Treatment of pain in acutely burned children.

The child with burns suffers severe pain at the time of the burn and during subsequent treatment and rehabilitation. Pain has adverse physiological and emotional effects, and research suggests that pain management is an important factor in better outcomes. There is increasing understanding of the private experience of pain, and how children benefit from honest preparation for procedures. Developmentally appropriate and culturally sensitive pain assessment, pain relief, and reevaluation have improved, becoming essential in treatment. Pharmacological treatment is primary, strengthened by new concepts from neurobiology, clinical science, and the introduction of more effective drugs with fewer adverse side effects and less toxicity. Empirical evaluation of various hypnotic, cognitive, behavioral, and sensory treatment methods is advancing. Multidisciplinary assessment helps to integrate psychological and pharmacological pain-relieving interventions to reduce emotional and mental stress, and family stress as well. Optimal care encourages burn teams to integrate pain guidelines into protocols and critical pathways for improved care.

Ten-year research review of physical injuries.

OBJECTIVE: To review the past 10 years of research relevant to psychiatry on injuries in children and adolescents. METHOD: A literature search of databases for "wounds and injuries, excluding head injuries," was done with Medline and PsycINFO, yielding 589 and 299 citations, respectively. Further searching identified additional studies. RESULTS: Progress is occurring in prevention, pain management, acute care, psychiatric treatment, and outcomes. The emotional and behavioral effects of injuries contribute to morbidity and mortality. Psychiatric assessment, crisis intervention, psychotherapy, psychopharmacological treatment, and interventions for families are now priorities. Research offers new interventions for pain, delirium, posttraumatic stress disorder, depression, prior maltreatment, substance abuse, disruptive behavior, and end-of-life care. High-risk subgroups are infants, adolescents, maltreated children, suicide attempters, and substance abusers. Staff training improves quality of care and reduces staff stress. CONCLUSIONS: Despite the high priority that injuries receive in pediatric research and treatment, psychiatric aspects are neglected. There is a need for assessment and for planning of psychotherapeutic, psychopharmacological, and multimodal treatments, based on severity of injury, comorbid psychopathology, bodily location(s), and prognosis. Psychiatric collaboration with emergency, trauma, and rehabilitation teams enhances medical care. Research should focus on alleviating pain, early psychiatric case identification, and treatment of children, adolescents, and their families, to prevent further injuries and reduce disability.

Treatment-resistant pain and distress during pediatric burn-dressing changes.

Recent research has suggested some efficacy for the use of hypnosis in the control of pain and distress in a pediatric population undergoing painful medical procedures. Here, we study a sample (N=23) of pediatric subjects undergoing burn-dressing changes and receiving either an imagery-based or control (social-support) treatment. Subjects' levels of distress were assessed with the Observational Scale of Behavioral Distress. Results indicated that distress behaviors in this population can be measured reliably using this scale. However, no support was found for the main hypothesis that imagery treatment would be superior to control treatment in the alleviation of distress, nor were these treatments effective in comparison to baseline conditions. We discuss the formidable problem that burn and dressing-change pain presents, as well as the reasons why this treatment attempt might have failed to have the predicted effects. We also discuss important developmental considerations regarding the adequate assessment of pain and distress.

Parent participation during burn debridement in relation to behavioral distress.

The data on the benefits of parent participation during pediatric medical procedures are mixed. Although a wealth of clinical experience and survey data strongly recommend parent participation in a child's medical care, the mere presence of a parent, particularly during medical procedures, may be insufficient to decrease behavioral distress. This study examined a sample of children aged 3 through 12 undergoing three successive burn dressing changes. For some sessions, parents were present, and for others, they were not. A valid and reliable measure of behavioral distress was taken, as was an informal measure of the level of parent participation. Results indicated no differences between mothers and fathers in the level or the nature of participation, little change in the level of participation across time, and higher levels of physical comforting than verbal comforting. Results also indicated higher levels of behavioral distress in subjects when parents were present versus when absent, which extends previous findings. Results are discussed in terms of the literature on parent and child preferences for parent involvement and parent coaching programs.

Primary nursing: psychological implications.

Even with the decreasing lengths of stay, primary nurses and their patients become attached. These issues of "involvement" can be sources of stress and can complicate primary nursing. Recognizing psychological issues leads to greater job satisfaction and professional identity.

Posttraumatic stress disorder in mothers of children and adolescents with burns.

This is the first study of of posttraumatic stress symptoms in parents (24 mothers and one father) of children with burns. The purpose of the study was to determine what factors relate to parental posttraumatic stress disorder (PTSD). Because the sample is all mothers, except for one father, the conclusions are about mothers. Through use of the Structured Clinical Interview for DSM-III-R, symptoms were determined as occurring from the time of the burn injury until 1 month before the interview (past), 1 month before the interview only (present), or from the date of the burn trauma up to and including 1 month before the interview (past and present). By Structural Clinical Interview criteria, 52% of the mothers had past PTSD, with four (31%) of those mothers having present PTSD symptoms. Eleven mothers and the one father reported neither past nor present PTSD. Multiple regression analysis revealed that larger burns were more strongly related to present PTSD symptoms than were proximity, social support, or perceived stress. Additional findings indicated that mothers with more than one child burned and those mothers who were burned themselves met diagnostic criteria for PTSD. Implications are that posttraumatic stress symptoms can be disruptive to a mother feeling capable of caring for her child with burns after the injury. Individual and group therapy during and after a child's hospitalization may be useful for mothers to reduce stress and to develop better coping skills.

Depression in children after recovery from severe burns.

This outcome study of children and adolescents with severe burns (ages 7 to 19 years) reports that unrecognized depression is common during their lifetimes. Thirty children who had severe burns (range, 5% to 95% body surface area) were assessed for depression at a mean of 9 years after burn injury. This article presents an analysis of depression items from the Diagnostic Interview for Children and Adolescents, which was used in face-to-face interviews to assess child psychiatric disorders with diagnostic criteria from the American Psychiatric Association's Diagnostic and Statistical Manual--Third Edition. At the time that the interviews took place, only one child had symptoms of major depression and only three children had symptoms of dysthymic disorder. However, eight children had a lifetime history of major depression; two of them had been abused by burning and two had been physically or sexually abused. Four had made suicide attempts: one suicide attempt was the cause of the burn injury and three attempts were made after burn injury. Thirteen children had had suicidal thoughts, and their parents were often unaware of this. Other types of affective disorders were prevalent. There was no statistically significant association between depression and burn size or disfigurement. Although burn-related factors were associated with some depressive episodes, other biologic and social risk factors were also very important. The authors conclude that referral for diagnostic services and psychotherapy, and for some, treatment with antidepressant medication, is often a necessary part of medical services for children with burns.

Psychiatric outcome of burned children and adolescents.

Recent medical and surgical advances allow many severely burned patients to survive who formally would have died. Assessment of psychiatric outcomes with these patients may provide ways of measuring effects of acute burn care methods on later quality of life, specify more accurately their emotional needs during rehabilitation, and stimulate further research. Thirty children, aged 7 to 19, with severe burns are compared with 30 nonburned subjects matched for age, sex, SES, and parents' marital status according to DSM-III criteria. The burned children had significantly higher levels of overanxious disorder, phobias, and enuresis, but they had the same rates of present depressive disorders.

A diagnostic outcome study of children and adolescents with severe burns.

The results of a diagnostic outcome study of children and adolescents with severe burns are presented. The positive research findings include evidence of present and lifetime full and partial anxiety and depressive disorders and statistically significant within-sample, burn-related, and demographic differences. The negative findings are less depression and post-traumatic stress disorder by DSM-III criteria than expected, the presence of a subgroup of severely burned children who appeared to be functioning well with only a few or no diagnoses, and absence of significant differences on many variables on within-group comparisons. Based on these data, periodic psychiatric evaluation or reevaluation and specifically targeted followup treatment are indicated for many burned children, adolescents, and their families.

Psychiatric benefits and insurance regulation in Massachusetts: a national model?

The Massachusetts Mandatory Mental Health Insurance Act requires all health insurance plans in the state to cover mental illness. Because of their concerns that this law might be taken as a national model, the authors describe the problems encountered in implementing it and the conflicts between the insurance carriers and psychiatry. The authors attribute the problems to some insurance carriers' failure to deal directly with organized psychiatry in obtaining screening guidelines, the absence of psychiatrists on the carriers' central committees, and psychiatrists' generally indifferent and hostile attitudes toward the carriers. The authors describe recent improvements and recommendations based on 10 years of experience.

Coping with pain: a developmental approach to treatment of burned children.

The treatment of children aged 1-18 who experienced physical pain from an acute burn and the emotional pain of disfigurement offers a prototype for treatment of pain and understanding its impact on the child's emotional life. The author presents an initial report on differential response to and treatment of burn pain in infancy, the preschool years, latency, preadolescence, and adolescence. He describes the basic therapeutic interventions for such children, including psychological preparation, consistent "holding" relationships, selective reinforcement of denial, tolerance of regression, medications, and hypnosis or relaxation techniques.

Preliminary trial of the noradrenergic agonist clonidine in psychiatric patients.

The hypotensive drug clonidine, which stimulates central alpha-adrenergic receptors, was administered to psychiatric patients in a preliminary double-blind study. Two schizophrenic patients became more agitated and aggressive during the trial. The drug showed some antidepressant effects in three of five depressed patients. Clonidine withdrawal appeared to potentiate symptoms in a manic patient. Drug treatment reduced blood pressure and rapid eye movement sleep. Interpretation of behavioral effects of clonidine is limited by uncertainty about the balance of its pre- and postsynaptic effects.

Alterations in motor activity, sleep, and biochemistry in a cycling manic-depressive patient.

Biochemical and electrophysiological factors were studied longitudinally in a rapidly cycling manic-depressive patient. Slow changes in mood, motor activity, sleep, and urinary norepinephrine levels during the course of each depressed and manic episode are reported, as well as rapid alterations in many variables at the time of mood switch. Urinary concentrations of norepinephrine and its metabolite, 3-methoxy-4-hydroxyphenyl glycol (MHPG) were significantly lower in depression than in mania; norepinephrine but not MHPG excretion increased prior to the switch. We postulate that the slow behavioral and biological changes preceding switches in this patient are an important manifestation of the cyclic process in manic-depressive illness.

Slow and rapid psychobiological alterations in a manic-depressive patient: clinical phenomenology.

A distinctive pattern of clinical change during eight affective episodes is reported in a rapidly cycling manic-depressive patient. After a rapid switch to near maximal intensity of affective symptoms, slow changes in symptomatology were documented by significant slopes and correlation coefficients over the course of each episode. Decreases in depression, anxiety, drowsiness, helplessness/hopelessness, anger, and sadness preceded the switches into mania; decreases in mania, euphoria, seeking others, and talking preceded the switches into depression. Psychologically important events appeared to regularly precede rapid mood switches. It is suggested that the consistent, slow clinical changes which occur during affective episodes may reflect part of an underlying rhthmic biological process and that environment events may be capable of triggering a final common pathway for the mood switch during a vulnerable period.