Psychological problems in children with burns—Parents’ reports on the Strengths and Difficulties Questionnaire

"It's a big trauma for the family": A qualitative insight into the psychological trauma of paediatric burns from the perspective of mothers

BACKGROUND

Despite the medical and surgical improvements of paediatric burn injuries, burn injuries can be a painful and traumatic experience for the child and their family. It is therefore important to explore the experiences of caregivers who support their child throughout the burn journey. Thus, the purpose of this study was to explore the traumatic nature of paediatric burns on the family from a caregiver's perspective.

METHODS

This study used a descriptive qualitative approach to conduct online semi-structured interviews with caregivers (18 years and older) of children (aged four to 17 years) that had previously been admitted with an unintentional acute burn injury to a paediatric burns unit in Western Australia. Interviews explored the child's and caregiver's experiences throughout the burn journey from the perspective of the caregiver and were digitally recorded and transcribed verbatim. Transcripts were analysed using Braun and Clarke's six stages of reflexive thematic analysis.

RESULTS

Eleven mothers participated in the interviews and identified a range of poor psychological and psychosocial outcomes that themselves and their child experienced. Three overarching themes were elaborated from the interviews: Child and caregiver mental health difficulties during and after the burn (including medical trauma, mental health outcomes and caregiver guilt); Lifestyle and physical changes following the burn (including disruptions to routine, appearance concerns and puberty); and factors supporting or inhibiting the recovery journey (including personality factors, coping strategies, family dynamics and support).

FINAL CONSIDERATIONS

This study has presented the difficulties that children, young people, and their family face throughout a paediatric burn injury, which makes the implementation of timely and effective family centred interventions imperative. Meeting the needs and supporting these families with their mental health throughout this traumatic recovery journey, can ensure positive psychosocial outcomes and adaptive coping strategies are adopted early on.

Validation of the Psychosocial Assessment Tool 2.0 for paediatric burn patients

OBJECTIVE

The Psychosocial Assessment Tool 2.0 (PAT-B) is an adaptation of an existing screening tool with the aim of the present study to examine its effectiveness and suitability to identify children and families at risk of emotional, behavioral, and social maladjustment following paediatric burns.

METHODS

Sixty-eight children aged between 6 months - 16 years (M = 4.40) admitted into hospital following paediatric burns, and their primary caregivers, were recruited. The PAT-B comprises several dimensions including family structure and resources, social support, as well as caregiver and child psychological difficulties. Caregivers completed the PAT-B and several standardized measures for validation purposes (e.g., caregiver reports of family functioning, child emotional and behavioural problems, caregiver distress). Children old enough to complete measures reported on their psychological functioning (e.g., posttraumatic stress and depression). Measures were completed within 3 weeks of child admission and then again at 3 months after burn.

RESULTS

The PAT-B demonstrated good construct validity, evidenced by moderate to strong correlations between the PAT-B Total and subscale scores and several criteria measures (family functioning, child behaviour and caregiver distress, child depressive symptoms, rs ranging from 0.33 -0.74). Preliminary support for criterion validity of the measure was observed when examined against the three tiers of the Paediatric Psychosocial Preventative Health Model. The proportion of families falling within these tiers of risk (Universal [low risk], 58.2%; Targeted, 31.3%; or Clinical range, 10.4%) was consistent with prior research. Sensitivity of the PAT-B to identify children and caregivers at high risk of psychological distress was 71% and 83%, respectively.

CONCLUSION

The PAT-B appears to be a reliable and valid instrument for indexing psychosocial risk across families who have sustained a paediatric burn. However, further testing and replication using a larger sample size is recommended before the tool is integrated into routine clinical care.

Quality of life in paediatric burn patients with non-severe burns

BACKGROUND

Burns are common worldwide, and the vast majority are non-severe burns of less than 20% of the total body surface area (TBSA). In Australia, paediatric burns account for a third of all burn admissions, thus understanding the quality-of-life outcomes after a non-severe burn in children is important.

METHODS

This retrospective cohort study describes a paediatric cohort from Western Australia with non-severe burns occurring between 2018 and 2020 and characterises the child's quality-of-life outcomes which is measured using the Paediatric quality of life survey (PedsQL). The PedsQL included a parent-report and child-report assessment, each with a physical function domain and a psychosocial function domain which comprised of an emotional, a social and a school category.

RESULTS

Data collected from 249 patients; 50.6% were male, 45.6% were toddlers. The most common cause was scald (48.19%), the majority had burns smaller than 5% TBSA (91.97%), and most included visible areas such as head, neck or hands (77.51%). The parent-report PedsQL scores were significantly different for both physical and psychosocial domains between the different age groups (p = 0.002, p = 0.001, respectively) and for burn cause (p = 0.004, p = 0.005, respectively). For child-reported scores we found evidence of an effect of burn cause across both domains that did not reach a statistical significance (p = 0.076, p = 0.078, respectively). The psychosocial functions in both the parent-report and the self-report were significantly different for the socioeconomic status groups (p = 0.015, p = 0.032, respectively). Quality of life scores were critically low in 16.46% of paediatric burn patients at three months after burn.

CONCLUSION

Parent-reported and child-reported psychosocial function was significantly poorer in higher socioeconomic groups, for older children and for those with flame burns. About 16% of patients had scores below the critical cut off. These data provide insight into the quality-of-life outcomes of paediatric patients with non-severe burns, allowing future studies to investigate burn prevention strategies and services to help paediatric burn patients in their recovery.

Item Pool Development for the School-Aged Life Impact Burn Recovery Evaluation Profile Computerized Adaptive Test: An Observer-Reported Outcome Assessment Measuring the Impact of Burn Injuries in School-Aged Children

The transition from early childhood to teen years (5-12) is a critical time of development, which can be made particularly challenging by a burn injury. Assessing postburn recovery during these years is important for improving pediatric survivors' development and health outcomes. Few validated burn-specific measures exist for this age group. The purpose of this study was to generate item pools that will be used to create a future computerized adaptive test (CAT) assessing postburn recovery in school-aged children. Item pool development was guided by the previously developed School-Aged Life Impact Burn Recovery Evaluation (SA-LIBRE5-12) conceptual framework. The item pool development process involved a systematic literature review, extraction of candidate items from existing legacy measures, iterative item review during expert consensus meetings, and parent cognitive interviews. The iterative item review with experts consisted of six rounds. A total of 10 parent cognitive interviews were conducted. The three broad themes of concern were items that needed 1) clarification, needed context, or were vague, 2) age dependence and relevance, and 3) word choice. The cognitive interviews indicated that survey instructions, recall period, item stem, and response choices were interpretable by respondents. Final item pool based on parental feedback consists of 57, 81, and 60 items in physical, psychological, and family and social functioning, respectively. Developed item pools (n = 198) in three domains are consistent with the existing conceptual framework. The next step involves field testing the item pool and calibration using item response theory to develop and validate the SA-LIBRE5-12 CAT Profile.

Physical, Psychological, and Social Outcomes in Pediatric Burn Survivors Ages 5 to 18 Years: A Systematic Review

Acute pediatric burn injuries often result in chronic sequelae that affect physical, psychological, and social outcomes. To date, no review has comprehensively reported on the impact of burn injuries across all three domains in school-aged children. The aim of this systematic review was to identify published literature that focuses on the impact of burn injuries on physical, psychological, or social functioning, and report upon the nature of study characteristics and their outcomes. We included literature published after 1980, focusing on burn outcomes in children aged 5 to 18 years. Each eligible study was systematically reviewed and primary outcomes were classified into outcome domains based on existing frameworks. Fifty-eight studies met inclusion criteria, and reported on physical (n = 24), psychological (n = 47), and social (n = 29) domains. The majority of the studies had sample sizes of <100 participants, burn size of <40%, and findings reported by parents and/or burn survivors. Only eight of 107 different measures were used in three or more studies. Parents and burn survivors generally reported better physical and social outcomes and worse psychological functioning compared to non-burn populations. Physical disabilities were associated with psychological and social functioning in several studies. Follow-up data reported improvements across domains. This review demonstrates the importance of physical, psychological, and social status as long-term outcomes in burn survivors. Mixed findings across three outcome domains warrant long-term research. Findings of this review will guide the foundation of comprehensive burn and age-specific instruments to assess burn recovery.

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.

The psychological impact of paediatric burn injuries: a systematic review

OBJECTIVE

To review and synthesise qualitative literature regarding the psychological outcomes following paediatric burn injuries, and to determine if children and adolescents who experience a burn injury have elevated risk of psychopathology following the injury.

DESIGN

Systematic review of quantitative and qualitative studies.

DATA SOURCES

Informit health, Medline, Embase, and PsycINFO were searched from January 2010 to December 2020.

DATA EXTRACTION AND SYNTHESIS

Two reviewers screened articles, and one reviewer extracted data (with cross-checking from another reviewer) from the included studies and assessed quality using an established tool. Narrative synthesis was used to synthesise the findings from the quantitative studies, and thematic synthesis was used to synthesise the findings of included qualitative studies.

RESULTS

Searches yielded 1240 unique titles, with 130 retained for full-text screening. Forty-five studies from 17 countries were included. The psychological outcomes included in the studies were mental health diagnoses, medication for mental illness, depression, anxiety, stress, fear, post-traumatic stress, post-traumatic growth, emotional issues, self-harm, self-esteem, self-concept, stigmatisation, quality of life, level of disability, resilience, coping, and suicidality.

CONCLUSIONS

Our findings highlight paediatric burn patients as a particularly vulnerable population following a burn injury. Studies suggest elevated anxiety and traumatic stress symptoms, and higher rates of psychopathology in the long-term. Further research is recommended to determine the psychological outcomes in the other mental health domains highlighted in this review, as findings were mixed. Clinical care teams responsible for the aftercare of burn patients should involve psychological support for the children and families to improve outcomes.

Differences in parent-perceived and patient-reported quality of life among young adult burn patients: A prospective longitudinal study

PURPOSE

This study examines the differences in parent-perceived and patient-reported quality of life (QoL) among young adult burn patients three years after injury and the factors affecting these differences.

METHOD

The sample comprised 35 burn patients from the Formosa Fun Coast Water Park dust explosion and their parents. The study was conducted from June 2016 to August 2018. We used self-report questionnaires to collect socio-demographic data, the adapted Chinese version of the Burn Specific Health Scale-Brief, and the Impact of Events Scale for Burn.

RESULTS

The analysis indicated that simple abilities recovered the fastest, while body image recovered the slowest. The variation trends of these factors were similar but parents' scores were lower than patients' scores. Parents' post-traumatic stress disorder (PTSD) scores were higher than that of patients, but were not statistically significant. Parents' gender and PTSD levels and patients' burn area affected differences in parent-perceived QoL among patients. PTSD levels were significantly higher among mothers.

CONCLUSIONS

For parents, PTSD is a common response to their children experiencing burn injuries. Parents' observations of warning signs enable early medical intervention. Establishing a family-centered care plan, providing psychological support for both parents and patients, and forming a continuous care system with efficient communication can support patients' return to society.

"On the Recovery Journey:" An Integrative Review of the Needs of Burn Patients From Immediate Pre-Discharge to Post-Discharge Period Using the Omaha System

BACKGROUND

To establish a conceptual understanding of the needs of burn patients, the specific research question asked is: "What are the needs of burn patients from 1-week pre-discharge to the post-discharge period?"

METHODS

Whittemore and Knafl's integrative review approach was used to answer the review question. The databases searched were the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Embase, and Scopus. Thirty-two primary studies were retained at the end of the screening process. Directed content analysis was undertaken, with the Omaha system as an organizing framework.

RESULTS

Recovery after burns is not a linear process, but an intricate one filled with varied needs in the physiological (pain, skin, neuro-musculo-skeletal, and infection), psychosocial (social contact, role changes, spirituality, grief, mental health, and sexuality), health-related behavior (nutrition, sleep and rest patterns, and physical activity), and environmental (income) domains of the Omaha system. The nature and intensity of these needs change over time, suggesting that recovery for the burn patient is an ongoing process.

CONCLUSIONS

Several needs exist from 1 week before discharge to the post-discharge period. The mutual relationship and evolving nature of these needs create an avenue for a flexible, regular, holistic transitional program, similar to the support offered to persons living with chronic conditions.

CLINICAL RELEVANCE

Hospital discharge does not imply an end to the recovery of burn patients, and burn survivors still require holistic care even after discharge. The review shows the applicability of the Omaha system in exploring and classifying the needs of burn survivors and situates nursing at the core of such a program. It is possible that a nurse-led program of care needs to be considered.

Injury-related fear-avoidance and symptoms of posttraumatic stress in parents of children with burns

Parents of children with burns experience a range of psychological reactions and symptoms, and parents' health is known to impact children's health. So far, there is little research into potential mechanisms that maintain parents' symptoms. The aim was to investigate parental injury-related fear-avoidance, and its associations with injury severity and health measures. Parents (n=107) of children aged 0.4-18 years that sustained burns 0.1-9.0 years previously completed questionnaires on fear-avoidance, posttraumatic stress, and health of the child. Analyses showed that the average level of fear-avoidance was low and positively associated with measures of injury severity and parents' symptoms of posttraumatic stress, and negatively associated with parents' ratings of their child's health. In two separate multiple regressions with parents' symptoms of PTSD and the child's health as dependent variables, fear-avoidance made the largest contribution in both models while injury severity was non-significant. Results were not related to comorbid conditions of the child, scarring, or parent-related socio-demographic variables. In summary, injury-related fear-avoidance is more likely among parents whose children sustain more severe burns. In turn, fear-avoidance contributes significantly to parents' symptoms of PTSD and to poorer health ratings regarding the child, irrespective of injury severity or child comorbidity.

Child and adolescent internalizing and externalizing problems 12 months postburn: the potential role of preburn functioning, parental posttraumatic stress, and informant bias

Adjustment after pediatric burn injury may be a challenge for children as well as their parents. This prospective study examined associations of internalizing and externalizing problems in children and adolescents 12 months postburn with preburn functioning, and parental acute and chronic posttraumatic stress symptoms (PTSS) from different perspectives. Child, mother, and father reports of 90 children (9-18 years), collected within the first month and 12 months postburn, were analyzed. Results indicated that overall, child and parental appraisals of pre- and postburn behavioral problems were not significantly different from reference data. Rates of (sub)clinical postburn behavioral problems ranged from 6 to 17 %, depending on the informant. Pre- and postburn behavioral problems were significantly related, but only from the parents' perspective. Path models showed an association between parental PTSS 12 months postburn and parental reports of child internalizing problems, as well as a significant indirect relationship from parental acute stress symptoms via PTSS 12 months postburn. Notably, no associations between parental PTSS and child reports of postburn behavioral problems were found. In conclusion, parental observations of child externalizing problems appear to be influenced by their perspectives on the child's preburn functioning, while parental observations of internalizing problems are also related to long-term parental PTSS. However, these factors seem of no great value in predicting behavioral problems from the child's perspective, suggesting substantial informant deviations. To optimize adjustment, clinical burn practice is recommended to adopt a family perspective including parent perception of preburn functioning and parental PTSS in assessment and intervention.

Perceived support in parents of children with burns

OBJECTIVE

Children sustaining burns that require treatment in a burn center have a need for multiprofessional aftercare services over a prolonged time. So far, there is little research into satisfaction with care and support after pediatric burns. The aim was to investigate parents' perception of support after pediatric burn and associations with parent, child and injury characteristics.

METHOD

Parents (n=101) of children aged 0.4-17.8 years completed questionnaires on support, parent's psychological symptoms and health of the child. Time since injury was 0.1-9.0 years.

RESULTS

Perceived lack of psychosocial, medical, societal or family support was reported by 21% of the parents. Lack of support was not associated with injury or sociodemographic characteristics, but it was significantly associated with parents' symptoms of general anxiety, depression and injury-related fear avoidance, as well as parents' ratings of their child's general health and heat sensitivity.

CONCLUSION

Perceived support did not differ on account of burn severity or sociodemographic status. However, care providers should be more attentive to and supportive of parents signaling poorer general health in their child and cognitive beliefs that the child is at risk for harm when active and parents who themselves show signs of psychological symptoms.

The Effects of Being an Only Child, Family Cohesion, and Family Conflict on Behavioral Problems among Adolescents with Physically Ill Parents

Background: This study aimed to examine the parental physical illness’ effect on behavioral problems among adolescents, and the effects of being an only child, family cohesion, and family conflict on behavioral problems among adolescents with physically ill parents in Liaoning province, China. Methods: This cross-sectional study was performed in 2009. A questionnaire including two dimensions of the Family Environment Scale (family cohesion and family conflict), self-reported Strength and Difficulties Questionnaire (SDQ), and demographic factors was distributed to the subjects. Results: Among the 5220 adolescents, 308 adolescents lived with physically ill parents. The adolescents with physically ill parents had more behavioral problems than adolescents with healthy parents. Among the girls who lived in families with physically ill parents, the SDQ score and the prevalence of SDQ syndromes were higher in the girls with siblings than the girls without siblings after adjusting for variables; the effect of family cohesion on SDQ was significant after adjusting for variables. Conclusion: Interventions targeting family cohesion may be effective to reduce behavioral problems of adolescents with physically ill parents.

Parents' perceptions of adaptation and family life after burn injuries in children

The aim of this study was to explore parents' experiences after their child's burn injury, focusing on how the burn had influenced family life and child adjustment. Six semi-structured interviews with parents of children treated at burn centers 2 to 7 years previously revealed the theme, "Feeling quite alone in striving to regain family wellbeing". Identification of difficulties perceived by the parents during rehabilitation and up until the present is useful when developing pediatric burn care and support for parents of children with burns.