Screening tools for the evaluation of toxic stress in children and adolescents

What to evaluate	Whom to evaluate	Examples of tools
Risk factors
Social determinants of health (SDOH)^*	Child or parent/caregiver	Well child care, Evaluation, Community resources, Advocacy, Referral, Education (WE CARE)^*[1] Survey of the Well-Being of Young Children (SWYC)^¶[2]
Depression in the parent/caregiver^Δ	Parent/caregiver	Patient Health Questionnaire-2 (PHQ-2)^[3] Edinburgh Postnatal Depression Scale (EPDS)^[4]
Protective factors
Features of resilience	Child or parent/caregiver	Connor-Davidson Resilience Scale (CD-RISC)^[5]
Toxic stress symptoms or related conditions
Developmental delay	Child	Ages and Stages Questionnaire (ASQ)^[6] Parents' Evaluation of Developmental Status (PEDS)^[7] Survey of Well-Being of Young Children (SWYC)^¶[2]
Behavioral and mental health conditions (eg, attention deficit hyperactivity disorder [ADHD], depression, anxiety)^◊	Child	NICHQ Vanderbilt Assessment Scale for ADHD Patient Health Questionnaire-9 (PHQ-9) Screen for Anxiety Related Disorders (SCARED) General Anxiety Disorder-7 (GAD-7)
Post-traumatic stress disorder (PTSD)	Child	UCLA PTSD Reaction Index^[8,9] Child Trauma Screen (CTS; ages 6 to 17 years)^[10] Child and Adolescent Trauma Screen (CATS; ages 7 to 17 years)^[11] Pediatric Traumatic Stress Screening Tool (PTSST; ages 6 to 18 years)^[12]
Complex trauma or developmental trauma disorder (DTD)	Child	Trauma Symptom Checklist for Young Children (TSCYC; ages 3 to 12 years)^[13] Trauma Symptom Checklist for Children (TSCC; ages 8 to 16 years)^[14]

Surveillance and screening for toxic stress in children and adolescents include assessment for exposure to trauma (eg, adverse childhood experiences [ACEs]), risk and protective factors, and symptoms of toxic stress and trauma-related disorders. This table provides examples of screening tools that may be useful in this assessment. Refer to related UpToDate content on pediatric trauma-informed care for additional information.

* Adverse SDOH are a risk factor for toxic stress and can also identify risk for adversities. Although there is no consensus regarding the use of screening tools for SDOH, information obtained from these tools can be used to direct resources for families. The WE CARE survey has been validated for use in pediatric primary care settings; it can be administered by physicians or social workers and is available in multiple languages. It screens for various SDOH including adequate housing/utilities, food, employment, childcare, education, hospital transportation, and ability to pay for medications. Other available tools include Hunger Vital Signs and Safe Environment for Every Kid (SEEK) Questionnaire.

¶ The SWYC can be used for children between ages 0 to 5 years to assess developmental milestones, behavioral/emotional development, and psychosocial risk factors (eg, food insecurity, smoke exposure, parental/caregiver depression, substance use in the family, and domestic violence). Refer to related UpToDate content for more details on the use of developmental and behavioral screening tools in children.

Δ Parental/caregiver depression can impact the ability of the parent/caregiver to shield the child from adverse experiences. Routine screening for maternal postpartum depression is recommended during early infancy.

◊ Symptoms of conditions such as ADHD, depression, and anxiety can overlap with symptoms of toxic stress related to trauma exposure. Refer to related UpToDate content for more details regarding the use of screening tools for ADHD, depression, and anxiety in children and adolescents.

References:

Garg A, Butz AM, Dworkin PH, et al. Improving the management of family psychosocial problems at low-income children's well-child care visits: The WE CARE project. Pediatrics 2007; 120:547.
The SWYC. TEAM UP Scaling and Sustainability Center of Boston Medical Center. https://www.teamupforchildren.org/swyc/ (Accessed on May 14, 2025).
Kroenke K, RL Spitzer, JB Williams. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care 2003; 41:1284.
Cox JL, JM Holden, R Sagovsky. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150:782.
Connor KM, Davidson JR, Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety 2003; 18:76.
Boyce A. Review of the ages and stages questionnaires. In: The Sixteenth Mental Measurements Yearbook, Buros Institute of Mental Measurements 2005. p.31.
Glascoe FP. Collaborating with Parents, 2nd ed, PEDStest 2013.
Kaplow JB, Rolon-Arroyo B, Layne CM, et al. Validation of the UCLA PTSD Reaction Index for DSM-5: A developmentally informed assessment tool for youth. J Am Acad Child Adolesc Psychiatry 2020; 59:186.
Rolon-Arroyo B, Oosterhoff B, Layne CM, et al. The UCLA PTSD Reaction Index for DSM-5 Brief Form: A screening tool for trauma-exposed youths. J Am Acad Child Adolesc Psychiatry 2020; 59:434.
Lang JM, CM Connell. Development and validation of a brief trauma screening measure for children: The Child Trauma Screen. Psychol Trauma 2017:9:390.
Sachser C, Berliner L, Holt T, et al. International development and psychometric properties of the Child and Adolescent Trauma Screen (CATS). J Affect Disord 2017; 210:189.
Care process model: Diagnosis and management of traumatic stress in pediatric patients. Intermountain Health Care. https://intermountainhealthcare.org/ckr-ext/Dcmnt?ncid=529796906 (Accessed on May 14, 2025).
Briere, J. Trauma symptom checklist for young children (TSCYC). Psychological Assessment Resources. https://www.parinc.com/products/TSCYC (Accessed on May 14, 2025).
Briere, J. Trauma symptom checklist for children (TSCC). American Psychological Association. https://psycnet.apa.org/doiLanding?doi=10.1037%2Ft06631-000 (Accessed on May 14, 2025).

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Screening tools for the evaluation of toxic stress in children and adolescents

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