Psychological and procedural distress following a young child’s burn injury

Abstract

Aim. The aim of this thesis is to understand the parent’s role in pediatric procedural distress and recovery following a burn injury. Understanding how parents influence their child can inform future work to reduce pediatric procedural distress and improve recovery outcomes. Literature Review. Following a pediatric burn injury, the associated wound care procedures can be potentially traumatic events that are often painful and distressing. Children under 6-years-old are particularly at risk of sustaining a burn injury, yet their pain-related procedural distress is also difficult to manage because of their young developmental level. Acute child and parental distress during the first weeks following a burn injury might impact the child’s physical recovery, and the child and parent’s ongoing psychological distress. There is some evidence to indicate that parents influence their child through their own psychological distress, and through parenting behavior. A review of the broader procedural distress empirical and theoretical literature led to the development of a new theoretical model for understanding the relationship between parent and child distress during medical procedures. The review also identified current gaps in the literature regarding current assessment tools and investigating the impact of procedural distress on long-term physical and psychological recovery. Therefore, the studies in this thesis aim to 1) develop and evaluate an appropriate observational assessment tool; 2) test the proposed theoretical model in a sample of parents and young children (1–6-years-old) during pediatric burn wound care; 3) investigate the parent’s influence on their child’s burn wound healing, and; 4) investigate the long-term (6-month) psychological outcomes of children and their parents following distressing burn wound care. Study 1. The Burns-Child-Adult Medical Procedure Interaction Scale (B-CAMPIS) observational tool included nonverbal codes to assess parent-young child interactions during burn wound care. Parents of 87 children (1–6-years-old) were recruited at their child’s first burn dressing change at the Pegg Leditschke Children’s Burns Centre, Queensland Children’s Hospital, Brisbane, Australia. Inter-coder reliability was good to excellent. Convergent and incremental validity was demonstrated through correlations with other previously validated observational parent-child behavior measures, and parent- and nurse-reported measures of the child’s procedural pain and fear. Discriminant validity showed greater variation. The results indicate overall that the B-CAMPIS is a reliable and valid tool for parent-child interactions during burn wound care. Study 2. The proposed theoretical model of the relationship between parent and child distress was tested on 87 families undergoing the child’s first burn dressing change. Parents reported injuryrelated posttraumatic stress symptoms, pre-procedural fear, general anxiety/depression symptoms, and guilt before the first dressing change. Parent-child behavior was observed during the first dressing change. Mediation analyses identified three indirect effects. Parental posttraumatic stress symptoms predicted more child distress, mediated through parental distress-promoting behavior. Parental guilt predicted more child distress, mediated through parental distress-promoting behavior. Parental general anxiety/depression symptoms predicted less child coping, mediated through less parental coping-promoting behavior. The proposed model was updated to reflect that parents with posttraumatic stress affect their child differently compared to parents with anxiety/depression symptoms during pediatric burn wound care. Study 3. Research has established connections between stress and delayed wound healing. A model of the relationship between the child and parents’ stress and re-epithelialization (wound healing) following pediatric burn injury was presented and tested on 83 families of young children (1–6years-old). Time to re-epithelialization was obtained from medical charts. After the effects of injury severity and procedural pain, parental posttraumatic stress symptoms accounted for 5% of the additional variance in time to re-epithelialization. This finding equated to a one posttraumatic stress symptom increase in parents predicting a 1.36 day delay in the child’s re-epithelialization. Potential mechanisms for this finding include genetic influences of stress and changes to parent-child interactions following the burn injury. Study 4. The prevalence of psychological impairment of children and their parents at 6 months post-injury was investigated, and if initial procedural distress influenced these outcomes. Fortythree parents responded to a questionnaire regarding the child’s posttraumatic stress symptoms, behavioral problems, health-related quality of life, and current pain, and the parents’ own posttraumatic stress symptoms, parenting stress, and parenting style. Low levels of impaired functioning were reported. The presence of parental anxiety/depression symptoms at the first dressing change predicted lower child emotional health-related quality of life at 6 months, after controlling for current parenting stress. Secondly, higher procedural pain at the first dressing change predicted more overprotective parenting behavior at 6 months, after controlling for current child behavioral problems. Conclusions. Overall, the findings of the thesis provide compelling evidence that parental acute psychological distress plays an integral role for the child’s 1) experience of wound care, 2) rate of re-epithelialization, and 3) psychological recovery. Beyond the theoretical advances, these findings have implications for the clinical treatment of children undergoing burn dressing changes, and the development of psycho-behavioral interventions to increase support for parents during the acute phase of burn re-epithelialization.