Although there is no specific measure for toxic stress, there are several instruments available to help screen for adverse childhood experiences and for related behavior problems. Several of those measures are summarized below:
Adverse Childhood Experiences (ACE) Questionnaire
The Adverse Childhood Experiences (ACE) Questionnaire was originally developed by Dr. Felitti and colleagues. 1 It is a 10-item measure intended to assess 10 types of childhood adversity in three different areas of abuse, including emotional and physical abuse, physical neglect, and abuse associated with living in a dysfunctional household. Adverse childhood experiences include: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, mother treated violently, household substance abuse, household mental illness, parental separation or divorce and incarcerated household member. This questionnaire was designed to measure the occurrence of adverse experiences an individual experienced before the age of 18 years.
• The ACE is a brief screener.
• Is available in English, Spanish, French, German, Norwegian, and Swedish.
• “The ACE is a reliable, valid and economic screen for retrospective assessment of adverse childhood experiences.”2
• Has adequate internal consistency (Cronbach’s alpha = .88).3
Administering, Scoring, and Interpreting the ACE
The questionnaire begins with the following statement: While you were growing up, during your first 18 years of: Did you …. The answer choices are Yes or No. Each affirmative answer (Yes) is assigned 1 point. ACE score is determined by adding up all the points.
An ACE Score of 0 suggest that the person reported no exposure to childhood trauma. An ACE Score of 10 suggests that the person reported exposure to childhood trauma. The higher the ACE Score, the greater the likelihood that a person will develop one or more of the following health problems: ischemic heart disease, cancer, chronic bronchitis or emphysema, hepatitis or jaundice skeletal fractures, diabetes, smoking, sexually transmitted diseases , depression, etc.
1Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading cause of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245-258.
2Wingenfeld, K., Schäfer, I., Terfehr, K., Grabski, H., Driessen, M., Grabe, H., . . . Spitzer, C. (2010). Reliable, valide und ökonomische Erfassung früher Traumatisierung: Erste psychometrische Charakterisierung der deutschen Version des Adverse Childhood Experiences Questionnaire (ACE). Psychotherapie Psychosomatik Medizinische Psychologie Psychother Psych Med, 61(01). doi:10.1055/s-0030-1263161.
3Murphy, A., Steele, M., Dube, S. R., Bate, J., Bonuck, K., Meissner, P., . . . Steele, H. (2014). Adverse Childhood Experiences (ACEs) Questionnaire and Adult Attachment Interview (AAI): Implications for parent child relationships. Child Abuse & Neglect, 38(2), 224-233.
Pediatric Symptom Checklist (PSC)
The Pediatric Symptom Checklist (PSC) is a brief questionnaire used to screen for mental health disorders in children and adolescents. It is used by pediatricians and other health professionals to improve the recognition and treatment of psychosocial problems in children.
• Available in three versions: PSC-35,1 PSC-172 and Y-PSC.
• Time to completion: 5 to 10 minutes.
• Available in several languages including English, Spanish, Haitian Creole, etc.
• PSC-35: available in 19 languages.
• PSC-17: available in 4 languages.
• The PSC-35 and PSC-17 have demonstrated “good validity and reliability of the scale has been demonstrated across multiple pediatric outpatient populations.”3
• Test-re-test reliability of the PSC ranges from r = .84 - .91. 1, 4
• Inter-item Analysis: Strong (Cronbach alpha = .91) internal consistency of the PSC items and highly significant (p < 0.001) correlations between individual PSC items and positive PSC screening scores.5, 6
• The PSC-17 has a range of .67 to .89 for its internal consistency and a significant correlation with other instruments assessing psychosocial impairment.7
• The PSC cut-off score of 28 has a specificity of 0.68 and a sensitivity of 0.95 when compared to clinicians’ ratings of children’s’ psychosocial dysfunction.1
Administering, Scoring, and Interpreting the PSC
The PSC-35 consists of 35 items in which the parents is asked to rate the statement that best describes his or her child by choosing one of the following choices: "Never (0)", "Sometimes (1)", and "Often (2)." The total score is calculated by adding up the score for each of the 35 items.
A PSC cutoff score of 28 or higher is indicative of psychological impairment for children and adolescents ages 6 through 16.
A PSC cutoff score of 24 or higher is indicative of psychological impairment for children ages 4 and 5. The scores on items 6, 7, 14, and 15 are ignored and a total score based on the 31 remaining items is completed.
“The Youth self-report (PSC-Y) can be administered to adolescents ages 11 and up.” A cutoff score of 30 or higher suggests a child is at risk for psychological impairment.
Unanswered items are ignored and given a 0. The questionnaire is considered invalid if the person left four or more items blank.
When a person has a positive screen on the PSC or the Y-PSC this is indicative there is a need for further evaluation by a qualified health or mental health professional. “Positive screens are those with scores above 27 for ages 6-18 and scores of 24 and higher for children ages 4 and 5. For the PSC-Y, the cutoff is 30 and higher and for the PSC-17, the cutoff score is 15.”
“Data from past studies using the PSC indicate that 2 out of 3 children who screen positive on the PSC will be correctly identified as having moderate to serious impairment in psychosocial functioning. The one child "incorrectly" identified usually has at least mild impairment, although a small percentage of children turn out to have very little actually wrong with them (e.g., an adequately functioning child of an overly anxious parent). Data on PSC-negative screens indicate 95% accuracy, which, although statistically adequate, still means that 1 out of 20 children rated as functioning sufficiently may actually be impaired.” For more information, visit http://www.massgeneral.org/psychiatry/services/psc_scoring.aspx
1Jellinek, M. S., Murphy, J. M., Robinson, J., Feins, A., Lamb, S., & Fenton, T. (1988). The Pediatric Symptom Checklist: Screening school-age children for psychosocial dysfunction. J Pediatr 112, 201-209.
2Gardner, W. & Kelleher. (1999). The PSC-17: A brief pediatric symptom checklist psychosocial problem subscale: A Report from PROS and ASPN. Ambulatory Child Health, 5:225-236.
3Reed-Knight, B., Hayutin, L. G., Lewis, J. D., & Blount, R. L. (2011). Factor structure of the pediatric symptom checklist with a pediatric gastroenterology sample. Journal of Clinical Psychology in Medical Settings, 18(3), 299-306. doi: 10.1007/s10880-011-9242-7.
4Murphy, J. M., Reede, J. Jellinek, M., & Bishop, S. (1992). Screening for psychosocial dysfunction in inner-city children: further validation of the Pediatric Symptom checklist. Am Acad Child Adolesc Psychiatry 31(6), 1105-1111.
5Murphy, J. M., & Jellinek, M. S. (1988). “Screening for psychosocial dysfunction in economically disadvantaged and minority group children: further validation of the pediatric symptoms checklist.” Am J Orthopsychiatry 58, 450-456.
6Murphy, J. M., Ichinose, C., Hicks, R. C., Kingdon, D., Crist-Whitzel, J., Jordan, P., Feldman, G., & Jellinek, M. S. (1996). Utility of the Pediatric Symptom Checklist as a psychosocial screen to meet the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) standards: A pilot study. J Pediatr 129(6), 864-869.
7Stoppelbein, L., Greening, L., Moll, G., Jordan, S., & Suozzi, A. (2012). Factor analyses of the pediatric symptom checklist-17 with African-American and Caucasian pediatric populations. Journal of Pediatric Psychology, 37(3), 348-357.
The Patient Health Questionnaire (PHQ-9)
The Patient Health Questionnaire 9 items (PHQ-9) is a 9- item diagnostic tool used by health care professionals to assess depression and monitor treatment response. The nine items of the PHQ-9 are based on the nine criteria for major depressive disorder in the DSM-IV. The PHQ-9 is a diagnostic, severity, and outcome measure to evaluate patient’s depression treatment response. 1,2
• Is a brief measure of depression.
• Can be self-administered or clinician administered, can be administered in person, by phone.
• Facilitates diagnosis of major depression,
• Provides assessment of symptom severity.
• Evaluate depression treatment response
• Is available in several languages including English, Spanish, Haitian Creole, etc. from http://www.phqscreeners.com.
• The PHQ-9 has been validated in primary care.
• “The PHQ-9 is also a reliable and valid measure of depression severity.”
• Is “a responsive and reliable measure of depression treatment outcomes.”
• Has excellent test-retest reliability.
• Well-validated as a diagnostic measure.
• A PHQ-9 score greater than or equal to 10 had a sensitivity of 88% and a specificity of 88% for major depression.
• PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively.
• “The PHQ-2 is a valid screening tool for major depression in older people but should be followed by a more-comprehensive diagnostic process.”5
• The PHQ-2 has good criterion validity for major depression (sensitivity = 100%, specificity = 77%, AUC = 0.88).
• The construct and criterion validity of the PHQ-2 make it an attractive measure for depression screening.
Administering, Scoring, and Interpreting the PHQ-9
The questionnaire starts by asking: “Over the last 2 weeks, how often have you been bothered by any of the following:” 9 items in which the patient choses from the response categories of ?not at all (0) ?several days (1) ?more than half the days (2) and ?nearly every day (3). The final question asks the patients to report “how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?” The responses choices are: Not Difficult at All, Somewhat difficult, Very Difficult, Extremely Difficult, which allows to assess for functionality.
There is also a 2-item version of the PHQ depression, the PHQ-2.4,5 The patient is asked about the frequency of depressed mood and anhedonia experienced over the past 2 weeks, scoring each as 0 to 3 (Total score 0-6). It is used as an initial depression screening. If the patient responds positively to either of these two items, the remaining 7 items are asked.
As a severity measure, the PHQ-9 score ranges from 0 to 27. This is calculated by assigning scores of 0, 1, 2, and 3, PHQ-9 total score for the nine items.
PHQ-9 Scores and Proposed Treatment Actions1
|PHQ-9 Score||Depression Severity||Proposed Treatment Actions|
|5 – 9||Mild||Watchful waiting; repeat PHQ-9 at follow-up|
|10 – 14||Moderate||Treatment plan, considering counseling, follow-up and/or pharmacotherapy|
|15 – 19||Moderately Severe||Active treatment with pharmacotherapy and/or psychotherapy|
|20 – 27||Severe||Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy, expedited referral to a mental health specialist for psychotherapy and/or collaborative management|
1Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32(9), 509-515.
2Löwe, B., Unützer, J., Callahan, C. M., Perkins, A. J., & Kroenke, K. (2004). Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical Care, 42(12), 1194-1201. doi:http://dx.doi.org/10.1097/00005650-200412000-00006.
3Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. doi:http://dx.doi.org/10.1046/j.1525-1497.2001.016009606.x.
4Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2003). The patient health questionnaire-2: Validity of a two-item depression screener. Medical Care, 41(11), 1284-1292. doi:http://dx.doi.org/10.1097/01.MLR.0000093487.78664.3C.
5Li, C., Friedman, B., Conwell, Y., & Fiscella, K. (2007). Validity of the patient health questionnaire 2 (PHQ-2) in identifying major depression in older people. Journal of the American Geriatrics Society, 55(4), 596-602. doi:http://dx.doi.org/10.1111/j.1532-5415.2007.01103.x