Els van Meijel

113 General discussion | Chapter 7 Introduction This thesis presents the results of our research on posttraumatic stress following accidental injury in children aged 8-18 years and their parents. The aims of this research project were (1) to evaluate the utility in the Netherlands of the STEPP, a screening instrument to identify children and parents at risk for PTSD following child accidental injury, and (2) to examine short and long-termposttraumatic stress in children and parents following child accidental injury, including possible associated factors such as acute pain, permanent physical impairment and choices regarding trauma-focused psychotherapy. In the final part of this thesis, we reflect on the main themes and issues that emerged fromour findings. The current chapter also includes clinical implications of the findings, a reflection on the limitations of the studies, and suggestions for future research. Reflections on the main findings of the studies Evaluation of the utility of the STEPP in the Netherlands In addition to the first validation of the STEPP (Winston et al., 2003), we tested the tool not only in traffic-related injury, but also in a mixed sample of accidentally injured children. We considered this sample to be more representative of clinical practice. The performance of the original STEPP (Winston et al., 2003) was not replicated in our study; at the original cut-off scores, the STEPP performed only moderately in the prediction of PTSD three months later. In Chapter 2 of this thesis, we discuss possible explanations for this lack of performance. However, the negative predictive value was high; the STEPP performed very well in screening out those who are not at risk for PTSD. With adjusted cut-off scores, both the predictive power and the negative predictive power of the STEPP were improved. Knowing who is not at risk is important in targeting follow-up efforts. The high rate of false positives requires special attention in the screening procedure. However, if the STEPP is used by trained professionals in a careful stepped care procedure (see below), it is a useful instrument for Dutch clinical practice.