SECTION II. CHILD AND ADOLESCENT NEEDS AND STRENGTHS Check the appropriate box (one box only) for each question that most closely reflects the and / or needs. If the child’s current functioning or functioning are age appropriate, the first box for the question should be checked. child’s needs A. EMOTIONAL CHARACTERISTICS (Ages Birth to 5) I-1. Adjustment / Emotional Response to Past Trauma Affect Regulation (PAST 30 DAYS) – Infant / child has no problems Infant / child has mild to Infant / child has significant Infant / child has severe with emotional response. moderate problems with problems with emotional problems regulating affect Concerns are age / emotional response response regulation but is / emotional response even developmentally appropriate regulation. able to control affect at with caregiver’s support. this information is unknown or times. Problems are to me. interfering with child’s functioning. If the needs / functioning fall within a shaded box, explain why: child’s I-2. Adjustment to Past Trauma Re-experiencing the Trauma (PAST 30 DAYS) – There is no evidence that Child experienced some Child experiences consistent Child experiences infant / child re-experiences indications that the trauma indications that the trauma is repeated and severe the trauma. Concerns are age was being re-experienced in being re-experienced: sleep incidents of re- / developmentally the form of sleep disruption disturbance, nightmares. experiencing trauma that appropriate or this or play after the trauma but Play mimicking trauma significantly interferes with information is unknown to me. is no longer present. Subtle experienced. functioning and can not be changes in managed by caregivers. child’s functioning. If the needs / functioning fall within a shaded box, explain why: child’s I-3. Adjustment to Past Trauma Avoidance (PAST 30 DAYS) – No evidence of avoidant Mild problems with avoiding Moderate problems with Severe problems with behavior. Concerns are age / some situations either after avoidant behavior that avoidant behavior that developmentally appropriate the trauma or presently on occurs on a consistent basis occurs consistently but or this information is unknown an infrequent basis. Infants when child is exposed to cannot be mediated by to me. due to limited mobility rarely triggers related to the caregivers and causes exhibit this symptom. trauma. Caregiver can significant distress. support the child. If the needs / functioning fall within a shaded box, explain why: child’s A. EMOTIONAL CHARACTERISTICS (Ages Birth to 5) (Continued)
SECTION II. CHILD AND ADOLESCENT NEEDS AND STRENGTHS Check the appropriate box (one box only) for each question that most closely reflects the child’s current functioning and / or needs. If the child’s needs or functioning are age appropriate, the first box for the question should be checked. A. EMOTIONAL CHARACTERISTICS (Ages Birth to 5) I-1. Adjustment / Emotional Response to Past Trauma – Affect Regulation (PAST 30 DAYS) Infant / child has no problems with emotional response. Concerns are age / developmentally appropriate or this information is unknown to me. Infant / child has mild to moderate problems with emotional response regulation. Infant / child has significant problems with emotional response regulation but is able to control affect at times. Problems are interfering with child’s functioning. Infant / child has severe problems regulating affect / emotional response even with caregiver’s support. If the child’s needs / functioning fall within a shaded box, explain why: I-2. Adjustment to Past Trauma – Re-experiencing the Trauma (PAST 30 DAYS) There is no evidence that infant / child re-experiences the trauma. Concerns are age / developmentally appropriate or this information is unknown to me. Child experienced some indications that the trauma was being re-experienced in the form of sleep disruption or play after the trauma but is no longer present. Subtle changes in child’s functioning. Child experiences consistent indications that the trauma is being re-experienced: sleep disturbance, nightmares. Play mimicking trauma experienced. Child experiences repeated and severe incidents of re- experiencing trauma that significantly interferes with functioning and can not be managed by caregivers. If the child’s needs / functioning fall within a shaded box, explain why: I-3. Adjustment to Past Trauma – Avoidance (PAST 30 DAYS) No evidence of avoidant behavior. Concerns are age / developmentally appropriate or this information is unknown to me. Mild problems with avoiding some situations either after the trauma or presently on an infrequent basis. Infants due to limited mobility rarely exhibit this symptom. Moderate problems with avoidant behavior that occurs on a consistent basis when child is exposed to triggers related to the trauma. Caregiver can support the child. Severe problems with avoidant behavior that occurs consistently but cannot be mediated by caregivers and causes significant distress. If the child’s needs / functioning fall within a shaded box, explain why: A. EMOTIONAL CHARACTERISTICS (Ages Birth to 5) (Continued)