Pathways to PTSD, Part I: Children With Burns
Saxe GN, Stoddard F, Hall E, Chawla N, Lopez C, Sheridan R, et al.;
Commented by , 26 Jul 2005
Background
Fire is one of the leading causes of accidental injury in children. Severe burns in children often are associated with Acute Stress Disorder (ASD) and frequently lead to the development of Post-Traumatic Stress Disorder (PTSD). Little is known, however, about which of the children will develop PTSD and which not.
Aims of the study
To investigate the relative importance of four factors for the development of PTSD in children with burns: the size of the burns, the level of pain, the level of separation anxiety, and the presence of dissociative symptoms.
Method
72 children admitted for an acute burn to Shriners Burns Hospital in Boston participated in the study. The level of pain was assessed by the child him/herself (sliding a marker along the Colored Analog Pain Scale).
Separation anxiety was assessed by one of the investigators (who interviewed the child using the Multidimensional Scale for Children).
The presence of dissociative symptoms was assessed by the child’s primary nurse (who completed the Child Stress Disorders Checklist).
PTSD symptoms were assessed 3 months after the burn by one of the investigators (who interviewed the child using the Child PTSD Reaction Index).
Results
Separation anxiety and dissociation of mental processes were identified as major factors for predicting PTSD. Both anxiety and dissociation were influenced by the size of the burn. Separation anxiety was greater in children with greater pain.
Professor Pull's comments
ASD and PTSD have a very long history. They have first been described in soldiers during and after combat, under names such as "combat fatigue" or "shell shock", long before they were included in ICD-10 or the DSMs (from DSM-III to the current DSM-IV-TR).
The text descriptions of ASD and PTSD in DSM-III were, however, primarily related to signs and symptoms that had been observed in patients suffering from severe burns. (Nancy Andreasen, who drafted these descriptions, has provided an interesting account on how she based the descriptions on her experience caring for burn patients. See reference).
There are many reasons why severe burns are extreme traumatic stressors, in adults, and even more so in children. First, severe burns are associated with often excruciating pains, especially during dressing changes, skin grafts, and physical therapy.
Second, serious burns require hospitalization and treatment in unfamiliar, anxiety provoking surroundings.
Third, treatment of severe burns requires hospitalization in specific intensive care units, in which children are separated from their parents for most of the time, often over long periods of time.
The results of the present study suggest the presence of two separate causal pathways to PTSD in children with burns. The first pathway is in line with findings from previous studies, in that it highlights the involvement of the size of burns and the presence of dissociative symptoms.
The second pathway emphasizes the importance of the size of burns and the severity of anxiety (with in particular separation anxiety), and the influence of severity of pain on the severity of anxiety, as major factors in the development of PTSD.
The results have important implications for treatment and prevention. They suggest the following specific interventions to help children with severe burns:
- Biological and psychological interventions to alleviate pain, anxiety, and dissociation
- Increased availability of the parents in the hospital
- Intensive collaboration between hospital staff and parents to provide a maximum of comfort and feelings of security
Reference
1. Andreasen N. Acute and Delayed Posttraumatic Stress Disorders: A History and Some Issues. Am J Psychiatr 2004; 161; 1321-1323