Els van Meijel

52 Chapter 3 | Acute pain and posttraumatic stress symptoms whether or not mediated by relief of anxiety. They can be applied dependent on the situation and the child’s characteristics and preferences (Koller & Goldman, 2012; Langeland & Olff, 2008). Furthermore, Trauma-Informed Care (TIC) offers a multidisciplinary approach to reduce the risk for persisting posttraumatic stress and PTSD following injury (Marsac et al., 2016; Weiss et al., 2017). TIC is characterized by realizing the effect of trauma, recognizing how trauma can affect those involved, bringing trauma-related knowledge into practice and preventing further negative reactions (Marsac et al., 2016). Implementing TIC can increase medical staff awareness of stressors following injury and can provide them with strategies that can help minimize the adverse effect of these stressors. Strengths and limitations Due to the nature of our study and the acute situation after an accident, a retrospective pain rating was used, which increases the chance of unreliable ratings. Some of the children may have reported less reliably on the worst experienced pain, due to a period of unconsciousness or amnesia. Since we only used a single pain scale, we could not perform sensitivity analyses using another instrument. Moreover, pain medication could have had a confounding effect on the outcome but we were unable to account for this possible effect. The administration of pain medication was reported in the medical records, but children reported the worst experienced pain retrospectively. They did not report the exact moment in time that they experienced this pain. Therefore we were unable to relate pain to information on pain medication. Additionally, we did not assess pain over time, although this could have providedmore insight into the relationship between pain and the other variables. Furthermore, only the presence or absence of an extremity fracture was specifically registered as part of the STEPP study. We therefore did not include other types of injury classifications as an independent variable in the current study. Baseline acute stress may have contributed to the report of pain at baseline and to posttraumatic stress at 3 months but this was not assessed in our study. Ideally, we would have examined the relationship between acute pain and a diagnosis of PTSD or significant PTSS. In this case, logistic regression analysis would have been appropriate. We would then have examined differences between the relationships