Psychosocial Interventions Targeting Recovery in Child and Adolescent Burns

A Systematic Review

Nancy Hornsby, MA (NEUROPSYCHOLOGY); Lisa Blom PHD; Mathilde Sengoelge, PHD


J Pediatr Psychol. 2020;45(1):15-33. 

In This Article

Abstract and Introduction


Children post-burn injury experience a range of psychosocial sequelae that benefit from early provision of psychosocial support. However, no systematic review exists evaluating the full range of psychological interventions.

Objective: To critically evaluate psychosocial interventions for children (<18 years old) with burn injuries in improving psychosocial recovery.

Study design: All-language studies were identified from inception to March 2018 in six electronic databases and appraised according to PRISMA checklist and Cochrane Risk of Bias Tool for quality. Studies were stratified into three groups: distraction (virtual reality, child life therapy, imagery-based therapy, hypnosis), burn camps, and other (social skills, cognitive behavioral therapy, parent group counseling).

Results: Out of a total of 5,456 articles identified, 297 underwent full review resulting in 27 included articles published between 1986 and 2018. Sample sizes ranged from 9 to 266, comprising child and adult participants. A range of interventions and psychosocial outcome measures were found. Several studies (n = 21) reported statistically significant improvements in outcome; the majority were distraction interventions to reduce pain and anxiety. A limited number of studies showing effect was found for cognitive behavioral therapy and parent counseling. Risk of bias was high in studies of burn camps and mixed for all other interventions.

Conclusions: A range of psychosocial interventions and outcome tools exist in pediatric burns. Distraction interventions prior to and/or during dressing changes or physical therapy were shown to effectively reduce pain and anxiety for a wide range of pediatric ages.


Pediatric burns are devastating injuries and progress has been made worldwide for their prevention due to a range of primary prevention measures, such as smoke alarms and thermostatic mixing valves (Mock, Peck, Peden, & Krug, 2008; Smolle et al., 2017). As a result of scientific advances in management of acute burns (e.g., grafting) and the multidisciplinary care offered by specialized pediatric burn centers, the survival rate of children with severe burns has increased considerably (Hyland & Holland, 2015). The psychological consequences of burns are wide-ranging (Bakker, Maertens, Van Son, & Van Loey, 2013) and it is well-documented in the burn literature how outcomes vary across the recovery phase (Liber, Faber, Treffers, & Van Loey, 2008). For example, the treatment needs during the acute stage focuses on physiological recovery which is accompanied by management of pain, anxiety, distress, and depressive symptoms while the long-term rehabilitative phase is characterized by social reintegration challenges (e.g., family stressors, going back to school) and issues with self-esteem and body image (Wiechman & Patterson, 2004). Depression and anxiety are typically problems the child may struggle with even in the rehabilitative phase. The psychosocial difficulties the child and parents experience will therefore be influenced by the period during which the assessment is made.

Children remain a high-risk group for experiencing adverse psychological outcomes following a burn, particularly young ones, due to multiple factors related to their stage of development, rapid rate of physiological development, limited emotion regulation and communication skills, and the importance of a protective attachment relationship early in life (De Young, Haag, Kenardy, Kimble, & Landolt, 2016). Yet there are no models of psychosocial recovery currently available specific to a burn injury, although several theories in recovery and adjustment to a visible difference may apply to scarring from a burn (Armstrong-James, 2017). All professionals working with children have a responsibility to assess the physical and psychosocial needs of burn injured children and to provide evidence-based intervention to ensure the best possible recovery after such a traumatic, life changing experience. Burn victims and their families face not only physical challenges post-injury, but also psychosocial difficulties that often have devastating consequences for quality of life (QOL) if not treated in an effective and timely manner (Esselman, 2007). For intervention strategies to be holistic, recovery targets must therefore focus on both the physiological and psychosocial aspects of rehabilitation (Esselman, 2007; Wiechman & Patterson, 2004).

Pain and anxiety management is a main priority in the immediate care phase to assist in the recovery process, physically, and psychologically (Mock et al., 2008). The experience of pain, and especially poor pain management, have been linked to psychological sequelae such as depression, anxiety, helplessness and withdrawal, factors which all impact on physical and emotional recovery (Ghandi, Thomson, Lord, & Enoch, 2010; Gorczyca, Filip, & Walczak, 2013). In addition, other aspects arise including posttraumatic stress symptoms (PTSS) or disorder (PTSD), social stigmatization (Goodhew et al., 2014), bullying and teasing (Rimmer et al., 2007a), and problems coping with reintegration (De Sousa, 2010; De Young, Kenardy, Cobham, & Kimble, 2012; Landolt, Buehlmann, Maag, & Schiestl, 2007; Pan et al., 2018). Reduced social competence (Szabo, Ferris, Urso, Aballay, & Duncan, 2017) and personality disorders in severe burns (Thomas et al., 2012) have also been examined.

It is estimated that one-fourth to one-third of children suffer acute and posttraumatic stress within the first months after a burn (Bakker et al., 2013) and 36–65% experience psychosocial problems including anxiety, depression, issues with self-esteem, among others (van Baar et al., 2011). Significant deficits in multiple functional domains (such as gross motor skills, language, and play) were found in children 5 years from the burn injury compared with age-matched peers without a burn (Kazis et al., 2016), indicating the essential need for adequate and timely psychosocial interventions for children and adolescents. Equally important is the need to assist parents in the recovery process, as parental distress has been shown to range from 17% to 45% within the first 6 months of a child's injury (Bakker et al., 2013; De Young, Hendrikz, Kenardy, Cobham, & Kimble, 2014; Parrish et al., 2019). This is especially so for younger children who are highly dependent on their parents due to their limited range of skills to communicate or cope with the pain and strong emotions associated with a burn injury, particularly during burn dressing changes (Egberts, de Jong, Hofland, Geenen, & Van Loey, 2018). Parents' mental health and well-being is closely linked to the child's age and distress levels (Odar et al., 2013) and thus contribute to the development and maintenance of recovery in their injured child and to the family as a whole (De Young et al., 2014; Landolt, Ystrom, Sennhauser, Gnehm, & Vollrath, 2012; Phillips & Rumsey, 2008). Moreover, effective pain management is a critical component of psychosocial interventions and is central to the facilitation of recovery and positive psychosocial outcomes (including mood, relationships with others, reintegration) after burn trauma (Fagin & Palmieri, 2017; Ghandi et al., 2010).

Over time, the focus in pediatric burn care has changed from survival and functional restoration to include the provision of psychosocial care, defined as providing culturally sensitive psychological, social, and spiritual care during patient recovery and reintegration (De Young et al. 2012; Dodd, Fletchall, Starnes, & Jacobson, 2017). Interventions are tailored to the acute, rehabilitation, and reintegration phases (Arceneaux & Meyer, 2009) and include psychotherapeutic approaches, distraction therapy with or without virtual reality (VR), school reintegration (Dodd et al., 2017), and burn camps (Rimmer et al., 2012). A number of studies support positive outcomes associated with a specific psychosocial intervention for burn injured children (Blakeney et al., 2005; Brown, Kimble, Rodger, Ware, & Cuttle, 2014; Tarnowski, Rasnake, & Drabman, 1987), but no systematic review has been completed evaluating the full range of psychological interventions available, for example, pain management options only for all ages (Luo, Cao, Zhong, Chen, & Cen, 2019; Scapin et al., 2018) or burn camps only (Kornhaber et al., 2019; Gaskell et al., 2010; Maslow & Lobato, 2010). The objective of this review was to identify and critically evaluate the types of psychosocial interventions, outcome measures utilized, and quality of comparative studies directed at supporting the psychosocial recovery of pediatric burn survivors. Filling this knowledge gap is important for child survivors, their families, and pediatric resource providers.