Els van Meijel

120 Chapter 7 | General discussion the psychological consequences of accidents and injury entail considerable costs for society at large. However, because these costs are not acutely visible, reducing them is not a priority. Our findings suggest that risk screening, monitoring and referral should be integrated into a broader system of hospital care. Furthermore, work needs to be done to illustrate the importance of prevention of mental health problems (see also our recommendations for future research). The results of a recent study on implementation of a standardized screening program for risk of PTSD in injured youth (Price et al., 2019) can give further insight into barriers and facilitators of such a screening program. In this study, the STEPP was integrated into standard care following treatment in a Level I pediatric trauma center. The findings suggest that standardized screening is feasible and that such a program improves the application of TIC. Finally, within a system of screening and monitoring, children and parents with substantial posttraumatic stress symptoms need referral for further diagnostics. Children and parents with PTSD or clinically significant symptoms should then be referred to a registered psychotrauma therapist. In the Netherlands, these professionals can be found via https://www. traumaexperts.nl/verwijzen-naar-een-geregistreerde-professional Reflections on the limitations of the studies There are several limitations in the studies that deserve attention because they may influence conclusions and generalizability of our findings. These limitations concern the prevalence of PTSD, drop-out for follow-up and the use of questionnaires. The prevalence of child PTSD in our studies was lower than expected. This resulted in methodological restrictions: we were not able to determine causal relationships between possible associated factors and PTSD or PTSS, or correct for factors such as variance in time and interaction effects. These restrictions can preclude generalization of our findings. There was a substantial drop-out for the follow-up studies and specifically in the groupwith PTSD or PTSS at 3months. This loss to follow-up precludes generalization and conclusions about the change over time. Parental posttraumatic stress was only assessed by questionnaire and not by a clinical interview. Although the questionnaire has a good agreement with the PTSS interview, the outcome is an indication of PTSD but is not a diagnosis. The prevalence of parental PTSS should therefore be interpreted carefully.