Susanne P. Martin-Herz

Psychological principles of burn wound pain in children. II: Treatment applications.

The pain involved in acute burn care can be excruciating and intractable. Even the best pharmacologic pain control efforts often fail to adequately control pain, especially procedure-related pain, in pediatric patients with burn injuries. Nonpharmacologic interventions have been found to be effective in reducing pain in both children and adults and can be extremely important adjuvants to standard pharmacologic analgesia in the burn care setting. In the first article in this series, we outlined psychological factors that influence the emotions, cognitions, and behaviors of children during wound care. Building on this theoretical framework, we now present a detailed discussion of the implementation of nonpharmacologic intervention strategies in the burn care setting. Because accurate measurement of discomfort is imperative for the development of interventions and for the evaluation of their efficacy, we begin with a brief review of pain measurement techniques. We follow this with suggestions for tailoring interventions to meet specific patient needs and conclude with a detailed and practical discussion of specific intervention techniques and the implementation of those techniques.

Recurrent Headache in Adolescents: Nonreferred Versus Clinic Population

Objective.—To compare headache activity, psychosocial measures, and cold pressor response between referred and nonreferred adolescents with frequent headache.

Comparison of pain control medication in three age groups of elderly patients

There are no published reports of burn pain management in the elderly population. To assess the range of requirement and use of opioids among elderly patients with burns of different age categories, a retrospective review of 89 consecutive admissions of patients over 55 years of age (January 1995 through July 1996) was conducted. Complete data were available on 44 patients with a burn mean total body surface area of 17.2%. Patient ages ranged from 55 to 92 years. Individuals were divided into three age categories: Group I (55 to 65) n = 20; Group II (66 to 75) n = 14; and Group III (76 to 92) n = 10. Use of commonly prescribed opioids for procedural pain and breakthrough pain were evaluated. We compared the opioid equivalents of medications prescribed versus the actual amount administered. Paired t tests comparing minimum amount of medication ordered with that given revealed Group I patients received significantly more procedural medication than the minimum prescribed (t = 3.88, p = 0.001), and that Group III patients were given significantly less as needed medication than the minimum prescribed (t = 2.58, p < 0.05).

Psychological principles of burn wound pain in children. I: theoretical framework.

Burn injuries and the care of burn injuries are punishing experiences for hospitalized children. Pain, novelty, and altered reinforcement schedules elicit instinctive escape and avoidance behaviors that complicate wound care. An understanding of the psychological principles that underlie these complex, complicating behaviors paves the way for effective cognitive and behavioral interventions. In this first article of a two-part series, we use the principles of classical conditioning, operant conditioning, and control coping to describe the developmentally normal emergence of avoidance behaviors that are incompatible with burn wound care. Then, using brief case examples, we outline how classical conditioning transforms neutral stimuli into anxiety-producing, fearful stimuli, how operant behaviors are intentionally or unintentionally reinforced, and how the umbrella of reduced control in the novel hospital environment makes coping difficult for children. We conclude by discussing obstacles to effective application of cognitive and behavioral strategies for the enhancement of control and of compliance with wound care.

Perceived risks and benefits of HIV testing, and predictors of acceptance of HIV counselling and testing among pregnant women in Zimbabwe

This project evaluated perceived risks and benefits and determined predictors of acceptance of voluntary HIV counselling and testing (VCT) among pregnant women in Zimbabwe. One hundred and seventy pregnant women attending an urban antenatal clinic were surveyed. Implications of a negative or positive HIV test result and of telling a partner or community members that one is HIV positive were queried. Forty women (23.5%) consented to VCT, and 16 (40%) were HIV positive. Women who saw VCT as lower risk (odds ratio [OR] = 2.3, 95% confidence interval [CI] [1.1–5.0]) and women who had had a stillbirth or child die (OR = 0.4, 95% CI [0.16–0.97]) were more likely to consent. Prenatal HIV VCT offers the best opportunity for prevention of mother-to-child transmission of HIV; however, less than 25% of women consented. If such interventions are to be successful, attention must be directed towards developing culturally appropriate strategies to address womens concerns and improve future acceptance of VCT in Zimbabwe.

Correlates of reinjury risk in sibling groups: a prospective observational study.

OBJECTIVES: The objective of this study was to identify child, parent, and family characteristics that are associated with short-term recurrence of injury within sibling groups. METHODS: A prospective cohort study was conducted of 92 children who were aged 0 to 15 years and treated for injury at a regional pediatric trauma center and their 166 siblings. The outcome of interest was a second or subsequent injury in the sibling group, occurring within 3 months of the index injury event. Explanatory variables included injury variables, child factors (age, gender, previous injury experience, behavior problems, and traumatic stress symptoms), parental factors (age, education, social support, depressive symptoms, and traumatic stress symptoms), and family factors (socioeconomic status, family function, family structure, and life events). Poisson regression was used in multivariable models with statistical adjustment for clustering within sibling groups. RESULTS: More than 19% of families had at least 1 child injured or reinjured during 3 months of follow-up. The rate of reinjury to index children (8.7%) was similar to that in siblings (7.2%). Controlling for age, gender, and race, the risk for reinjury during follow-up was increased with single-parent family structure (relative risk [RR]: 3.39 [95% confidence interval (CI): 1.69–6.80]), receipt of public assistance (RR: 3.65 [95% CI: 1.61–8.28]), and clinically significant posttraumatic stress disorder arousal symptoms in the child (RR: 3.76 [95% CI: 1.51–9.33]). CONCLUSIONS: Along with their siblings, children who receive treatment for injury are at short-term risk for additional injury. Children in single-parent households, in families who receive public assistance, and those with posttraumatic stress disorder arousal symptoms 1 month after injury to themselves or a sibling are at highest risk. These associations could be used to develop interventions to identify and support families through periods of high injury risk.

Predictors of Parental Posttraumatic Stress Disorder Symptoms in the Year After Adolescent Traumatic Injury

OBJECTIVES Parental posttraumatic stress disorder (PTSD) is common after pediatric traumatic injury and may negatively impact parental functioning and quality of life during this key period of the childs early postinjury recovery. This study aimed to evaluate the course and predictors of PTSD in parents during the year after an adolescent traumatic injury. METHODS This prospective cohort study included a population-based sample of 99 parent-adolescent dyads. Assessment was through structured interview administration of standardized measures. Interviews were conducted within 30 days of injury and 2, 5, and 12 months after injury. Mixed model regression was used to evaluate variables potentially associated with repeated measures of parental PTSD symptoms at the follow-up time points. RESULTS Twenty-three percent of parents met symptomatic criteria for PTSD at the first postinjury evaluation, as did 15% at 2 months, 7% at 5 months, and 6% at 12 months after the injury. The percentage of parents meeting symptomatic PTSD criteria decreased significantly between the 2-month and 12-month evaluations. Mixed-model regression analyses revealed greater PTSD symptoms within 30 days of injury and a greater number of postinjury parental traumatic and/or stressful life events as significant predictors of parental PTSD. Adolescent factors did not affect the risk of parental PTSD. CONCLUSIONS A substantial subgroup of parents demonstrate high PTSD symptom levels during the course of the year after an adolescent injury. Given that early modifiable risk factors can be identified, future investigations focusing on screening and intervention are warranted.

Ethical challenges in research with orphans and vulnerable children: a qualitative study of researcher experiences

BACKGROUND Orphans and vulnerable children (OVCs) represent a significant population worldwide, enduring poor health and living conditions. Evidence-based interventions are needed. However, without parents, ethical concerns about including OVCs in research persist. The aim of our study was to better understand the ethical challenges facing researchers who work with OVCs. METHODS We conducted semi-structured interviews with 12 international pediatric researchers working with OVCs in seven countries. We used descriptive content analysis to characterize the ethical rationale for inclusion and associated challenges. RESULTS Researchers believed research was justified as a necessary means for informing evidence-based interventions to benefit OVCs directly or as a population. Ethical challenges included difficulty identifying OVCs given variation among children living without parents; difficulty identifying guardians among a range of caregivers; concerns about meaningfulness of guardian consent; difficulty assessing risk; and responding to childrens many needs. CONCLUSIONS A range of caregivers bear responsibility to protect OVCs interests in place of parents in research but are often not prepared to do so. This places greater burden on researchers to assess risks and respond to childrens needs. Findings suggest that we should improve support and rethink the roles of guardians, researchers and older children in research participation and protection.