Psychological consequences of pediatric burns from a child and family perspective: A review of the empirical literature

Abstract

In order to inform clinical practice, we reviewed the empirical literature on emotional, behavioral and social outcomes in children with burns and their families published between 1989 and 2011. A systematic search of the literature yielded 75 articles. Qualitative synthesis of the results showed that child anxiety, traumatic stress reactions, and behavioral problems were considerably prevalent in the first months after the burn event. Among parents, high rates of posttraumatic stress, depressive symptoms, and guilt feelings were found. Cross-sectional studies, often performed many years after the injury, suggest that some children experience long-term psychological problems, such as anxiety, depression, and difficulties with social functioning. However, there was little evidence that behavior in general, self-esteem, or body image were impaired in the total population of children with a history of burns. Long-term family outcome studies suggest that psychological problems persist in a substantial subgroup of parents. Child peritraumatic factors anxiety and pain, parental posttrauma psychological reactions, and family functioning were the most consistently reported factors associated with child outcome. More recent studies have demonstrated that burn severity may have an indirect effect on child postburn psychosocial outcome. Clinical implications, methodological strengths and limitations of the reviewed studies, and directions for future research are discussed.

Introduction

The confrontation with serious pediatric burns irrevocably evokes questions about the child's and the family's adjustment and emotional wellbeing after the burn. Pediatric burn injuries suddenly disrupt normal life, threaten the child's health and bodily integrity, and may require intensive and long-lasting physical treatment. Children are possibly faced with permanent scarring and in some cases with limited functionality. How will these children be doing after hospitalization and later on in their lives? And how can they and their families be most effectively supported to cope with potential difficulties along their way? The purpose of this review is to contribute aggregated evidence on postburn adjustment in order to enhance clinical aftercare and future research on children with burns and their families.

In 1991, Tarnowski et al. substantively summarized the research literature on child and family outcome after pediatric burns (Tarnowski, Rasnake, Gavaghan-Jones, & Smith, 1991). The authors found mixed results regarding psychopathology in children, but cautiously concluded that a minority, 15–20%, of children seemed to develop negative psychosocial outcome. Parents, in particular mothers, presented with high rates of emotional disturbance. The authors documented the relatively modest importance of demographic and injury factors on postburn outcome, opposed to a stronger relation with maternal adjustment and family functioning. Small sample sizes, poor participation rates, questionable representativeness, lack or difficulty in assessment of premorbid functioning, and the predominant use of unstandardized measures were commonly reported methodological shortcomings. The authors proposed areas in need of further examination, such as predictors of psychosocial outcome, family and sibling wellbeing, and specific areas of child outcome such as social functioning and posttraumatic stress disorder (PTSD).

In the past 20 years, multiple aspects of burn care have changed, which might have had implications for psychological adjustment. Advances in pediatric burn care including critical care, e.g., control of shock and sepsis, and surgical improvements have resulted in substantially higher survival rates of even the most severely injured children (Sheridan, 2002). To illustrate, children with massive burns ≥ 70% TBSA (i.e. Total Body Surface Area burned, the estimated proportion of the body with second or third degree burns) now have a realistic chance to survive their injuries (Sheridan, 2002). The multidisciplinary team, including surgeons and nurses, social workers, psychologists, occupational and physiotherapists, child life specialists etc. has become increasingly acknowledged for optimal pediatric burn treatment (Arceneaux & Meyer, 2009). Pain registration, pharmacological, and non-pharmacological pain interventions are on the clinical and research agenda (de Jong et al., 2010). Today, parents can opt for rooming-in in most hospitals, or can stay nearby a hospital in facilitated homes. Notwithstanding these significant changes, other important aspects of a burn trauma have remained the same. Burns are still associated with a significant amount of pain (Martin-Herz, Thurber, & Patterson, 2000). Hospitalization inevitably leads to separation from home and to family life disruption. Invasive medical procedures such as frequent wound dressing changes and skin grafting procedures are imperative. Deep dermal burns still cause permanent scarring, which may require medical attention throughout the life span. So in spite of many positive recent developments, burns may still have a tremendous psychological impact on the child and its family. The current review presents an updated overview of empirical evidence published in the past two decades concerning psychological outcome following pediatric burns in children and their families and factors associated with this outcome.