International Trauma Questionnaire – Child and Adolescent Version (ITQ-CA)

The International Trauma Questionnaire – Child and Adolescent Version (ITQ-CA) is based on the International Classification of Diseases 11 (ICD-11) model of trauma-related diagnoses, offering a clinically relevant tool for identifying PTSD and Complex PTSD (CPTSD) symptoms. It is the child and adolescent version of the International Trauma Questionnaire (ITQ) for adults.

Example ITQ-CA Items

The ITQ-CA has two subscales with three symptom clusters in each.

Post Traumatic Stress Disorder (PTSD)

• Re-experiencing – intrusive memories, flashbacks, or nightmares where the traumatic event feels as though it is happening again in the present
• Avoidance – deliberate efforts to avoid thoughts or feelings and situations, people, or places that evoke memories of the traumatic event
• Sense of threat – persistent feelings of being in danger, manifesting as hypervigilance (being “on guard”) and heightened startle response

Disturbances in Self Organization (DSO)

• Affective dysregulation – difficulties managing emotions, including heightened emotional reactivity or emotional numbing
• Negative self-concept – persistent negative beliefs about oneself, including feelings of worthlessness or viewing oneself as a failure
• Disturbances in relationships – difficulties in forming and maintaining close relationships, feeling distant or cut off from others, and finding it challenging to stay emotionally close to people

The ITQ-CA reliably discriminates between young people with PTSD alone and those with CPTSD (Haselgruber et al. 2020a; Ho et al., 2022; Kazlauskas et al., 2020; Redican et al., 2022). Individuals with PTSD alone score above the threshold on the PTSD symptom clusters without meeting criteria for DSO, whereas those with CPTSD score above the threshold on both PTSD and DSO subscales. The ITQ-CA also assesses functional impairments associated with PTSD and DSO, ensuring a comprehensive assessment of trauma-related symptoms and their impact on functioning.

Scores on the ITQ-CA indicate the presence and severity of PTSD and/or DSO symptoms and associated functional impairments. The ITQ-CA can be used by qualified professionals, such as psychologists, as part of a comprehensive diagnostic assessment process for PTSD and CPTSD and for monitoring treatment progress over time.

Compared to other PTSD assessment tools, such as the Child and Adolescent Trauma Screen (CATS), the ITQ-CA has a distinct advantage in its inclusion of CPTSD.

Research suggests that CPTSD is experienced by approximately 50% of adolescents who meet criteria for a trauma-related disorder (Kazlauskas et al., 2020). Young people with CPTSD tend to experience greater functional impairment compared to those with PTSD alone, affecting their relationships, schooling, and overall quality of life.

PTSD and CPTSD are often associated with different types of traumatic experiences:

• PTSD is frequently linked to single-event traumas, such as serious accidents, natural disasters, or witnessing isolated incidents of violence.
• CPTSD is more commonly associated with prolonged, repeated or accumulated interpersonal trauma, particularly sexual trauma and exposure to direct harm or violence (Daniunaite et al., 2021; Haselgruber et al., 2020a; Redican et al., 2022).

By differentiating between PTSD and CPTSD, the ITQ-CA helps qualified professionals identify the distinct symptom profiles associated with different trauma experiences. Individuals with CPTSD may benefit from treatment approaches that address not only the core PTSD symptoms but also difficulties with emotional regulation and self-identity. This differentiation allows clinicians to develop more tailored treatment plans based on the specific presentation of trauma-related symptoms.

The International Trauma Questionnaire – Child and Adolescent Version (ITQ-CA) has two subscales:

• Post Traumatic Stress Disorder (PTSD) – assesses the core symptoms of PTSD according to the ICD-11, focusing on intrusive re-experiencing, deliberate avoidance, and persistent sense of threat.
• Disturbances in Self Organization (DSO) – assesses the additional symptom clusters that, together with PTSD symptoms, constitute Complex PTSD (CPTSD), and which reflect pervasive psychological disturbances that typically arise following prolonged or repeated traumatic experiences

It includes six items measuring PTSD symptoms from three symptom clusters:

• Re-experiencing (Items 1 and 2) – assesses intrusive memories, flashbacks, or nightmares where the traumatic event feels as though it is happening again in the present moment, rather than being remembered as a past event
• Avoidance (Items 3 and 4) – measures deliberate efforts to avoid internal reminders (thoughts, feelings, physical sensations) and external reminders (people, places, conversations, objects, activities, situations) that evoke memories of the traumatic event
• Sense of threat (Items 5 and 6) – evaluates persistent feelings of current danger, manifesting as hypervigilance (being “on guard” or watchful) and heightened startle response (being jumpy or easily startled)

It also includes six items measuring DSO symptoms from three symptom clusters:

• Affective dysregulation (Items 12 and 13) – measures difficulties managing emotions, including heightened emotional reactivity (difficulty calming down when upset) and emotional numbing (feeling emotionally shut down or disconnected from feelings)
• Negative self-concept (Items 14 and 15) – assesses persistent negative beliefs about oneself, including feelings of worthlessness and viewing oneself as a failure, reflecting a diminished sense of value or identity
• Disturbances in relationships (Items 16 and 17) – evaluates difficulties in forming and maintaining close relationships, feeling distant or cut off from others, and finding it challenging to stay emotionally close to people

The PTSD and DSO subscales are each accompanied by three items measuring associated functional impairments in relation to friends, family, school, other important areas (e.g., hobbies, other relationships), and general happiness.

• PTSD related functional impairment (Items 7, 8, 9, 10, and 11) – measures the impact of PTSD symptoms on relationships with friends and family, schoolwork, other important areas (e.g., hobbies, other relationships), and general happiness, indicating how significantly these symptoms disrupt daily functioning
• DSO related functional impairment (Items 18, 19, 20, 21, and 22) – measures the impact of DSO symptoms on relationships with friends and family, schoolwork, other important areas (e.g., hobbies, other relationships), and general happiness, indicating how significantly these disturbances disrupt daily functioning

Each symptom item is rated on a 5-point Likert-type scale from 0 to 4 and each functional impairment item is answered in a binary Yes (1) or No (0) format.

The scoring approach uses dichotomous scoring for diagnostic purposes and dimensional scoring for symptom severity.

Dichotomous Scoring

A score of 2 (Likert = “Moderately”) or higher on a symptom item and a score of 1 (“Yes”) on a functional impairment item indicates the presence (i.e., endorsement) of that symptom or impairment.

PTSD is indicated if:

• at least one symptom is present from each PTSD symptom cluster, and
• there is at least one functional impairment associated with these PTSD symptoms.

Complex PTSD (CPTSD) is indicated if:

• at least one symptom is present from each PTSD symptom cluster,
• there is at least one functional impairment associated with these PTSD symptoms,
• at least one symptom is present from each DSO symptom cluster, and
• there is at least one functional impairment associated with these DSO symptoms.

A person may receive a diagnosis of PTSD or CPTSD, but not both.

Dimensional Scoring

• The PTSD symptom severity score is the sum of items 1 to 6 and ranges from 0 to 24.
• The DSO symptom severity score is the sum of items 12 to 17 and ranges from 0 to 24.

The respondent’s scores are presented as raw scores and as percentiles based on normative data for trauma-exposed children and adolescents, contextualising their scores relative to the typical scores of children and adolescents in this normative sample. For example, the 50th percentile represents the typical level of symptom severity for a child or adolescent who has been exposed to trauma (i.e., “Mild”), while scores on the 90th percentile fall within the top 10% and are considered “Severe”.

Qualitative descriptors categorise the respondent’s scores based on specific ranges of percentiles.

• “Minimal” – Below the 25th percentile (subscale score between 0 and 3)
• “Mild” – 25th to 50th percentile (subscale score between 4 and 7)
• “Moderate” – 51st to 75th percentile (subscale score between 8 and 11)
• “Severe” – 76th to 95th percentile (subscale score between 12 and 17)
• “Very Severe” – Above the 95th percentile (subscale score between 18 and 24)

A diagnostic criteria descriptor also accompanies each score, indicating whether diagnostic criteria for PTSD and DSO symptoms are met, and whether specific symptom clusters and functional impairments are present, according to the dichotomous scoring threshold. CPTSD is indicated if the diagnostic criteria descriptor says “Criteria met” for both the PTSD subscale and the DSO subscale.

On first administration, graphs are presented showing the respondent’s scores as percentiles based on normative data for trauma-exposed children and adolescents (Baker et al., 2025). A graph is also presented comparing the respondent’s PTSD and DSO symptom severity scores to two samples: (1) the normative sample of trauma-exposed children and adolescents; and (2) a diagnostic sample. For the PTSD symptom severity score, this diagnostic sample consists of children and adolescents meeting the ITQ-CA’s criteria for PTSD. For DSO symptom severity scores, the diagnostic sample consists of children and adolescents meeting the ITQ-CA’s criteria for CPTSD. Shaded areas correspond to scores between the 25th and 75th percentile. This graph contextualises the respondent’s scores relative to typical symptom severity levels in these samples.

If administered more than once, longitudinal graphs are presented for the respondent’s raw PTSD and DSO symptom severity scores, which is useful for monitoring any changes in symptom severity over time and treatment progress and outcomes. A meaningful change in PTSD symptom severity is defined as a change of 7 or more points in the PTSD symptom severity score, and a meaningful change in DSO symptom severity is defined as a change of 6 or more points in the DSO symptom severity score, based on Reliable Change Index (RCI) calculations (i.e., a 6-7 or more point decrease indicates significant improvement; a 6-7 or more point increase indicates significant deterioration; and less than a 6-7 point change indicates no significant change).

The International Trauma Questionnaire – Child and Adolescent Version (ITQ-CA) has been validated across different populations of young people, demonstrating good reliability and validity as a measure of ICD-11 Post-Traumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). It facilitates differential diagnosis between PTSD and CPTSD by capturing both PTSD and Disturbances in Self Organization (DSO) symptoms together with associated functional impairment in areas relevant to children and adolescents.

Confirmatory factor analysis (CFA) has yielded mixed results regarding the optimal factor structure of the ITQ-CA. In a study of Austrian foster children (Haselgruber et al., 2020b) and in a study of Chinese mental health service seeking adolescents (Ho et al., 2022), a two-factor second-order model (i.e., PTSD and DSO) was found to have the best fit, consistent with CFA studies of the ITQ for adults (Cloitre et al., 2018; Hyland et al., 2017, 2024), while in a study of Lithuanian adolescents, a correlated six-factor model (with factors representing six symptom clusters) was preferred (Kazlauskas et al., 2020). The PTSD and DSO factors have been found to be highly correlated in these studies, ranging from 0.75 to 0.92, suggesting that while they are related, they represent distinct constructs.

Latent class analysis and factor mixture modeling (FMM) has also supported the conceptual distinctiveness of PTSD and CPTSD in young people (Haselgruber et al. 2020a; Ho et al., 2022; Kazlauskas et al., 2020; Redican et al., 2022), aligning with the ICD-11 conceptualisation of trauma-related disorders.

The ITQ-CA has demonstrated good to excellent internal consistency, with Cronbach’s alpha values of 0.79 for the PTSD subscale and 0.86 for the DSO subscale (Kazlauskas et al., 2020). Composite reliability (CR) estimates have also been excellent for both the PTSD subscale (CR = 0.85-0.86) and DSO subscale (CR = 0.91-0.95) (Haselgruber et al., 2020a; Haselgruber et al., 2020b).

The concurrent validity of the ITQ-CA has been supported through correlations between ITQ-CA symptom clusters and corresponding PTSD symptom clusters as assessed by the Child and Adolescent Trauma Screen (CATS) (Haselgruber et al., 2020b; Kazlauskas et al., 2020). Convergent validity has been demonstrated by moderate to strong correlations with depression, anxiety, dissociation, and lifetime traumatisation (Haselgruber et al., 2020a; Ho et al., 2022). The PTSD and DSO subscales also show distinct associations with external variables, providing support for discriminant validity. For example, Ho and colleagues (2022) found PTSD symptoms were more strongly associated with anxiety and DSO symptoms were more strongly associated with depression, while Redican et al. (2022) observed different patterns of comorbidity across symptom profiles.

Research has identified several key factors that predict PTSD and CPTSD in children and adolescents. Trauma characteristics are particularly important, with both trauma type and quantity influencing outcomes. While cumulative trauma exposure increases risk for both PTSD and CPTSD, interpersonal trauma — particularly sexual trauma and exposure to direct harm or violence — has been identified as a particularly salient risk factor for CPTSD (Daniunaite et al., 2021; Redican et al., 2022). Social factors such as family problems, school problems, and lack of social support have also been found to discriminate between PTSD and CPTSD in adolescents (Daniunaite et al., 2021), highlighting the specific relevance of such factors to CPTSD.

The ITQ-CA has been validated across different countries and cultures, including Austria, China, Lithuania, and Northern Ireland (Haselgruber et al., 2020b; Ho et al., 2022; Kazlauskas et al., 2020; Redican et al., 2022). These validation studies have included both general population samples and more specific populations such as foster children and mental health service seeking adolescents.

Thus, the ITQ-CA demonstrates good psychometric properties, including reliability, validity, and cross-cultural and multilingual applicability. It provides a developmentally appropriate tool for the assessment and differential diagnosis of PTSD and CPTSD in children and adolescents (Sarr et al., 2024).

Percentiles for normative and diagnostic samples, developed by NovoPsych, are presented in NovoPsych’s review of the ITQ-CA (Baker et al., 2025), which includes detailed information about the composition of these reference samples.