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Flaura K. Winston, MD, PhD; Nancy Kassam-Adams, PhD; Felipe Garcia-España, PhD; Richard Ittenbach, PhD; Avital Cnaan, PhD

JAMA. 2003;290:643-649.

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 injury.

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 assessment.

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 stress").

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.

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.

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