Trauma Screener Ages 0-5 Date MM slash DD slash YYYY Name First Last Email 1. Are you aware of or do you suspect the child has experienced any of the following:Known or suspected exposure to drug activity aside from parental use First ChoiceKnown or suspected exposure to any other violence not already identifiedImpaired Parenting (i.e. Parent Mental Illness or Parental substance abuse)Multiple separations from parent/ caregiver, including out of home placement (s)Frequent and multiple moves or homelessnessSuspected neglectful home environmentSuspected or known Prenatal Exposure to Alcohol/Drugs or Maternal StressPhysical abuseEmotional abuseExposure to domestic violenceSignificant loss of people, placesSexual abuse or exposure etc.Hospitalization (s)If you are not aware of a trauma history, but multiple concerns are present in questions 2, 3, and 4, then there may be a trauma history that has not come to your attention. Note: Concerns in the following areas do not necessarily indicate trauma; however, there is a strong relationship.2. Does the child show any of these behaviors:Excessive aggression or violence towards self or othersRepetitive violent and/or sexual play (or maltreatment themes)Explosive behavior (excessive and prolonged tantruming)Disorganized (sudden changes/extremes) in behavioral states (i.e. attention, play)Very withdrawn or excessively shyBossy and demanding behavior with adults and peersSexual behaviors not typical for child’s ageDifficulty with sleeping or eatingRegressed behaviors (i.e. toileting, play)Lags in social/developmental skills3. Does the child exhibit any of the following emotions or moods:Chronic sadness, doesn’t seem to enjoy any activities.Very flat affect or unresponsive behaviorQuick, explosive anger4. Is the child having relational and/or attachment difficulties?Lack of eye contactSad or empty eyed appearanceOverly friendly with strangers (lack of appropriate stranger anxiety)Vacillation between clinginess and disengagement and/or aggressionFailure to reciprocate (i.e. hugs, smiles, vocalizations, play)Failure to seek comfort when hurt or frightened