Identifying the Variables Impacting Post-Burn Psychological
Adjustment: A Meta-Analysis
Delilah O. Noronha, MS, and Jan Faust, PHD
Nova Southeastern University
Objective The purpose of this study was to identify and evaluate variables that have the greatest
impact on psychological adjustment after burn injury among children, adolescents, and young
adults. Methods Meta-analytical procedures were utilized to determine the strength of association
indices of identified impact variables. Only 13 articles were utilized due to the scarcity of and statistical limitations of the research. Results The body location variable (.26) had the greatest mean
strength of association in relation to psychological adjustment. The burn injury variable (.21) had
the second greatest mean strength of association. Finally, both the parental adjustment variable and
the child premorbid psychological functioning variable (.15) had the third greatest mean strength of
association. Conclusions A major implication of this research is that the impact variables identified will be useful in targeting burn patients who are at risk for psychological adjustment problems.
Key words
burn adjustment; pediatric burn.
Approximately 1 million children in the United States
sustain burn injuries each year (American Academy of
Pediatrics, 2000). While some burn injuries can be acute
life-threatening events, they can also share similar characteristics to chronic illness and may result in serious
long-term physical and psychological morbidity
(McLoughlin & McGuire, 1990; Patterson et al., 1993;
Tarnowski, Rasnake, Gavaghan-Jones, & Smith, 1991).
Thus, it is important to determine who is at risk of developing poor psychological adjustment after burn injury.
Although it appears that there is concern for the
psychological adjustment and quality of life of child,
adolescent, and young adult burn survivors, there is limited literature in this area (Landolt, Grubenmann, &
Meuli, 2002; Tarnowski et al., 1991). The research available generally focuses on the prevalence of psychological
maladjustment rather than on identifying the variables
that impact psychological adjustment.
Psychological Reactions to Burn Injury
To obtain a comprehensive understanding of the impact
of burn injury on the psychological adjustment of children,
adolescents, and young adults, a critical review of the literature was conducted which revealed contradictory
findings regarding the prevalence of post-burn psychological maladjustment within this population. Some outcome studies of pediatric burn survivors indicate that
child burn survivors adjust well (Blakeney, Meyer, Moore
et al., 1993; Stoddard, Norman, Murphy, & Beardslee,
1989a; Stoddard, Norman, & Murphy, 1989). However,
other studies generally suggest that 20–50% of samples
of pediatric burn patients experience psychological maladjustment such as symptoms of depression and anxiety
(e.g. Stoddard et al., 1989; Tarnowski et al., 1991;
Stoddard, Norman, & Murphy, 1989). Furthermore,
Meyer, Blakeney, Le Doux and Herndon (1995) found
that although children who are burned may not suffer
serious psychological adjustment problems, they may be
deficient in adaptive behaviors necessary for positive psychological adjustment.
One of the reasons there are contradictory findings in
the literature regarding prevalence rates of post-burn psychological maladjustment may be the variations in time
elapsed after the burn across studies. This is important
because many of the outcome studies that report little-to-no
All correspondence concerning this article should be addressed to Delilah O. Noronha, Nova Southeastern University,
3301 College Avenue, Ft. Lauderdale, Florida 33314-7796. E-mail: [email protected].
Journal of Pediatric Psychology 32(3) pp. 380–391, 2007
doi:10.1093/jpepsy/jsl014
Advance Access publication August 1, 2006
Journal of Pediatric Psychology vol. 32 no. 3 © The Author 2006. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: [email protected]
Identifying Variables Impacting Post-Burn Psychological Adjustment
psychological morbidity may have been conducted after
symptoms were resolved or before symptoms surfaced
and/or were recognized. Blakeney, Meyer et al.’s (1998)
study acknowledges the importance of time in psychological adaptation. Similarly, La Greca, Silverman, Vernberg,
and Prinstein (1996) found that in school-aged children
traumatized by Hurricane Andrew, posttraumatic stress
symptoms decreased and changed over time.
Psychological Adjustment Categories
Although there is some indication in the literature of
positive psychological adjustment after burn injury, this
appears trivial in comparison to the breadth of research
supporting the high prevalence of poor adjustment. This
gives reason to explore the various psychological reactions to burn injury. For the purpose of this study, poor
psychological adjustment was defined as the presence of
post-burn psychological symptoms, other manifestations
of emotional or behavioral adjustment (i.e., coping style
and decreased life satisfaction), and/or DSM diagnoses
as determined by individual studies included in this
meta-analysis. In the interest of being clear and concise,
psychological reactions were clustered into three categories (depression, anxiety and other psychological reactions) and will be discussed in this section.
Depression
Many studies have found that of the negative psychological outcomes, depression is a common childhood
psychological reaction to burn injury (Patterson et al.,
1993; Stoddard, 1982b; Stoddard, Stroud, & Murphy,
1992). The most problematic of the depressive reactions
for children who have been burned include suicidal
ideation, self-rejection, aggressiveness, irritability, and
withdrawal (Campbell, 1976; Carvajal, 1990; El
Hamaoui, 2002; Stoddard & O’Connell, 1983). Furthermore, Stoddard (1982b) reported that anger, grief, and
guilt were also identified among pediatric burn patients.
Anxiety
Anxiety is another common psychological reaction to
burn injury among children, adolescents, and young
adults (Clarke & Martin, 1978; Patterson et al., 1993;
Stoddard, 1982b). Knudson-Cooper (1982b), Stoddard,
Chedekel, and Remensnyder (1984), as well as Stoddard
(1982b) found that anxiety was a major complaint among
pediatric burn patients. It appears that a large portion of
research in the area of pediatric burn-related anxiety
focuses on participants who met the diagnostic and statistical manual of mental disorder’s (DSM) criteria for
posttraumatic stress disorder (PTSD). PTSD and symptoms of PTSD have been observed as being prevalent
among burn survivors (i.e., Bryant, 1996; El Hamaoui,
2002; Patterson et al., 1993). La Greca et al. (1996) suggest that symptoms of PTSD were a common reaction to
trauma such as physical burn.
Other Psychological Reactions
In addition to anxiety and depression, there are several
other psychological reactions discussed in the literature
to a lesser extent. A broad spectrum of transient and
long-term psychological issues will be addressed within
this category. Children, adolescents, and young adults
who have been burned may experience body image
issues and academic difficulties (Carvajal, 1990; Clarke &
Martin, 1978; Stoddard, 1982a). Sleep disturbances are
also found to be common among burn victims (Meyer &
Blakeney, 1995). In addition, Bryant (1996), El Hamaoui
(2002), Herndon et al. (1986), and Rusch (1998)
reported that there is an occurrence of somatic complaints
in pediatric burn patients. Finally, burn injury has been
found to impact social, educational, and occupational
functioning as well as medical compliance (Ilechukwu,
2002; Stoddard, 1982b; Stoddard et al., 1984).
Variables Impacting Post-Burn Adjustment
A review of the literature indicates that there are several
adjustment variables that may exacerbate or cause
psychological maladjustment in child, adolescent, and
young adult burn patients. For the purposes of this
study, only variables that have been historically deemed
most important in the psychological adjustment to burn
injury were identified and evaluated (i.e., Tarnowski
et al., 1991). These variables will be referred to as
impact variables. The impact variables evaluated in this
study were labeled social support, body location, burn
injury, visible scarring, child premorbid psychological
functioning, parental adjustment, demographics, age,
and total body surface area (TBSA) (cf. Yu & Dimsdale,
1999; Landolt et al., 2002; LeDoux, Meyer, Blakeney, &
Herndon, 1998; Rusch, 1998; Tarnowski et al., 1991;
Tyack & Zivani, 2003).
Social Support Variable
Social support is defined by the care, support, and
acceptance of others (Giljohann, 1979; Landolt et al.,
2002; Sheridan, 2000; Williams, Reeves, Cox, & Call,
2004). For the purpose of this study, social support
encompassed the quality of relationships, interactions,
and social situations among the burn survivors and their
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family and peers. Support provided by family and peers
appears to play a significant role in youth adjustment
after burn injury (Blakeney, Portman, & Rutan, 1990;
LeDoux et al., 1998; Perry, Difede, Musngi, Frances, &
Jacobson, 1992; Rusch, 1998; Vernberg et al., 1996). It
also plays an important role in helping children cope with
stressors (i.e., Compas & Epping, 1993). One reason this
may be true is that strong social support influences the
burn survivors’ self-esteem and may act as a buffer
against the trauma of the burn (Bowden et al., 1980;
Davidson Bowden, & Feller, 1981).
Direct family support and family relationships were
found to impact psychological adjustment after burn
injury (Beard, Herndon, & Desai, 1989; Blakeney et al.,
1988; Knudson-Cooper, 1984). In addition, it has been
suggested that children’s recovery to other traumas has
been mediated by both parental support and family conflict (Faust & Furdella, 2004; La Greca, 2004). However,
positive adjustment after traumatic injury such as burn
injury is not dependent on family support alone; peer support plays an important role as well (Luther & Price, 1981;
Prinstein & La Greca, 2004). To summarize, the literature
suggests that the more positive support available to a child
who has experienced a trauma such as burn, the less likely
that child will have psychological adjustment problems.
Burn Injury Variable
There were several burn injury-related variables that were
found in the literature to be significantly related to postburn psychological adjustment (Baker et al., 1996; Yu &
Dimsdale, 1999; Rusch, 1998). However, there is a
paucity of research available for each individual burn
injury-related impact variable. Thus, because of the lack
of qualitative and quantitative research to warrant individual impact variables, the burn injury variable was comprised of several different burn injury-related variables. In
this study, the burn injury variable is comprised of treatment environment, length of hospital stay, medical complications, burn severity, patient compliance, and pain.
This section will provide a brief description of the
six components of the burn injury impact variable. The
first component that will be discussed is medical noncompliance. Although it may be a behavioral outcome
after burn injury, it may also lead to poorer physical
functioning which, in turn, may result in poorer psychological adjustment and quality of life over time (Sheffield
et al., 1988). In particular, it has been found to be a
problematic occurrence among children who have been
burned (Tarnowski, 1995). For example, the literature
suggests lack of activity during hospitalization has a
negative impact on physical and emotional functioning
(Patterson & Ptacek, 1997). The second component,
burn severity, has been found to be related to post-burn
psychological maladjustment (Bowden, Feller, Tholen,
Davidson, & James, 1980). The third component, pain,
whether caused by the actual injury or medical procedures, may impact psychological outcome (Patterson &
Ptacek, 1997; Ptacek, Patterson, Montgomery, &
Heimbach, 1995). The fourth component, the environment for which the burn patient is treated (e.g., Intensive
Care Unit) also has been found to overstimulate or understimulate burn patients, which may lead to difficulties with
psychological adjustment (Steiner & Clark, 1977). Finally,
lengths of hospital stay and medical setbacks have been
associated with depressive symptoms (Andreason et al.,
1972; Choiniere, Melzack, Rondeau, Girard, & Paquin,
1989; Hamburg, Hamburg, & deGoza, 1953).
Total Body Surface Area Variable
Total body surface area (TBSA) is the percentage of total
body surface area affected by the burn. Many studies
have identified a relationship between TBSA and psychological adjustment (De Wet, Cywes, & Davies, 1979;
Smith, Barclay, Quesada, Sedowofia, & Thompson, 1997).
In addition, Stoddard, Norman et al. (1989) found that
there were significantly more psychological diagnoses
among participants who had greater than 30% TBSA
burned than those who did not. However, Byrne et al.’s
(1986) study found that children who had a larger TBSA
did not differ in psychological adjustment problems
when compared to children with less TBSA burned.
Based on the breadth of literature regarding TBSA’s
impact on psychological adjustment, TBSA was further
evaluated in this study (i.e. De Wet, Cywes & Davies
et al., 1979; Smith, Barclay, Quesada, Sedowofia, &
Thompson, 1997).
Premorbid Psychological Functioning Variable
Premorbid psychological functioning was found in the literature to be related to post-burn psychological adjustment
among children, adolescents, and young adults. It should
be noted that for the purpose of this study, premorbid
psychological functioning included psychopathology, psychological symptoms, and coping styles that were present
prior to burn injury. It has been reported that the risk for
post-burn psychological adjustment problems is elevated in
children with a preburn psychiatric history (Clarke &
Martin, 1978; Fauerbach et al., 1997; LeDoux et al., 1998;
Seligman, Carroll, & MacMillan, 1972). Coping styles of
the youth who have experienced burn injury have been
found to be related to poor adjustment and quality of life
(Browne et al., 1985; Sheffield et al., 1988). Literature
Identifying Variables Impacting Post-Burn Psychological Adjustment
on stress and medical disorders suggest that patients
who have premorbid psychological vulnerability show
poorer use of adaptive coping strategies after their burn
injury (Vitaliano, Maiuro, Bolton, & Armsden, 1987).
In addition, La Greca, Silverman, and Wasserstein
(1998) found that premorbid emotional and behavioral
functioning contributed to posttraumatic stress reactions after disasters such as hurricanes. In conclusion,
researchers appear to agree that premorbid psychological functioning impacts post-burn psychological adjustment (Clarke & Martin, 1978; Fauerbach, Lawrence,
Schmidt, Munster, & Costa, 2000; Giljohann, 1979;
Moore et al., 1993; Patterson & Ford, 2000; Rusch,
1998; Seligman et al., 1972; Stoddard, Norman et al.,
1989; Tyack & Zivani, 2003).
Visible Scaring Variable
A common outcome for survivors of severe burn injury
is visible scaring, which may often result in negative
physical and emotional consequences (Sawyer, Minde, &
Zucker, 1982; Williams et al., 2004). The visible scaring
variable relates to the burn victim’s body image, which is
believed to alternately affect psychological well-being.
Body image is a component of the self-concept formed
from both sensory and social experiences (Orr, Reznikoff,
& Smith, 1989; Pruzinski, 2004; Shakespeare, 1998).
Relationships between such experiences (e.g., appearancerelated teasing) and psychological adjustment have been
found in the literature [Yu & Dimsdale, 1999;
Campbell, 1976; Gilbert & Thompson, 2002 (as cited in
Gilbert & Miles); Giljohann, 1979; Jessee, Strickland,
Leeper, & Wales, 1992; Sawyer et al., 1982; Zeitlin,
1997]. Specifically, it has been postulated that when children who are burned are faced with changes in their body
image, they are likely to become anxious and/or
depressed (Stoddard, 1982a). For the purpose of this
study, only visible scarring was considered. Visible scaring
was defined as any burn injury that is visible and has been
defined in terms of location, severity, degree, or TBSA.
Location of Burn Variable
The location of burn impact variable in this study was
defined as the area of the body which the burn occurred.
Authors such as Clarke and Martin (1978) found that
the location of the burn played a role in psychological
adjustment. However, they were unable to determine
why location of burn impacted psychological adjustment.
Demographic Variable
The trauma conceptual model proposes that demographic variables predict psychological maladjustment
over time in children exposed to natural disasters; thus it
was explored in this study (Green, 1991; Green et al.,
1994; La Greca et al., 1996; Pynoose & Nader, 1988). The
demographic variable comprised socioeconomic status
(SES), race, and gender. Although age is a demographic
variable, it was separated into its own category because of
the multitude of studies that focused on it. The three components of the demographic variable will be discussed
here. First, SES plays an important role in psychological
adjustment and the development of adaptive behaviors
after burn injury (Clarke & Martin, 1978; Meyer et al.,
1995). Second, race has also been shown to impact postburn psychological adjustment (Campbell, La Clave, &
Brack, 1987). For example, African-American children
were reportedly more depressed than Caucasian children.
Third, gender has been found in the literature to impact
post-burn adjustment. For example, being male has been
found to be significantly related to better self-esteem and
body image after burn injury (Orr et al., 1989).
Age Variable
The literature varied on how age impacted psychological
adjustment to burn injury. Several studies suggest that
age at the time of the burn was related to post-burn psychological adjustment (Landolt, Grubenmann, & Martin,
2002; Sawyer et al., 1982; Tyack & Zivani, 2003). However, Abdullah et al. (1994) found no significant correlation between age at time of injury and psychological
outcome. Contradictory findings give reason to evaluate
this variable further.
Parental Adjustment Variable
Parents’ psychological state has been found to be predictive of psychological adjustment in children, adolescents, and young adults who have experienced a trauma
such as burn (Beard et al., 1989; Browne et al., 1985;
Goodman & Gotlib, 2002; Moore et al., 1993; Tyack &
Zivani, 2003; Wasserstein & La Greca, 1998). However,
there is limited research regarding the impact of parental
psychological adjustment on child post-burn psychological adjustment. For the purpose of this study, the
parental impact variable will be defined as the parent’s
psychological state and ability to utilize adaptive coping
strategies after their child was burned.
Purpose
The scarcity of empirical research and contradictory
findings among previous studies make it difficult to
determine which of the aforementioned variables have the
greatest strength of association on post-burn adjustment.
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Thus, the purpose of this study was to identify variables
that impact post-burn adjustment and to determine the
strength of association of the following identified impact
variable categories: body location, burn injury, parental
adjustment, premorbid psychological functioning, visible
scaring, demographics, social support, age, and TBSA.
Method
Literature Search Procedure
An extensive literature search was conducted in an
attempt to find studies within the area of child, adolescent,
and young adult burn. The literature reviewed included
studies beginning from 1970, when research of the psychological effects of pediatric burn was initially published,
through 2005. Three methods were used to locate potentially relevant studies: (a) manual search of journals, (b)
review of references from identified studies, and (c) internet resources such as PsychINFO and PsychLit. Within
these sources, keywords such as “pediatric burn, pediatric
trauma, and psychological outcome of burn” were used.
Criteria for Review
To be included in this review, studies had to meet the following criteria: (a) burn injuries were present within the
sample studied, (b) burn injury was defined as any burn
sustained via flame, thermal, radiation, electrical, or
chemical source, (c) studies contained data on variables
which impacted psychological adjustment after burn
injury, (d) study samples had to contain information
about one or more of the identified impact variables, (e)
sample participants had to attain injures that were severe
enough to require medical attention, (f) samples included
children, adolescents, and young adults who ranged from
age 1 month to 23 years, (g) the studies included quantifiable empirical data necessary to compute the strength of
association indices between impact variables and psychological adjustment outcomes, and (h) samples presented
with specific DSM diagnoses (e.g., PTSD, major depressive disorder, and panic disorder), psychological symptoms, or other manifestations of emotional/ behavioral
distress (e.g., academic problems and coping issues).
Coding Procedure
Over 100 studies were reviewed, and two coding procedures were utilized in order to delineate which of these
studies were most appropriate to include in the metaanalysis, given the age and statistical parameters of this study.
The first procedure consisted of coding studies according
to age group: pediatric and mixed age groups. The pediatric
code was assigned to studies that contained burn victims
who ranged from age 1 month to 23 years. The mixed pediatric code was applied to the studies with samples comprised of children, adolescents, young adults, and adults.
The mixed studies were utilized because of the limited
number of studies with participants under 23 years of age.
The second coding procedure categorized studies
with respect to their statistical contribution to this study.
Articles were coded as (a) containing variables that had
statistically significant findings, (b) containing variables
that did not have statistically significant findings, and (c)
containing descriptive and qualitative data.
Data Analysis
This meta-analysis involved a two-stage procedure. Only
studies that utilized univariate and multivariate statistics
[i.e., multiple regressions, conical correlations, t-tests,
chi-square, analysis of variance (ANOVA), and analysis
of covariance (ANCOVA)] and that had significant findings were included in the meta-analysis. In stage 1, studies that provided values (i.e., t, F, chi-square, r, standard
deviation, mean, and degrees of freedom) for identified
impact variables (e.g., age) were converted to strength of
association indices (i.e., r2, η2, Crammer’s V, and ϕ coefficient) using a statistical program written by Alfed Sellers,
PHD (2004) (see Table I). In stage 2, impact variables
from each individual study were delegated into nine
impact variable categories: body location, burn injury,
parental, premorbid psychological functioning, visible
scaring, demographics, social support, age, and TBSA.
The mean strength of association for each of the nine
variable categories was then calculated (see Table II).
Results
In Table I, the strongest associations between individual
impact variables and psychological adjustment were concerns regarding scarring, avoidant coping style, age at
burn, mother’s adjustment, and burn size (log % BSA). In
Table II, the body location variable category had the
greatest mean strength of association and accounted for
.26 of the psychological adjustment. The burn injury variable category (.21) had the second greatest mean strength
of association of the impact variable categories. The
parental variable and the child premorbid psychological
functioning variable had the third greatest mean strength
of association (.15) among all the impact variable categories. The visible scaring variable and the demographic
variable had the fourth greatest strength of association
(.09) indices. Finally, social support (.07), age (.05), and
TBSA (.01) had the lowest strength of association indices
among all nine impact variable categories.
Identifying Variables Impacting Post-Burn Psychological Adjustment
Table I. Strength of Association Indices of Impact Variables in Selected Pediatric Burn Studies
Author and year
N
Adjustment measure(s)
Tyack and Zivani (2003)
68 Vineland adaptive behavior measure
Impact variable(s)
Demographics,
Strength of
association index
r2 = .30
(Functional outcome)
injury,
r2 = .05
premorbid functioning,
r2 = .21
parent variable
r2 = .17
El Hamaoui et al. (2002)
60 Hamilton rating scales for depression and anxiety
Age of child
r2 = .31
Kent, King, and Cochrane (2002)
40 CBCL total
Time since burn
r2 = .01
CBCL internalizing
r2 = .02
CBCL externalizing
r2 = .03
HADS anxiety
r2 = .04
r2 = .04
HADS depression
Smith et al. (1997)
35 Stress response (i.e., depression) Hormone
Burn size (log % BSA)
AVP
r2 = .50
ANP
r2 = .30
AII
r2 = .26
PRA
r2 = .51
ALDO
r2 = .38
NOR
r2 = .18
ADR
r2 = .12
r2 = .39
DA
Bryant (1996)
Baker et al (1996)
35 Watson PTSD Scale
250 (BSHS Scores)
Concern over scaring,
r2 = .41
Avoidant coping style
r2 = .41
Degree of burn
Poor emotional adjustment
r2 = .28
Poor body image
r2 = .24
r2 = .26
Affective
Mason and Hiller (1993)
Orr et al. (1989)
57 General health questionnaire child
121 Semantic differential
Mother’s adjustment
Φ2 = .30
Age
r2 = .01
TBSA
r2 = .01
Body image 1 (strength)
Perceived social
r2 = .01
Body image 2 (animation)
Perceived social
support (family)
r2 = .13
support friends)
Body image 3 (social anxiety and animation)
Age
r2 = .00
TBSA
r2 = .02
Perceived social
r2 = .03
support (family)
Perceived social
r2 = .08
support (friends)
Age
r2 = .00
TBSA
r2 = .00
Perceived social
r2 = .01
support (family)
The Rosenberg Self-Esteem Scale
Perceived social
r2 = .04
support (friends)
Age
r2 = .06
TBSA
r2 = .00
Perceived social
r2 = .07
support (family)
BDI
Perceived social support (friends)
r2 = .16
Age
r2 = .01
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Noronha and Faust
TBSA
r2 = .03
Perceived social support (family)
r2 = .04
Perceived social support (friends)
r2 = .22
Campbell et al. (1987)
286 Clinical interview DSM
Location of burn
Byrne et al. 1986
145 CBCL (social competence)
Burn severity
r2 = .05
Socioeconomic status
r2 = .01
Family environment/support
r2 = .01
Family Enviroment Scale
Browne et al. (1985)
Davidson et al. (1981)
Mother’s adjustment,
r2 = .09
Avoidance,
r2 = .09
ACBP
Emotional distancing,
r2 = .11
ACBP
Recreational activities,
r2 = .08
ACBP
Religiosity
r2 = .08
Age during study
η2 = .13
Social support (family/friends)
r2 = .16
145 ACBP
Knudson-Cooper (1981)
Cramer’s V = .26
89 Coopersmith Self-esteem
314 Coopersmith Self-esteem
Life satisfaction
r2 = .14
Recreational activities
r2 = .02
Locus of control
r2 = .02
Satisfaction with education
r2 = .04
Contact with Team
r2 = .04
Perceived help
r2 = .06
ACBP, Achenbach Child Behavior Profile; BDI, Beck Depression Inventory; BSA, body surface area; BSHS, Burn Specific Health Scale; DSM, Diagnostic Statistical Manual;
HADS, Hospital Anxiety and Depression Scale; TBSA, total body surface area.
Table II. Mean Strength of Association of Impact Variables
Impact variables
Body location
Mean strength
of association
.26
Burn injury
.21
Parental
.15
Premorbid psychological functioning
.15
Visible scaring
.09
Demographic
.09
Social support
.07
Age
.05
Total Body Surface Area
.01
Discussion
A major implication of this study is that the impact variables identified and evaluated will be useful in targeting
child, adolescent, and young adult burn patients who
are at risk for psychological adjustment problems. This
emphasizes the importance of utilizing brief psychological screening measures with patients who have been
identified as having one or more impact variables.
The body location variable had the greatest mean
strength of association in impacting post-burn adjustment. Perhaps this was because pain and functionality
were also affected by body location. Nover (1973),
Stoddard (1982b), and Stoddard and O’Connell (1983)
were of the few who addressed pain and functionality as
independent factors in terms of psychological adjust-
ment. Their studies found that exposure to physical pain
and experiencing limited physical functionality increased
the likelihood of psychological maladjustment. Keeping
this in mind, healthcare professionals may need to
increase use of interdisciplinary interventions since pain
and functionality are likely linked to psychological
adjustment as in pediatric sickle cell disease research
(Lutz, Barakat, Smith-Whitley, & Ohene-Frempong,
2004). Because pain and functionality were not controlled for, or separated in the previous literature, they
may have elevated the body location variable’s strength of
association index. Hence, it would be important for
future research to evaluate moderating and mediating
variables such as these.
The burn injury variable had the second greatest
mean strength of association. This finding contradicted
Blakeney and Creson’s (2002) article that suggests
injury-related variables such as the presence of amputations and the depth of the burn did not predict psychological outcome. The present study’s findings regarding
the burn injury variable may be attributed to the fact
that several burn injury-related variables were placed
into one impact variable category, which may have
superficially elevated its mean strength of association. It
would be important to separate and individually examine variables included in this category in future research.
The parental variable and the child’s premorbid
psychological functioning variable were both found to
be associated with post-burn psychological adjustment.
Identifying Variables Impacting Post-Burn Psychological Adjustment
This was consistent with previous research (Blakeney
et al., 1990; Blakeney, Robert et al., 1998; Browne et al.,
1985; LeDoux et al., 1998; Moore et al., 1993). It is
likely both had equal mean strength of association indices because parental psychological functioning has been
found to be related to children’s psychological development (Power, 2004).
The social support, age, and TBSA impact variables
had the lowest strength of association indices (<.09)
among all nine impact variables. It was interesting to find
that the social support variable had such a low strength of
association index, given that one would expect it to be
related to the parental variable based on previous research
that suggests that parent emotional state may be related to
the quality of support parents provide (Power, 2004;
Prinzie et al., 2004; Satake, Yamashita, & Yoshida, 2004).
For example, even though a child may directly experience
the trauma of being burned, the parent also may experience the trauma of witnessing the distress of their child
and may not be able to provide emotional support needed
by the child to ensure their healthy adjustment. The social
support, age, and TBSA impact variables have minimal
impact on post-burn psychological adjustment; therefore,
they may be least helpful in identifying children, adolescents, and young adults at risk.
There were three major limitations of this study. First,
because this study utilized meta-analytic procedures,
results were limited by the data provided by the previous
studies. Second, it is unknown whether the diversity of
adjustment measures and respective outcomes led to the
results of this meta-analysis. For example, previous studies
have not been able to distinguish between the disorder of
depression and depressive symptoms. Third, the present
meta-analysis did not account for the impact of moderating and mediating variables. The variability in the strength
of association indices may be due to the impact of mediator and moderator variables that were not accounted for
across the research. These limitations highlight the need to
conduct well-controlled, well-designed studies to further
investigate risk factors associated with maladjustment
among child, adolescent, and young adult burn survivors.
This study has several implications for future
research in the area of pediatric burn. More empirical
research is needed to further investigate the potential
risk factors associated with this population especially
because results may be generalized to other areas of
pediatric injury such as spinal cord injury and amputation (Blakeney, Robert et al., 1998). This study draws
attention to the importance of utilizing psychological
screening measures and promotes the development of
measures that are specific to this population. Further-
more, the present findings may serve as a starting point
for developing clinical interventions that may increase
the likelihood of positive psychological adjustment.
One factor that was not commonly discussed in the
pediatric burn literature or this study that may play an
integral role in the prediction of post-burn adjustment,
based on the conceptual model for predicting children’s
reactions to natural disasters and accidental injuries, is
exposure to the actual trauma (i.e., house fire, car accident,
and explosion) (La Greca et al., 1996). Rusch (1998)
reported that factors that are predictive of poor post-burn
psychological adjustment are threat of death and exposure to shocking images. Perhaps, future research could
evaluate exposure to trauma as a predictor variable.
Finally, although there has been advancement in the
integration of psychological services in the medical field,
there is no evidence of empirically developed interdisciplinary models and interventions addressing the needs
of child, adolescent, and young adult burn patients in
the literature.
The lack of theoretical models for child, adolescent,
and young adult burn survivors may in part be due to
the paucity of adequate theory behind the research.
Those that may have utilized a theoretical framework to
guide their research were likely to have utilized the
medical model or stage theory. These models are inadequate for describing the dynamic experiences of a young
burn patient and may lead to overemphasis of medically
related variables as predictors in recovery (Clark, 1999;
Patterson et al., 1993). For example, because there are
other factors that may be particular to burn injury such
as TBSA, other models (i.e., trauma model) may not be
comprehensive and specific enough for this population.
Keeping theoretical limitations in mind, this study utilized trauma-related conceptual models such as the
Blakeney and Creson (2002) “habilitation” model to
explore variables that may impact this population’s postburn psychological adjustment. Results of this metaanalysis were consistent with La Greca et al.’s (1996) conceptual model that utilizes premorbid psychological functioning and parental factors as predictors of children’s
reactions to natural disasters. In conclusion, a pediatric
burn model may help healthcare professionals be more
effective and efficient in assisting in the psychological
recovery of children, adolescents, and young adults.
Acknowledgments
We wish to express our deepest gratitude for Dr. Alfred
Seller’s contributions and encouraging support throughout the development of this study.
387
388
Noronha and Faust
Received September 13, 2005; revision received March 1,
2006; accepted June 2, 2006
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