The University of California at Los
Angeles Post-traumatic Stress Disorder
Alan M' Steinberg, PhD3, Melissa 5' 6rymer, PsyD, Kelly 6' Decker, MA, and
Robert S' Pynoos, MD, MPH
*National Center for Child Traumatic Stress, Department of
Psychiatry and Biobehavioral Sciences, University of California at
Los Angeles, 11150 Olympic Boulevard, Suite 650, Los Angeles, CA
Current Psychiatry Reports 2004, 6:96–100
Current Science Inc. ISSN 1523-3812
Copyright © 2004 by Current Science Inc.
Over the past decade, the University of California at
Los Angeles Post-traumatic Stress Disorder Reaction
Index has been one of the most widely used
instruments for the assessment of traumatized
children and adolescents. This paper reviews its
development and modifications that have been made
as the diagnostic criteria for post-traumatic stress
disorder have evolved. The paper also provides a
description of standard methods of administration,
procedures for scoring, and psychometric properties.
The Reaction Index has been extensively used across
a variety of trauma types, age ranges, settings, and
cultures. It has especially been broadly used across
the US and around the world after major disasters
and catastrophic violence as an integral component
of public mental health response and recovery
programs. The Reaction Index forms part of a battery
that can be efficiently used to conduct needs
assessment, surveillance, screening, clinical
evaluation, and treatment outcome evaluation after
mass casualty events.
As diagnostic criteria for post-traumatic stress
disorder (PTSD) have evolved over the past two decades,
the University of California at Los Angeles (UCLA) PTSD
Reaction Index has gone through a number of iterations.
In 1985, the UCLA Trauma Psychiatry Program, in
collaboration with Calvin Frederick, developed a
screening questionnaire based on Diagnostic and
Statistical Manual of Mental Disorders (DSM)-III
diagnostic criteria for PTSD to assess post-traumatic stress
reactions among children and adolescents, the UCLA
PTSD Reaction Index . This instrument included 16
items, each rated as no=0, yes=1. Cut-offs for this
instrument were established as follows: 0 to 6=none; 7 to
9=mild; 10 to 12=moderate; greater than 12=severe.
Although a precursor to this instrument was used among
children after the Three Mile Island Nuclear Accident ,
the first major use was to assess post-traumatic stress
reactions among elementary school children after a fatal
sniper attack on their
Subsequently, a DSM-III-R version was developed to take
account of modifications to the diagnostic criteria [5,6].
This DSM-III-R version included 20 items, and used a
Likert scale to rate the frequency of symptom occurrence
over the past month as follows: none of the time=0; a little
of the time=1; some of the time=2; much of the time=3;
and most of the time=4. During this time period of DSM-
III and DSM-III-R, these versions of the UCLA scale were
the most widely used clinical and research tools for the
assessment of traumatized children, especially in studies
of children after disasters.
The UCLA PTSD Reaction Index for DSM-IV
(Revision 1)  is a revised version of the DSM-III-R scale
that is geared closely to DSM-IV criteria for PTSD. The
DSM-IV version has child, adolescent, and parent forms,
along with accompanying score sheets for each form.
Subsequently, the child and adolescent forms were
collapsed, using the simpler language of the child form in
order to have one instrument for use among children and
adolescents. Most recently, an abbreviated version of the
symptom scale of this instrument was developed for
conducting efficient needs assessment and screening of
students in New York City after September 11, 2001. This
abbreviated scale, with good sensitivity and specificity for
detecting cases of PTSD, was useful in screening
populations of children for needs assessment and
surveillance in public schools across New York City 
and in algorithms for clinical assessment and referral for
enhanced services within Project Liberty. The full PTSD
Reaction Index is currently being used by the Child and
school playground [3,4].
administered by the New York State Office of Mental
Health to provide services to children and adolescents
severely affected by the September 11, 2001 terrorist
attacks in New York City.
Trauma Treatment Service Program
University of California at Los Angeles Post-
traumatic Stress Disorder Reaction Index for
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (Revision 1)
The UCLA PTSD Reaction Index for DSM IV
(Revision 1) is a paper and pencil screening instrument
for the assessment of trauma exposure and post-traumatic
stress symptoms among children and adolescents.
Considerable effort was devoted to creating clear and
succinct questions that would be easy for respondents to
understand. Part I constitutes a brief lifetime trauma
screen, allowing for categorization
exposures, including exposure to community violence,
natural disaster, medical trauma, and abuse. These
exposure items are scored as present or absent. If more
than one event is endorsed, the youth is asked to identify
the one currently most bothersome, and a brief summary
of the event is recorded. The brief review of the traumatic
experience sets the stage for the subsequent questions,
helps the child recall details of the traumatic event, and
contributes to documenting satisfaction of criterion A1.
Part II allows for a systematic evaluation of A1 and A2
DSM-IV criteria that encompass objective and subjective
features of the traumatic exposure. These items are also
scored as present or absent. Part III provides for a
thorough evaluation of the frequency of occurrence of
post-traumatic stress symptoms during the past month
(rated from 0=none of the time to 4=most of the time).
These items map directly onto the DSM-IV criterion B
(intrusion), criterion C (avoidance), and criterion D
(arousal) for PTSD. Twenty of the items assess PTSD
symptoms, whereas two
associated features—fear of recurrence and trauma-
related guilt. These associated features were included in
the symptom section because the authors’ studies over the
past two decades have indicated their public mental
health and clinical salience. Fears of recurrence are often
pervasive, shared across dimensions of exposure, and
represent children’s perception of the seriousness of the
danger. Trauma-related guilt for perceived commission or
omission of actions has been found to increase overall
severity of post-traumatic stress reactions within
categories of exposure, and can serve as an important
indicator for triage. The instrument is accompanied by a
frequency rating sheet to visually assist children in
providing accurate responses about how often the
reaction has occurred over the past month. There is also a
additional items assess
score sheet with instructions for tabulation of total score,
and B, C and D symptom subscale scores. Although the
instrument was not designed to be diagnostic, it can
provide preliminary diagnostic information.
The continuous scale, however, allows for finer
discrimination across exposure groups, and is especially
useful in informing clinical treatment and public mental
health planning. Continuous scale instruments have
important use in treatment outcome studies and public
health monitoring of course of recovery after catastrophic
Administration and scoring
The UCLA Reaction Index for DSM-IV (Revision 1)
can be administered, scored, and interpreted by a
graduate level student under the supervision of a licensed
Master’s level clinician with experience in the area of
assessment of trauma exposure and PTSD in children. The
measure may be administered in the following three
ways: 1) as a self-administered paper and pencil measure;
2) by one-to-one verbal administration, in which the
instructions and questions are read to the child; and 3) by
group administration, for example, in a classroom setting
in which the instrument can be self-administered or read
aloud to the group. To increase reliability, it is helpful to
repeat the time frame being asked about (over the past
month) for each item, and to insert reference to the
specific traumatic event within items that ask about
symptoms in regard to “what happened” or “the bad
thing that happened.” The instrument was designed for
use with youth from 7 to 18 years of age. It is
recommended that the instructions and questions be read
aloud to children under the age of 12 or to youth with
known reading comprehension difficulties. Time for
completion of the instrument varies with age, reading
ability of the child, and method of administration, but
typically can be completed in 20 to 30 minutes.
The score sheet provides for coding endorsement of
exposure to a traumatic event in Part I, and criteria A1
and A2 in Part II. Although the symptom scale contains
20 PTSD symptom–related items, only 17 scores
(corresponding to the 17 DSM-IV PTSD symptom criteria)
make up the total symptom scale score in Part III. Three
of the symptom criteria
formulations, with the highest frequency score used to
calculate the total score. The score sheet provides
instructions for calculating a total PTSD severity score,
and severity scores for each of the DSM-IV B, C, and D
subcategories. When criterion A is met, children who
meet criteria B, C, and D (using endorsements of “much
of the time” and “most of the time” as indicating
symptom presence) are scored as having a likely
diagnosis of DSM-IV “full” PTSD. Where criterion A is
met, children meeting criteria for only two symptom
subcategories are scored as “partial” PTSD likely. A cut-
off of 38 or greater for a single incident traumatic event
have two alternative
has the greatest sensitivity and specificity for detecting
PTSD [9,10]. Scoring of
approximately 5 to 10 minutes.
the instrument takes
Over the past two decades, versions of the UCLA
PTSD Reaction Index have been translated and broadly
used in clinical evaluation, trauma research, and post-
disaster screening and recovery programs across the US
and around the world. As a result, the Reaction Index has
been widely translated for use across various settings and
cultures. For example, with regard to natural disasters,
the Reaction Index was used for over a decade in the
largest post-disaster public mental health recovery
program that followed the 1988 Spitak earthquake in
Armenia [6,11–15]. In this work, its use has been
demonstrated for needs assessment, surveillance, and
clinical studies and also in the study of neurohormonal
and developmental alterations [13,15]. The Reaction Index
was used after the 1994 Northridge Earthquake in
California , and has been recently translated into
Turkish for use after the 1999 Marmara earthquake in
Turkey , and into Cantonese and Greek for use after
the 1999 earthquakes in Taiwan , and Greece [19•]. It
has also been used after the two most studied hurricanes,
Hurricane Hugo [20,21] and Hurricane Andrew [22–25]. It
was also used more recently in Nicaragua after Hurricane
Mitch [26•]. Modified versions were used in Hawaii after
Hurricane Iniki  and after an industrial fire .
The Reaction Index has been used among children
and adolescents after large-scale political violence, for
example, in Bosnia and
Mozambique , Kuwait , Israel [33–35], Palestine
[36,37], and Lebanon . In the US, it has been used
among Cambodian adolescents exposed to atrocities ,
children exposed to the bombing of the Federal Building
in Oklahoma City , and after the 2001 terrorist attack
on the World Trade Center in New York City [41,42].
It has also been used in research and treatment
outcome studies among children exposed to community
violence [43,44], catastrophic school violence after a
sniper attack , a school shooting , among children
who witnessed the sexual assault of their mother , and
adolescents who witnessed the suicide of a peer .
Additionally, it has been used among children after
severe dog bites , children with life-threatening
medical illness [48–55], children with severe burn injuries
, and among children and adolescents after traffic
Over the years, successive versions of the UCLA PTSD
Reaction Index have been psychometrically studied.
Validity across all the versions is suggested by numerous
studies that have found consistently higher Reaction
Index scores among traumatized samples compared with
control subjects, and a clear “dose of exposure”
relationship of Reaction Index scores across exposure
groups. Convergent validity has been supported by the
agreement of cut-off scores with a diagnosis of PTSD. For
example, in studies after the 1988 earthquake in Armenia,
Pynoos et al'  reported a significant association between
the severity categories of the DSM-III-R version and a
DSM-III-R diagnosis of PTSD, with a cut-off of 40 or
higher correctly identifying 78% of subjects who met
DSM-III-R criteria, and 79% of those who did not. Of
those subjects who scored 40 or higher, 90% met the
DSM-III-R criteria for PTSD. The DSM-IV version has
good convergent validity, 0.70 in comparison with the
PTSD Module of the Schedule for Affective Disorders and
Schizophrenia for School-Age Children, Epidemiologic
version (0.82 in comparison with the Child and
Adolescent Version of the
PTSD Scale), with a cut-off of 38 having a sensitivity of
0.93 and specificity of 0.87 in detecting PTSD [9,10].
With regard to internal consistency across versions,
several reports have found Chronbach’s alpha to fall in
the range of 0.90 [9,10,19•,29]. Again, over the different
versions, test-retest reliability has ranged from good to
excellent, with Pynoos et al'  reporting a test-retest
inter-item agreement of 94% for the DSM-III version.
Subsequently, Goenjian et al' [26•] reported an intra-class
correlation coefficient of 0.93 for adolescents evaluated
with the DSM-II-R version initially and again after 7 days,
whereas Roussos et al' [19•] recently reported a test-retest
reliability coefficient of 0.84 for the DSM-IV version. With
regard to the seven- and nine-item abbreviated UCLA
PTSD Reaction Index scales, the Cronbach’s alpha was
0.85 for the seven-item scale, and 0.87 for the nine-item
scale. The receiver operator characteristic curves indicated
that corresponding cut-offs to the full scale are 16 for the
seven-item scale and 20 for the nine-item scale.
Part II items of the DSM-IV version of the UCLA
PTSD Reaction Index (those assessing objective and
subjective features of exposure) are currently rated using
a “yes/no” format. As suggested by Goenjian et al' [26•],
having these items rated on a Likert scale would render
them more sensitive to detecting differences across
exposure groups. There is also a need to add items that
assess related functional impairment as reflected in DSM-
IV criterion F (interference with important areas of
functioning, including peer, school, and family).
Over the years, the UCLA PTSD Reaction Index has
proven to be an extremely useful part of an assessment
battery (along with specific exposure questions, questions
about post-event stresses and adversities, and measures
of comorbid depression, grief, and anxiety) that has been
used effectively to conduct
surveillance, screening, clinical evaluation, and treatment
outcome evaluation after traumatic events. Most recently,
several new scales have been developed, including the
UCLA Trauma Reminder Inventory  and the
UCLA/Brigham Young Expanded Grief Inventory .
The National Center for Child Traumatic Stress Traumatic
Loss Reminder Inventory  provides a clinically useful
tool to identify the types and frequency of exposure to
loss reminders, the frequency and intensity of reactivity to
them, and the extent to which exposure to such reminders
interferes with academic, peer, and family functioning.
The Measures and Data Operations Committees of the
National Child Traumatic Stress Network have selected
the UCLA PTSD Reaction Index for DSM-IV to be a core
data instrument for Network-wide use. In doing so, they
will be developing Internet-based tools that allow for data
entry and software that can provide information for
clinicians about symptom profile and algorithms for
strategies of intervention and monitoring course of
recovery. Past work examining the pattern of accrual of
symptoms across dose of exposure  suggests that the
Reaction Index will be useful for developing algorithms
to guide intervention decision-making. Symptom cluster
analyses have also indicated its use in identifying risks of
associated functional impairment  that may also guide
algorithms for intervention.
References and Recommended Reading
Papers of particular interest, published recently, have been
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5 Download full-text
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