01 Aug Bobby is a 9-year-old boy who up until four months ago had been living with his single mother in a large apartment complex, was moved to a foster family for about a three months, an
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(Please note that while every question or statement may not be shown below or match word-for-word the way the assessments are worded, there is enough information below to make an informed decision using the assessment instruments. After carefully reviewing the assessments and narratives several times, if you do not see a particular criteria or statement answered by the narrative, you can safely assume that it is not part of the diagnostic picture for this client.)
Bobby is a 9-year-old boy who up until four months ago had been living with his single mother in a large apartment complex, was moved to a foster family for about a three months, and has been back in his mother’s care for the past month. According to the best records you have available, Bobby grew up in a very chaotic home, where drug deals and violence were a weekly, sometimes daily, occurrence. His biological father and mother were both users of quite a few different substances, and for the most part, any money that was earned went to buy drugs and alcohol far more often than food. On many occasions the police had been called to their home due to the yelling and fighting between his parents, and on several instances Child Protective Services (CPS) has intervened due to Bobby being found wandering around outside as a toddler looking dirty and hungry, and being unsupervised. His mother’s mom was “contracted” to take care of Bobby rather than have him remanded into foster care. He would live with his grandmother for a month or two until things returned to “normal” and social services stopped their weekly visits, then he would go back to his mother and father.
His father had a very volatile temper, and there were many domestic violence calls to their home from the local police or county sheriffs. Because of his temper and drug and alcohol use, his father has been in and out of jail many times during Bobby’s ages of infant through 7-years-old, with his longest incarceration being nine months (early release for good behavior) and the average stay being three-to-four months. Bobby says he remembers his dad “hitting his mom a lot, and yelling at him all the time, saying he (Bobby) was ugly and stupid.” Bobby says he could never understand why his dad “didn’t like me.” He also wanted to “stand up to my dad and protect my mom from getting hurt, but I was always too scared to do anything.” He mentions that he thinks about feeling that way “a lot.”
On at least one occasion when Bobby was 5-years-old, CPS had him removed from the home due to bruises and welts he had on his body that his kindergarten teacher had noticed, but since there were “no clear picture of abuse” (e.g., a bruise/red mark that looked like a belt or hand, no witness to the marks), he was returned to his parents’ care in a few days. When his mother was interviewed by the social workers, she admitted that things were very difficult, and that her husband did have a temper, but he “never hit the kid; he is just clumsy and falls a lot.” She says that Bobby is a “difficult child to take care of: clingy one moment and then won’t let me touch him the next.” A service plan was put in place that included parenting classes (the father went twice and stopped, but the mother finished all six). Over the period of six months, the home appeared less chaotic and services were stopped. A social worker randomly stopped by once a month for three or four more months, but that also eventually stopped.
When Bobby was around seven, he remembers one night when someone came to their house wanting to buy drugs. He says that things seemed to be fine until the guy started yelling that Bobby’s dad was “cheating him out of his stuff.” The man went away when his mom threatened to call the cops. A few days later when his dad was out at a bar, someone waited until he left and came up and shot him, killing him instantly. While there were many suspects, there was no evidence to hold any one of them, and the killing became a “cold case.” His mom never really talked about what happened to his dad, and treated it as if it really did not happen. While things were less chaotic at his home, his mom could not keep up with the payments and had to move them to an apartment complex where she could afford the rent with her job working in a local dry cleaners. Since she couldn’t afford a daycare nor a babysitter, his mom locked Bobby in the apartment while she was gone, making sure she had peanut butter sandwiches and juice for him, and the TV on to his favorite cartoons on the weekends when he wasn’t at school.
This leads up to the reason for Bobby being in your office. About eight months ago when Bobby was eight, and older man in the apartment complex (the maintenance worker) “befriended” Bobby when he saw him playing alone in the hallways. Over the next month, he coerced Bobby into his apartment where they would eat popcorn and candy, and drink sodas while watching movies. They would watch all kinds of movies, some that were funny, and some that were violent and action-packed. The man also showed some that were cartoonish, while others were normal types of movies. Many of the cartoonish movies had nudity and sex in them, which embarrassed him a little, but since the man did not act like it was wrong, he figured it must be okay, too. After a week or so, the cartoonish movies became more graphic in the sexual acts being displayed, but since the man did mention anything, Bobby did not either. As the movies became more graphic, the man started rubbing Bobby’s genitals. While Bobby says he “did not like it,” he feels guilty because he did not tell the man to stop. This continued on until one day the man performed oral sex on Bobby, then made Bobby do the same to him. Bobby says he “did not want to, but he held me there until I did it.” Then man then told Bobby he “must never tell anyone about these things or he would hurt his mom.” He said that frightened him “an awful lot, but after what’s happened to mom before, I didn’t want something worse to happen to her because of me.” This happened several more times over the next few weeks.
Over this period of time, his behavior at home and school became worse until approximately three months ago his teacher sat down with him and asked him what was wrong (rather than sending him to the principal as she had done several times before, or put him in “time-out”). He then started crying and told her all that had been happening with the man. The teacher calmed him down and got him something to eat and drink (she had done this for him before when she noticed he would come to school a little dirty and disheveled, and when the other kids would tease and make fun of him). While he was eating, she contacted the principal and they immediately contacted CPS. The CPS workers came and talked with Bobby some more, then they contacted the police while they took Bobby to an emergency foster care shelter.
After he relates a little of his story, you let him know that you are going to ask a bunch of questions about how he has been feeling for the past month, or three to four weeks. You let him know to just answer the best he can, and that you will help him if he’s not sure about something. You start with if he has any upsetting thoughts or pictures that pop into his mind about what happened to him? Bobby says he sometimes has dreams about them, and they make him “feel kinda bad.” You then explain to him to answer as many of these questions with a number, with 0 being “not there,” 1 meaning “a little bit,” 2 meaning “sometimes,” 3 meaning “a lot,” and 4 meaning “almost all the time.” He says the dreams “sometimes wake him up,” and he feels “yucky” when he wakes up, so “I say 2.” He says he cannot remember how many times he has had the dreams, but he thinks it has “been a lot.” You follow up with asking if they happen when he is awake? He answers, “Yea, sometimes; oops I mean 2.” When asked how many times has it happened in the past month, he answers, “A couple of times a week, I think. Usually when I’m watching cartoons. I don’t like watching them as much as I used to.” You ask if there have been times that he felt like he was back with the man and that it was happening to him again, and Bobby looks away, shakes his head, and doesn’t give an answer. You then ask him if he gets upset, afraid, or sad talking about what happened, and he answers, “Sad, and kinda mad. He shouldn’t have touched me or made me do things. I thought he was just being nice because he liked me.” Asked how much it makes him sad and mad, he says “3.” You ask him if his body ever feels funny or does your stomach hurt when you think about what happened, and he looks a little bewildered, and says “I don’t think so.”
You next ask if he has tried to not think about what happened, and he says, “Yea, a little bit.” What thoughts or feelings do you not want to think about? He says, “Just the feelings I had when I would watch his movies, and then some of the feelings I had when the man was touching me.” When asked how often it had happened, he says, “I don’t know, a couple of times, maybe a 2.” Have you tried to stay away from other people, or places that remind you of what happened? Bobby remarks, “Yea; I’m really mad at him. I thought he liked me. I’m afraid to go anywhere now without my mom, but she sleeps a lot, so I usually just end up playing by myself in my room.” What kinds of things do you try to stay away from? Bobby mentions that, “I don’t like to go near any men I don’t know; I don’t know what they may do to me.” When you ask how often have you tried to stay away from other people, Bobby answers, “Every day.”
You continue by asking him if he has had any trouble remembering any parts of what happened to him? Bobby pauses a moment, and says, “I don’t think so; I remember everything.” You follow up with have you had any bad thoughts about yourself, like you are bad because this happened to you? Bobby looks away, looks down, and says, “I must be a bad kid. My dad is dead, and I know he hated me. My mom doesn’t pay attention to me or care what I do. I thought someone liked me but they did bad things to me. I’m just bad.” How often do you think you are a bad kid? He answers, “All the time.” Do you feel that what happened was all your fault? Bobby answers, “Yea, a lot. I shouldn’t have been in that man’s place. I ate his cookies and candy and drank his drinks; I shouldn’t have done all of that. I just thought he liked me.” Are you angry at him? “Yea, he shouldn’t do that to kids; that’s wrong. I mean, he didn’t really hurt me, but I didn’t like feeling like he would hurt my mom.” You ask how often do you think about that, and he says, “Just about every day, probably a 3.” Your next question is do you ever feel what happened was gross, or do you feel embarrassed, or guilty about it? Bobby takes a moment and irritably says, “Of course it’s gross! He made me do things I didn’t like. But I didn’t say anything because he said he would hurt my mom, and I didn’t want her to be hurt anymore. I have to be the man of the house now.” How often do you feel this way? “A lot; just about every day, I think.” Did you feel any of these things before this happened with that man? Bobby looks at you quizzically, “I don’t think so; I was scared, but not because of those things with the man. I was scared of my dad.” You ask if he did not feel like doing things with his family or friends like you used to? Bobby says that, “I never really did a lot anyway. I don’t have any friends at school; they all call me ‘stinky’ and ‘dirty-face boy’ and things like that. Mom is usually asleep so we don’t do things anyway.” Is there anything that you used to do that you don’t do anymore? Bobby says, “That’s easy; I don’t go out and play anymore at the apartments; maybe a 2. I don’t want to see the man again” (Note: the trial is still pending and the man is free on bond since there were no witnesses or evidence to the event[s]; since he wasn’t raped, the defense is claiming that Bobby “made it all up, and framed someone who was trying to be nice to him; and that his mom put him up to it to get money from the man and the apartment complex owners”). You next ask him if he feels alone even when you are with your mom? He seems confused, but answers, “I don’t mind being alone; I like it. That way there’s no one to hurt me. Mom doesn’t pay that much attention to me anyway.” How about at school? Do you feel alone if when you are at school? “I don’t have any friends at school, so I’m always playing by myself there.” Did these feelings get worse after what happened with the man? Bobby just shakes his head and says, “Naw; I never played with the other kids anyway. I don’t like them and they don’t like me.” Do you ever feel like it is really hard to be happy, or that no one loves you, or you can’t have any other good feelings like that? He says, “I guess my mom loves me; I know my grandma does. I’ve never really thought about it.”
As you continue your questions, you ask have there ever been times recently where you got mad really easy, arguing with others or fighting with others? He rolls his eyes and says, “My teacher must have said something to you, right? Those kids were picking on me first. I did hit the one kid a couple of times, but I didn’t really hurt him.” Can you give me an example of what happens when you get mad at the other kids? Bobby explains, “I yell back at them. I call them names. I punch them, too. Maybe they’ll leave me alone now.” Did this get worse after what happened with the man? He looks thoughtful for a moment and remarks, “Yea; before I just never really paid attention to the other kids, now I want to hurt them when they make me mad.” How many times have you gotten into a fight this past month? “Well, I’ve hit three different kids pretty good, but only went to the office for one of them. I told the other two they better not say anything or I’ll hurt them worse. Hey, you’re not going to tell the teacher about those are you?” As you continue, you ask him if he has tried to hurt himself on purpose, or done thinks that could hurt him? He looks thoughtful and says, “I don’t think so; I’ve always liked to climb trees and go as high as I could go, and things like that.” Have you ever wanted to just jump to hurt yourself when you climb high like that? He looks at you like you are crazy and says, “No way! I don’t want break my legs! That’s just stupid!” Have you done anything else that might hurt you? He responds, “Naw; I don’t think so. I don’t do stupid things like that. Who’d take care of my mom?” You move on with asking, Have you been very watchful or on the lookout for things that make you afraid? He says, “Sometimes, maybe a number 2.” You ask: what kinds of things are you on the lookout for? Do you feel like you are in danger or that someone or something may hurt you in some way? He looks away for a moment and then says, “I just don’t trust other people like that man. My teacher is okay, even the principal seems okay, but I just don’t want to be around anyone.” How often have you felt that way in the past three or four weeks? “A lot, I think; probably a 3.” Have you always felt this way, or do you think it became worse because of what happened to you with the man? “I think it’s worse; I never really thought about it before.” You ask: Do you feel jumpy or easily startled, like when you hear a loud noise or get surprised by something? Bobby answers, “Yea, probably a 1; I never knew what was going to happen with my dad around. He could get so mad so easy that I just stayed out of his way.” Do you think you’ve always felt that way, or did it get worse after what happened with the man? Bobby ponders for a moment and answers, “I think I’ve always been that way. I just never knew what mood he was in, so I pretty much just stayed away from him.” Have you had any trouble concentrating or paying attention when you needed to pay attention? He responds, “You must be talking to my teacher again. She always is telling me that I need to pay attention. I can’t help it! I look out the window and that’s where I want to be! Not inside!” Can you concentrate when you really try? “Yea, most of time. When I really have to, like with tests and homework and stuff.” What number would you give your problems with concentrating? “Probably a 2; I can concentrate when I want to.” Do you think it’s worse since what happened with the man? About the same? He looks away and then says, “I think it’s a little worse, maybe a 2. I’ve always had trouble paying attention all the time. It does seem to be a little harder now, though.” You ask him how his sleeping has been; do you have any trouble getting to sleep? Staying asleep? Getting back to sleep? He says, “I don’t think so; I don’t have those dreams every night. It’s only those times when I dream of that man and those cartoons that it is harder to get back to sleep when I wake up. Sometimes I can go right back to sleep; sometimes I just lay there and think about the cartoon movies. Then it is harder to go back to sleep.” How many hours do you think you should be sleeping? “I don’t know; ask my mom.” How often have you had the dreams that woke you up in the past month? I don’t know; maybe two or three times?”
You let him know that you are almost done and that he has done a really great job of paying attention and answering all those questions. You ask: thinking about the last month, the last three of four weeks, and putting all those problems together, using a number, how much do you think you have been bothered by these problems you have told me about? “You mean everything?” He stops a moment and thinks. “Probably a 2, I think.” In the past month, have these problems made it hard to get along with your family? “I don’t think so; but we don’t really talk about it. She pretends like it never really happened.” How about at school? Do you think these things have made it harder there? If you do, what number do you think you would give it? Bobby thinks for a bit, and says, “probably a 3. I really did not get into trouble at school that much, other than not paying attention like I needed to.” Can you think of any other ways in your life what happened may have affected you? “I don’t think so” (clearly wanting to be done). Do you think that everything that has happened makes it harder to do what other kids your age are doing? If you do, what number would you give it? Bobby looks contemplative for a moment and says. “I think so, but I never really want to do the same things the other kids do anyway. Maybe a 1?”
Brief Trauma Questionnaire (BTQ)
Version date: 1999
Reference: Schnurr, P., Vielhauer, M., Weathers, F., & Findler, M. (1999). The Brief Trauma Questionnaire (BTQ) [Measurement instrument]. Available from http://www.ptsd.va.gov
URL: http://www.ptsd.va.gov/professional/as- sessment/te- measures/brief_trauma_question- naire_btq.asp
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Brief Trauma Questionnaire
The BTQ is a brief self- report questionnaire that is derived from the Brief Trauma Interview (Schnurr et al., 1995). (Information about the reliability and validity of the BTI is provided in Schnurr et al., 2002). The BTQ was originally designed to assess traumatic exposure according to DSM‐IV but specifically asked only about Criterion A.1 (life threat/serious injury) because of the difficulty of accurately assessing A.2 (subjective response) in a brief self- report format. Criterion A.2 has been eliminated from the PTSD diagnostic criteria in DSM- 5, so the BTQ provides a complete assessment of Criterion A.
The questionnaire may be used to determine whether an individual has had an event that meets the A Criterion, or to determine the different types of Criterion A events an individual has experienced. In either case, exposure to an event should be scored as positive if a respondent says yes to either:
• life threat or serious injury for events 1- 3 and 5- 7; • life threat for event 4; • serious injury for event 8, or; • “Has this ever happened to you?” for events 9 and 10.
Information about the BTQ appears in the following articles:
Koenen, K.C., De Vivo, I., Rich- Edwards, J., Smoller, J.W., Wright, R.J., & Purcell, S.M. (2009). Protocol for investigating genetic determinants of posttraumatic stress disorder in women from the Nurses’ Health Study II. BMC Psychiatry, 9 (article 29).
Kubzansky, L. D., Bordelois, P., Jun, H. J., Roberts, A. L., Cerda, M., Bluestong, N., & Koenen, K. C. (2014). The weight of traumatic stress: A prospective study of posttraumatic stress disorder symptoms and weight status in women. JAMA Psychiatry, 71, 44-51.
Lancaster, S.L., Melka, S.E., & Rodriguez, B.F. (2009). A factor analytic comparison of five models of PTSD symptoms. Journal of Anxiety Disorders, 23, 269- 274.
Morgan, C.A., III, Doran, A.P., Steffians, G., Hazlett, G.,& Southwick, S. (2006). Stress- induced deficits in working memory and visuo- constructive abilites in special operations soldiers. Biological Psychiatry, 60, 722- 729.
Morgan, C.A., III, Hazlett, G., Wang, S., Richardson, E.G., Jr., Schnurr, P.P., & Southwick, S.M. (2001). Symptoms of dissociation in humans experiencing acute, uncontrollable stress: A prospective investigation. American Journal of Psychiatry, 158, 1239- 1247.
Morgan, C.A., III, Rasmusson, A.M., Winters, B., Hauger, R.L., Morgan, J., Hazlett, G., & Southwick, S.M. (2006). Trauma exposure rather than posttraumatic stress disorder is associated with reduced baseline plasma neuropeptide- Y levels. Biological Psychiatry, 54, 1087- 1091.
Schnurr, P.P., Spiro, A. III, Vielhauer, M.J., Findler, M.N., & Hamblen, J.L. (2002). Trauma in the lives of older men: Findings from the Normative Aging Study. Journal of Clinical Geropsychology, 8, 175- 187.
Whealin, J.M., Batzer, W.B., Morgan, C.A. III, Schnurr, P.P., & Friedman, M.J. (2007). Cohesion, burnout, and past trauma in Tri- Service medical and support personnel. Military Medicine, 172, 266- 272.
Page 1 of 2 BTQ (1999) National Center for PTSD
Brief Trauma Questionnaire
The following questions ask about events that may be extraordinarily stressful or disturbing for almost everyone. Please circle “Yes” or “No” to report what has happened to you.
If you answer “Yes” for an event, please answer any additional questions that are listed on the right side of the page to report: (1) whether you thought your life was in danger or you might be seriously injured; and (2) whether you were seriously injured.
If you answer “No” for an event, go on to the next event.
Event Has this ever happened to
If the event happened, did you think your
life was in danger or you might be
If the event happened, were you seriously injured?
1. Have you ever served in a war zone, or have you ever served in a noncombat job that exposed you to war-related casualties (for example, as a medic or on graves registration duty?)
No Yes No Yes No Yes
2. Have you ever been in a serious car accident, or a serious accident at work or somewhere else?
No Yes No Yes No Yes
3. Have you ever been in a major natural or technological disaster, such as a fire, tornado, hurricane, flood, earthquake, or chemical spill?
No Yes No Yes No Yes
4. Have you ever had a life-threatening illness such as cancer, a heart attack, leukemia, AIDS, multiple sclerosis, etc.? No Yes No Yes
5. Before age 18, were you ever physically punished or beaten by a parent, caretaker, or teacher so that: you were very frightened; or you thought you would be injured; or you received bruises, cuts, welts, lumps or other injuries?
No Yes No Yes No Yes
6. Not including any punishments or beatings you already reported in Question 5, have you ever been attacked, beaten, or mugged by anyone, including friends, family members or strangers?
No Yes No Yes No Yes
7. Has anyone ever made or pressured you into having some type of unwanted sexual contact?
Note: By sexual contact we mean any contact between someone else and your private parts or between you and some else’s private parts
No Yes No Yes No Yes
8. Have you ever been in any other situation in which you were seriously injured, or have you ever been in any other situation in which you feared you might be seriously injured or killed?
No Yes N/A No Yes
9. Has a close family member or friend died violently, for example, in a serious car crash, mugging, or attack?
No Yes N/A No Yes
10. Have you ever witnessed a situation in which someone was seriously injured or killed, or have you ever witnessed a situation in which you feared someone would be seriously injured or killed?
Note: Do not answer “yes” for any event you already reported in Questions 1-9
No Yes N/A N/A
Page 2 of 2 BTQ (1999) National Center for PTSD
National Center for PTSD
CLINICIAN-ADMINISTERED PTSD SCALE FOR DSM-5
(Revised September 2015)
Child’s Name: __________________________ ID #________ Age: _____ Sex: □ Girl □ Boy
Grade in School: _____ School: _________________________________________________
Teacher: _______________________ City/State: __________________________________
Interviewer Name/ID # ________________________________________________________
Date (month, day, year): ____/____/____ (Session #________)
Robert S. Pynoos, Frank W. Weathers, Alan M. Steinberg, Brian P. Marx, Christopher M. Layne,
Danny G. Kaloupek, Paula P. Schnurr, Terence M. Keane, Dudley D. Blake, Elana Newman,
Kathleen O. Nader & Julie A. Kriegler
National Center for Posttraumatic Stress Disorder and National Center for Child Traumatic Stress
Do not use, duplicate or distribute without permission from: National Center for PTSD
Inquiries, comments, or requests for copies may be directed to the National Center for PTSD: [email protected]
Please note that several authors have switched affiliations; K. Nader is now at Nader and Associates, Aliso
Viejo, CA; J. A. Kriegler is at Permanente Medical Group, Santa Clara, CA; D. D. Blake is now at Boise
Department of Veterans Affairs Medical Center; and, E. Newman is at University of Tulsa.
The authors acknowledge the assistance of Julie Kaplow for pilot testing item wording for DSM-5.
Standard administration and scoring of the Clinician-Administered PTSD Scale for DSM-5 – Child/Adolescent Version
(CAPS-CA-5) are essential for prod
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