Paediatric medical trauma: The impact on parents of burn survivors☆
Introduction
Burns are a serious global health threat to young children [1]. In 2008 in Western Australia (WA), 7305 children aged 0–15 years were hospitalised for a burn [2]. Children under 15 years accounted for 31 percent of all burn related hospitalisations in WA [2]. It is estimated that 250 per 10,000 children aged zero to four are hospitalised for a burns injury in WA [2]. Improved surgical and medical interventions mean more children survive burns [3] and the quality of physical scars is improving [4]. However, it is vital the underlying emotional scars are also addressed.
Paediatric medical traumatic stress refers to the psychological and physical responses experienced by children and their families as a result of encountering pain, injury, serious illness and invasive medical procedures [5]. Symptoms of posttraumatic stress disorder (PTSD) are identified in children who experience a traumatic accident such as a burn [6], [7], [8] and limited studies have addressed the psychological impact on parents of a child who sustains a burn. Parents need to help their child cope as an inpatient in hospital and often experience stress as they make complex treatment decisions whilst watching their child in pain, in the frequent context of self recrimination and concern for their child's future. Once discharged, children are dependent on their parents for the correct after-care of their burn including extensive wound care, pain management and attending hospital follow up. If parents are experiencing significant levels of psychological distress their daily functioning may be impaired [9].
The available research evidence investigating parental responses to burns in children has shown that parents experience clinically significant symptoms of PTSD in the acute phase (1–4 weeks post burn) [10], [11], [12]. Reported rates of PTSD symptoms in this phase vary across studies with rates reported between the ranges of 18.8 percent (n = 16 mothers) [10] to 50 percent (n = 182 mothers) [12]. During the acute phase it has also been reported that parents experience symptoms of anxiety and depression with rates of symptoms varying from 18.8 percent (n = 16) [10] to 69.9 percent (n = 16) [13].
To date, no studies have investigated resilience levels of parents of burn survivors or what relationships may exist between resilience and adverse psychological outcomes. Resilience is the capacity to positively adapt and cope despite adversity [14] and has been described as an innate psychological immune capacity which may be an underestimated concept missing in trauma literature [15], [16]. It has been suggested that in order to completely understand dysfunction as a result of trauma, a greater understanding of resilience is required [15]. Investigating the capacity of resilience in parents of children with burns is important to explain why some families survive the psychological effect of burns trauma. This understanding will be helpful in developing strategies to assist families in the future.
Previous research investigating the wellbeing of fathers is limited [12], [17], with the notable exception being a recent study which investigated acute stress reactions in 154 fathers one month or less after their child sustained a burn [12]. Findings from this research showed fathers reported less clinically significant acute stress reactions compared to a sample of 183 mothers [12]. This study enhances our understanding of the experience of fathers however more research is required to further explore this area.
Relevant epidemiological research in Australia has found that children of fathers, who show signs of depression in the first year after birth, have more than three times the rate of behavioural problems by the time they reach school, compared to children whose fathers do not have symptoms of depression [18]. Given that infants and toddlers represent the highest age group for burns admissions throughout the western world [1], [2], developing an understanding of the mental health of their fathers is critical. Other research describes increased rates of developmental and mental health problems in children of fathers with even mild symptoms of mental illness [18], [19]. Documentation of mental health impairment in the fathers of burns survivors could lead to the development of effective therapeutic supports.
Previous studies of parental distress within a burns population have been two months after the injury with few studies assessing parental distress within 48 h to two weeks post injury [10], [13], [20], [21]. Identification of precursors in the acute stage, whilst children are inpatients, may help to identify those parents at greater risk of mental health issues once discharged into the community. Predictive factors known to influence psychological distress in parents of children with burns include being a mother [12], younger age of mother [13], lower emotional stability [13], poor family functioning [13] and family conflict [20]. Varying evidence has been reported on the size of burn as a predictive factor with some studies showing it does predict parental distress [12], [20], whilst others report no relationship between psychological distress and size of burn [13]. Identifying those parents at greatest risk allows for the provision of immediate services which will encourage ongoing therapeutic engagement, and provide benefit to the mental health of parents, which may inturn optimise adherence to treatments for the burns victim [22].
It has been identified that people from aboriginal populations are more than twice as likely to sustain a burn [3], have higher rates of pre-existing mental illnesses [23] and have high levels of life stressors [23]. Forty one percent of aboriginal people in WA live in remote or very remote areas [24] and connection with land is central to their well-being [23]. Aboriginal children who sustain a burn in a rural or remote community are flown with one parent to the children's hospital in the city. Many of these children have never been out of their community, on a plane or in a hospital. In addition to the physical context of the burn, being away from family and land can add to the stress experienced as an inpatient. No research to our knowledge has investigated the experiences of aboriginal families in relation to burns. This highlights that culture should be considered in future psychosocial research. In Australia, it is vital that there is a greater appreciation of the needs and experiences of aboriginal parents.
It has been suggested that extensive psychological research is required in the area of traumatic stress, to develop effective interventions for broader populations as well as documenting prevalence rates [25]. Improved understanding of relationships between resilience and adverse psychological symptoms, and consideration of differences between the gender of parents and cultural effects may assist in the understanding and management of paediatric medical traumatic stress. This study posed three hypotheses. We hypothesised that (a) the psychological profiles of parents exposed to paediatric medical trauma were less optimal than controls, (b) pre-existing factors were associated with psychological responses in parents, and (c) relationships exist between symptoms of psychological distress and resilience. These hypotheses were investigated within the total population sample and sub populations of gender and aboriginality.
Section snippets
Participants and procedure
Princess Margaret Hospital (PMH) is the sole tertiary paediatric hospital in Western Australia. Parents of children admitted to PMH, for a burn requiring at least one over night stay were invited to participate in the study. One researcher was responsible for data collection and all new burn admissions between day-time working hours on Monday through Friday were invited to participate. Participation was voluntary and of those parents asked to participate 90 percent agreed. Only three parents
Results
Table 1 describes the sample deographics. The sample consisted of 63 parents, 46 mothers and 17 fathers of which 5 were mother/father dyads. Of the sample, just over half (52.4 percent) were aged between 35 and 44 years and seven parents had a previously diagnosed mental illness. Table 2 describes the demographics of the parent's children and characteristics of the injury. The mean total burn surface area (TBSA) was 4.12 percent, SD = 4.05. Arm burns were the most common burn (14 children),
Discussion
Findings from this research suggest parents of children who have sustained a burn will experience significantly more symptoms of PTSD than the US general population. Although these findings are not statistically significant parents reported lower levels of resilience and more symptoms of depression and anxiety than adults in a comparative community population. Approximately one in every four parents experienced above average symptoms of anxiety and one in five parents experienced clinically
Conclusion
We report that parents of burn survivors have low levels of resilience and experience significant psychological distress. There are several important clinical implications from this research. Health professionals should screen parents to identify those parents at greatest risk. As part of standard routine care we recommend that health professionals assist parents by providing effective evidence based interventions aimed at improving resilience and reducing stress to prevent ongoing symptoms. In
Conflict of interest statement
No authors had a conflict of interest.
References (47)
- et al.
Urban compared with rural and remote burn hospitalisations in Western Australia
Burns
(2012) The changing face of burn care: the Adelaide Children's Hospital Burn Unit: 1960–1996
Burns
(1999)- et al.
Considerations of the provision of psychosocial services for families following paediatric burn injury—a quantitative study
Burns
(2008) - et al.
Internalizing problem behaviour and family environment of children with burns: a Dutch pilot study
Burns
(2006) - et al.
Maternal and child psychological sequelae in paediatric burn injuries
Burns
(2000) - et al.
Psychometric properties of the Impact of Event Scale-Revised
Behav Res Ther
(2003) Epidemiology of burns throughout the worl. Part I: distrubution and risk factors
Burns
(2011)- et al.
An integrative model of pediatric medical traumatic stress
J Pediatr Psychol
(2006) - et al.
Prevalence, comorbidity and course of trauma reactions in young burn-injured children
J Child Psychol Psychiatry
(2012)
Pathways to PTSD. Part I: children with burns
Am J Psychiatry
Brief report: quality of life is impaired in pediatric burn survivors with posttraumatic stress disorder
J Pediatr Psychol
The psychological sequelae on mothers of thermally injured children and adolescents: future direction: part 3
Dev Neurorehabil
Posttraumatic stress symptoms and depression in mothers of children with severe burn injuries
Psychol Rep
Posttraumatic stress disorder in mothers of children and adolescents with burns
J Burn Care Rehabil March
Acute stress reactions in couples after a burn event to their young child
J Pediatr Psychol
What is resilience? A review and concept analysis
Rev Clin Geron
Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events?
Am Psychol
Natural resilience and innate mental health
Am Psychol
The effects of early paternal depression on children's development, 2011
Fathers and mental illness: implications for clinicians and health services
Med J Aust
Posttraumatic stress symptoms in parents of children with acute burns
J Pediatr Psychol
Fouth mental health plan: an agenda for collaborative government action in mental health 2009–2014
Cited by (0)
- ☆
This work should be attributed to Princess Margaret Hospital for Children and Edith Cowan University.