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Winston FK, Kassam-Adams N, Garcia-España F, Ittenbach R, Cnaan A. Screening for Risk of Persistent Posttraumatic Stress in Injured Children and Their Parents. JAMA. 2003;290(5):643–649. doi:10.1001/jama.290.5.643
Author Affiliations: Division of General Pediatrics, Department of Pediatrics, School of Medicine, University of Pennsylvania (Dr Winston), and Traumalink: The Pediatric Interdisciplinary Injury Control Research Center (Drs Winston, Kassam-Adams, and Garcia-España), Center for Pediatric Traumatic Stress (Drs Winston and Kassam-Adams), and Division of Biostatistics (Drs Garcia-España, Ittenbach, and Cnaan), The Children's Hospital of Philadelphia, Philadelphia.
Context Injury, a leading health threat to children, is also a common cause
of posttraumatic stress disorder (PTSD) in childhood. Most injured children
with PTSD are not diagnosed or treated.
Objective To develop a stand-alone screening tool for use by clinicians during
acute trauma care to identify injured children and their parents who are at
risk of significant, persistent posttraumatic stress symptoms.
Design The Screening Tool for Early Predictors of PTSD (STEPP) was derived
from a 50-item risk factor survey administered within 1 month of injury as
part of a prospective cohort study of posttraumatic stress in injured children
and their parents. Symptoms of PTSD were assessed at least 3 months after
Setting Urban, pediatric level I trauma center.
Participants A sample of 269 children aged 8 to 17 years admitted for treatment of
traffic-related injuries between July 1999 and October 2001, and one parent
per child, completed a risk factor survey assessing potential predictors of
PTSD outcome. One hundred seventy-one families (63%) completed a follow-up
Main Outcome Measures The Clinician-Administered PTSD Scale for Children and Adolescents and
the PTSD Checklist served as criterion standards for child and parent outcomes,
respectively. Positive cases were defined as those meeting criteria for at
least subsyndromal PTSD with continuing impairment ("persistent traumatic
Results The STEPP contains 4 dichotomous questions asked of the child, 4 asked
of one parent, and 4 items obtained easily from the emergency medical record.
STEPP sensitivity in predicting posttraumatic stress was 0.88 for children
and 0.96 for parents, with negative predictive values of 0.95 for children
and 0.99 for parents. The odds ratio for prediction of persistent traumatic
stress was 6.5 (95% confidence interval [CI], 1.8-22.8) in children and 26.6
(95% CI, 3.5-202.1) in parents.
Conclusions The STEPP represents a new method to guide clinicians in making evidence-based
decisions for the allocation of scarce mental health resources for traumatic
stress. Its brevity and simple scoring rule suggest that it can be easily
administered in the acute care setting.
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