on sources that are readily available and (c) require minimal training to administer and interpret. The need for such an instrument was highlighted by two recent surveys of pediatric emergency care providers [14] and primary care pediatricians [15]. The findings indicated that respondents severely underestimated the risk of traumatic stress reactions in injured children, were largely unaware of measures to assess risk for traumatic stress and infrequently assessed for traumatic stress in their patients, citing time constraints as a major barrier.

Currently, there are a number of instruments for assessing PTSD symptoms in children and adolescents. However, the majority are not meant to assess traumatic stress symptoms in the immediate aftermath of a trauma, and most rely on child report of symptoms, which may, by itself, be subject to reporting inaccuracies due to cognitive immaturity, lack of insight or other factors [16]. One exception is the Child Stress Disorders Checklist (CSDC) [17], a 36-item observer-report measure designed to assess PSTD symptoms as well as ASD symptoms in children and adolescents. The CSDC has demonstrated adequate reliability and validity in assessing traumatic stress symptoms in burned children and children injured in a traffic crash, including high test–retest reliability (r=.84), moderate interrater reliability between parents and nurses (r=.44), and moderate correlations with a variety of established traumatic stress instruments (r's ranged from .26 to .59) [17]. The purpose of the current study was to develop a psychometrically comparable short version of the CSDC that could be utilized in settings where injured children are treated to identify quickly and easily children at risk for traumatic stress reactions. Furthermore, the current study extends prior work on the CSDC by examining the psychometric properties of the instrument in a larger sample of children with a greater variety of traumatic injuries.

Section snippets

Participants

Data obtained from two samples of children admitted to two Boston hospitals were used to develop and test the short version of the CSDC. One sample consisted of children admitted for burn-related injuries, and the second of children admitted for a variety of injuries, including motor vehicle accidents, falls and interpersonal violence Fig. 1. Prior to study enrollment, written informed consent was obtained from all adult participants and, when appropriate, written assent was obtained from child

Step 1: Develop short form of CSDC

Due to the nature of the scale development procedures, only participants whose parents provided responses to all 30 items on the CSDC were included in Step 1 (n=120). Among the parents who were administered the CSDC but who did not provide complete CSDC data, 70% skipped one item, 11% skipped two to three items and 19% skipped four or more items. Children whose parents did and did not provide complete CSDC data did not differ on any of the study variables.

With the use of parents' response data

Discussion

The objective of the current study was to develop a very short, reliable and valid measure that assesses risk for traumatic stress symptoms in youth following a medical trauma. The resultant 4-item Child Stress Disorders Checklist-Short Form (CSDC-SF) was derived from the 36-item Child Stress Disorders Checklist (CSDC). The CSDC-SF evidenced psychometric properties equivalent to those of the previously validated CSDC, including comparable reliability and concurrent, discriminant and predictive

Acknowledgments

The authors would like to thank Dr. Erin Hall and Alisa Miller, Katie Bedard, Meaghan Geary and David Bartholomew for their assistance in the preparation of this manuscript. The authors would also like to thank the families and nurses whose generous donation of time made this project possible.

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      The authors developed a short version of the Child Stress Disorders Checklist (CSDC), a 36-item observer-report measure of traumatic stress symptoms to predict PTSD in children after a traumatic injury including burns. They concluded that a short 4-question checklist is both reliable and predictive for PTSD.23 Another novel test is the 4-question screening tool called: Primary Care–PTSD screen (PC-PTSD) which proved to be a shorter alternative to the 17-question PCL-C.

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    The research was supported by NIMH grant R01 MH57370 and SAMHSA grant U79 SM54305 to Dr. Saxe. During the preparation of this manuscript, Dr. Bosquet Enlow was supported by K08MH074588.

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