What screening questions should I ask to assess for post‑traumatic stress disorder?

Screening Questions for Post-Traumatic Stress Disorder (PTSD)

Begin by directly asking: "Has anything scary or concerning happened to you or your family recently?" followed by open-ended questions to explore trauma exposure. 1, 2 This direct approach is essential because approximately two-thirds of patients with PTSD symptoms do not voluntarily seek care. 1

Initial Screening Approach

Universal Opening Questions

• Start with trauma exposure inquiry: Ask all patients if they have experienced, witnessed, or learned about actual or threatened death, serious injury, or sexual violence affecting themselves or close family members. 1 This establishes whether the fundamental criterion for PTSD is met.

Age-Specific Screening Questions

For Adolescents (12-18 years)

Incorporate trauma questions into the HEEADSSS framework (Home, Education, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety), specifically asking: 1, 2, 3

• "Have you started using drugs or alcohol more than before, or started using them for the first time?" 1, 2
• "Are you taking more risks than you used to—like driving recklessly, getting into fights, or doing dangerous things?" 1, 2
• Questions about changes in peer relationships and social withdrawal 3

For Younger Children (via Parent Interview)

Ask parents about observable changes since the traumatic event: 1, 2

• "Does your child have trouble falling asleep, staying asleep, or have nightmares?"
• "Have you noticed changes in your child's appetite?"
• "Is your child more clingy or afraid to be separated from you?"
• "Have you seen any behavioral regression, like bedwetting or baby talk?"
• "Does your child have physical complaints like stomachaches or headaches without a clear medical cause?"

Four Core Symptom Clusters to Assess

Once trauma exposure is confirmed, screen for these four required symptom domains (symptoms must persist >1 month): 1

1. Intrusion Symptoms (≥1 required)

Ask: 1

• "Do you have unwanted memories of the event that pop into your mind when you don't want them to?"
• "Do you have nightmares about what happened?"
• "Do you ever feel like the traumatic event is happening again right now—like you're back there?"
• "When something reminds you of what happened, do you feel very upset or does your body react (heart racing, sweating, shaking)?"
• For children: "Does your child play games over and over that seem related to what happened?"

2. Avoidance Symptoms (≥1 required)

Ask: 1

• "Do you try hard not to think about or talk about what happened?"
• "Do you avoid people, places, activities, or things that remind you of the trauma?"

3. Negative Changes in Thinking and Mood (≥2 required)

Ask: 1

• "Are there parts of what happened that you can't remember, even though you weren't knocked out?"
• "Do you blame yourself or others for what happened, even if it wasn't really your fault?"
• "Do you feel like you can't trust anyone anymore, or that the world is completely dangerous?"
• "Do you feel angry, guilty, ashamed, or scared most of the time?"
• "Have you lost interest in things you used to enjoy?"
• "Do you feel disconnected from other people, like you're watching life from the outside?"
• "Do you have trouble feeling happy or loving feelings, even toward people you care about?"

4. Changes in Arousal and Reactivity (≥2 required)

Ask: 1

• "Do you get irritable or have angry outbursts over small things?"
• "Are you doing reckless or self-destructive things you didn't do before?"
• "Are you constantly on guard or watching for danger?"
• "Do you startle easily when you hear sudden noises?"
• "Do you have trouble concentrating?"
• "Do you have trouble sleeping?"

Validated Screening Tools

For Known Trauma Exposures

Use the PTSD Reaction Index Brief Form when you already know the patient experienced trauma. 1, 2 This tool directly assesses symptom severity across the four required domains.

For General Primary Care Settings

Use the Pediatric Traumatic Stress Screening Tool for routine screening when trauma history is unknown. 1, 2 This identifies both trauma exposure and symptoms in one instrument.

Brief 4-Question Screen

A 4-question screening tool has demonstrated good sensitivity, specificity, and predictive value across diverse adolescent populations and can be administered by non-mental health professionals. 4 While the specific questions are not detailed in the guidelines, this approach is validated for rapid assessment.

For Traffic-Related Injuries

An 8-question screen has excellent predictive characteristics for detecting post-traumatic stress symptoms specifically in children who sustained traffic-related injuries. 4

Critical Implementation Points

Do Not Rely on Observable Behavior Alone

Most PTSD symptoms are internal and invisible. 1, 2 Parents and teachers consistently underestimate children's distress, so you must ask the child directly when age-appropriate. 1, 2 Behavioral problems in the gender less typically affected (eating disorders in boys, fighting in girls) may be the only visible clue that sexual assault or trauma occurred. 4

Screen Children Directly When Possible

Even young school-age children can report their own symptoms more accurately than adult observers. 1, 2 Use developmentally appropriate language and concrete examples.

Timing Considerations

• Symptoms must persist >1 month to distinguish PTSD from Acute Stress Disorder (which lasts 3 days to 1 month). 1
• However, do not wait passively for one month in high-risk populations. 1 Screen early and monitor trajectory, as 10% of children develop PTSD by 3-5 months after medical procedures. 1

Screen for Suicidal Ideation

All trauma victims must be screened for suicidal thoughts and self-harm behavior. 4 This is non-negotiable, as rates of suicidal ideation and attempts are significantly elevated in trauma survivors.

Common Pitfalls to Avoid

• Underdiagnosis is the norm: Many patients will not volunteer PTSD symptoms, requiring direct questioning. 1
• Partial PTSD matters: Patients who meet some but not all criteria still benefit from treatment and should not be dismissed. 1
• Don't confuse frameworks: HEEADSSS (with two E's for Eating) differs from HEADSS or SSHADESS. 3
• Ensure follow-up exists: Screening without adequate treatment and follow-up systems can cause harm. 2