Annals of
Burns and Fire Disasters - vol. XII - n° 3 - September 1999
LONG-TERM PSYCHOLOGICAL
EFFECTS OF BURN UNIT ADMISSION AMONG PAEDIATRIC PATIENTS WITH MINOR BURNS
Haddadin K.J., Kurdy K.A., Haddad A.I.
Burn Unit, Farah Royal Jordanian Rehabilitation
Centre/King Hussein Medical Centre, Jordan
SUMMARY. This is a study of
the long-term psychological effects of burn unit admissions among paediatric patients with
minor burns treated at the Burn Unit in the Farah Royal Jordanian Rehabilitation
Centre/King Hussein Medical Centre. The psychological assessment was made by means of an
interview and a questionnaire conducted on 98 children with a minimum follow-up period of
30 months post-burn, during visits to the Burn Rehabilitation Out-patients Clinic. The
cohort of patients examined were children less than 12 years of age (average age on
admission, 4.2 yr) admitted to hospital for the treatment of minor burns over the 3-year
period 1 January 1993 to 31 December 1995. The patients were divided into two groups: 57
patients treated in the restricted Burn Unit, with parental separation, and a control
group of 41 patients treated in the open Paediatric Ward, without parental separation. The
effects on social integration, family and peer group acceptance, self-esteem, and
behaviour were studied. Relevant factors such as place of treatment, age, sex, cause and
site of burn, burn surface area, and hospital stay were analysed. There was no
statistically significant difference between the Burn Unit and the control groups with
respect to the Total Psychological Score for each patient. Patients with a hospital stay
longer than 14 days had significantly lower Total and Individual Psychological Scores.
There were more significant behavioural changes among patients treated in the restricted
Burn Unit, as also among patients with a larger total burn surface area. Recommendations
to minimize the long-term psychological effects of hospitalization include the reduction
of overall hospital stay, the reduction of burn unit stay to the minimum necessary for
critical care, and the reduction of the period of parental separation.
Introduction
Minor paediatric burns constitute the
largest single group of burn admissions to many units all over the world. The cost of
treatment and rehabilitation of these patients is enormous both financially and
psychologically. The purpose of an epidemiological study of burns is to attempt to
identify factors in the population under study that may be amenable to preventive
techniques. Many burn units around the world have a policy of restricted access to
patients treated in their units, and until recently our policy was similar.
The aim of this study was to describe the long-term psychological effects of burn unit
admission on children in order to understand the relevant factors and to make
recommendations to minimize the effects. In particular we were interested in the long-term
effect of parental separation during the period of admission to the restricted Burn Unit
in comparison with burned children admitted to the open wards, where parents are allowed
to be with their children during the period of hospitalization.
There are many published papers describing the epidemiology of burns in children both in
the developing and the developed world. The psychological and social effects of burns on
children have been extensively studied in the literature. The data in these papers may or
may not be relevant to our society.
The Burn Unit at the Farah Royal Jordanian Reha-bilitation Centre has twelve beds for the
treatment of critically burned patients in a restricted area, plus a further nine beds in
the open wards annexed to the Unit for the care of minor burns. This is the largest of the
three burn units in Jordan and it has a recognized burn treatment protocol.
Patients and methods
This is a study of the long-term
psychological effects of burn unit admission among patients with minor paediatric burns
treated at the Burn Unit of the Farah Royal Jordanian Rehabilitation Centre/King Hussein
Medical Centre, Jordan.
The main purpose of the study was to find out whether there were any long-term
psychological effects on children admitted for treatment to the restricted Burn Unit, with
its inevitable parental separation. As a control group for comparison we chose children
who were treated for similar burns in the open paediatric ward, where parents were allowed
unlimited access to their children for the duration of treatment. It is difficult to
separate the effects of hospital admission from the long-term psychological effects of the
actual physical burn. To minimize the psychological effects of post-burn sequelae such as
sears and contractures on the result of the study, only minor burns with a total burn
surface area (T13SA) of less than 20% were included for study. It should be noted that
most burns that need hospital admission to our Centre are preferentially admitted to the
Burn Unit except when there is a shortage of beds, in which case patients with lesser
burns are admitted to the open wards. In addition, some burned children who would
otherwise be admitted to the Burn Unit are treated in the open ward because the family
refuse to leave their children unaccompanied. In recent months we have started to allow
limited access of parents to children being treated in the Burn Unit. We still have not
assessed the effect of this change in policy.
The inclusion criteria for the study were as follows: age, less than 12 yr; TBSA, less
than 20%; hospital admission for treatment during the 3-yr period from 1 January 1993 to
31 December 1995 either in the then restricted Burn Unit or in the open Paediatric Ward;
and a minimum follow-up period of 30 months in the Burn Rehabilitation Out-patients
clinic. A long follow-up was carried out because by the end of the period many of the
problems directly related to the post-burn scar - such as itchiness, unstable scars, and
problems related to pressure garments - would to a great extent have subsided.
There were 176 patients satisfying the inclusion criteria. No deaths occurred.
The children's families were contacted and parental consent was sought for conduct of the
study by means of an interview and the use of a specially prepared questionnaire which
concentrated on aspects of behaviour and psychology that were appropriate to our culture.
The questions were specially worded in order to investigate changes in psychology and
behaviour between the pre-burn and the current status.
Consent was obtained to interview and complete the questionnaire in 98 patients. A
qualified nurse not directly involved in the patients original care conducted the
interview during a routine follow-up visit to the Burn Rehabilitation Out-patients clinic.
The interview was conducted in the presence of one of the parents and with the child fully
clothed so that the burn scars did not become the main focus of the interview. Each
patient was given an Individual Score on a scale from 03 (a high score representing No Psychological
Change) for each of the five psychological categories studied, depending on the
answers given to the questionnaire. A Total Psychological Score was calculated by
adding the five individual scores (scale 0-25) (Table I).
| The questionnaire, prepared by a
trained psychologist, consisted of 25 questions investigating the following individual
criteria: |
| |
Social |
(5 items) |
| |
Family acceptance |
(5 items) |
| |
Peer group acceptance |
(5 iterns) |
| |
Self-esteem |
(5 items) |
| |
Behavioural changes |
(5 items) |
| The following scores were
measured in each patient: |
| |
Overall Total Psychological Score |
(Scale 0-25) |
| |
Individual Score for each individual
criterion |
(Scale 0-5) |
| The interviews were conducted by
a qualified nurse not directly involved in the patient's original care. |
|
| Table I - Details of Psychological Assessment |
|
The scores were used to
identify changes in behaviour and psychology and were not designed to measure the child's
absolute behaviour or psychological make-up. No patient was excluded from the analysis
after completion of the interview and questionnaire.
For the purposes of analysis the patients were divided into two groups: 57 patients
treated in the restricted Burn Unit, with parental separation, and a control group of 41
patients treated in the open Paediatric Ward, without parental separation. Long-term
effects on social integration, family and peer group acceptance, self-esteem, and
behavioural changes were studied. Relevant factors such as place of treatment, age, sex,
cause and site of burn, TBSA, and total hospital stay were analysed.
Statistical analysis was performed using the Chi square and the Mann-Whitney U tests.
Results
The average age on admission to
hospital of this group of 98 patients was 4.2 yr. The male to female ratio was 1.M. The
average T13SA for the group was 9%. The average hospital stay was 19.7 days. Fifty-seven
patients in the study group were admitted to the Burn Unit during the period and 41
patients in the control group were admitted to the open Paediatric Ward for treatment.
For purposes of analysis the patients were divided into two groups, on the basis of the
following factors: age (< 5 yr vs > 5 yr), sex, cause of burn (scald vs direct
flame), site (high-profile burns involving face or hands vs lowprofile with no involvement
of face or hands), T13SA < 10% vs 10-19%), and duration of hospital stay (< 14 days
vs > 14 days). Cut-off points for groupings were chosen a priori before the data were
analysed. There was no statistically significant difference between the Burn Unit study
group and the control group with respect to age, sex, cause, and site of burns. As
expected, the Burn Unit group presented a significantly larger TBSA and a longer hospital
stay (Table II).
| |
|
Burn Unit
(n = 57) |
Ward
(n = 41) |
Chi square
p |
| Age (yr) |
< 5 vs
>= 5 |
36/21 |
25/16 |
0.83 n.s |
| Sex |
Male vs
female |
30/25 |
27/16 |
0.41 n.s. |
| Cause of burn ¹ |
Scald vs direct flame |
45/11 |
33/7 |
0.8 n.s. |
| Site of burn |
High vs low
profile ² |
23/34 |
16/25 |
0.9 n.s. |
| TBSA (percentage) |
< 10 vs
11-19 |
28/29 |
29/9 |
< 0.01 sig. |
| Hospital stay (days) |
<= 14 vs
> 14 days |
18/39 |
24/17 |
< 0.01 sig |
¹ Two children
had electrical burns.
² High profile burns are defined as burns involving the face or hands, and low not
involving the face or hands. |
|
| Table 11 - Comparative analysis between patients treated in the
restricted Burn Unit with parental separation and patients treated in the Open Ward
without parental separation |
|
The Total Psychological Score was also studied with respect to age, sex, cause of
burn, site of burn, T13SA, and duration of hospital stay (Figs. 2-6).
|
|
Fig. 1
- Total Psychological Scores ¹ according to place of treatment (burn unit vs ward).*
¹ High score represents no psychological change.
* Mann-Whitney U test, p = 0.08 n.s. |
Fig. 2
- Total Psychological Scores ¹ according to age group (< 5 yr vs 5-12 yr).*
¹ High score represents no psychological change.
* Mann-Whitney U test, p = 0.05 n.s. |
|
|
Fig. 3 -
Total Psychological Scores ¹ according to sex (male vs female).*
¹ High score represents no psychological change.
* Mann-Whitney U test, 1) = 0.07 n.s. |
Fig. 4 -
Total Psychological Scores ¹ according to site of burn (high vs low profile).*
¹High score represents no psychological change.
* Mann-Whitney U test, p = 0.05 n.s. |
|
|
Fig. 5
- Total Psychological Scores ¹ according to total burn surface area (< 10% vs
10-19%).*
¹ High score represents no psychological change.
* Mann-Whitney U test, p = 0.07 n.s. |
Fig. 6
- Total Psychological Scores ¹ according to total hospital stay ( <=14 days vs > 14
days).*
¹ High score represents no psychological change.
* Mann-Whitney U test, p = 0.001 sig. |
|
Patients with a hospital
stay longer than 14 days had significantly lower Total Psychological Scores (Mann-Whitney
U test; p < 0.001) (Fig. 6). The other factors studied had no statistically
significant effect on the Total Psychological Score (MannWhitney U test; p >
0.05).
We also analysed the effects of these various factors on the Individual Scores for
the five psychological criteria studied using the Mann-Whitney U test, as shown in Table
III. We found more significant behavioural changes among patients treated in the
restricted Burn Unit, as also among patients with a larger TBSA. The detrimental effect of
longer hospital stay was seen in all five of the psychological criteria studied.
| |
Individual
psychological criteria |
| |
Social
integration
p |
Family
acceptance
p |
Peer group
acceptance
p |
Self-
esteem
p |
Behavioural
changes
p |
Place of treatment
(Burn unit vs ward) |
n.s. |
n.s. |
n.s |
0.09 |
< 0.05 |
| Age (< 5 yr vs >= 5 yr) |
n.s. |
0.09 |
n.s. |
n.s. |
n.s. |
| Sex (male v female) |
n.s. |
n. s. |
n.s. |
n.s. |
n. s. |
| Cause (scald vs direct flame) |
n. s. |
n.s. |
n. S. |
n.s. |
n.s. |
Site of burn
(high vs low profile |
n.s. |
n.s. |
n.s. |
n. s. |
n.s. |
| Percentage TBSA |
|
|
|
|
|
| (<= 10 vs 11-19) |
n.s. |
n.s. |
n.s. |
n.s. |
< 0.05 |
Hospital stay (days)
(<= 14 vs > 14) |
< 0.01 |
< 0.05 |
< 0.001 |
< 0.001 |
< 0.001 |
|
| Table III - Analysis of
Psychological Scores for each individual criterion according to various factors using the
Mann-Whitney U test. |
|
Discussion
There are still too many childhood
burns in our society, most of which, with a little bit of care, are preventable.
Paediatric burns constitute the largest single group of admissions to our Burn Unit. Many
consist of minor burns involving less than 10% TBSA and some of the patients are admitted
for reasons other than those related to burn site or depth.
Many of our patients come from distant villages and are admitted to our hospital with
minor burns for purely social reasons, such as poor home conditions or the cost of travel.
Some patients are first treated conservatively in general district hospitals all over the
country prior to late referral to our unit, which is one of the reasons why not all
patients with deep burns are treated with early excision in order to minimize hospital
stay.
The policy in our unit is early tangential excision` of deep burns and reconstruction
using autograft from available donor sites. Surgical opportunities were missed on many
occasions in our series for two main reasons: the late referral of a significant
percentage of patients and the reluctance on the part of some parents of children with
deep burns to allow them to be subjected to surgery in the early stages of treatment, in
the hope that the burns would heal spontaneously.
Wilson et al. showed that a sick child is more likely to suffer a burn because he is
clumsier than usual and therefore more inclined to stay closer to his mother, consequently
remaining in the dangerous environment of the kitchen. Pegg et al. stated that
predisposing factors such as epilepsy, mental deficiency, and behaviour disorders occur in
only a small proportion of burns.
There are many difficulties in the conduct of psychosocial research as compared with other
medical disciplines. Existing psychometric assessment tools developed in one culture but
used to assess patients from a differing background and culture may have inherent flaws.
The validity of the content of any questionnaire investigating psychology and behaviour
depends on the extent to which the items in a scale accurately and completely reflect the
domain of interest (e.g. the psychological and social sequelae of burn injury). Future
refinements of our questionnaire will enable us to quantify more precisely the variety of
problems that burn patients from our culture experience at different stages of the
rehabilitation process. This will help us to improve our ability to monitor patient
progress, to identify patients experiencing sub-optimal recovery, to set in motion methods
to reduce the number of such patients, and to treat them accordingly. The ultimate goal is
to achieve an overall reduction in the residual disabilities of burn survivors.
Children differ from adults in their ability to adapt to new situations because of their
undifferentiated nervous system, their unstable and still improving psychological
processes, and their poor personal defences. Scott remarked that the burn patient is in
"foreign territory", with unfamiliar sights and smells and largely
incomprehensible technical languace. The unexpected trauma of the burn accident, the acute
pain, the countless painful manipulations, the sudden separation from the home
environmental, and the long-lasting physical effect of the burn injury place a large
demand on the child's adaptation mechanisms. Identification of factors that increase and
individual's risk of experiencing certain problems can enable health care providers to
focus on patients at highest risk and thus assist them in the making of resource
allocation decisions.
Our study found that the length of hospital stay was the most important factor in the
long-term psychological effects of hospital admission for minor burns. Attempts should be
made to reduce the duration of hospital stay by early surgery, when indicated, and by
treatment on an outpatient basis, where possible, for the whole or part of the duration of
treatment. Children likely to stay in hospital for longer than two weeks should receive
extra psychological support. Our study also showed that children with minor burns admitted
to the restricted Burn Unit are more likely to suffer long-term behavioural changes. Our
recommendations are to reduce the number of minor burn admissions to the Burn Unit, to
facilitate parental access to children in the Burn Unit, and to reduce the length of stay
in the Burn Unit to the minimum necessary for critical care.
Conclusion
Recommendations to minimize the
long-term psychological effects of hospitalization include the following: the reduction of
total hospital stay by early surgery for those patients indicated, treatment on an
out-patient basis as far as possible for the whole or part of the duration of treatment,
the reduction of Burn Unit stay in the restricted area to the minimum necessary for
critical care, and the reduction or elimination of the period of parenteral separation.
The early identification of children at high risk of being psychologically affected by the
ordeal of hospital admission for the treatment of minor burns allows the provision of
extra psychological support for such children. It also allows the provision of necessary
advice for those in direct contact with the children, particularly parents, peers, and
nursing staff alike, as regards handling both in hospital and after discharge.
RESUME. Les
Auteurs ont étudié les effets à long terme de l'hospitalisation dans une unité des
brûlures des patients pédiatriques atteints de brûlures mineures traités dans l'Unité
des Brûlures du Centre Réal Jordanien de Réhabilitation Farah/Centre Médical Roi
Hussein. L'évaluation psychologique a été effectuée moyennant une entrevue et un
questionnaire réalisé sur 98 enfants, avec des visites de contrôle pour 30 mois
effectuées à la Clinique Ambulatoire pour la Réhabilitation des Patients Brûlés. Les
patients, âgés de moins de 12 ans (âge moyen au moment de l'hospitalisation, 4,2 ans),
ont été hospitalisés pour le traitement de brûlures mineures pendant la période
triennale 1 janvier 1993-31 décembre 1995. Les patients ont été divisés en deux
groupes: un groupe de 57 patients traités dans l'unité des brûlures limitée, avec
l'exclusion des parents, et en groupe témoin de 41 patients traités dans le service
pédiatrique ouvert, sans l'exclusion des parents. Les Auteurs ont étudié les effets sur
l'intégration sociale, l'acceptation par la famille et les groupes des pairs, le respect
de soi et le comportement; en outre ils ont analysé des facteurs associés, comme le lieu
du traitement, l'âge, le sexe, la cause et le site de la brûlure, la surface brûlée et
la durée de l'hospitalisation. Pour ce qui concerne le Score Psychologique Total pour
chaque patient, il n'y avait pas de différence statistiquement significative entre les
patients de l'unité des brûlures et le groupe témoin. Les patients hospitalisés pour
plus de 14 jours ont présenté un Score Psychologique Total et Individuel
significativement inférieur. Les modifications comportementales des patients traités
dans l'unité des brûlures limitée étaient plus significatives, comme aussi celles des
patients qui présentaient une surface brûlée majeure. Pour minimiser les effets
psychologiques à long terme de l'hospitalisation, les Auteurs recommandent la réduction
du séjour hospitalier total, la réduction du séjour dans l'unité des brûlures au
minimum nécessaire pour les soins pendant la phase critique, et la réduction de la
période de la séparation d'avec les parents.
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| This paper was received on 15 March 1999. Address correspondence and requests for reprints to
Dr Khaldoun J. Haddadin, Dahiyat EI-Emir Rashid
PO Box 37
Amman 11831, Jordan
tel.: 962-6-5827564 - fax: 9626-5813834 |
|