{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T01:34:28Z","timestamp":1778636068740,"version":"3.51.4"},"reference-count":51,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2025,6,2]],"date-time":"2025-06-02T00:00:00Z","timestamp":1748822400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/"}],"funder":[{"DOI":"10.13039\/100000025","name":"National Institute of Mental Health","doi-asserted-by":"publisher","award":["U01MH110925"],"award-info":[{"award-number":["U01MH110925"]}],"id":[{"id":"10.13039\/100000025","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100021976","name":"Medical Technology Enterprise Consortium","doi-asserted-by":"publisher","award":["MTEC-21-06-MPAI-075"],"award-info":[{"award-number":["MTEC-21-06-MPAI-075"]}],"id":[{"id":"10.13039\/100021976","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>In the immediate aftermath of trauma exposure, individuals may experience an acute stress reaction (ASR). ASRs may be transient but for individuals operating in high-stakes occupations, these reactions can potentially endanger themselves and those around them. Thus, a better understanding of ASRs could\u00a0facilitate\u00a0development of early interventions that help prevent longer-term sequelae. Although existing measures (e.g., PCL-5, CAPS-5) target symptoms that occur in the weeks following trauma, they do not encompass the range of ASR symptoms identified in emerging research. Using data from a large-scale study conducted across emergency departments in the United States, we employed confirmatory factor analysis to identify survey items that sensitively assess ASR symptoms during the peri- and post-trauma phases. These analyses identified 23 core items that are appropriate for administration both immediately following trauma exposure and at later timepoints, as well as 11 supplementary items that can be added to the core items for assessment at later timepoints. Collectively, these items constitute the Stress Monitoring and Response Tool (SMART). Both the SMART Core Scale and the combined SMART Core Scale with Supplemental Items demonstrate good convergent and concurrent validity with several other measures of mental health, physical health, somatic symptoms, pain, and functioning. In addition, the SMART scale remains moderately-to-strongly correlated with multiple measures of symptoms and functional impairment at three months post-trauma. Consequently, the SMART can be used to assess individuals in clinical settings, predict trajectories of recovery, and inform tailoring of interventions across time. Future studies should be conducted to assess the potential utility of the SMART as a decision aid in high-intensity occupational contexts.<\/jats:p>","DOI":"10.1371\/journal.pone.0321939","type":"journal-article","created":{"date-parts":[[2025,6,2]],"date-time":"2025-06-02T18:12:59Z","timestamp":1748887979000},"page":"e0321939","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Initial development of the Stress Monitoring and Response Tool (SMART): A holistic measure of stress following trauma"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9696-5354","authenticated-orcid":true,"given":"Emily G.","family":"Lowery-Gionta","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Haley","family":"Stritzel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Liana 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Wolfe","year":"2003","journal-title":"J Rheumatol"},{"issue":"3","key":"pone.0321939.ref022","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1177\/1073191111411667","article-title":"Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS\u00ae): depression, anxiety, and anger","volume":"18","author":"PA Pilkonis","year":"2011","journal-title":"Assessment"},{"issue":"2","key":"pone.0321939.ref023","first-page":"309","article-title":"Measurement Equivalence of the Patient Reported Outcomes Measurement Information System\u00ae (PROMIS\u00ae) Pain Interference Short Form Items: Application to Ethnically Diverse Cancer and Palliative Care Populations","volume":"58","author":"JA Teresi","year":"2016","journal-title":"Psychol Test Assess Model"},{"issue":"6","key":"pone.0321939.ref024","doi-asserted-by":"crossref","first-page":"781","DOI":"10.1093\/sleep\/33.6.781","article-title":"Development and validation of 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Trauma"},{"issue":"2","key":"pone.0321939.ref034","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1002\/mpr.168","article-title":"The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI)","volume":"13","author":"RC Kessler","year":"2004","journal-title":"Int J Methods Psychiatr Res"},{"key":"pone.0321939.ref035","doi-asserted-by":"crossref","DOI":"10.1176\/appi.books.9780890425596","article-title":"Diagnostic and Statistical Manual of Mental Disorders","author":"American Psychiatric Association","year":"2013"},{"issue":"7","key":"pone.0321939.ref036","doi-asserted-by":"crossref","first-page":"532","DOI":"10.1016\/S0006-3223(02)01335-5","article-title":"Acute stress reactions in adults","volume":"51","author":"AY Shalev","year":"2002","journal-title":"Biol Psychiatry"},{"key":"pone.0321939.ref037","doi-asserted-by":"crossref","first-page":"149","DOI":"10.3389\/fpubh.2018.00149","article-title":"Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer","volume":"6","author":"GO Boateng","year":"2018","journal-title":"Front Public Health"},{"key":"pone.0321939.ref038","doi-asserted-by":"crossref","first-page":"799769","DOI":"10.3389\/fpsyg.2022.799769","article-title":"The Depression Anxiety Stress Scale 8-Items Expresses Robust Psychometric Properties as an Ideal Shorter Version of the Depression Anxiety Stress Scale 21 Among Healthy Respondents From Three Continents","volume":"13","author":"AM Ali","year":"2022","journal-title":"Front Psychol"},{"key":"pone.0321939.ref039","doi-asserted-by":"crossref","first-page":"1421","DOI":"10.3389\/fpsyg.2020.01421","article-title":"Psychometric Properties and a Preliminary Validation Study of the Italian Brief Version of the Communication Styles Inventory (CSI-B\/I)","volume":"11","author":"P Diotaiuti","year":"2020","journal-title":"Front Psychol"},{"key":"pone.0321939.ref040","article-title":"Development and validation of a climate change perceptions scale","volume":"76","author":"AM van Valkenoed","year":"2021","journal-title":"J Environ Psychol"},{"issue":"2","key":"pone.0321939.ref041","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1207\/s15327906mbr2502_4","article-title":"Structural Model Evaluation and Modification: An Interval Estimation Approach","volume":"25","author":"JH Steiger","year":"1990","journal-title":"Multivariate Behav Res"},{"issue":"1","key":"pone.0321939.ref042","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/BF02291170","article-title":"A Reliability Coefficient for Maximum Likelihood Factor Analysis","volume":"38","author":"LR Tucker","year":"1973","journal-title":"Psychometrika"},{"issue":"2","key":"pone.0321939.ref043","doi-asserted-by":"crossref","first-page":"238","DOI":"10.1037\/0033-2909.107.2.238","article-title":"Comparative fit indexes in structural models","volume":"107","author":"PM Bentler","year":"1990","journal-title":"Psychol Bull"},{"key":"pone.0321939.ref044","volume-title":"LISREL 8: user\u2019s reference guide","author":"KG J\u00f6reskog","year":"1996"},{"issue":"4","key":"pone.0321939.ref045","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1037\/1082-989X.3.4.424","article-title":"Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification","volume":"3","author":"L Hu","year":"1998","journal-title":"Psychological Methods"},{"issue":"1","key":"pone.0321939.ref046","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1080\/10705519909540118","article-title":"Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives","volume":"6","author":"L Hu","year":"1999","journal-title":"Structural Equation Modeling: A Multidisciplinary Journal"},{"key":"pone.0321939.ref047","volume-title":"Mplus user\u2019s guide","author":"L Muth\u00e9n","year":"2017"},{"key":"pone.0321939.ref048","doi-asserted-by":"crossref","first-page":"53","DOI":"10.5116\/ijme.4dfb.8dfd","article-title":"Making sense of Cronbach\u2019s alpha","volume":"2","author":"M Tavakol","year":"2011","journal-title":"Int J Med Educ"},{"issue":"1","key":"pone.0321939.ref049","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1111\/j.1467-6494.1986.tb00391.x","article-title":"The role of factor analysis in the development and evaluation of personality scales","volume":"54","author":"SR Briggs","year":"1986","journal-title":"Journal of Personality"},{"key":"pone.0321939.ref050","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1186\/s13104-016-2034-2","article-title":"Appraising convergent validity of 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