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114 Chapter 7 | General discussion The risk of PTSD following accidental injury Accidents are a major cause of injury to children and can be traumatic. Initial posttraumatic stress is a normal reaction to a potentially traumatic experience; most children and parents recover in the first weeks following the accident. However, a significant proportion of children and parents are likely to continue to experience persistent posttraumatic stress symptoms or PTSD over the long-term if they do not receive treatment (J. Kenardy, Cobham, Nixon, McDermott, & March, 2010). Timely and effective trauma-focused treatment of PTSD can only be offered if PTSD is recognized. The purpose of screening for risk is to identify persons at high risk of developing PTSD at a later stage, who will perhaps require closer monitoring (NICE, 2005). The most important reason to screen for risk is that clinicians are not able to predict who will develop PTSD. Two decades ago, researchers had already noted that if clinicians use severity of injury as a guideline for referral to psychological follow-up services, then many children at risk for PTSD may be overlooked (de Vries et al., 1999). This referred to children with—on closer inspection—minor injuries, often sent home after the medical screening. However, just like severely injured children, these children had been exposed to potentially traumatic events. They experienced a serious accident and had a medical screening and treatment in the trauma room of the Emergency Department. A valid and user-friendly instrument to screen for risk helps clinicians to ensure that no children and parents will be missed for active monitoring. With the Dutch STEPP, a valid instrument has been made available for clinical practice in the Netherlands. Screening for risk may also have negative side-effects. Specific questions can generate distress, concerns and expectations (NICE, 2005). However, research on participation in clinical research showed very low risk of distress from questions about one’s traumatic experience (Kassam-Adams & Newman, 2005). Furthermore, if the screening procedure is implemented within a broad and professional program of stepped care, the risk of negative effects can be largely prevented. A stepped care approach includes not only identification of those at risk, but also further evaluation of those with a positive test result, including screening for PTSD, further assessment and evidence based early interventions if necessary (Kassam- Adams et al., 2011). The disadvantages of false positives in screening can be addressed by using a brief questionnaire to assess the probability of PTSD. Only those who