Resilience and Severe Burns

A survey of the knowledge and practices of nursing students of Mbarara University of Science and Technology around Monitoring Fluid Requirements for burns patients on surgical ward at Mbarara Regional Referral Hospital

Background

There is a high mortality of burns especially in low- and middle-income countries which already have less developed healthcare systems. Besides, little is known about nursing students’ knowledge and practices towards the need to monitor fluid requirements in admitted burns patients.

Objective

To assess the knowledge and practices of nursing students regarding monitoring fluid requirements for hospitalised paediatrics and adult burn patients on the surgical ward at Mbarara regional referral hospital.

Methods

We conducted an online descriptive cross-sectional study among clinical nursing students at Mbarara University of Science and Technology (MUST) during September and November 2021. We assessed knowledge and practices using an adapted questionnaire. Summary statistics were then used to describe the data.

Results

Thirty-seven nursing students (64.9% response rate) participated in our survey. Twenty one (56.8%) were female and had a modal age range of 20-24 years. Nineteen (51.4%) of the students were BNC (Bachelor of Nursing Completion) students, with the rest being BNS (Bachelor of Nursing). More than 75% of students correctly answered each of two out of the ten questions. More than three quarters of the students reported having done each of six out of the eleven practices surveyed.

Conclusion

Nursing students had poor knowledge and fair satisfactory practices regarding monitoring of the fluid requirements in burns patients. More similar studies are needed to survey more nursing students on this topic and to henceforth evaluate the need for periodic re-trainings and reassessment of clinical skills of nursing students.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-01041-7.

Adolescents with and without head and neck burns: comparison of long-term outcomes in the burn model system national database

INTRODUCTION

Facial burns account for persistent differences in psychosocial functioning in adult burn survivors. Although adolescent burn survivors experience myriad chronic sequelae, little is known about the effect of facial injuries. This study examines differences in long-term outcomes with and without head and neck involvement.

METHODS

Data collected for 392 burn survivors between 14-17.9 years of age from the Burn Model System National Database (2006-2015) were analyzed. Comparisons were made between two groups based on presence of a head and neck burn (H&N) using the following patient reported outcome measures: Satisfaction with Appearance Scale, Satisfaction with Life Scale, Community Integration Questionnaire, and Short Form-12 Health Survey at 6, 12, and 24 months after injury. Regression analyses were used to assess association between outcome measures and H&N group at 12-months.

RESULTS

The H&N group had more extensive burns, had longer hospital stays, were more likely to be burned by fire/flame and were more likely to be Hispanic compared to the non-H&N group. Regression analysis found that H&N burn status was associated with worse SWAP scores. No significant associations were found between H&N burn status and other outcome measures.

CONCLUSIONS

Adolescents with H&N burn status showed significantly worse satisfaction with appearance at 12-months after injury. Future research should examine interventions to help improve body image and coping for adolescent burn survivors with head and neck burns.

Coping in Pediatric Burn Survivors and Its Relation to Social Functioning and Self-Concept

Pediatric burn survivors experience increased risk for bullying, stigmatization, body image concerns, and problematic social functioning. Although coping behaviors are associated with engagement in social supports and positive self-concept in multiple pediatric illness populations, their relation has not been examined in pediatric burns. This study examined coping in relation to social functioning and self-concept in 51 pediatric burn survivors aged 7–17years (M=12.54; SD=2.65). Survivors and their caregivers completed the Child Coping Strategies Checklist (CCSC; youth report); the Burn Injury Social Questionnaire (BISQ; parent and youth report); and the Piers-Harris Children’s Self-Concept Scale-2 (PH-2; youth report). Associations between coping, social functioning, self-concept, demographic features, and burn injury characteristics were examined via bivariate correlations. Hierarchical linear regressions examined whether coping strategies predicted social functioning and youth self-concept beyond burn injury and demographic variables. Social functioning concerns were positively correlated with total body surface area (TBSA; r=0.63 and 0.40, respectively). TBSA was the only significant predictor of parent-reported social concerns (β=0.65, p<0.001). Greater distraction coping predicted fewer youth-reported social concerns (β=−0.39, p=0.01). Greater active coping (B=0.67, p=0.002) and lower avoidance coping (B=−0.36, p=0.03) predicted better youth-reported self-concept. This study advances our understanding of coping as potentially protective for psychosocial adjustment. Clinicians working with child burn survivors should incorporate active coping interventions into treatment. Further research including larger and more diverse samples is needed to understand the role of coping approaches on psychological adjustment during burn healing.

A longitudinal study on psychological reactions and resilience among young survivors of a burn disaster in Taiwan 2015-2018

Aim

To investigate the long‐term psychological reactions and resilient process of the young survivors after a large‐scale burn disaster of the Formosa Color Dust Explosion in Taiwan.

Design

Longitudinal study with follow‐up interviews using standardized questionnaire during November 2015–June 2018.

Methods

The burn survivors received structured assessment in the four‐wave interviews including the five‐item Brief Symptom Rating Scale, nine‐item Concise Mental Health Checklist, and two‐item Patient Health Questionnaire for depressive symptoms and suicide risk assessment. Post‐traumatic psychological symptoms were assessed through the four‐item Startle, Physiological Arousal, Anger, and Numbness Scale, and six‐item Impact of Event Scale.

Findings

The response rates were 65.1%, 74.2%, 76.9%, and 78.5% across the four‐wave interviews among 484 burn survivors. The participants were mean‐aged 23.1 years with just over half having 40% or more burn wounds in total body surface area. The respondents at each wave were similar in gender, age, and per cent of total body surface area burned. In the first 2 years of recovery, the respondents showed resilience in coping with stress of trauma under family and social support. While there was a decreasing trend of psychological symptoms over the first 2 years, hypnotic use and alcohol consumption remained at about 10% in the final interview, which were accompanied by psychological symptom recurrence.

Conclusion

Young burn survivors recovered both psychologically and physically under supportive care and personal resilience in 2 years after the burn event, yet post‐traumatic mental distress and coping efforts after 2 years during community reintegration should be detected and managed. Early prevention and detection of mental health deterioration is needed even after 2 years of burn disasters.

Impact

The study demonstrated post‐burn longitudinal changes on psychological reactions. Nursing staffs may help young burn survivors identify mental distress and stress management needs in the long‐term psychological adaptation process.

Rebuilding Life after Burn Injuries in Korea: Using Photovoice

This study analyzed life after injury for burn survivors using the photovoice research method. Study participants were six burn survivors who lived in the community after being discharged from the hospital. These six participants engaged in a series of photovoice workshops and activities that took place over a period of 4 months. The study results were as follows: burn survivors were able to achieve a positive body image during their physical recovery. They overcame many psychological difficulties that accompanied their burn injuries. Their attitudes toward their lives changed positively. The greatest influence in bringing out these changes was support from family, friends, and other burn survivors. They were better able to fight against social oppression with their recovered self-esteem. The participants had experienced a disconnect from the activities and interpersonal relationships they had prior to their injury owing to long-term hospital stays and time away from work. However, as they began new social activities, they were able to establish new interpersonal relationships. Based on the research results, this study suggests that medical, psychological, and social approaches as well as positive changes in social attitude are necessary to support burn survivors' recovery.

Psychometric properties of Adolescent Resilience Questionnaire among Nepalese adolescents in Lalitpur

BACKGROUND

Although the need of measuring resilience among adolescents has gained attention in recent decades, there is no availability of an appropriate tool designed yet to assess resilience among Nepalese adolescents. This paper describes the psychometric properties of Adolescent Resilience Questionnaire (ARQ) among Nepalese adolescent students in Lalitpur which could be a possible tool for measuring resilience.

METHOD

The ARQ was translated into Nepali and back translated in English. The Nepali ARQ was self-administered in 512 adolescent students with 46.7% boys between the age of 13 and 19 years (M = 16.07 years, SD = 1.49) enrolled in six secondary schools in Lalitpur, Nepal. Test-retest reliability was assessed among 52 adolescent students within an interval of two weeks.

RESULTS

Findings confirmed 12 scales and 5 domain factor structure of adolescents' resilience. Cronbach's alpha coefficient (α) for the scales and domains ranged between 0.64-0.86 and 0.71-0.86. The values of Intraclass correlation coefficient (ICC) showed that test-retest reliability of the scales and domains ranged between good and excellent with an overall ICC 0.95 (95% CI 0.92-0.97).

CONCLUSION

The Nepali version of the ARQ can be used to measure resilience among adolescents in Lalitpur, Nepal. Further studies are recommended to assess adolescents' resilience using the ARQ in diverse settings including communities of various provinces and regions of Nepal.

The Relationship of Level of Education to Social Reintegration after Burn Injury: A LIBRE Study

Social and emotional recovery from burn injury is a complex process impacted by both clinical and social factors. Because level of education (LOE) has been correlated to overall health, health outcomes, and life expectancy, we questioned whether LOE might be associated with successful social recovery after burn injury. The Life Impact Burn Recovery Evaluation (LIBRE) data set served as a novel tool to explore this question. The LIBRE project is a collaborative effort designed to provide a clinical yardstick for social reintegration among burn survivors. After institutional review board approval, 601 burn survivor respondents, aged 18 or over with >5% TBSA burn were surveyed and a six-scale, 126-item LIBRE Profile was derived from their responses. LOE was collapsed into four categories ranging from less than high school equivalency certificate to graduate degree. Impact of burn injury on subsequent LOE was examined by splitting the sample into those burned at age 30 years or less and those burned at greater than 30 years of age. Regression models were run to estimate associations between education and scale scores with adjustment for age at injury, sex, marital status, work status, TBSA, and time since burn. Regression models were run on the entire cohort and then stratified by age at burn injury (≤30 vs >30). Among all subjects, we found an association between LOE and social recovery as measured by LIBRE scale scores. This association was contributed entirely from the cohort burned at age 30 or less: for those burned at greater than age 30, there was no association between LOE and social recovery. Of particular interest, the distribution of LOE among those burned at ≤ 30 was very similar to LOE distribution in both millennials and in the U.S. population at large. LOE appears to be associated with social recovery for those burned at younger ages but not for those burned at over age 30. More importantly, burn injury during schooling may have no impact on a survivor's educational trajectory since distribution of LOE in our ≤30 cohort mirrors that of the general population. LOE and age at burn injury may provide a quick screen for survivors at risk of difficult social reintegration, allowing providers to target those at risk with additional peer support and counseling.

Resilience, Sense of Coherence, and Coping with Stress as Predictors of Psychological Well-Being in the Course of Schizophrenia. The Study Design

The main research objective was seeking for the predictive role of such personal resources as resilience, sense of coherence, and coping with stress in psychological well-being of schizophrenia patients and their treatment. The study group comprised 201 individuals with schizophrenia, aged between 18 and 62. The following instruments were used: The sense of coherence scale SOC-29, The resilience scale for adults, polish adaptation of the stress appraisal measure, semistructured clinical interview, the positive and negative syndrome scale, the mood scale, and the general health questionnaire. A stepwise regression analysis aimed at selecting a group of significant predictors for the verified factors of psychological well-being in patients suffering from schizophrenia was carried out. The results of the study demonstrated the following to be significant predictors of psychological well-being in patients with schizophrenia: Resilience (explaining significantly the level of schizophrenic symptomatology Beta = -0.30, negative symptoms Beta = -0.385, and cognitive disorders Beta = -0.303), sense of coherence, which significantly predicted mood (in the case of manageability, Beta = 0.580 for positive mood, and Beta = 0.534 for negative mood) and psychiatric symptomatology (comprehensibility, Beta = 0.311 for negative symptoms, Beta = 0.173 for excessive arousal, and Beta = 0.330 for cognitive disorganization). The level of perceived stress appraised as challenge predicted positive mood (Beta = 0.164), while stress appraisal in terms of threat served as a predictor for negative mood and depressiveness (Beta = 0.190). The study results can prove helpful in creating therapeutic and programs and psychiatric rehabilitation for patients with schizophrenia.

Resiliency in burn recovery: a qualitative analysis

This phenomenological study engaged an availability sample of eight, long-term, adult burn survivors living a primarily rural burn center catchment area of the U.S. in face-to-face interviews focused on their holistic health since their burn injuries occurred. Criteria for the primary study involved females (n = 1) and males (n = 7) with an age range of 18 to 65 years and a minimum of 20% total body surface area (TBSA) injuries that required hospitalization in a specialized burn center. The mean age of participants at the time of interviews was 54.38 years. Burns ranged between 20% and 98% TBSA and one to 22 years since burn injuries occurred. Thematic data analysis revealed resilient protective factors as contributing to participants' post-burn health and recoveries. Resilient factors included resourcefulness, achievement motivation, optimism, spirituality, and empathy. Increased understanding of resilient protective factors and how they impacted long-term burn recovery in this sample may aid social workers in development and implementation community-based interventions in rural communities that promote resilience, health/mental health and long-term recovery for this population and others who have experienced trauma.

Women's recovery, negotiation of appearance, and social reintegration following a burn

The gendered nature of postburn coping has received scant research attention in South Africa, a country that has a high rate of burns with significant concentrations among women. In this study, narratives that emerged from in-depth interviews with seven women were examined. The narratives emphasized essential needs of these burn survivors for personal support, the complexities of negotiating intimate relationships, struggles with the humiliation from family and friends, in some instances strained relationships with children, the support found through religious beliefs and institutions, and often frustratingly slow psychological acceptance of scars. These difficulties faced by women survivors of burns have highlighted the need to include religion/spirituality, intimate male partners, and women's children into the psychological recovery process, in an attempt to assist women's journey to psychological and emotional healing after burn.

Translation and validation of "Adolescent Resilience Questionnaire" for Iranian adolescents

BACKGROUND AND AIM

Resilience is the process by which adolescents are able to maintain or regain positive outcomes despite stress and negative emotional experiences. Assessing resilience is important to identify adolescentś strengths and vulnerabilities. There are currently no resilience instruments available for Iranian adolescents. This paper describes the translation and validation of Adolescent Resilience Questionnaire (ARQ) for use with Iranian adolescents.

METHOD

The ARQ was translated into Persian and back-translated. Proportional stratified sampling was used to recruit a representative sample of 523 adolescents aged 11-19 years from 38 public and private high schools in Tehran. Total scale and subscale reliability were examined using Cronbach alpha. Test-retest reliability was conducted with 38 adolescents who completed the ARQ twice with a two week interval in between and assessed using intra-class correlation coefficients (ICC).

FINDINGS

Cronbach alpha coefficients were equal to or greater than 0.70 for all scales, after the removal of one item in the Community scale. Test-retest reliability for the overall ARQ score was excellent (ICC=0.83, 95%CI, 0.76-0.93) and very good for individual subscales (ICC=0.70-0.79).

CONCLUSION

The present study provides evidence of good validity, reliability and test-retest reliability of the Persian ARQ for Iranian adolescents. Further testing, including construct validity, and testing across different contexts will strengthen the evidence. The instrument will have applications in resilience research, educational and clinic settings and could facilitate the development and evaluation of intervention programs to build resilience in Iranian adolescents.

Patients' perspectives on quality of life after burn

BACKGROUND

The concept quality of life (QOL) refers to both health-related outcomes and one's skills to reach these outcomes, which is not yet incorporated in the burn-related QOL conceptualisation. The aim of this study was to obtain a comprehensive overview of relevant burn-specific domains of QOL from the patient's perspective and to determine its hierarchical structure.

METHODS

Concept mapping was used comprising a focus group (n=6), interviews (n=25), and a card-sorting task (n=24) in burn survivors. Participants sorted aspects of QOL based on content similarity after which hierarchical cluster analysis was used to determine the hierarchical structure of burn-related QOL.

RESULTS

Ninety-nine aspects of burn-related QOL were selected from the interviews, written on cards, and sorted. The hierarchical structure of burn-related QOL showed a core distinction between resilience and vulnerability. Resilience comprised the domains positive coping and social sharing. Vulnerability included 5 domains subdivided in 13 subdomains: the psychological domain included trauma-related symptoms, cognitive symptoms, negative emotions, body perception and depressive mood; the economical domain comprised finance and work; the social domain included stigmatisation/invalidation; the physical domain comprised somatic symptoms, scars, and functional limitations; and the intimate/sexual domain comprised the relationship with partner, and anxiety/avoidance in sexual life.

CONCLUSION

From the patient's perspective, QOL following burns includes a variety of vulnerability and resilience factors, which forms a fresh basis for the development of a screening instrument. Whereas some factors are well known, this study also revealed overlooked problem and resilience areas that could be considered in client-centred clinical practice in order to customize self-management support.

Structural equation modeling on life-world integration in people with severe burns

PURPOSE

The aim of this study was to construct and test a structural equation modeling on life-world integration in people with severe burns.

METHODS

A survey design was used. Data were collected in 2008 from 376 people who had experienced severe burns using questionnaires. The data were analyzed using structural equation modeling.

RESULTS

The fitness parameters of the modified model (χ(2)/df = 3.15, goodness of fit: .91, normal fit index: .93, Tucker Lewis Index: .93, root mean square error of approximation: .07, root mean square residual: .04, and comparative fit index: .95) indicated its suitability as the research model. Physical function directly influenced burn factor, and family support indirectly influenced life-world integration.

CONCLUSION

Physical function should be directly improved to adjust to life-world integration. A comprehensive integration approach is also necessary to help people with severe burns successfully return to society.

Concept analysis: resilience

This paper will systematically analyze the concept of resilience using an integrated review of literature. The historical perspective, attributes, antecedents, and consequences of resilience will be reviewed. A theoretical and operational definition will be provided. The Walker and Avant method will be used to describe the cases. Finally, the use of concept map will capture the relationships among the attributes, antecedents, consequences, and empirical indicators through clustering and chaining.

Meeting the Leadership Challenge of Employee Well-Being Through Relationship PsyCap and Health PsyCap

Increasing recognition is being given to the role that employee overall well-being plays in desired outcomes of today’s organizations. To help organizational leaders searching for understanding and answers, we propose that the positive core construct of psychological capital (or simply PsyCap), consisting of the positive psychological resources of hope, efficacy, resiliency, and optimism can be extended into the well-being domain. Although PsyCap has been clearly demonstrated to be related to employee attitudes, behaviors, and performance, linking it with other life domains relevant to overall well-being has yet to be tested. After first building a comprehensive conceptual foundation for extending PsyCap into the well-being domain, we empirically found that a cross section of employees’ ( N = 523) “Relationship PsyCap” and “Health PsyCap” were related to both their respective satisfaction appraisals and desired objective outcomes. In addition, these two extended life satisfactions, along with the already well-established work satisfaction, combined to relate to the appraisal of the study participants’ overall well-being. This well-being was in turn found to be related to their overall level of PsyCap. These findings have implications for helping leaders meet the challenges they face in both understanding and helping develop the overall well-being of their employees.

Life after burn injury: striving for regained freedom

Focusing beyond survival, the priority of modern burn care is optimal quality of life. Our aim with this study, which was informed by phenomenology, was to describe and identify invariant meanings in the experience of life after major burn injury. Fourteen adults having sustained a major burn were interviewed, on average, 14 months postinjury, and asked about their experience of important aspects of life. The accident meant facing an extreme situation that demanded vigilance, appropriate action, and the need for assistance. The aftermath of the burn injury and treatment included having to put significant effort into creating coherence in their disrupted personal life stories. Continuing life meant accepting the unchangeable, including going through recurrent processes of enduring, grief, fatalism, comparisons with others, and new feelings of gratefulness. Furthermore, a continuous struggle to change what was changeable, to achieve personal goals, independence, relationships with others, and a meaningful life, were all efforts to regain freedom, aiming for a life as it was before--and sometimes even better.

Development of a theoretically derived model of resilience through concept analysis

BACKGROUND

Resilience refers to a dynamic process that results in adaptation in the context of significant adversity (Margalit 2004). The concept of resilience has been of interest to various professional groups for many years; however, it is only recently that the nursing profession has begun to recognise its potential contribution in diverse clinical contexts.

OBJECTIVE

First, to identify current theoretical and operational definitions of resilience and second, to identify and describe defining attributes of resilience.

METHODS

The method of inquiry was guided by Walker and Avant's (1995) approach to concept analysis.

FINDINGS

From this analysis, a conceptual model of resilience postulates that the constructs of self-efficacy, hope and coping are defining attributes of resilience.

DISCUSSION

Resilience appears to be a process that can be developed at any time during lifespan, and thus is not an inherent characteristic of personality. Further, the development of resilience is based on the synergy shared between individuals and their environments and experiences.

CONCLUSIONS

Further theoretical clarification of the ways in which individuals transform stressful experiences into opportunities for increased growth may contribute to nursing knowledge in the form of better understanding of the resilience concept in the context of identifying strategies that build it.

Coping strategies, injury characteristics and long-term outcome after burn injury

Coping consists of cognitive and behavioural strategies aimed at enhancing adaptation, and the use of certain coping strategies is proposed to be beneficial for health. The relationship between coping strategies and burn injury characteristics, sociodemographics and long-term outcome was evaluated in 161 previous victims of severe burn injury. Functional and psychosocial restrictions were measured with the burn specific health scale-brief (BSHS-B) and related to coping strategies measured by the coping with burns questionnaire (CBQ). Patients were on average 47.7 years at measurement of health status and they were assessed 9.2 (S.D. = 4.8) years after injury. The mean area burned was 24.0 and 7.2% was full thickness injury. There was no relation between coping strategies and injury characteristics except in individuals with a full thickness burn exceeding 10%, who exhibited more Revaluation/adjustment. An Avoidant coping strategy was related to work status, marital status and living conditions, and this was the strategy most clearly related to "Bad outcome" in all scales of the BSHS-B. Emotional support was the most beneficial strategy and was mainly associated with the psychosocial scales of the BSHS-B.

Creating a social work link to the burn community: a research team goes to burn camp

Social work faculty and graduate students conducted focus groups with 52 burn-injured adolescents from three burn camps to explore perceptions of their camp experience. Three themes emerged from data analysis that suggest burn camps play an important role in participants' lives. Camp is a place where burn-injured adolescents: (1) feel "normal" and accepted; (2) acquire insight in regard to self and meaning in life; and (3) gain confidence, increase self-esteem, and develop empathy. This project highlights how the use of qualitative research methods with grassroots organizations such as burn camps can serve as a link to greater social work involvement with this community.

Shedding the Layers: Exploring the Impact of the Burn Camp Experience on Adolescent Campers??? Body Image

The purpose of this qualitative study was to explore the impact of the burn camp experience, as it relates to body image, on participating burn-injured adolescents. Focus groups were conducted with 52 burn-injured adolescents at three burn camps in geographically diverse regions of the United States. Data revealed that burn camp is a place where these adolescents feel a sense of belonging and acceptance, a place where they don't have to hide their bodies, and a place where they can learn to integrate their scars into their overall body image in a positive way. Implications of this study include highlighting the contributions that burn camps may provide in helping burn-injured adolescents learn to cope with the devastating disfigurements that often accompany their injuries.

Rising from the ashes: stories of recovery, adaptation and resiliency in burn survivors

Burn-injured people are confronted with enormous challenges in their recovery process on a physical, emotional, and spiritual level. Despite the magnitude of trauma, there has been a dearth of research exploring adult burn survivors' perception of their experiences. In this qualitative study, eight burn survivors were interviewed. Influences that impacted their experiences such as perceived memories, time, and age when burned were distinguished from the multiple themes of losses to identity, life style, relationships and physical functioning as well as themes of adaptation, coping and resiliency. Drawing from the burn survivors' stories of recovery can provide insights for social workers and other health care professionals in serving this compelling population more effectively.

Cognitive distortions in recovered burn patients: the emotional Stroop task and autobiographical memory test

The aim of the study was to explore cognitive distortions in recovered burn patients. Previous studies in trauma patients have shown trauma-specific attentional bias, long response latencies, and deficits in memory specificity. Eighteen former patients, burn injured 5-19 years ago and 18 matched controls performed the emotional Stroop task, including burn and general trauma-related words, and the autobiographical memory test (AMT). In addition, verbal fluency, life events, and current mood were assessed. Regarding the Stroop task, the recovered patients had longer response latencies to burn words than to neutral and trauma words, a difference not seen in the control subjects. Regarding the AMT, the memory specificity did not differ between the groups. Overall, the former patients had longer latencies than the controls and poorer verbal fluency. The present study showed that recovered burn patients display a moderate Stroop effect, i.e. an attentional bias, in spite of the fact that the injury occurred several years before the testing. This may imply that the recovered burn patients consider the burn an important issue in life. The post-burn patients also presented signs of a slight cognitive slowness as compared to the controls. This finding deserves further attention in the rehabilitation of burn patients.

Trauma exposure and psychological reactions to genocide among Rwandan children

A total of 3030 children age 8-19 years from Rwanda was interviewed about their war experiences and reactions approximately 13 months after the genocide that started in April 1994. Rwandan children had been exposed to extreme levels of violence in the form of witnessing the death of close family members and others in massacres, as well as other violent acts. A majority of these children (90%) believed that they would die; most had to hide to survive, and 15% had to hide under dead bodies to survive. A shortened form of the Impact of Event Scale used in a group of 1830 of these children documented high levels of intrusion and avoidance. While children living in shelters were exposed to more trauma, they evidenced less posttraumatic reactions. Analyses showed that reactions were associated with loss, violence exposure, and, most importantly, feeling their life was in danger.