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112 Chapter 7 | General discussion Table 7.1 Main findings of the studies on posttraumatic stress in accidentally injured children and their parents Chapter 2 The Screening Tool for Early Predictors of Posttraumatic Stress Disorder ( STEPP ) was evaluated in 147 children 8-18 years old, and 135 parents. Three months after the accident, PTSD was diagnosed in 11.6% of the children; 9.6% of their parents had clinically significant PTSS. At the originally recommended cut-off, the sensitivity in our sample was too low. With adjusted cut-off scores, 82% of the children and 92% of the parents with a subsequent positive diagnosis were identified correctly. The results show that the STEPP is a valid and useful instrument that can be used in the Netherlands as a first screening method in stepped psychotrauma care following accidents. Special attention in the procedure is required due to a high rate of false positives. Chapter 3 The association between acute pain and PTSD 3 months later was examined in 135 children, 8-18 years old. The amount of pain was negatively associated with injury severity in girls and positively associated with the presence of an extremity fracture in boys. In children who reported severe pain, this pain was significantly associated with PTSS and may account for around 10% of the variance in the severity of posttraumatic stress symptoms. Although the experience of pain is subjective, our study indicates that severe pain is associated with the severity of later posttraumatic stress symptoms. Chapter 4 In the follow-up study in children that we performed 2–4 years after the accident (n=90; 11-22 years old), we found a prevalence of PTSD of 11.4%. At 3 months this was 11.6%. PTSD was associated with a new traumatic event or with the initial accident. Children who completed trauma-focused psychotherapy reported no symptoms or low levels of symptoms at follow-up, in contrast to those who did not complete psychotherapy. Of the participants, 31% reported permanent physical impairment and ongoing physical problems; a majority of this subgroup reported that these problems had negative consequences on their education, social life and future plans. There was a substantial difference between children with and without PTSD regarding permanent physical impairment, indicating an association between the presence of PTSD and permanent physical impairment. Chapter 5 In the follow-up study in 69 parents 2–4 years after the accident (T2) we found a prevalence of PTSD of 5.8% compared to 9.6% in 135 parents after 3 months (T1). If all parents with PTSS had participated in the follow-up study, it is likely that the prevalence at follow-up would have been higher. Acute parental stress was significantly associated with parental PTSS severity at T1 and T2, as was child’s hospitalization of more than 1 day at T1 and the child’s permanent physical impairment at T2. Parental and child posttraumatic stress were significantly associated at T1. Given the adverse effect of parental stress on the child’s PTSS and recovery, adequate psychotherapy for parents is advisable. In our sample, although it was very small, the majority of the parents reported no need for therapy. Chapter 6 In an exploratory study we examined algorithms for posttraumatic stress reactions in parents of 98 accidentally injured children up to 8 years old . Substantial PTSS was found in 9.2% of the children. The DSM-5 subtype for children 6 years and younger and the PTSD-AA algorithm appeared to be better suited for PTSD diagnostics than the previous DSM-IV algorithm. Our results suggest that the DSM-5 subtype for PTSD in children 6 years and younger is an important improvement in identifying young children with PTSD compared to the DSM-IV algorithm.