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Psychosocial concerns in the paediatric burn unit
208
Burns,7,208-210
Printedin GreatBritain
Psychosocial unit
concerns in the paediatric
burn
T. J. Wilkins Section of Plastic Surgery, Indiana University School of Medicine, Indianapolis
and Judith L. Campbell Department of Ps ychiatry, Indiana University School of Medicine, Indianapolis
Summary
In reviewing the medical charts of 264 patients treated in the Indiana University Riley Pediatric Bum Unit over a IO-year period, we found that 52 per cent came from broken homes or other abnormal situations. This paper describes these findings and the protocol we now follow for the psychosocial evaluation and treatment of the burned child. INTRODUCTION
DURINGthe treatment of burned children, we have seen strains in the relationship between the burn unit staff and the patient and his family. These range from minor problems in communication to mutual mistrust and anxiety. Such problems seem to occur more often with burn patients than with other acutely ill individuals. In reviewing the patients admitted to our paediatric burn unit over a IO-year period, we found a majority came from abnormal home backgrounds. We feel that this correlates with problems in the burn unit. METHODS
The charts of all the patients younger than 18 years admitted to the Indiana University Riley Burn Unit from 1968 to 1977 were reviewed. Only those patients with no information as to marital status of parents or any other social background were excluded from the study. The family structure at the time the child was burned
was listed. Other pertinent ground was also recorded.
psychosocial
back-
RESULTS
A total of 3 10 patients were treated in our burn unit from 1968 to 1977. Of these, 46 had no social or psychological information recorded and were excluded from this study. This left 264 determinate patients, 127 of whom came from homes with the original parents still married and no significant problems documented. The remaining 137 patients (52 per cent) came from broken homes or other abnormal situations. These are listed in Tub/e I, where Table /. Family status of burned children
Married parents Divorced or separated Divorced and remarried Widowed Orphaned Unmarried Not living with parents Other problems Severe marital discord Child abuse Serious unemployment Retarded child
127 57 13 9 1 14 9
Total
264
21 4 8 1
209
Wilkins and Campbell: Psychosocial Concerns
Tab/e I!. Burn unit psychosocial protocol Psychiatry Patient evaluation following admission: 1. Mental status interview 2. Piers-Harris Self Concept Questionnaire for School-age Children (Piers and Harris, 1969) 3. Developmental testing Inpatient re-evaluation and treatment as indicated Outpatient follow-up of patient at 6 months, then yearly for 5 years, according to criteria of evaluation on admission. Social service Family evaluation following admission: 1. Emotional adjustment evaluation 2. Family relationship assessment 3. Spielberger State-Trait Questionnaire for Anxiety (Spielberger et al., 1970) 4. Alpern-Boll Interview for Child’s Self Help Level (Alpern and Boll, 1972) 5. School report Contact between patient and family and Burn Unit staff while inpatient Outpatient follow-up of family at 6 months, then yearly for 5 years, according to criteria of evaluation following admission.
discord’ includes problems related to alcoholism, very young parents and conflicts with the grandparents living in the same home. In several of these, divorce was being considered. ‘Severe marital
Burn
Unit protocol
In 1977, because of the high incidence of family discord in our patient population, a Burn Unit protocol was established. All patients admitted to the Riley Hospital Burn Unit, up to the age of I8 years, now receive psychiatric consultation by the Child Psychiatry Service. This is requested as a routine admitting order. The patient is evaluated by a consultant as soon as he or she is physically able to be interviewed. A paediatric social worker assigned to the Burn Unit sees the parents or guardians as soon as possible after admission and makes a psychosocial assessment. This report is also sent to the psychiatric consultant and the attending surgeon. The goals of the consultation are as follows: to anticipate and prevent as many psychiatric problems as possible. both during hospitalization and after: to treat those which existed prior to the burn as well as those which surfaced during the study; to identify factors predisposing children to burns: to identify personality strengths and successful coping mechanisms, the knowledge of which can be used to help others; and to increase the awareness of family, staff and the community of many of the stresses that burned children face. If the child and family appear psychiatrically stable. the psychiatrist provides no further treat-
ment unless speciftcally requested. If problems arise, further psychiatric evaluation and treatment is undertaken during the inpatient stay. The Burn Unit social worker maintains contact with the unit staff, patients and families and assesses the need for further psychiatric consultation. Following discharge, the psychiatric consultation staff see the child and the family at 6 months. Follow-up is more frequent, if necessary. Interviews and questionnaires are repeated yearly for a minimum of 5 years. Routine development testing is included. DISCUSSION
The lndiana University Medical Center is a referral centre for the entire State of Indiana. Most of the burns occurring in the state are sent to the centre’s burn units. Hence, the patients at the Riley Burn Unit represent a cross section of the population ofthe state. The 52 per cent incidence of an abnormal home situation existing prior to injury is higher than we would expect in the population. This figure might be slightly low because some of the families with married parents may have had stressful situations not documented in the charts. This is especially true for the earlier years of this study. At that time, investigation of family background was less intensive. In dealing with this patient population, we have encountered difficult problems fairly frequently. This situation is enhanced by the severe strain that the intensive and prolonged burn therapy places on both the patient and family.
Burns Vol. ~/NO.
210
For these reasons we have developed the protocol outlined in Table II. The early assessment of the patient and family by the psychiatrist and social worker respectively alerts us to potential problems. This enables the entire staff to adjust treatment accordingly. We feel it has enabled us to anticipate and avoid some of the crises affecting not only the patient and family, but also their relationships with the staff. The continued close follow-up by the social worker has been invaluable. The attending surgeons and nurses are often too concerned with the serious physiological problems and attendant treatment to recognize psychiatric problems as they are developing. The outpatient follow-up is also proving valuable. The adjustments to a new way of life for both the badly burned patient and his family are Requesr.s,/tir
3
many. We are able to provide help during these years, when necessary. Acknowledgement
This report was partially funded by the Indiana Department of Mental Health. REFERENCES
Alpem G. D. and Boll T. J. (1972) Developmental Profile. Aspen, Colorado, Psychological Development Publications. Piers E. V. and Harris D. B. (1969) The Piers-Harris Children Self Concept Questionnaire. Nashville, Tennesee, Counselor Recordings and Tests. Spielberger C. D., Gorsuch R. L. and Lushene R. i. (I 970) Manualfor the State- Trait Anxiety Inventory (Self-Evaluation Questionnaire). Palo Alto, Ca, Consulting Psychologists Press. Paper accepted 20 August 1979.
rrprinrs should be addressed lot Dr Judith L. Campbell, Riley Hospital for Children, Indiana University School of Medicine, 1 100 West Michigan Street. Indianapolis, Indiana 46223, USA.
Burns,7,208-210
Printedin GreatBritain
Psychosocial unit
concerns in the paediatric
burn
T. J. Wilkins Section of Plastic Surgery, Indiana University School of Medicine, Indianapolis
and Judith L. Campbell Department of Ps ychiatry, Indiana University School of Medicine, Indianapolis
Summary
In reviewing the medical charts of 264 patients treated in the Indiana University Riley Pediatric Bum Unit over a IO-year period, we found that 52 per cent came from broken homes or other abnormal situations. This paper describes these findings and the protocol we now follow for the psychosocial evaluation and treatment of the burned child. INTRODUCTION
DURINGthe treatment of burned children, we have seen strains in the relationship between the burn unit staff and the patient and his family. These range from minor problems in communication to mutual mistrust and anxiety. Such problems seem to occur more often with burn patients than with other acutely ill individuals. In reviewing the patients admitted to our paediatric burn unit over a IO-year period, we found a majority came from abnormal home backgrounds. We feel that this correlates with problems in the burn unit. METHODS
The charts of all the patients younger than 18 years admitted to the Indiana University Riley Burn Unit from 1968 to 1977 were reviewed. Only those patients with no information as to marital status of parents or any other social background were excluded from the study. The family structure at the time the child was burned
was listed. Other pertinent ground was also recorded.
psychosocial
back-
RESULTS
A total of 3 10 patients were treated in our burn unit from 1968 to 1977. Of these, 46 had no social or psychological information recorded and were excluded from this study. This left 264 determinate patients, 127 of whom came from homes with the original parents still married and no significant problems documented. The remaining 137 patients (52 per cent) came from broken homes or other abnormal situations. These are listed in Tub/e I, where Table /. Family status of burned children
Married parents Divorced or separated Divorced and remarried Widowed Orphaned Unmarried Not living with parents Other problems Severe marital discord Child abuse Serious unemployment Retarded child
127 57 13 9 1 14 9
Total
264
21 4 8 1
209
Wilkins and Campbell: Psychosocial Concerns
Tab/e I!. Burn unit psychosocial protocol Psychiatry Patient evaluation following admission: 1. Mental status interview 2. Piers-Harris Self Concept Questionnaire for School-age Children (Piers and Harris, 1969) 3. Developmental testing Inpatient re-evaluation and treatment as indicated Outpatient follow-up of patient at 6 months, then yearly for 5 years, according to criteria of evaluation on admission. Social service Family evaluation following admission: 1. Emotional adjustment evaluation 2. Family relationship assessment 3. Spielberger State-Trait Questionnaire for Anxiety (Spielberger et al., 1970) 4. Alpern-Boll Interview for Child’s Self Help Level (Alpern and Boll, 1972) 5. School report Contact between patient and family and Burn Unit staff while inpatient Outpatient follow-up of family at 6 months, then yearly for 5 years, according to criteria of evaluation following admission.
discord’ includes problems related to alcoholism, very young parents and conflicts with the grandparents living in the same home. In several of these, divorce was being considered. ‘Severe marital
Burn
Unit protocol
In 1977, because of the high incidence of family discord in our patient population, a Burn Unit protocol was established. All patients admitted to the Riley Hospital Burn Unit, up to the age of I8 years, now receive psychiatric consultation by the Child Psychiatry Service. This is requested as a routine admitting order. The patient is evaluated by a consultant as soon as he or she is physically able to be interviewed. A paediatric social worker assigned to the Burn Unit sees the parents or guardians as soon as possible after admission and makes a psychosocial assessment. This report is also sent to the psychiatric consultant and the attending surgeon. The goals of the consultation are as follows: to anticipate and prevent as many psychiatric problems as possible. both during hospitalization and after: to treat those which existed prior to the burn as well as those which surfaced during the study; to identify factors predisposing children to burns: to identify personality strengths and successful coping mechanisms, the knowledge of which can be used to help others; and to increase the awareness of family, staff and the community of many of the stresses that burned children face. If the child and family appear psychiatrically stable. the psychiatrist provides no further treat-
ment unless speciftcally requested. If problems arise, further psychiatric evaluation and treatment is undertaken during the inpatient stay. The Burn Unit social worker maintains contact with the unit staff, patients and families and assesses the need for further psychiatric consultation. Following discharge, the psychiatric consultation staff see the child and the family at 6 months. Follow-up is more frequent, if necessary. Interviews and questionnaires are repeated yearly for a minimum of 5 years. Routine development testing is included. DISCUSSION
The lndiana University Medical Center is a referral centre for the entire State of Indiana. Most of the burns occurring in the state are sent to the centre’s burn units. Hence, the patients at the Riley Burn Unit represent a cross section of the population ofthe state. The 52 per cent incidence of an abnormal home situation existing prior to injury is higher than we would expect in the population. This figure might be slightly low because some of the families with married parents may have had stressful situations not documented in the charts. This is especially true for the earlier years of this study. At that time, investigation of family background was less intensive. In dealing with this patient population, we have encountered difficult problems fairly frequently. This situation is enhanced by the severe strain that the intensive and prolonged burn therapy places on both the patient and family.
Burns Vol. ~/NO.
210
For these reasons we have developed the protocol outlined in Table II. The early assessment of the patient and family by the psychiatrist and social worker respectively alerts us to potential problems. This enables the entire staff to adjust treatment accordingly. We feel it has enabled us to anticipate and avoid some of the crises affecting not only the patient and family, but also their relationships with the staff. The continued close follow-up by the social worker has been invaluable. The attending surgeons and nurses are often too concerned with the serious physiological problems and attendant treatment to recognize psychiatric problems as they are developing. The outpatient follow-up is also proving valuable. The adjustments to a new way of life for both the badly burned patient and his family are Requesr.s,/tir
3
many. We are able to provide help during these years, when necessary. Acknowledgement
This report was partially funded by the Indiana Department of Mental Health. REFERENCES
Alpem G. D. and Boll T. J. (1972) Developmental Profile. Aspen, Colorado, Psychological Development Publications. Piers E. V. and Harris D. B. (1969) The Piers-Harris Children Self Concept Questionnaire. Nashville, Tennesee, Counselor Recordings and Tests. Spielberger C. D., Gorsuch R. L. and Lushene R. i. (I 970) Manualfor the State- Trait Anxiety Inventory (Self-Evaluation Questionnaire). Palo Alto, Ca, Consulting Psychologists Press. Paper accepted 20 August 1979.
rrprinrs should be addressed lot Dr Judith L. Campbell, Riley Hospital for Children, Indiana University School of Medicine, 1 100 West Michigan Street. Indianapolis, Indiana 46223, USA.