- Email: [email protected]
Paediatric suicidal burns: A growing concern
JBUR-4825; No. of Pages 5 burns xxx (2016) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Paediatric suicidal burns: A growing concern Smitha Segu, Rachana Tataria * Department of Plastic Surgery and Burns, Bangalore Medical College and Research Institute, Victoria Hospital, Bengaluru, Karnataka, India
article info
abstract
Article history:
An alarming rise in rates of paediatric population committing self-immolation acts is a
Accepted 27 December 2015
growing social and medical problem. In recent times there seems to be a rising concern in paediatric population. A study was conducted at a government tertiary care burn centre over
Keywords:
5 years in paediatric age group of <18 years who had committed self-immolation. Demo-
Paediatric
graphic data, aetiology, burn severity, associated illnesses, treatment and outcomes of the
Self immolation
patients were collected with preventive strategies. Of total 89 patients, 12 patients were
Suicidal burns
below 12 years (children) and 77 between 12–18 years (adolescent) with female preponderance. Majority belonged to lower middle and upper lower class families. Most had deep partial thickness burns. Psychiatric and personality disorder were found in 24.03% and 31.46% patients respectively. Kerosene was the main agent chosen to inflict injury. The average length of hospital stay was 19.8 days. The crude mortality rate observed was 38.2%. With cultural and socio-economic changes children and adolescents are exposed to increased levels of stress and peer pressure leaving them vulnerable. A multidisciplinary care involving medical, psychological and social support is required. Identifying children at risk and proper counselling and support can form an important strategy at prevention rather than cure. # 2016 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burn injuries are known to be a major global hazard, leading to morbidity and mortality along with major economic and social impact [1]. It has long term sequelae which includes psychosocial rehabilitation along with treatment of the primary wound. Incidence and mortality due to burn injures is high in developing nations [2]. Self-inflicted burns represent a major social and medical problem. Worldwide more than 8 lakh people die of suicide every year. Suicide occurs throughout the lifespan and was the second leading cause of death among 15–29 year olds globally in 2012 [3]. Overall suicide rate in Asia is approximately 19.3 per 100,000, about
30% higher than the global rate of 16.0 per 100,000 [4]. Several cases of self-immolation suicides go unreported due to social and medico legal reasons. Self-immolation as a mode of suicide is a common method chosen in Asia [5]. These selfinflicted burns with an accelerant produces extensive full thickness burns and are often associated with inhalational injuries. Management is complicated due to multiple factors, poor compliance, and worsening of their depression. Suicide rates among children have increased worldwide so has the incidence of self-inflicted burns [6]. Literature suggests children form a major proportion of burn admissions [7–10]. There is paucity of data on self-inflicted burns in paediatric age group in India. We aimed to study the epidemiology, aetiology of paediatric suicidal burns with its impact on
* Corresponding author at: Department of Plastic Surgery, MBCC, 1st Floor, Victoria Hospital, Bengaluru - 560 002, Karnataka, India. Tel.: +91 9036248518. E-mail address: [email protected] (R. Tataria). http://dx.doi.org/10.1016/j.burns.2015.12.012 0305-4179/# 2016 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Segu S, Tataria R. Paediatric suicidal burns: A growing concern. Burns (2016), http://dx.doi.org/10.1016/ j.burns.2015.12.012
JBUR-4825; No. of Pages 5
2
burns xxx (2016) xxx–xxx
physical and social aspects of the subject and the society and also the related preventive strategies.
2.
Methods & material
2.1.
Methodology
Acute admissions of suicidal burns up to the age of 18 years to our tertiary level government referral burn Centre at Victoria Hospital of Bangalore medical college and research institute in Bengaluru were prospectively studied over a period of five years (2009–2013). All patients of suicidal burns were included in the study. The subjects were divided into children (<12 years) and adolescent (12–18 years) group [11]. A Performa was prepared to document sociodemographic data which included age, gender, education, type of family and per capita income. Information regarding the circumstances surrounding the incident, burn severity, cause of suicide and any associated illnesses was also collected. During history taking particular emphasis was given to know the intent of suicide by talking to patients/relatives/friends. The admitted patients were treated according to ATLS protocol [12]. As per the protocol, patient first underwent a primary survey followed by a secondary survey. The secondary survey was burn specific and included detailed history and regional examination including eye and ear, with associated facial and inhalational burns. Abuse specific history if any was documented in all patients. Assessment of the burn wound was done by Rule of nine/ Lund & Browder chart. Fluid resuscitation was administered using modified Parkland’s Formula. Management of burn wound, dressings, splinting, drugs and counselling was done. The patients were subjected to detailed psychiatric assessment to see for underlying mental illnesses and put on therapy as required. They were scored to Beck’s Depression Inventory II, an objective questionnaire scale used to rate subjects who have underlying depression and are at risk for committing suicide [13]. It is a 21-item, self-report questionnaire with answer options that include four increasing levels of severity. Scores for each item range from 0 to 3; the total score is the sum of all responses. Subjects are divided into minimal/mild/ moderate/severe depression categories. Impact of the injury on physical and social aspect of the patient, treatment received, outcomes of the injury and possible preventive strategies were studied. The collected data was compiled thoroughly and documented into MS excel spreadsheets and analysed.
2.2.
Setting
The study was done in Bengaluru, the capital of the Indian state of Karnataka. Bengaluru has an estimated population of 8.5 million in 2011 [14], making it the fifth most populous city in India and the 18th most populous city in the world [15]. Bangalore was the fastest-growing Indian metropolis after New Delhi between 1991 and 2001, with a growth rate of 38% during the decade. The cosmopolitan nature of the city has led to migration of people from other states to Bengaluru [16]. According to the 2001 census of India, 79.4% of Bengaluru’s population is Hindu, roughly the same as the national average
[17]. Muslims comprise 13.4% of the population. Christians and Jains account for 5.8% and 1.1% of the population, respectively, double that of their national averages. The sex ratio in the city is 916 females for every 1000 males, and a literacy rate of 89% [18].
3.
Results
3.1.
Demographics
Over a period of five years, of 8246 admissions to the burns unit of Victoria hospital, 1439(17.5%) were paediatric population of which 89 cases were suicidal (Tables 1 and 2). Patients in whom history was not clearly available or any discrepancies in same were excluded from the study. There was a trend of increasing number of admissions seen in every progressive year with 10 paediatric patients in 2009 and 28 in 2013 (Fig. 1). The mean age of the group was 16.1 yrs. On age wise distribution, 12(13.5%) patients were children (<12 years) and 77(86.5%) fell into adolescent group (12–18 years). Age of victims ranges from 9–18 years of age. Female preponderance is seen in both groups. 67 (75.28%) out of 89 were females. Majority of cases belonged to lower middle and upper lower class families according to Kuppuswamy socioeconomic scale (2007) [19] (Fig. 2).
3.2.
Pattern of burns
The average percentage burn surface area involved in children and adolescent group is 72.4% and 58.7% respectively. Most of them had deep partial thickness burns. Area wise involvement distribution mainly involved head &neck area (82.02%), upper limbs (71.91%), anterior trunk (29.21%), posterior trunk (17.98%), lower limbs (11.23%) and genitalia (5.62%).
3.3.
Cause of suicide
Most of our subjects had a precipitating event like not getting something they want, demands not met and personal issues with underlying personality changes that led them to commit self-immolation (Table 3). Kerosene, a commonly used household fuel for cooking in India was found to be the main agent used for self-immolation.
Table 1 – Total burns admissions (2009–2013).
Male Female Total
Paediatric
Adult
694(8.4%) 745(9.03%) 1439(17.4%)
3175(38.5%) 3632(61.5%) 6807(82.55%)
Total
8246
Table 2 – Suicidal burns admission statistics (2009-2013). Suicidal burns Paediatric Male Female Total
22(2.03%) 67(6.17%) 89(8.2%)
Total Adult 410(37.78%) 586(54%) 996(91.78%)
1085
Please cite this article in press as: Segu S, Tataria R. Paediatric suicidal burns: A growing concern. Burns (2016), http://dx.doi.org/10.1016/ j.burns.2015.12.012
JBUR-4825; No. of Pages 5 burns xxx (2016) xxx–xxx
Year Wise Distribuon of Paents 30
28 22
20
15 10
14
10
0 2009
2010
2011
2012
3
patients had an underlying personality disorder e.g. borderline, antisocial and narcissistic. 24.7% (22) were diagnosed with psychiatric disorder including depressive disorder, bipolar disorder and substance abuse. All of them were treated with pharmacotherapy and counselling by the psychiatrist.
2013
3.5.
Year Wise Distribuon
Figure 1 – Year wise distribution of patients of paediatric suicidal burns at MBCC, Victoria hospital, Bengaluru (2009–2013).
Surgical outcomes
23 patients required surgeries like grafting, contracture release, facial procedures and other reconstructions. 32 patients underwent regular dressings and healed with scarring. The crude mortality observed was 38.2%. Average length of stay was 19.8 days.
Kuppuswamy Socioeconomic Status Scale 4. 18
4
6
Upper Class
28
Upper Middle Class Lower Middle Class
33
Upper Lower Class Lower
Figure 2 – Socio economic status (Kuppuswamy Scale) of paediatric suicidal burns patients.
3.4.
Psychological assessment
On subjecting the patients to Beck’s Depression Inventory II, 67.41% (60) were classified into ‘‘Severe’’ category. On evaluation by a psychiatrist it was found that 31.46% (28)
Table 3 – Causes of suicide. Children Cause Failure in love Peer pressure Parental pressure /Family conflict Sibling Pressure Pressure at School Failing an exam Previous personality disorder Previous co-morbidities Trigger factors in recent pasta Attention seeking attempt History of Sexual abuse Other Pressures a
Adolescent
Male Female Male Female 0 1 1
0 2 2
1 2 2
5 4 7
0 1 0 0 0 0 0 0 1
1 1 1 0 0 1 0 0 0
0 1 2 0 0 2 2 1 5
3 5 4 3 1 5 6 3 13
Trigger factors- patient illness/physical discomfort, illness/sudden death in family, parenteral violent behaviour, loneliness, social rejection, financial issues.
Discussion
Self-inflicted burn or self-immolation is a common suicidal approach. According to the American Burn Association, selfimmolation is placed in the burn injury category that requires long-term treatment as well as social and emotional rehabilitations [20,21]. The method of choice in suicidal attempts in different societies is determined by availability and accessibility of suicide instruments [22], and occasionally by imitative or symbolic measures [23]. A study by Laloe (2004) compares trends of self-inflicted burns and describes India as a leading cause of same with high mortality rate [24]. Self-immolation accounts for 0.4-40% of the burn centre admissions worldwide and from 4% to 37% in developing countries [25,26]. There has been a 21.6% increase in suicidal rates in India in past 10 years. In India (2013), 2.1% deaths are comprised of suicide under the age group of 14 years [27]. According to latest statistics of India in 2013, there were 203 deaths due to self-immolation under the age of 14 years of which 143 were females [27]. It is indeed alarming to notice such high numbers at a tender age. Also females comprised 75.28% of the sample which is comparable to 81% and 87% seen in the study done by Ahmadi et al. in 2007 and 2015 respectively [28,29]. It is well known that selfimmolation rates are high in developing nations especially in women with low education rates. In countries like India, female child has been treated inferior to male and this is deeply engraved in the mind of the child. A social development report presented in 2010 to the World Bank and UNDP, found that the time a female child and a male child spends on various activities is similar, with the exception of domestic work and social/resting time; a female child spends nearly three forth of an hour more on domestic work than a male child and therefore lesser hours of social activity/resting than boys [30]. Kerosene is a commonly used fuel in middle and lower middle class households in India sold at subsidized rates and easily available both over the counter as well as government distribution centres for below poverty line families. All the patients had used this fuel for immolation subject to its easy availability. Kerosene as a fuel for selfimmolation is commonly used in third world countries [31,32]. Many patients confessed of imitating such acts secondary to visualizing the same in media and films. The impact of media on minds of children in modern world cannot be underestimated. According to our data the common causes
Please cite this article in press as: Segu S, Tataria R. Paediatric suicidal burns: A growing concern. Burns (2016), http://dx.doi.org/10.1016/ j.burns.2015.12.012
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were someone elderly scolding them, not getting something they want and ‘insulting’ issues. Children today are subjected to immense peer pressure and stress, and are sometimes unable to cope up with it. The causes of suicide listed in Table 3 suggest the impulsive behavioural act taken without thinking of the consequences. Few of the patients submitted retrospectively that the act was to seek attention. On close lines, the risk factors of suicide in self-inflicted burn patients in the study done by Ahmadi et al. (2015) were mainly adverse events, financial hardship and break-up of an intimate relationship albeit done in adult population [29]. There is a growing consensus that untreated psychiatric disorders are the most substantial remediable risk factor for suicide. Some of the preventive measures advocated and implied to the patients are listed in Table 4. At risk children should be identified at household and even schools by their teachers and psychologists so that a calamity may be averted. The subjects under our study were made to undergo regular counselling with the psychiatrist and treated accordingly. Since the subjects belonged to the paediatric age group it was very important to influence people who are directly in contact with the subject. Parents need to be educated and made aware of alarming behavioural changes in the child and when to seek treatment in time and no be embarrassed about it [33]. At the same time, discretion on media viewing with education of guardians for upbringing the child in a healthy environment. Schools, where children almost spend a third of their day has a direct influence on social and emotional development. Periodic mandatory counselling sessions for early diagnosis of any mental illnesses should be implemented. With more number of females in the study, measures to curb gender discrimination with girl education programmes should be encouraged. Treating a girl child at par with equal education opportunities directly contributes to nation’s development. Treatment of mental illnesses should be emphasized from childhood itself. Easily available helpline via telephone, internet and mail should be encouraged. Studies also show a community prevention program targeting self-immolation can be effective. Local data and the showing of videos depicting victim
stories from self-immolation attempts provided a stimulus for community action [34]. It is very important that household fuel consumption be regulated. Over the counter and illegal sale of kerosene should be curbed. Alternative cooking fuels should be made easily available and at affordable prices so as to reduce kerosene use as a household fuel for cooking. Nongovernment organisations (NGOs) in India are often the preliminary care providers in the most remote and backward areas. The government can involve them to play a more proactive role in raising awareness in the society about suicide in general as well as self-immolation. Shields et al. have suggested that burns are a major source of paediatric morbidity and are associated with significant national healthcare resource utilization annually. Future burn prevention efforts should emphasize implementing passive injury prevention strategies, especially for young children who live in low-income communities [35].
5.
Limitations
Our study included all prospective cases of paediatric suicidal burns admitted to the hospital. There is a high likelihood that some patients with minor burns might have been treated on OPD basis. They were not included in the study leading to underestimation of suicidal rates in children. Due to social stigma and legal reasons, sometimes the parents or relatives deny history of suicidal intent. They may pressurise the children at times, who are already traumatised by the event. This may also lead to under reporting of the cases. As the data of the clinical events was recorded by interviews and medical records, we cannot rule out reporting and observer bias. We also understand that it is premature to generalize our findings to other parts of India, as the study includes patients only from Bengaluru city. The study gives a rough estimate of the prevalence of this serious yet under-reported issue. We have not attempted to find the preventive and remedial measures for the same. We are only suggesting the possible measures which may help us in identifying and in turn prevent these children from committing suicide. Further randomised control trials with larger study group would be required to validate our findings and to lay down concrete and definitive measures for prevention of the same.
Table 4 – Preventive measures. Individual level Family oriented
School & Environmental changes
Community& Organisations
Early recognition and treatment of mental illnesses Girl child education programmes & Gender equality Parent education and child training Education and awareness programmes Screening of high risk individuals at school Social & crisis supporting groups, telephonic counselling Improved media reporting practice Surveillance & Research for in depth view of subject Regulatory acts for consumption of inflammatory liquids
6.
Conclusion
Rising incidence in suicidal burns in the paediatric population is an alarming warning for the society and the nation as they are the future productive group. Increasing levels of stress and peer pressure have contributed to rising incidence. Also easy availability of household inflammable liquids which need to undergo regulatory acts for their discrete consumption. The affected patients require a multidisciplinary approach in the form of adequate medical, psychological, occupational and social support. Both mental and physical health need to be given importance during the growing years. Counselling and behavioural training at grass root level in their educational institute is needed. It is very essential that these children at
Please cite this article in press as: Segu S, Tataria R. Paediatric suicidal burns: A growing concern. Burns (2016), http://dx.doi.org/10.1016/ j.burns.2015.12.012
JBUR-4825; No. of Pages 5 burns xxx (2016) xxx–xxx
risk be identified at household level by parents and at learning institutions so they can receive therapy in the nick of time. Increased awareness and education of these vulnerable children may be the only way to help prevent self-inflicted injuries by burning.
Conflict of interests The authors have no conflicts of interest.
references
[1] Low, A.J. It’s not just a burn: physical and psychological problems after burns. Uppsala University,; 2007 http://urn. kb.se/resolve?urn=urn:nbn:se:uu:diva-7758. [2] WHO. UNICEF. World report on child injury prevention. Geneva: World Health Organization; 2008. [3] World Health Organization. Available at: www.who.int/ mental_health/prevention/suicide/suicideprevent/en/. [4] World Health Organization. Geneva, Switzerland: World Health Organization; 2011. Mental health—country reports and charts available. (http://www.who.int/mental_health/ prevention/suicide/country_reports/en/index.html). [5] Wu KC, Chen YY, Yip PSF. Suicide methods in Asia: Implications in suicide prevention. Int J Environ Res Public Health 2012;9:1135–58. [6] Cash SJ, Bridge JA. Epidemiology of youth suicide and suicidal behavior. Curr Opin Pediatr 2009;21:613–9. [7] Zhu L, Zhang Y, Liu L, Jiang J, Liu Y, Shi F, et al. Hospitalized Pediatric Burns in North China: a 10-year epidemiologic review. Burns 2013 (journal of the International Society for Burn Injuries). [8] Bessey PQ, Arons RR, Dimaggio CJ, Yurt RW. The vulnerabilities of age: burns in children and older adults. Surgery 2006;140 (705-15; discussion 15-7). [9] Han TH, Kim JH, Yang MS, Han KW, Han SH, Jung JA, et al. A retrospective analysis of 19,157 burns patients: 18-year experience from Hallym Burn Center in Seoul, Korea. Burns 2005;31:465–70. [10] Liu EH, Khatri B, Shakya YM, Richard BM. A 3 year prospective audit of burns patients treated at the Western Regional Hospital of Nepal. Burns 1998;24:129–33. [11] http://www.indianpediatrics.net/may1999/may-461-463. htm. [12] American College of Surgeons Committee on Trauma, Advanced Trauma Life Support Student Course Manual, Chicago, Ill, USA, 8th edition, 2009. [13] Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory–II. San Antonio, TX: Psychological Corporation; 1996. [14] ‘‘Urban Agglomerations/Cities having population 1 lakh and above’’ (PDF).Censusindia. The Registrar General & Census Commissioner, India. Retrieved 17 October2011. [15] ‘‘Cities having population 1 lakh and above’’ (PDF). censusindia.gov.in. Retrieved 24 July 2012.
[16] ‘‘Kannadigas assured of all support’’. The Hindu (Chennai, India). 23 July 2004. Retrieved 10 May 2010. [17] ‘‘Census GIS Household’’. censusindiamaps.net. 2006. [18] ‘‘Provisional Population Totals, Census of India 2011’’ (PDF). Government of India. Retrieved 28 December 2011. [19] Kumar N, Shekhar C, Kumar P, Kundu AS. Kuppuswamy’s Socioeconomic Status Scale-Updating for 2007. Indian J Pediatr 2007;74(12):1131–2. [20] Scully JH, Hutcherson R. Suicide by burning. Am J Psychiatry 1983;140:905–6. [21] Sheth H, Dziewulski P, Settle JAD. Self-inflicted burns: a common way of suicide in the Asian population. A 10-year retrospective study. Burns 1994;20:334–5. [22] Modan B, Nissenkorn I, Lewkowski SR. Comparative epidemiologic aspects of suicide and attempted suicide in Israel. Am J Epidemiol 1970;91:393. [23] Jacobson R, Jackson M, Berelowitz M. Self-incineration: a controlled comparison of inpatient suicide attempts. Clinical features and history of self-harm. Psychol Med 1986;16:107. [24] Burns. 2004 May; 30(3):207-15.Patterns of deliberate selfburning in various parts of the world. A review. Laloe¨ HYPERLINK ‘‘http://www.ncbi.nlm.nih.gov/pubmed/ ?term=Lalo%C3%AB%20V%5BAuthor%5D&cauthor= true&cauthor_uid=15082345’’ V1. [25] Ben Meir P, Sagi A, Ben Yakar Y, Rosenberg L. Suicide attempts by self-immolation–our experience. Burns 1990;16:257–8. [26] Saadat M. Epidemiology and mortality of hospitalized burn patients in Kohkiluye va Boyerahmad province (Iran): 2002-2004. Burns 2005;31:306–9. [27] http://ncrb.gov.in/adsi2013/suicides%202013.pdf. [28] Ahmadi A. Suicide by self-immolation: comprehensive overview, experiences, and suggestions. J Burn Care Res 2007 Jan-Feb;28(1):30–41. [29] Ahmadi A, Schwebel DC, Bazargan-Hejazi S, Taliee K, Karim H, Mohammadi R. Self-immolation and its adverse life-events risk factors: results from an Iranian population. J Inj Violence Res 2015 Jan;7(1):13–8. [30] Ngwira N, Kamchedzera G, Semu L. Malawi: Strategic Country Gender Assessment (SCGA) Vol 1: Main Report. June 2003, The World Bank. URL: http://siteresources. worldbank.org/EXTAFRREGTOPGENDER/Resources/ MalawiSCGA.pdf. [31] Mabrouk AR, Mahmod Omar AN, Massoud K, Magdy Sherif M, El Sayed N. Suicide by burns: a tragic end. Burns 1999 Jun;25(4):337–9. [32] Laloe V, Ganesan M. Self-immolation a common suicidal behaviour in eastern Sri Lanka. Burns 2002 Aug;28(5):475–80. [33] Rezaie L, Khazaie H, Soleimani A, Schwebel DC. Selfimmolation a predictable method of suicide: a comparison study of warning signs for suicide by self-immolation and by self-poisoning. Burns 2011 Dec;37(8):1419–26. http:// dx.doi.org/10.1016/j.burns.2011.04.006. [34] Ahmadi A, Ytterstad B. Prevention of self-immolation by community-based intervention. Burns 2007 Dec;33(8):1032–40. [35] Shields BJ, Comstock RD, Fernandez SA, Xiang H, Smith GA. Healthcare resource utilization and epidemiology of pediatric burn-associated hospitalizations, United States, 2000. J Burn Care Res 2007;28:811.
Please cite this article in press as: Segu S, Tataria R. Paediatric suicidal burns: A growing concern. Burns (2016), http://dx.doi.org/10.1016/ j.burns.2015.12.012
5
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Paediatric suicidal burns: A growing concern Smitha Segu, Rachana Tataria * Department of Plastic Surgery and Burns, Bangalore Medical College and Research Institute, Victoria Hospital, Bengaluru, Karnataka, India
article info
abstract
Article history:
An alarming rise in rates of paediatric population committing self-immolation acts is a
Accepted 27 December 2015
growing social and medical problem. In recent times there seems to be a rising concern in paediatric population. A study was conducted at a government tertiary care burn centre over
Keywords:
5 years in paediatric age group of <18 years who had committed self-immolation. Demo-
Paediatric
graphic data, aetiology, burn severity, associated illnesses, treatment and outcomes of the
Self immolation
patients were collected with preventive strategies. Of total 89 patients, 12 patients were
Suicidal burns
below 12 years (children) and 77 between 12–18 years (adolescent) with female preponderance. Majority belonged to lower middle and upper lower class families. Most had deep partial thickness burns. Psychiatric and personality disorder were found in 24.03% and 31.46% patients respectively. Kerosene was the main agent chosen to inflict injury. The average length of hospital stay was 19.8 days. The crude mortality rate observed was 38.2%. With cultural and socio-economic changes children and adolescents are exposed to increased levels of stress and peer pressure leaving them vulnerable. A multidisciplinary care involving medical, psychological and social support is required. Identifying children at risk and proper counselling and support can form an important strategy at prevention rather than cure. # 2016 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burn injuries are known to be a major global hazard, leading to morbidity and mortality along with major economic and social impact [1]. It has long term sequelae which includes psychosocial rehabilitation along with treatment of the primary wound. Incidence and mortality due to burn injures is high in developing nations [2]. Self-inflicted burns represent a major social and medical problem. Worldwide more than 8 lakh people die of suicide every year. Suicide occurs throughout the lifespan and was the second leading cause of death among 15–29 year olds globally in 2012 [3]. Overall suicide rate in Asia is approximately 19.3 per 100,000, about
30% higher than the global rate of 16.0 per 100,000 [4]. Several cases of self-immolation suicides go unreported due to social and medico legal reasons. Self-immolation as a mode of suicide is a common method chosen in Asia [5]. These selfinflicted burns with an accelerant produces extensive full thickness burns and are often associated with inhalational injuries. Management is complicated due to multiple factors, poor compliance, and worsening of their depression. Suicide rates among children have increased worldwide so has the incidence of self-inflicted burns [6]. Literature suggests children form a major proportion of burn admissions [7–10]. There is paucity of data on self-inflicted burns in paediatric age group in India. We aimed to study the epidemiology, aetiology of paediatric suicidal burns with its impact on
* Corresponding author at: Department of Plastic Surgery, MBCC, 1st Floor, Victoria Hospital, Bengaluru - 560 002, Karnataka, India. Tel.: +91 9036248518. E-mail address: [email protected] (R. Tataria). http://dx.doi.org/10.1016/j.burns.2015.12.012 0305-4179/# 2016 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Segu S, Tataria R. Paediatric suicidal burns: A growing concern. Burns (2016), http://dx.doi.org/10.1016/ j.burns.2015.12.012
JBUR-4825; No. of Pages 5
2
burns xxx (2016) xxx–xxx
physical and social aspects of the subject and the society and also the related preventive strategies.
2.
Methods & material
2.1.
Methodology
Acute admissions of suicidal burns up to the age of 18 years to our tertiary level government referral burn Centre at Victoria Hospital of Bangalore medical college and research institute in Bengaluru were prospectively studied over a period of five years (2009–2013). All patients of suicidal burns were included in the study. The subjects were divided into children (<12 years) and adolescent (12–18 years) group [11]. A Performa was prepared to document sociodemographic data which included age, gender, education, type of family and per capita income. Information regarding the circumstances surrounding the incident, burn severity, cause of suicide and any associated illnesses was also collected. During history taking particular emphasis was given to know the intent of suicide by talking to patients/relatives/friends. The admitted patients were treated according to ATLS protocol [12]. As per the protocol, patient first underwent a primary survey followed by a secondary survey. The secondary survey was burn specific and included detailed history and regional examination including eye and ear, with associated facial and inhalational burns. Abuse specific history if any was documented in all patients. Assessment of the burn wound was done by Rule of nine/ Lund & Browder chart. Fluid resuscitation was administered using modified Parkland’s Formula. Management of burn wound, dressings, splinting, drugs and counselling was done. The patients were subjected to detailed psychiatric assessment to see for underlying mental illnesses and put on therapy as required. They were scored to Beck’s Depression Inventory II, an objective questionnaire scale used to rate subjects who have underlying depression and are at risk for committing suicide [13]. It is a 21-item, self-report questionnaire with answer options that include four increasing levels of severity. Scores for each item range from 0 to 3; the total score is the sum of all responses. Subjects are divided into minimal/mild/ moderate/severe depression categories. Impact of the injury on physical and social aspect of the patient, treatment received, outcomes of the injury and possible preventive strategies were studied. The collected data was compiled thoroughly and documented into MS excel spreadsheets and analysed.
2.2.
Setting
The study was done in Bengaluru, the capital of the Indian state of Karnataka. Bengaluru has an estimated population of 8.5 million in 2011 [14], making it the fifth most populous city in India and the 18th most populous city in the world [15]. Bangalore was the fastest-growing Indian metropolis after New Delhi between 1991 and 2001, with a growth rate of 38% during the decade. The cosmopolitan nature of the city has led to migration of people from other states to Bengaluru [16]. According to the 2001 census of India, 79.4% of Bengaluru’s population is Hindu, roughly the same as the national average
[17]. Muslims comprise 13.4% of the population. Christians and Jains account for 5.8% and 1.1% of the population, respectively, double that of their national averages. The sex ratio in the city is 916 females for every 1000 males, and a literacy rate of 89% [18].
3.
Results
3.1.
Demographics
Over a period of five years, of 8246 admissions to the burns unit of Victoria hospital, 1439(17.5%) were paediatric population of which 89 cases were suicidal (Tables 1 and 2). Patients in whom history was not clearly available or any discrepancies in same were excluded from the study. There was a trend of increasing number of admissions seen in every progressive year with 10 paediatric patients in 2009 and 28 in 2013 (Fig. 1). The mean age of the group was 16.1 yrs. On age wise distribution, 12(13.5%) patients were children (<12 years) and 77(86.5%) fell into adolescent group (12–18 years). Age of victims ranges from 9–18 years of age. Female preponderance is seen in both groups. 67 (75.28%) out of 89 were females. Majority of cases belonged to lower middle and upper lower class families according to Kuppuswamy socioeconomic scale (2007) [19] (Fig. 2).
3.2.
Pattern of burns
The average percentage burn surface area involved in children and adolescent group is 72.4% and 58.7% respectively. Most of them had deep partial thickness burns. Area wise involvement distribution mainly involved head &neck area (82.02%), upper limbs (71.91%), anterior trunk (29.21%), posterior trunk (17.98%), lower limbs (11.23%) and genitalia (5.62%).
3.3.
Cause of suicide
Most of our subjects had a precipitating event like not getting something they want, demands not met and personal issues with underlying personality changes that led them to commit self-immolation (Table 3). Kerosene, a commonly used household fuel for cooking in India was found to be the main agent used for self-immolation.
Table 1 – Total burns admissions (2009–2013).
Male Female Total
Paediatric
Adult
694(8.4%) 745(9.03%) 1439(17.4%)
3175(38.5%) 3632(61.5%) 6807(82.55%)
Total
8246
Table 2 – Suicidal burns admission statistics (2009-2013). Suicidal burns Paediatric Male Female Total
22(2.03%) 67(6.17%) 89(8.2%)
Total Adult 410(37.78%) 586(54%) 996(91.78%)
1085
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Year Wise Distribuon of Paents 30
28 22
20
15 10
14
10
0 2009
2010
2011
2012
3
patients had an underlying personality disorder e.g. borderline, antisocial and narcissistic. 24.7% (22) were diagnosed with psychiatric disorder including depressive disorder, bipolar disorder and substance abuse. All of them were treated with pharmacotherapy and counselling by the psychiatrist.
2013
3.5.
Year Wise Distribuon
Figure 1 – Year wise distribution of patients of paediatric suicidal burns at MBCC, Victoria hospital, Bengaluru (2009–2013).
Surgical outcomes
23 patients required surgeries like grafting, contracture release, facial procedures and other reconstructions. 32 patients underwent regular dressings and healed with scarring. The crude mortality observed was 38.2%. Average length of stay was 19.8 days.
Kuppuswamy Socioeconomic Status Scale 4. 18
4
6
Upper Class
28
Upper Middle Class Lower Middle Class
33
Upper Lower Class Lower
Figure 2 – Socio economic status (Kuppuswamy Scale) of paediatric suicidal burns patients.
3.4.
Psychological assessment
On subjecting the patients to Beck’s Depression Inventory II, 67.41% (60) were classified into ‘‘Severe’’ category. On evaluation by a psychiatrist it was found that 31.46% (28)
Table 3 – Causes of suicide. Children Cause Failure in love Peer pressure Parental pressure /Family conflict Sibling Pressure Pressure at School Failing an exam Previous personality disorder Previous co-morbidities Trigger factors in recent pasta Attention seeking attempt History of Sexual abuse Other Pressures a
Adolescent
Male Female Male Female 0 1 1
0 2 2
1 2 2
5 4 7
0 1 0 0 0 0 0 0 1
1 1 1 0 0 1 0 0 0
0 1 2 0 0 2 2 1 5
3 5 4 3 1 5 6 3 13
Trigger factors- patient illness/physical discomfort, illness/sudden death in family, parenteral violent behaviour, loneliness, social rejection, financial issues.
Discussion
Self-inflicted burn or self-immolation is a common suicidal approach. According to the American Burn Association, selfimmolation is placed in the burn injury category that requires long-term treatment as well as social and emotional rehabilitations [20,21]. The method of choice in suicidal attempts in different societies is determined by availability and accessibility of suicide instruments [22], and occasionally by imitative or symbolic measures [23]. A study by Laloe (2004) compares trends of self-inflicted burns and describes India as a leading cause of same with high mortality rate [24]. Self-immolation accounts for 0.4-40% of the burn centre admissions worldwide and from 4% to 37% in developing countries [25,26]. There has been a 21.6% increase in suicidal rates in India in past 10 years. In India (2013), 2.1% deaths are comprised of suicide under the age group of 14 years [27]. According to latest statistics of India in 2013, there were 203 deaths due to self-immolation under the age of 14 years of which 143 were females [27]. It is indeed alarming to notice such high numbers at a tender age. Also females comprised 75.28% of the sample which is comparable to 81% and 87% seen in the study done by Ahmadi et al. in 2007 and 2015 respectively [28,29]. It is well known that selfimmolation rates are high in developing nations especially in women with low education rates. In countries like India, female child has been treated inferior to male and this is deeply engraved in the mind of the child. A social development report presented in 2010 to the World Bank and UNDP, found that the time a female child and a male child spends on various activities is similar, with the exception of domestic work and social/resting time; a female child spends nearly three forth of an hour more on domestic work than a male child and therefore lesser hours of social activity/resting than boys [30]. Kerosene is a commonly used fuel in middle and lower middle class households in India sold at subsidized rates and easily available both over the counter as well as government distribution centres for below poverty line families. All the patients had used this fuel for immolation subject to its easy availability. Kerosene as a fuel for selfimmolation is commonly used in third world countries [31,32]. Many patients confessed of imitating such acts secondary to visualizing the same in media and films. The impact of media on minds of children in modern world cannot be underestimated. According to our data the common causes
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were someone elderly scolding them, not getting something they want and ‘insulting’ issues. Children today are subjected to immense peer pressure and stress, and are sometimes unable to cope up with it. The causes of suicide listed in Table 3 suggest the impulsive behavioural act taken without thinking of the consequences. Few of the patients submitted retrospectively that the act was to seek attention. On close lines, the risk factors of suicide in self-inflicted burn patients in the study done by Ahmadi et al. (2015) were mainly adverse events, financial hardship and break-up of an intimate relationship albeit done in adult population [29]. There is a growing consensus that untreated psychiatric disorders are the most substantial remediable risk factor for suicide. Some of the preventive measures advocated and implied to the patients are listed in Table 4. At risk children should be identified at household and even schools by their teachers and psychologists so that a calamity may be averted. The subjects under our study were made to undergo regular counselling with the psychiatrist and treated accordingly. Since the subjects belonged to the paediatric age group it was very important to influence people who are directly in contact with the subject. Parents need to be educated and made aware of alarming behavioural changes in the child and when to seek treatment in time and no be embarrassed about it [33]. At the same time, discretion on media viewing with education of guardians for upbringing the child in a healthy environment. Schools, where children almost spend a third of their day has a direct influence on social and emotional development. Periodic mandatory counselling sessions for early diagnosis of any mental illnesses should be implemented. With more number of females in the study, measures to curb gender discrimination with girl education programmes should be encouraged. Treating a girl child at par with equal education opportunities directly contributes to nation’s development. Treatment of mental illnesses should be emphasized from childhood itself. Easily available helpline via telephone, internet and mail should be encouraged. Studies also show a community prevention program targeting self-immolation can be effective. Local data and the showing of videos depicting victim
stories from self-immolation attempts provided a stimulus for community action [34]. It is very important that household fuel consumption be regulated. Over the counter and illegal sale of kerosene should be curbed. Alternative cooking fuels should be made easily available and at affordable prices so as to reduce kerosene use as a household fuel for cooking. Nongovernment organisations (NGOs) in India are often the preliminary care providers in the most remote and backward areas. The government can involve them to play a more proactive role in raising awareness in the society about suicide in general as well as self-immolation. Shields et al. have suggested that burns are a major source of paediatric morbidity and are associated with significant national healthcare resource utilization annually. Future burn prevention efforts should emphasize implementing passive injury prevention strategies, especially for young children who live in low-income communities [35].
5.
Limitations
Our study included all prospective cases of paediatric suicidal burns admitted to the hospital. There is a high likelihood that some patients with minor burns might have been treated on OPD basis. They were not included in the study leading to underestimation of suicidal rates in children. Due to social stigma and legal reasons, sometimes the parents or relatives deny history of suicidal intent. They may pressurise the children at times, who are already traumatised by the event. This may also lead to under reporting of the cases. As the data of the clinical events was recorded by interviews and medical records, we cannot rule out reporting and observer bias. We also understand that it is premature to generalize our findings to other parts of India, as the study includes patients only from Bengaluru city. The study gives a rough estimate of the prevalence of this serious yet under-reported issue. We have not attempted to find the preventive and remedial measures for the same. We are only suggesting the possible measures which may help us in identifying and in turn prevent these children from committing suicide. Further randomised control trials with larger study group would be required to validate our findings and to lay down concrete and definitive measures for prevention of the same.
Table 4 – Preventive measures. Individual level Family oriented
School & Environmental changes
Community& Organisations
Early recognition and treatment of mental illnesses Girl child education programmes & Gender equality Parent education and child training Education and awareness programmes Screening of high risk individuals at school Social & crisis supporting groups, telephonic counselling Improved media reporting practice Surveillance & Research for in depth view of subject Regulatory acts for consumption of inflammatory liquids
6.
Conclusion
Rising incidence in suicidal burns in the paediatric population is an alarming warning for the society and the nation as they are the future productive group. Increasing levels of stress and peer pressure have contributed to rising incidence. Also easy availability of household inflammable liquids which need to undergo regulatory acts for their discrete consumption. The affected patients require a multidisciplinary approach in the form of adequate medical, psychological, occupational and social support. Both mental and physical health need to be given importance during the growing years. Counselling and behavioural training at grass root level in their educational institute is needed. It is very essential that these children at
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risk be identified at household level by parents and at learning institutions so they can receive therapy in the nick of time. Increased awareness and education of these vulnerable children may be the only way to help prevent self-inflicted injuries by burning.
Conflict of interests The authors have no conflicts of interest.
references
[1] Low, A.J. It’s not just a burn: physical and psychological problems after burns. Uppsala University,; 2007 http://urn. kb.se/resolve?urn=urn:nbn:se:uu:diva-7758. [2] WHO. UNICEF. World report on child injury prevention. Geneva: World Health Organization; 2008. [3] World Health Organization. Available at: www.who.int/ mental_health/prevention/suicide/suicideprevent/en/. [4] World Health Organization. Geneva, Switzerland: World Health Organization; 2011. Mental health—country reports and charts available. (http://www.who.int/mental_health/ prevention/suicide/country_reports/en/index.html). [5] Wu KC, Chen YY, Yip PSF. Suicide methods in Asia: Implications in suicide prevention. Int J Environ Res Public Health 2012;9:1135–58. [6] Cash SJ, Bridge JA. Epidemiology of youth suicide and suicidal behavior. Curr Opin Pediatr 2009;21:613–9. [7] Zhu L, Zhang Y, Liu L, Jiang J, Liu Y, Shi F, et al. Hospitalized Pediatric Burns in North China: a 10-year epidemiologic review. Burns 2013 (journal of the International Society for Burn Injuries). [8] Bessey PQ, Arons RR, Dimaggio CJ, Yurt RW. The vulnerabilities of age: burns in children and older adults. Surgery 2006;140 (705-15; discussion 15-7). [9] Han TH, Kim JH, Yang MS, Han KW, Han SH, Jung JA, et al. A retrospective analysis of 19,157 burns patients: 18-year experience from Hallym Burn Center in Seoul, Korea. Burns 2005;31:465–70. [10] Liu EH, Khatri B, Shakya YM, Richard BM. A 3 year prospective audit of burns patients treated at the Western Regional Hospital of Nepal. Burns 1998;24:129–33. [11] http://www.indianpediatrics.net/may1999/may-461-463. htm. [12] American College of Surgeons Committee on Trauma, Advanced Trauma Life Support Student Course Manual, Chicago, Ill, USA, 8th edition, 2009. [13] Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory–II. San Antonio, TX: Psychological Corporation; 1996. [14] ‘‘Urban Agglomerations/Cities having population 1 lakh and above’’ (PDF).Censusindia. The Registrar General & Census Commissioner, India. Retrieved 17 October2011. [15] ‘‘Cities having population 1 lakh and above’’ (PDF). censusindia.gov.in. Retrieved 24 July 2012.
[16] ‘‘Kannadigas assured of all support’’. The Hindu (Chennai, India). 23 July 2004. Retrieved 10 May 2010. [17] ‘‘Census GIS Household’’. censusindiamaps.net. 2006. [18] ‘‘Provisional Population Totals, Census of India 2011’’ (PDF). Government of India. Retrieved 28 December 2011. [19] Kumar N, Shekhar C, Kumar P, Kundu AS. Kuppuswamy’s Socioeconomic Status Scale-Updating for 2007. Indian J Pediatr 2007;74(12):1131–2. [20] Scully JH, Hutcherson R. Suicide by burning. Am J Psychiatry 1983;140:905–6. [21] Sheth H, Dziewulski P, Settle JAD. Self-inflicted burns: a common way of suicide in the Asian population. A 10-year retrospective study. Burns 1994;20:334–5. [22] Modan B, Nissenkorn I, Lewkowski SR. Comparative epidemiologic aspects of suicide and attempted suicide in Israel. Am J Epidemiol 1970;91:393. [23] Jacobson R, Jackson M, Berelowitz M. Self-incineration: a controlled comparison of inpatient suicide attempts. Clinical features and history of self-harm. Psychol Med 1986;16:107. [24] Burns. 2004 May; 30(3):207-15.Patterns of deliberate selfburning in various parts of the world. A review. Laloe¨ HYPERLINK ‘‘http://www.ncbi.nlm.nih.gov/pubmed/ ?term=Lalo%C3%AB%20V%5BAuthor%5D&cauthor= true&cauthor_uid=15082345’’ V1. [25] Ben Meir P, Sagi A, Ben Yakar Y, Rosenberg L. Suicide attempts by self-immolation–our experience. Burns 1990;16:257–8. [26] Saadat M. Epidemiology and mortality of hospitalized burn patients in Kohkiluye va Boyerahmad province (Iran): 2002-2004. Burns 2005;31:306–9. [27] http://ncrb.gov.in/adsi2013/suicides%202013.pdf. [28] Ahmadi A. Suicide by self-immolation: comprehensive overview, experiences, and suggestions. J Burn Care Res 2007 Jan-Feb;28(1):30–41. [29] Ahmadi A, Schwebel DC, Bazargan-Hejazi S, Taliee K, Karim H, Mohammadi R. Self-immolation and its adverse life-events risk factors: results from an Iranian population. J Inj Violence Res 2015 Jan;7(1):13–8. [30] Ngwira N, Kamchedzera G, Semu L. Malawi: Strategic Country Gender Assessment (SCGA) Vol 1: Main Report. June 2003, The World Bank. URL: http://siteresources. worldbank.org/EXTAFRREGTOPGENDER/Resources/ MalawiSCGA.pdf. [31] Mabrouk AR, Mahmod Omar AN, Massoud K, Magdy Sherif M, El Sayed N. Suicide by burns: a tragic end. Burns 1999 Jun;25(4):337–9. [32] Laloe V, Ganesan M. Self-immolation a common suicidal behaviour in eastern Sri Lanka. Burns 2002 Aug;28(5):475–80. [33] Rezaie L, Khazaie H, Soleimani A, Schwebel DC. Selfimmolation a predictable method of suicide: a comparison study of warning signs for suicide by self-immolation and by self-poisoning. Burns 2011 Dec;37(8):1419–26. http:// dx.doi.org/10.1016/j.burns.2011.04.006. [34] Ahmadi A, Ytterstad B. Prevention of self-immolation by community-based intervention. Burns 2007 Dec;33(8):1032–40. [35] Shields BJ, Comstock RD, Fernandez SA, Xiang H, Smith GA. Healthcare resource utilization and epidemiology of pediatric burn-associated hospitalizations, United States, 2000. J Burn Care Res 2007;28:811.
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