Els van Meijel

72 Chapter 4 | Results of a 2–4-year follow-up study al., 2016; Weiss et al., 2017). TIC uses trauma-related knowledge in medical practice, and can facilitate the implementation of a hospital monitoring system after injury, including timely interventions if needed. Our findings regarding self-reported PTSS and spontaneous recovery are in line with those of (Verlinden et al., 2014), who showed that self-report measures are a good indication for PTSD, but cannot replace clinical interviews that yield a diagnosis based on more detailed information, severity of symptoms and level of impairment in functioning. With regard to permanent physical impairment, our results indicate a comparable outcome to the study of (Zatzick et al., 2008), in which long-term physical impairment was associated with the occurrence of PTSD at 12 months follow-up. Furthermore, the outcome confirms the suggestion that continuing physical problems can contribute to ongoing psychological distress (Gillies et al., 2003). With regard to acute pain, in our previous research (van Meijel et al., 2019) we found that severe acute pain was associated with the severity of posttraumatic stress 3 months later. These findings were not confirmed in our long-term results. A possible explanation is the use of dichotomous outcomes in the current study, instead of the continuously measured severity of symptoms in the previous study. The latter may be a more sensitive measure. Future research in larger samples may show whether acute pain is associated with longer-term PTSD or whether the long-term outcome is associated with different factors or a combination of factors. The role of experiencing a new traumatic event is not clear. Delahanty and Nugent (2006) suggested that prior trauma history can increase vulnerability for PTSD in children and adults after experiencing a new traumatic event. In our study, children in the group with PTSD or PTSS reported more traumatic events in the past than those in the group without, and the percentage of children that experienced a new traumatic event was substantially higher in the affected group. However, the difference between the groups was not statistically significant. For the three children in our sample who completed trauma-focused therapy, the therapy had a positive impact in the long term, although other factors may also have facilitated the reduction of PTSD symptoms. The group was too small to draw conclusions about an association between completing trauma-focused psychotherapy