Burns 24 (1998) 425-432

Relationship between parental emotional states, family environment

the behavioural adjustment of pediatric burn survivors
. LeDoux, W. J. Meyer III”, P. E. Blakeney, D. N. Herndon
Depatfnzetzf oj’ Family Services Shrirzers Bums Imtitute. and Department off’g~chiatry, The University qf Texas Medical Brarzclz, Galveston. TX, USA

Accepted 12 February 1998

Abstract

The purpcse of this study was to examine the relationship between psychosocial adjustment of the burned child and
characteristics of the child’s family. It hypothesized that parents who perceived their children without major behavioural
probiems would possess supportive family values and would, themselves, be better adjusted psychologically than those parents
who perceived their children as possessing multiple behavioural problems. A stratified random sampling technique was used to
select 35 (29 boys, 6 girls) paediatric burn survivors, ages 9 to 18, l-5 years post-burn, with burn sizes ranging from 3 to 92%
burn. Subjects’ parents were administered the Child Behaviour Checklist (CBCL), the Family Environment Scale (FES), the
Impact of Events Scale (IES), and the Beck Depression Inventory (BDI). The subjects were divided into two groups on the basis
of the total FlroblemCBCL scores,i.e. troubled (T360) or untroubled (T<60). One-way ANOVA testsrevealed no significant
differences between the two groups in the way parents reacted to trauma (IES) and parental depression (BDI). Significant
differences (‘JJ~0.01) were revealed between the two graups on FES subscales. The parents of the untroubled group scored
higher on ‘Cohesion’ and ‘Organization’ and lower on ‘Conflict’. ‘These parents also scored higher (pGO.05) on ‘Achievement
Orientation’. The results indicate that work with the family to promote cohesion, to decrease conflict, to enhance stability and
to promote expectation of positive achievement must be a part of the rehabilitation of the burned child. 0 1998 Elsevier Science
Ltd for ISBI. All rights reserved.

Keywords: Buras; Children; Psychology; Rehabilitation; Family

1. Imtrodmtion date these previous findings and to determine the

That burn children and their families experience
difficulties during the recovery period is well known.
Identifying the factors that most affect the quality of
the recovery process for these children and their
families is crucial in finding ways to maximize their
adjustment. Once these children are physically healed
and are ready to re-enter society, they begin to
encounter new challenges and stresses. Several
outcome studies of childhood burn injuries indicate
that a significant number of burned children develop
psychological probems. However, these studies also
found that burned children can be well adjusted
psychologically and socially [l-8]. The most consist-
ently recognized contributor to psychosocial adjust-
ment of burn survivors seemsto be the family support
system [6,7.1. The present study was designed to eluci-
*Gorresponding author. University of Texas Medical Branch: 301
University Boulevard. Galveston, TX 77555-0133, USA.
0305-4179/98/$ i 9.00 + 0.00 0 1998 Elsevier Science Ltd for ISBI. All rights reserved
PII: SO305-4 I79(98)00038-2
effects of parental emotional states on the burned
child’s adjustment.
2. Purpose
The purpose ‘of this study was to examine the
relationship between long-term psychosocial adjust-
ment of the burned child and characteristics of the
child’s family, including the emotional status of the
parent. It was hypothesized that the family environ-
ment of burned children would be disorganized and
unstable compared to a normal reference population.
In addition, parents who perceived their children as
not having behavioural problems (untroubled) are
hypothesized to possess specific family values that
differentiated them from parents who described their
children as having multiple behavioural problems
(troubled). Finally, it was hypothesized that the parents
describing their children as untroubled would
426 J. LeDoLLx et ul.ib~ms 34 (1998) 425-432

Table 1 T = 60. There were no statistically significant differ-

Demographic da:a of subjects (N = 35)
ences between the troubled and untroubled groups in
Male Female % Burn Age at burn Age at test gender, TBSA, age of child at burn, age of child at
(Mean + SD) (Mean i SD) (Mean i SD) testing, or time since burn. Table 3 illustrates the
demographic data on the two groups.
29 6 37.20+-21.88 10.55+2.83 13.25 i2.70
The Family Environment Scale (FES) [lo] is
composed of 90 true/false statements that relate to ten
themselves be better adjusted psychologically than subscales reflecting social-environmental character-
those parents who perceived their children as troubled. istics of families within three domains: the Relationship
domain, the Personal Growth domain, and the System-
Maintenance domain. The Relationship dimensions are
3. Methods measured by the Cohesion, Expressiveness, and
Conflict subscales. The Personal Growth dimensions
3. I. Populatiorl are measured by the Independence, Achievement
Orientation, Intellectual-Cultural Orientation, Active-
Thirty-five families who were patients at the Shriners Recreational Orientation, and Moral-Religious
Burns Institute in Galveston, Texas, were selected subscales. The System-Maintenance dimensions are
using a stratified random samp1in.g technique. The measured by the Organization and Control subscales.
paediatric burn survivors consisted of 29 boys and 6 The Beck Depression Inventory (BDI) [l l] is a
girls with burn sizes ranging from 3 to 92% total body 21-item rating of severity of depression. According to
surface area (TBSA). Their ages were 9 to 18 years, the BDI manual [ll], BDI total scores greater than 15
and they were 3 -5 years post-burn. Table 1 records the mav detect possible depression. In addition, Beck and
mean age at burn, mean age at testing, and the mean Steer [II] offer guidelines established by the Center for
TBSA of burn for each sex. Cognitive Therapy to classify the levels of depression:
The burned children were classified by level of scores from 0 to 9 are considered within normal range
severity according to their TBSA. TBSA from 1 to 24% of affect; scores of 10 to 18 indicate mild-moderate
is considered mild; TBSA from 25 to 39% is depression; scores of 19 to 29 indicate moderate-
considered moderate; and TBSA greater than 39% is severe depression; and scores above 29 indicate
considered severe. Table 2 records the mean TBSA, extremely severe depression. Oliver and Simmons [12]
the mean age at burn, and the mean age at testing for found that a BDI cutting point of 18/19 for epidemio-
each classification by severity. logic purposes yielded an unbiased estimate of the
prevalence of depression diagnosed by the DSM-III.
3.2. htiuments The impact of Events Scale (IES) 1131 is a 15-item
rating that measures intrusive thoughts and avoidance
The Child Behaviour Checklist (CBCL) [9] is a in response to traumatic events. After extensive scale
standardized measure of parental perception of their revisions and validation with patients with stress
children’s behavioural problems and competence; it disorders, Horowitz and co-workers [13,14] established
contains a 113-item rating of a child’s current a cut-off score of 20 for each of the two subscales.
behaviour problems as perceived by the parent. Scores above 20 on either the Avoidance or Intrusion
According to the CBCL total problem score, the subscales were found to be predictive of significant
children were then divided into those with multiple stress response symptomatology and a DSM-III
problems or ‘troubled’ (N = 9) and those with few diagnosis of posttraumatic stress disorder.
problems or ‘untroubled (N = 26) groups on the basis
of the CBCl total problem T score of 60. Acenbach [9] 3.3. Protocol und analysis
suggests that children who scored more than one
standard deviation above the mean on the CBCl One parent of each child completed the CBCL, FES,
receive further psychological examinations; this point is BDI and IES. In most cases (32 of 35) t
participating were the mothers. Using the t-test for
Tzble 2 standard populations, the study group was compared to
Demographic data elf subjects by severity levels
______.. -~_- the respective reference populations provided by the
Classification N % Burn Age at burn Age at test
instruments and the literature. As stated above, the
by severity (MeankSD) (MeankSD) (MeankSD) sample was divided into troubled (CBCL total problem
-___-.~ score 3 60) and untroubled (CBCL total problem score
Mild 12 15.17k4.99 10.20+2.69 13.07k2.55 ~60). Then the data concerning the parents and
Moderate 9 30.11&5.58 10.47* 1.81 13.08 +2.23
Severe 14 60.64&11.70 10.91*3.54
families of the troubled and untroubled children were
13.53k3.22
compared with each other using the Student’s t-test.
 J. LeDoux et d/Bums 24 (1998) 425-432 427

Table 3
Demographic data of subjects by adjustment groups

Group N % Burn Age at burn Age at test

(Mean + SD) (Mean k SD) (Mean i SD)

Troubled (CBCL score Ta60) 9 32.44i19.46 11.10+2.63 13.78 k2.56

Untroubled (CBCL score T< 60) 26 38.85i22.78 10.37k2.92 13.07k2.17

Finally, a one-way ANOVA was used to examine the
effect of severity of burn on the variables measured. In
all cases ap co.05 was considered significant.
4. Results
When the clinical sample of perceptions of family
characteristics were compared to the reference popula-
tion on the FES [lo], results revealed that the clinical
families were significantly higher on ‘Cohesion’ in the
Relationship domain (p < 0.02), on ‘Moral Religious
Emphasis’ in the Personal Growth domain (p < O.Ol),
and higher cn ‘Control’ in the System-Maintenance
domain 07 ~0.01) (see Fig. 1).
One-way ANOVA tests based on severity of injury
levels revealed no significant differences on any of the
scales in the CBCL, the BDI, or the IES. A significant
difference (p = 0.001) (see Fig. 2) was revealed relating
to severity level on Control’ on the FES. The families
of the mild and moderate injury groups appeared to be
more controlling than families of the severe injury
group.
Based on a BDI cut-off score of 15, 97% (34 of 35)
of the parents scored 15 or below. Of the 34 parents,
borderline BDI totals were scored by 2 parents; 8
parents scored between 10 and 12 indicating that they
had some depressive symptoms; and 24 parents scored
below 9, which is considered within normal range. A
total of 29 was scored by 1 parent indicating
moderate-severe depression. It should also be noted
that the 34 parents who scored totals of 15 or below
are well within the limits of the cut-off point of 18/19
as recommended by Oliver and Simmons [12].
Using a cut-of score of 20 on’ each scale of the IES,
86% (30 of 35) of the parents scored below 20 on the
Avoidance Scale, and 71% (25 of 35) scored below 20
on the Intrusion scale. Using a combined score for
both scales, 88% (31 of 35) of the parents scored below
40, indicating that they were not experiencing signifi-
cant stress related to the trauma of their children’s
burn injuries.
As shown in Fig. 3 no significant differences between
the untroubled and troubled adjustment groups in the
way parents reacted to trauma (IES) or in parental
depression (BDI) were detected.

Comparison of Mean Scores Of Family Environment Scale

II Burn Group (N=35)

Cobs* Express CFLT lndep A0 ICO AR0 MRE” ORG CTL’”

tpc.02
**p<.o1

Fig. 1. Comparison of mean scores of the family environment scale (FES).

128 J. LeDou et uI.IBums 24 (1998) 425-432

Comparison of Mean Scores E3ySeverity Levels Of The

“Control” Subscale of Family Environment Scale
10

Mild Moderate Severe

ps.001
Fig, 2. Comparison of mean scores by severity levels of the ‘Control’ subscale of the family environment scale (FES).

Significant differences at the p co.01 level were 5. Discussion

revealed between the two adjustment groups on FES
subscales (Fig. 4). The parents of the untroubled group
rated their families higher on ‘Cohesion’ and ‘Organiz-
ation’ and lower on ‘Conflict’. These parents also
scored higher 0, < 0.05) on ‘Achievement Orientation’.
These FES differences cannot be accounted for by
burn size.
This study supports previous findings that the
majority of burned children (26 of 35) as measured by
the CBCL adjusted well psychologically regardless of
size and severity of the burn injury [l-X]. Furthermore,
the families as a group seemed no more traumatized or
depressed that the normal reference population. In

Comparison Of Mean Scores Of Impact Of Events

Scale Between Adjustment Groups
I Troubled (N = 9)

El Untroubled (N = 26)

Avoidance Intrusion Total

Fig. 3. Comparison of mean scores of impact of events scale between adjustment groups.
 J. LeDoux et al.lBurrn 23 (1998) 125-432 429

Comparison Of Mean Scores Of Family Environment Scale

Between Adjustment Groups
80 H Troubled (N = 9)
!J3 Untroubled(N=26) p T
3

0
Cohes.* Express CFLT* lndep AO** co AR0 MRE ORG* CTL
l pr .Ol
“p5.05

Fig. 4. Comparison of mean scores of the family environment scale (FES) between adjustment groups.

fact, the FE!< scores suggest that the families of the
burned children may provide an environment that is
strong in vaiues and is thought to promote psycho-
logical health. The subject families, as a group, are
more cohesive, place greater emphasis on moral and
religious values, and are more controlling than the
normal reference population. These characteristics are
very similar to those found in studies with other
populations 1.0 be associated with positive adjustment.
Based on clinical experience, McCubbin and Figley
[15] and Figley [16,17] identified 11 universal charac-
teristics that differentiate families who cope well with
stress and trauma from those who do not; family-
centred focus of the problem, high family cohesion,
absence of violence and infrequency of substance use
were four that would seem to overlap with the charac-
teristics of the families in the current study. A study of
paediatric cancer patients reported that parental
efforts at maintaining family integration and coopera-
tion plus an optimistic definition of the illness were
associated with better adjustment in children ill with
cancer [18]. ‘Within the burn population, in addition to
the current study, our earlier studies of two different
samples fotmd a significant relationship between family
cohesion and better psychological adjustment [6,7].
Commitment and support among family members and
the ability of the family to pull together as a unit seem
to be crucial factors in coping with the unavoidable
stress caused by trauma within the family unit.
In our current sample, as well as in our earlier
studies [6,7] and the studies of Sanger et 01. [18], not
all families are equally able to pull together in cohesive
fashion. That the total group of parents of burned
children describe their families as more cohesive than
the normal reference group seems to suggest that this
‘pulling together’ may be a general adaptation to
trauma rather than an inherent family characteristic. In
addition to cohesion, families of successfully adapting
children were also more organized, less conflicted, and
placed greater value on achievement. In these charac-
teristics, the families of good adaptors of this study are
similar to those of the successful ‘capers’ of McCubbin
and Figley [15] and Figley [16,17] and to those of
socially competent burned children described by Byrne
et al. [5]. Perhaps the observations of the current study
a.re of a group of families attempting to cope with the
aftermath of a frightening and disfuguring traumatic
injury by drawing more closely together as a unit; but
other characteristic of the family enhance that adapta-
tion, and, when those are lacking, families do not
provide the support necessary for the burned child’s
successful adjustment.
It is important to note that the families of ‘troubled’
children did not show these differences. Results
indicate that the value structure of the family is linked
to good behavioural adjustment fior the burned child.
The current study was conducted post-burn and, there-
fore, reflects characteristics of the family as they have
evolved in response to the burn. These families may be
scoring higher than the norm on many positive family
characteristics because they are pulling themselves
together during their times of crises,
130 J. LeDom+ rt nl.~Bums
Perhaps these data reflect a development of defen-
sive coping strategies by reporting positive character-
istics. The question then arises of how adaptive these
defensive coping strategies are. Blakeney et al. [19]
sugested that parents’ coping strategies such as denial
may exacerbate difficulties in other areas of their lives.
Their reported family cohesiveness may be a part of
denial. It is certainly adaptive for families to pull
together and turn to religion. However, the ability to
focus their energies, organize their time, and pursue
with optimism the goal of achieving good outcome will
enhance the adjustment of the burned child. If the
parents are denying family problems and are
themselves ignoring their own emotional states, then
Lhere maybe a breakdown in the family system by
creating feelings of isolation. The burned children may
maladaptively learn to deny their feelings and experi-
ences, thus inhibiting optimal recovery.
Importantly, the results of this study provide further
support that enduring family vaIues appear to be most
influential in the burned child’s adjustment. In
particular, cohesive, organized and achievement
oriented families are found to facilitate the burned
child’s adjustment process. Previous studies by
Blakeney et al. [6] reported that positive psychological
adjustment was predicted by greater family cohesion,
independence and more open expressiveness within the
family. Byrne et al. [.5] found that an intellectual/
cultural emphasis with the family and family involve-
ment in sociai and community activities distinguished
socially competent burned children from the children
less competent in social interactions. Commitment and
support from the family members as well as their
ability to puil 1:ogether and utilize their resources are
crucial factors in coping with the unavoidable stress
caused by trauma within the family unit [5,15-181.
Also of interest are the results of the FES when
compared by severity levels. Although our previous
studies revealed no significant findings regarding injury
severity, these new findings may suggest that families of
burned children with smaller burns may be more
controlling than those families with larger, more severe
burns. Other studies have produced divergent opinions
concerning the relationship between burn severity and
adjustment. Andreason et al. [20] and Bowden et al.
[Zl] suggested that the adjustment problems were a
function of the burn severity. Byrne et al. [5] found that
children with bigger burns had fewer problems. In
contrast: Blakeney et al. [6] and Meyer et al. [22] found
that there was no relationship between psychological
adjustment of the child or parental stress and burn
size. It should be noted that results of this study
revealed no other relationship of injury severity with
the other scales in the FES or the other instruments.
Therefore, the issue may not be one of burn severity,
but rather of a relationship between control and
24 (1998) 425-432
parental emotional states. A parent who is in general
more vulnerable to stress or depressed feelings may
have a greater need to develop exercise of control as a
defensive coping strategy. Those families who tend to
be more controlling may be struggling to control family
life as a way of defending against the stress and worry
over their burned children and the feeling that every-
thing is falling apart.
Although parents of the ‘troubled’ children did not
report significantly higher levels of depression or exces-
sive avoidance or intrusive thoughts of their children’s
burn traumas, when compared to the ‘untroubled’
group, their reported family characteristics indicate
that family life for these ‘troubled’ children is not
conducive to good adjustment. These findings raise two
questions. (1) As initially posed by Meyer et al. [22],
are the burned children’s behavioural problems caused
by parental difficulties, or the converse? (2) Are the
parental difficulties caused by the characteristics of
their family systems or are these family characteristics
exacerbating parental difficulties, thus contributing to
their children’s perceived maladaptive adjustment?
Results from this study indicate that parental
emotional states immediately following a child’s burn
injury may resolve with time and do not significantly
impact the behavioural adjustment of the child post-
burn. Cella et al. 1231 found that within the first week
of their children’s hospitalization, delpression, hopeless-
ness, and stress-response symptoms to intrusion and
avoidance among parents of burned chi’,dren were
significantly more promiment than parents of children
hospitalized for other procedures. Results from
another study by Cella et al. [24] revealed that the high
levels of depression and anxiety experienced by
relatives of patients with burns returned to the
presumed baseline at a 6- to &month post-burn period.
These results also revealed that a quarter of the
relatives studied continued to show elevated avoidant
thinking and intrusive recollections of the event while
the other 75% receded to within the normal range.
The mean levels of depression, avoidant thinking and
intrusion for parents at l-5years post-burn in this
study are not significantly different from Cella’s [24]
non-burn group at 1 week nor are they different from
the relatives of burn patients at 6 to 8 weeks and 6 to
8 months (see Table 4).
Blakeney et al. [19] used the Parenting Stress Index
(PSI) to study stress among parents of burned children
and found that these parents’ depression levels
appeared to normalize at 3 years and to be significantly
less at 4 and 5 years than either the normative sample
or the group of parents who had children with acute
burns. As stated earlier, these authors suggest that
parents of burned children may develop defensive
coping strategies, such as denial, that serve to minimize
their depressed feelings but may exacerbate difficulties
 J. LeDoru et al./Bwm 24 (1998) 425-432 431

Table 4
Emotional ad”ustment to burn trauma of family members versus other stress-related events

Study N Time BDI: depression IES: avoidance IES: intrusion

scale range O-63 scale range O-40 scale range O-35

LeDoux er al. (current study). Parents of burn group 35 1-5 years 6.06k6.1 12.35 + 9.0 14.27i9.6
Cella et al. [24]. Parents of non-burn group 22 1-7 days 5.7+5.0 9.9k7.2 12.4 + 8.5
Cella et al. [24]. Parents of burn group 36 1-7 days 12.3 is.6 15.0 + 9.9 19.3 + 9.9

in other arcas of their lives. Identifying and recognizing beyond the initial coping pha,se in order to help
the defensive coping strategies used by these parents families develop characteristics that enhance success.
may be critical, since helping the burned children Work with the family to promote cohesion, to decrease
through their own recovery largely depends on their conflict, to enhance stability and to promote expecta-
parents and families. Family support, particularly tion of positive achievement rnust be part of the
parental support, has been consistently reported to be rehabilitation of the burned child.
a critical factor in the long-term recovery and rehabili-
tation of the child with burns [4-7,19,25-301. Meyer et
ai. [22] was the first to utilize the CBCL clinical cut-off References
score of 66 to divide burned children into ‘troubled’
and ‘untroubled’. Using the PSI, results of their study Blakeney P, Meyer W, Moore P, Broemeling L, Hunt R,
PI
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