Annals of Burns and Fire Disasters - vol. X - n. 4 - December 1997


Andreeva D., Atanasov A.

Siem Pirogov Centre for Burns and Plastic Surgery, Sofia, Bulgaria

SUMMARY. A description is given of the regular connection between thermal injury and its consequences (disability, functional and cosmetic defects) and its reflections on child psychology - a high degree of anxiety, an inferiority complex, neuropathic tendencies, negative self-acceptance, and aggressive behaviour. The investigation concerned 217 cases of burn consequences among children aged 3 to 18 years. The psychological methods used were: the "Draw-a-person" and the "Bewitched Family" tests; the SCSA scale (classical and sociosituational anxiety and agitation of mind); Dernbo-Ruben stain's self-evaluation test; Eysenck questions; IQ test; test for degree of pretensions; and the polyphase personal questionnaire.


In the last twenty years many Burns Centres have begun to use psychological rehabilitation as a routine method in the overall complex of burns treatment. The application of this method is motivated by the objective reality of post-burn consequences, which cause difficulties for patients in their interpersonal social relations and adaptation.
Our activity at the Pirogov Centre for Burns and Plastic Surgery (Sofia, Bulgaria) is orientated in two main directions: psychotherapy support during medical treatment, and preparation for adaptation and social development.
While for adult patients with a normal level of intelligence the process of adaptation proceeds fairly easily, in children - because of their undifferentiated nervous system, their unstable and still improving psychological processes, and their poor personal defences - burn treatment requires a close connection and interaction between the medical team, the psychologist, the affected child, and the parents. Unexpected traumas, acute pain, and sudden separation from the family following rapid hospitalization present the young patient with urgent demands for adequate adaptation to a completely unknown and exceptional situation, involving countless painful manipulations (infusions, dressing changes, operations, etc.). These requirements for rapid adjustment of the dynamic stereotype are a serious challenge to the adaptational mechanisms of the central nervous system.
A specific peculiarity of burns is the double experience of the trauma - short in itself but lasting from the time of the accident until convalescence - a prolonged process in time and painful for the patient because of the consequences and complications of serious burns, which often demand corrective operative interventions.

Purpose of the study

The purpose of the study was to show and explain the natural connection between changes in the physical "Me" and consequeDces in the adolescent mind - an inferiority complex, a high degree of anxiety and neurotic symptoms, social passivity, and nonintegration.

Psychodiagnostic methods

  1. Objective drawing tests - "Draw -a-person" (Machover) and the "Bewitched Family" test (Kos and Borman). These give information about a person's degree of adaptability to the external changes of the body, his/her way of interpreting the burn accident, and conflicts and family relationships.

  2. Self-evaluation test (D embo -Ruben stain). This gives information about the level and the adequacy of the person's self-estimation.

  3. Test for degree of pretensions. The purpose is to study the dynamics of the person's pretensions by means of the gradation of various tasks of different difficulty which individuals set themselves.

  4. SCSA scale (Kondash). This scale concerns classic and sociosituational anxiety and agitation of the mind. It determines the availability and the degree of a subjective, unpleasant feeling of objective and situational fear that is provoked by objects of classic phobias, sociointerpersonal situations, and the disturbance and emotions provoked by hospital treatment.

  5. QNTPD (Questionnaire for neuroticism and tendentious personal deviations (Kokoshkarova) for the screening of neurosis, offering the possibility for a syndrome estimation of the neurotic disorder.

  6. Eysetick's personal questionnaire. This shows extraor introverted inner adjustment, emotional stability, neuroticism, and peculiarities of temperament.

  7. Polyphase personal questionnaire for adolescents, including twelve spheres of manifestations in life: control of impulses, emotional tone, body image, social relationships, morality, sexual adjustment, family relationships, overcoming the external world, professional and educational purposes, psychopathology, high degree of adaptation, idealism.

  8. Lusher Test. This considers emotional status and the presence of inner conflicts.

  9. Raven's IQ test. This measures the person's potential possibilities of intellectual development.

Altogether, 217 children aged 4 to 18 years were examined using the above tests. The results are divided into the following groups:

  • Group 1: results in the first month post-burn (independent of degree)

  • Group 2: results one month post-burn, when it was necessary to perform face, neck and hand plastic surgery

  • Group 3: children with post-operative sequelae

  • Group 4: children suffering from severe cosmetic or functional sequelae in uncovered parts of the body and from functional disability


The projective "Draw-a-person method" shows that children in Group I (one month post-burn) up to the age of 12 years, although they had not entirely recovered from the thermal trauma, quietly accepted their new physical 11 self-image", with hope and confidence that "everything was OK". The interpretation of the accident in the "Bewitched Family" drawing method showed that the child succeeded in avoiding the worst consequences or suffered a temporary punishment. In children with fresh burns aged over 12 years - i.e, adolescents - the physical "self-image" was very much changed in their ideas and was, for them, entirely unacceptable. This created great inner discomfort and anxiety. The drawings of the "Bewitched Family" reflect family relationships and conflicts when the child has at least a medial level of intelligence. This facilitates the psychologists' work as regards the choice and application of psychotherapeutic methods of influence, and can also orientate them when working with the child's parents.
QNTPD in children with fresh burns aged over 12 years showed that children with a prolonged "bed regimen" were marked by certain neurotic tendencies to which the psychotherapist had to pay special attention.

Self-estimation in children in this group was very close to adequate - it was reduced only as regards the criterion "health", which is easy to explain. The pretension level, when it was already formed (i.e. over the age of 7-8 years), was medial or slightly increased.
The SCSA scale showed that the level of anxiety increased in fresh burns (Tables I and II). The scale was within normal limits in only 17 % of the children; in 31 % it was third degree, and in 52% it was very high (fourth degree).

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Table I - Results of SCSA in recent burns Table II - Decreasing anxiety during treatment

The qualitative estimation of the results showed that the most recurrent fears were:

  1. Fear of bandages and operations
  2. Fear of a prolonged stay in hospital
  3. Fear of a sudden accident

Among children in Group 2 (plastic changes of the neck, face and hands after the fresh burn), the projective drawing method showed complete denial of the physically changed "self-image" and a confused secret hope that things would change for the better. The children experienced the inner crisis of a split mind: on the one hand, they felt the same as before while, on the other, they saw and understood the fact that they were not the same and that this change was irreversible. Their drawings projected the search for support, understanding and sympathy. Their self-evaluation was inadequate - self-esteem was either extremely low or extremely high, which indicated that they had not succeeded in determining their place among other children. Shy, unsure of themselves, and hypodepressive - these characteristics were intensified by the need to wear elastic compression bandages for long periods. Psychotherapeutic interviews with these children are very important; collaboration with the parents is also of great significance, for they are the persons from whom the child expects to receive unreserved love, support, understanding and sympathy after discharge from hospital.
Results in Group 3 (consequences in covered parts of the body) show that at the age of twelve years most of these children (about 67%) had adapted well to their appearance, although partial adaptation also existed.
Children in Group 4 presented an especially heavy, hard and dramatic adaptation to plastic changes in the face, neck and hands, as these parts of the body are usually uncovered and inevitably provoke reactions among neighbouring persons, who may behave roughly and indelicately or express regret. Adaptation to these serious changes is very prolonged and can be achieved only after many operative corrections, especially when the burn dates from early childhood. In addition to psychotherapy and parental support, a significant role is played by personal realization on the social plane. Clinical observations conducted during medical checks showed dependence on the degree of adaptation from the time of inclusion and the adolescent's self-realization in socially significant relationships and activities.

At adolescence three kinds of reactions towards the changed appearance can often be observed:

  • there is a negative attitude towards the cosmetic defects, which leads to complete denial of the physical self-image and consequently of the person's inner qualities (Fig. 1)

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Fig.1 - Sixteen-year-old girl. Deep burn on palm
of right hand in early period post-burn.
Subjected to skin grafting. Mild contractive
and cosmetic defect.

  • there is non-acceptance only of certain parts of the body, i.e. where the defect is; otherwise the identification is positive (Fig. 2)

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Fig. 2 - "Draw-a-person" test reflecting patient's image of her body. She tries to hide defect

  • the person as a whole is integrated; the outer appearance as it is, but this is reflected in the physical "selfimage" (Fig. 3)

The drawings in the "Bewitched Family" test show that children from harmonious, complete and unite families adapted more easily and quickly to the changed inner body image.

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Fig. 3 - "Bewitched Family" test: patient's drawing, indicating magician's goodness, reflects the incapacity of her ego to give her a hand without defects.

The self-estimation of patients in Groups 3 and 4 did not indicate any statistically significant differences, being changed and inadequate in both groups. Real self-esteem is the first indicator of partial adaptation.
Examination of the degree of pretensions in Groups 3 and 4 shows that this was medial. A failure was experienced as a collapse, reducing the level of pretensions by two or three degrees. Contrarily, a success multiplied pretensions many times. This indicates an instability of pretensions, which tend to reduce because of an unreal choice of purposes, fear of failure, and caution.
The SCSA scale shows the following results in adolescents in Groups 3 and 4: boys, 67%, scale indicated 2nd degree, and at 33% was increased, 3rd degree; girls, 2nd degree, scale indicated 34.6%, increased 3rd degree at 38.4%, and 23% 4th degree - clearly increased (Table III).

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Table III - Results of SCSA by consequences

The qualitative analysis of the results shows however that even at a level of anxiety within normal limits, i.e. 2nd degree, there are high values as regards fear of social and interpersonal communication. First place, with the greatest number of points, is fear of separation from close relatives, followed in order by fear of being laughed at, fear of being ignored, and fear of disapproval. While the fear of medical manipulations is predominant among children with fresh sburns, among children with burn sequelae social and interpersonal contacts cause the main fears - fears of how other people will accept and consider them. This to a high degree motivates their desire for corrective treatment and explains the impatience with which they expect results. The Polyphase Personal Questionnaire shows the supersensitiveness of adolescents to their changed outer appearance and its reflection on the regulation of their behaviour. Ninety-one per cent of the persons examined could not tolerate criticism, and their feelings were easily affected. They were predisposed towards revenge. They took serious care of their health, and their mental image of their future appearance did not satisfy them. They considered themselves ugly and unattractive. About 77% confessed that it was extremely difficult for them to make friends. They were very upset by other people's disapproval. They were undecisive and unsure of themselves in their approach to the outside world, and afraid of the thought that one day they would be grown up. They were afraid of the future in general and preferred not to think about it.
In all the patients the Lusher test showed a displacement of the basic necessities and their compensatory replacement by secondary necessities - this is a manifestation of inner conflict and is also a precondition for the development of neurosis.
The Eyselick questionnaires, QNTP1) and IQ tests help the psychologist to investigate the patient's personal peculiarities and to choose adequate psychotherapeutic methods. In practice, the most widely used techniques are the psychotherapeutic interview, games, observation, cognitive methods, behavioural techniques, and autogenic training.


Burn sequelae naturally reflect on the mind and on the mental regulation of behaviour and activity. These consequences create barriers against communication and they hinder social adaptation and manifestation. By means of a variety of psychotherapeutic methods, the psychologist endeavours to reduce the patient's anxiety by removing neuroses, creating a positive adjustment to the changed physical image, and stabilizing a feeling of self-importance and acceptability. Because of corrective surgery's great influence on the patient's psychological status, surgeons have to solve the problem of the permanent improvement offered by curative methods for the treatment of sequelae.


RESUME. Les Auteurs décrivent le rapport régulier entre la lésion thermique et ses conséquences, d'une part (incapacité, insuffisances fonctionnelles et cosmétiques), et, d'autre part, les effets sur la psychologie de l'enfant (haut niveau d'anxiété, complexe d'infériorité, tendances neuropathiques, image négative de soi, comportement agressif). Ils considèrent 217 cas de conséquences de brûlure chez des enfants âgés depuis 3 jusqu'à 18 ans, en utilisant les méthodes d'observation psychologiques suivantes: "dessinez une personne" ; "la famille enchantée"; échelle SCSA (anxiété et agitation); test d'évaluation de soi selon Dembo-Rubenstain; questions de Eysenck; test de quotient intellectuel; degré de prétention; questionnaire personnel polyphasé.


  1. Bowden M.L., Feller Irving M.S.W.: Disfigurement and body image as variables in adaptation after burn injury. Bulletin Clinical Review Burn Injuries, Sept. 1982.
  2. Kammerer B.: School re-entry program for the burned child.Bulletin Clinical Review Burn Injuries, Sept. 1982.
  3. Konigova R., Pondelieek L: Role of "accompanying" relatives in burn care. Bulletin Clinical Review Burn Injuries, Sept. 1982.
  4. Levinson P., Onsterhout D.K.: Art and play therapy with pediatric burn patients. J. Burn Care Rehabil., 9/10: 1980.
  5. Gottsdanker R.: "Experimenting in psychology". Prentice-Hall, Inc., Englewood Cliffs, New Jersey, 1982.
  6. Walls D.: Apre-operative play program for burned children. Bulletin Clinical Review Burn Injuries, Sept. 1982.


This paper was received on 17 April 1997.

Address correspondence to: Dr D. Andreeva and Dr N. Atanasov
Siern Pirogov Centre for Burns and Plastic Surgery
Sofia, Bulgaria.


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