Parental well-being and behavioral adjustment of pediatric survivors of burns

Patient Experience of Wearing Compression Garments Post Burn Injury: A Review of the Literature

This review was conducted to critically appraise the literature regarding the patient's lived experience of, and adherence to, wearing compression garments post burn injury. Scholarly articles were identified from searches of the following databases: Pubmed, Cochrane Central, CINAHL, PsycINFO, and OT Seeker. Combinations of key words including compression therapy/garment, pressure therapy/garment, burn(s), adherence, and patient experience were utilized. Retrieved studies were included in the review if they were written in English, reported on adult burn populations, and the patient's lived experience of wearing compression garments. Included studies were critically appraised and content analysis was completed on the results sections of the two qualitative studies. Nine studies investigating patient's lived experiences were retained: one systematic review, one randomized controlled trial, five cross-sectional surveys, and two qualitative studies. An adherence framework provided a conceptual basis to categorize reported patient's lived experiences. Results identified a strong focus on patient and treatment-related experiences with limited investigation of condition, patient-provider and health care system experiences. Minimal investigation has been completed regarding the impact of these patient's lived experiences on the adherence to wearing compression garments. Additional research using qualitative methods is required to gain a deep understanding of patient's experiences and perspectives of wearing compression garments and how these experiences influence on their adherence to wearing them. Identification of key experiences that lead to patients removing their compression garments may lead to modification of treatment and system approaches to better align with patients' needs and development of potential interventions that promote adherence.

Measuring the burden of pediatric burn injury for parents and caregivers: informed burn center staff can help to lighten the load

This study sought to identify which commonly experienced burn-related issues parents/caregivers of burn-injured youth deemed most stressful, difficult, and disruptive during their child's initial acute burn care hospitalization, and following the child's discharge. Parents completed an 11-item survey, asking them to rate the difficulty of items regarding their child's burn injury. The scale was created by burn doctors, nurses, and psychologists with an average of 10.5 (SD ± 4.8) years of experience. Items selected were among common parental problems reported in the burn literature. Respondents included 69 parents/caregivers of previously hospitalized, burn-injured youth. The majority were mothers, n = 51 (74%), and n = 34 (49%) were Caucasian. The most represented age group was 37 to 45 years, n = 31 (45%). Children were on average, 6.04 years out from their initial injury. All parents reported their child's pain as the most difficult part of the injury, n = 69 (100%). The second most common issue was the child's first hospital stay. The other two items found to be "very hard" or "pretty hard" were the time spent away from their other children, and feelings of hopelessness in being unable to fix everything for their child. In this study, key parental problems occurred during the child's initial hospitalization. Burn staff cannot alleviate all problems, however, staff education regarding distressing problems faced by parents, as well as possible solutions, can be made available.

Perceived support in parents of children with burns

OBJECTIVE

Children sustaining burns that require treatment in a burn center have a need for multiprofessional aftercare services over a prolonged time. So far, there is little research into satisfaction with care and support after pediatric burns. The aim was to investigate parents' perception of support after pediatric burn and associations with parent, child and injury characteristics.

METHOD

Parents (n=101) of children aged 0.4-17.8 years completed questionnaires on support, parent's psychological symptoms and health of the child. Time since injury was 0.1-9.0 years.

RESULTS

Perceived lack of psychosocial, medical, societal or family support was reported by 21% of the parents. Lack of support was not associated with injury or sociodemographic characteristics, but it was significantly associated with parents' symptoms of general anxiety, depression and injury-related fear avoidance, as well as parents' ratings of their child's general health and heat sensitivity.

CONCLUSION

Perceived support did not differ on account of burn severity or sociodemographic status. However, care providers should be more attentive to and supportive of parents signaling poorer general health in their child and cognitive beliefs that the child is at risk for harm when active and parents who themselves show signs of psychological symptoms.

Parents' perceptions of adaptation and family life after burn injuries in children

The aim of this study was to explore parents' experiences after their child's burn injury, focusing on how the burn had influenced family life and child adjustment. Six semi-structured interviews with parents of children treated at burn centers 2 to 7 years previously revealed the theme, "Feeling quite alone in striving to regain family wellbeing". Identification of difficulties perceived by the parents during rehabilitation and up until the present is useful when developing pediatric burn care and support for parents of children with burns.

The relationship between behavioural problems in preschool children and parental distress after a paediatric burn event

This study examines mother- and father-rated emotional and behaviour problems in and worries about 0- to 5-year-old children at 3 and 12 months after a burn event and the relation with parental distress. Mothers (n = 150) and fathers (n = 125) representing 155 children participated in this study. Child emotional and behaviour problems and parental worries about the child were assessed with the Child Behavior Checklist at both time points. Parents' level of acute subjective distress was assessed within the first month after the burn event with the Impact of Event Scale. Mothers and fathers held comparable views of their child's emotional and behaviour problems, which were generally within the normal limits. Parents' own acute stress reactions were significantly related to parent-rated child behaviour problems at 3 and 12 months postburn. A substantial part of mothers' and fathers' worries about the child concerned physical and emotional aspects of the burn trauma, and potential future social problems. Parents with high acute stress scores more often reported burn-related concerns about their child at 3 and 12 months postburn. Health-care professionals should be informed that parents' distress in the subacute phase of their child's burn event may be related to subsequent worries about their child and to (parent-observed) child emotional and behaviour problems. The authors recommend a family perspective, with particular attention for the interplay between parents' distress and parent-reported child behaviour problems and worries, in each phase of paediatric burn care.

Prevalence and correlates of posttraumatic stress in parents of young children postburn

This study examined the prevalence and correlates of posttraumatic stress symptoms (PTSS) in the parents of very young children who sustained a minor to moderate size burn injury. Although prior research has explored this relationship in families of children with major burns, only minimal research has focused on children with minor to moderate injuries. Forty-five parents of young children (<6 years) with a burn injury (mean TBSA = 2.67%, SD = 2.40) completed questionnaires regarding PTSS and demographics at an outpatient burn clinic. Injury-related information was collected from medical records. Parents reported clinically significant levels of PTSS, although in most cases, full diagnostic criteria for posttraumatic stress disorder were not met. The amount of distress was related to the age of the child at burn, child PTSS, and the source of burn. Variables such as size of burn, days spent as inpatient, or parental presence at the time of burn were not found to be related to parental distress. PTSS assessment should be made mandatory for all parents of young children experiencing a burn injury, regardless of size and severity of burn or parental presence at the time of burn.

Content Analysis on Caring Experiences of Mothers of Children with Burns

PURPOSE

This study was conducted to identify the caring experience of the mothers of childhood burn patients.

METHODS

Data were collected from 28 mothers of childhood burn patients, through semi-structured in-depth interviews. Data were categorized and coded by using content analysis.

RESULTS

27 categories and 102 statements were drawn from 4 domains. The analyzed domains were psychological sufferings, confronted harsh reality, coping method, and future concerns. Psychological sufferings were categorized heartache, sense of guilt, confusion, regret, depression, sorriness, getting hurt, frustration and upset feeling. Confronted harsh nature were categorized economic difficulty, physical burn-out, lack of caring other children and family troubles. Coping method were categorized positive thinking, having hope, ventilating feelings, accepting the situations, demanding help from family members, changing patterns of the burned child rearing, collecting information for burn treatment, refusing accept the condition of burned child, avoiding personal and social relationship, and reliance on religion. Concerns were categorized concerns of growth and adaptation of the burned child, anxiety for scar, concerns of adapting school life and vague future concerns.

CONCLUSION

The nursing interventions for early assessing psychological problems and providing social supports for caring both burn patients and other siblings should be provided to the mothers of childhood burn patients.

Treatments for common psychiatric conditions among children and adolescents during acute rehabilitation and reintegration phases of burn injury

Advances in critical care and surgical management during the last 20 years have decreased mortality rates among children with severe burn injuries. This improved survival rate has prompted researchers to study the psychological aspects of recovering from a burn injury. Initially research focused primarily on epidemiology, prevention and descriptions of the psychological phenomenon experienced by the children and adolescents. Whereas previously interventions were often utilized during the acute phases of burn injury without knowledge of the long-term effects, more recently, priorities have shifted to include long-term treatment outcome studies. The purpose of this paper is to review and discuss the current evidence-based techniques and their efficacy in the treatment of common psychological and psychiatric conditions among children and adolescents during the three major phases of burn injury.

Psychological rehabilitation of pediatric burn patients

Pediatric burns are devastating injuries, physically and emotionally; however, with progressive medical treatment even with the most severe burns, more burn patients are surviving. This leads to the introduction of a new area of medicine including the psychologic rehabilitation requiring the attention of reconstructive surgeons. Successful psychologic rehabilitation depends on a coordinated interdisciplinary burn care team, family, and the school environment, as well as the child.

Physical and mental health problems in parents of adolescents with burns--a controlled, longitudinal study

OBJECTIVE

Caregiving has been described in the literature as a risk factor for ill health in the carer. This controlled, prospective study examines the course of physical and mental health problems in parents of adolescent survivors of a mass burn incident.

METHODS

Health information was extracted from electronic medical records. Continuous data were available for 1 year before and 4 years after the fire. Cohorts comprised 273 parents of survivors with burns, 199 parents of survivors without burns, and 1756 controls. Post-fire increases in health problems were compared by means of logistic regression.

RESULTS

Parents of burn victims were more likely to present mental health problems during the first 2 years after the incident, when compared to the baseline. Moreover, they were more likely to present cardiovascular health problems in every year following the disaster, compared to the baseline. Increases observed in mental and cardiovascular health problems were significantly larger in parents of burn victims compared to controls. Risk factors for presenting mental health problems were female gender of the parent and a large burn size in the child. Lower socioeconomic status and female gender of the parent predicted cardiovascular health problems.

CONCLUSION

Evidence gained in longitudinal studies informs on which health problems are most likely to develop in parental caregivers. In the interest of both parent and child, a family-oriented approach is proposed.

The importance of family environment for young adults burned during childhood

This study examined the role of family environment for young adult burn survivors making the transition from adolescence to adulthood. Ninety-three young adults who sustained large burns as children were asked to describe their families using the Family Environment Scale (FES). When examining the difference between burn survivors and the normative sample of the FES, burn survivors did not perceive their current family environment different than the normative group. However, burn survivors endorsed more items in the areas of achievement orientation and moral-religious emphasis, and less involvement in intellectual-cultural activities. We also examined the relationship between family characteristics on the FES and psychological adjustment of burn survivors as measured by the Young Adult Self-Report (YASR). Increased conflict on the FES was positively associated with YASR total problem score, internalizing behaviors, and externalizing behaviors. In addition, participation in recreational and social activities and organization both inversely correlated with YASR total problem score. In conclusion, increased family conflict was associated with decreased psychological adjustment of burn survivors as measured by the YASR total problem score.

Diagnósticos de enfermagem presentes em familiares de pacientes vítimas de queimaduras

O objetivo deste estudo foi investigar os diagnósticos de enfermagem de familiares de pacientes vítimas de queimaduras. Dezessete membros da família de pacientes vítimas de queimaduras foram avaliados por meio de observação e entrevista. Os diagnósticos de enfermagem foram estabelecidos com base na Taxionomia II da NANDA. Foram identificados 18 diferentes diagnósticos de enfermagem. Os diagnósticos: ansiedade, medo e sentimentos de pesar antecipado se caracterizaram pela manifestação de desespero ante a possibilidade da perda de um ente querido. Alguns diagnósticos, possivelmente, já estavam presentes antes do acidente ocorrer, como, por exemplo: desempenho de papéis ineficazes, manutenção do lar prejudicada, paternidade e maternidade prejudicadas.

Disaster and subsequent healthcare utilization: a longitudinal study among victims, their family members, and control subjects

BACKGROUND

The impact of disasters on primary healthcare utilization is largely unknown. Moreover, it is often overlooked how disaster affects those closest to the primary victims, their family members.

OBJECTIVE

The objective of this study was to examine the long-term effects of a catastrophic fire on primary healthcare utilization.

RESEARCH DESIGN

We conducted a prospective, population-based cohort study covering 1 year pre- and 3 years postfire. Utilization data were extracted from primary care records.

SUBJECTS

Subjects consisted of 286 disaster victims, 802 family members of disaster victims, 3722 community control subjects, and 10,230 patients from a national reference population.

MEASURES

As outcome measures, we studied 1) the annual number of contacts in primary care and 2) the annual number of contacts for problems related to mental health. Determinants are injury characteristics of victims and bereavement. All analyses control for age, gender, and insurance status.

RESULTS

Being an uninjured victim who witnessed the disaster increases the number of contacts by a factor of 1.55 during the first year postfire (95% confidence interval [CI], 1.35-1.78). Uninjured victims contact the family practitioner more often for mental health-related problems than adolescent community control subjects (incidence rate ratio [IRR], 4.54; 95% CI, 1.69-12.20). In adult family members, the loss of a child predicts overall utilization (IRR, 1.88; 95% CI, 1.35-2.63) and utilization for mental health (IRR, 8.69; 95% CI, 2.10-35.92) during the first year postfire.

CONCLUSION

Attention should be paid to the primary care needs of bereaved individuals and those who have witnessed the disaster.

Depression in mothers of burned children

The treatment of burned children needs to address also their psychic state. Since the child's emotional state depends heavily on the emotional state of its parents, especially the mother's, interest should also be focused on diagnosing and treating secondary psychiatric disorders in mothers of burned children. The AIM of this work was to study the prevalence of depression in mothers of burned children and its predicting factors.

METHODS

The enrolment of mothers of burned children was done in the Burns Department, Ibn Rushd University Hospital in Casablanca, Morocco. Twenty-eight mothers of seriously burned children agreed to participate in this study. A psychiatric interview was conducted after informed consent was obtained. The mothers completed a questionnaire; the diagnosis was made according to DSM IV criteria using the Mini International Neuro-psychiatric Interview (MINI). The Hamilton Depression Rating Scale and the Hamilton Anxiety Rating Scale were used to evaluate respectively the intensity of depression and the level of anxiety. Social functioning was assessed by the Global Assessment of Functioning scale (GAF). The minimum time interval between the child's being burned and the interview with the mother was one month.

RESULTS

The prevalence of depression was 35.7%, which is much higher in the mothers of burned children as compared to the general population. Several risk factors were found such as: several burned children or burn of the only child, severity and complications of burn, and the socio-economic level.

CONCLUSION

Depression is a common disorder in mothers of burned children. Thus early screening for depression in mothers and psychological and psychiatric support must be provided in conjunction with the treatment of the burned child.

Internalizing problem behavior and family environment of children with burns: A Dutch pilot study

The psychosocial development of children with burns is at risk. Children with health care issues tend to develop internalizing problems. Several areas of protective or risk factors were composed into a conceptual model on how internalizing problems might develop or might be prevented after getting burned. The purpose of this study was to explore the relation between post burn internalizing problems on the one hand and child characteristics, burn characteristics and the family environment on the other hand. Data have been collected from 28 mothers and 27 fathers of children with burns (N=29) in six burn centers in The Netherlands and Belgium. The age of the participating children ranged from 2 to 14, TBSA ranged from 1 to 42%. Parents reported problem behavior on the child behavior checklist (CBCL). Three scales of the family environment scale (FES) have been used to explore family conflict, family cohesion and family control. Relations between a clinical level of internalizing problems, reported in 25% of the sample and the family environment were found.

Acute stress symptoms in young children with burns

OBJECTIVE

Posttraumatic stress disorder symptoms are a focus of much research with older children, but little research has been conducted with young children, who account for about 50% of all pediatric burn injuries. This is a 3-year study of 12- to 48-month-old acutely burned children to assess acute traumatic stress outcomes. The aims were to (1) assess the prevalence of acute traumatic stress symptoms and (2) develop a model of risk factors for these symptoms in these children.

METHOD

Acute stress symptoms were measured using the Posttraumatic Stress Disorder Semi-Structured Interview and Observational Record for Infants and Young Children. Children's responses were then assessed, including behavior and physiological measures for developmental/functional consequences. A path analysis strategy was used to build a model of risk factors. Risk factors assessed in this model included observed pain (Visual Analogue Scale), parent symptoms (Stanford Acute Stress Reaction Questionnaire), and magnitude of trauma (total body surface area burned).

RESULTS

Of the 64 subjects meeting inclusion criteria, 52 subjects agreed to participate. These children were highly symptomatic; almost 30% of these children had acute stress symptoms. A path analysis model yielded two independent pathways to acute stress symptoms: (1) from the size of the burn to the mean pulse rate in the hospital to acute stress symptoms and (2) from the child's pain to the parents' stress symptoms to acute stress symptoms. This model accounted for 39% of the variance of acute stress symptoms and yielded excellent fit indexes.

CONCLUSIONS

A high percentage of acute stress symptoms were identified in young children with burns. A model of risk factors, including the size of the burn, pain, pulse rate, and parents' symptoms, was identified.

The inextricable link in caring for families of critically burned children

Advances in burn care have made recovery possible for children with burns on up to 99% of their body surface, which has prompted investigation of the psychosocial well-being of survivors. Although therapies have been suggested, no researchers have acknowledged or recognized nurses' potential contributions to children's and families' recovery. In this article, the author examines the lived experiences of 16 pediatric nurses on a burn intensive care unit. The purpose of the study was to articulate practices that helped critically burned children to heal holistically. Data showed that while helping burned children to heal holistically, the nurses simultaneously supported families to heal holistically. Nurses were observed laughing, talking, and crying with families, as well as role-modeling ways of being with and caring for the children. These practices illustrated the nurses' understanding that care of the children was inextricably linked to care of the families.

Measuring functional outcome in paediatric patients with burns: methodological considerations

Methodological criticisms of research undertaken in the area of paediatric burns are widespread. To date, quasi-experimental research designs have most frequently been used to examine the impact of impairments such as scarring and reduced range of motion on functional outcomes. Predominantly, these studies have utilised a narrow definition of functioning (e.g. school attendance) to determine a child's level of participation in activities post-burn injury. Until recently, there had been little attempt to develop and/or test a theoretical model of functional outcome with these children. Using a conceptual model of functional outcome based on the International Classification of Functioning, Disability and Health, this review paper outlines the current state of the research literature and presents explanatory case study methodology as an alternative research design to further advance the study of functional outcome post-burn injury.

What influences the functional outcome of children at 6 months post-burn?

The contribution of demographic, injury, pre-morbid, and parent factors to a child's functional outcome at 6 months post-burn injury was examined. Sixty-eight children, aged 5-14 years with percent total body surface area (%TBSA) burns ranging from <1 to 35%, and their primary caregivers participated in the study. It was expected that pre-morbid and parent factors but not injury factors would have a significant impact on the functional outcome of children at 6 months post-burn. Injury factors included the percent of total body surface area burned, number of operative procedures, and source of the burn (i.e. flame burn, scald burn). Pre-morbid child factors included the presence or absence of behaviour problems, psychological or psychiatric problems, learning difficulty or developmental delay. Parent factors included anxiety, depression, coping processes, and social support. Whilst investigating the contribution of these factors to functional outcome, the effect of demographic factors (i.e. age, gender, family socioeconomic status, and the number of previous hospitalizations) was controlled for and investigated. Analyses included two hierarchical multiple regression analyses that supported the expected results. R was significantly different from zero at the end of each step in both hierarchical regression analyses, indicating that each group of factors added significantly to the fit of the model. After step 4 in the final regression model with all independent variables in the equation, R=0.85, F(18,49)=6.89, P<0.001.

Social competence and behaviour problems in burned children

The aim of this study was to collect follow-up data on social competence and behavioural problems in a sample of Swedish burned children and to compare the results with normative data from a reference group of children comparable in age, socio-economic status and gender. Parents of 44 children (55% response rate) aged 7-12 years were asked to complete a questionnaire booklet including the Children's Behaviour Questionnaire (CBQ) and the Social Competence Inventory (SCI). Data from the children's teachers were also collected for 20 children using the same booklet. In addition, data on TBSA, localisation of injury, and other background factors were collected. Results showed that the burned children were rated by their parents as showing lesser degrees of social initiative and more externalising problems and concentration problems compared with the control group. Teachers rated the burn injured children as having less prosocial orientation, more externalising problems, and more concentration problems. No clear effects were found for gender and characteristics of the burn injury. Results on the Social Competence Inventory were associated with scores on the Children's Behaviour Questionnaire.The findings are consistent with previous research in that the differences found were relatively small. However, they do call for attention to the possible adverse effects of growing up with a burn injury, but also to the possible pre-morbid characteristics that may be related to the injury.

Family impact greatest: predictors of quality of life and psychological adjustment in pediatric burn survivors

BACKGROUND

Although there is some knowledge of psychological adjustment, almost nothing is known about quality of life in pediatric burn survivors.

METHODS

Parents of 105 burn survivors (age, 5-17 years; total body surface area burned, 10-64%) were assessed by standardized questionnaires 1 to 13 years postburn. Predictive values of clinical variables and family environment were assessed.

RESULTS

Most dimensions of quality of life and psychological adjustment were normal. Compared with healthy norms, burn survivors only showed less positive emotions. Good family relationships and younger age at burn injury were the only significant predictors of good quality of life. Psychological adjustment was predicted by family relationships.

CONCLUSION

If given optimal care, most pediatric burn survivors demonstrate excellent quality of life. Families with compromised relationships and patients with higher age at burn injury should be identified early, monitored closely, and offered psychosocial support as soon as dysfunctional family dynamics are detected.

The psychological aspects of pediatric trauma: perspectives on patient, family, and provider

Pediatric trauma engenders multi-system injury--physiological as well as psychological. Not only does injury to a child affect the patient, but also the family system within which the child functions. Professional caregivers, too, are not immune to the emotional aftermath of pediatric traumatic injury. Effective management of the pediatric trauma patient must, therefore, include an understanding of the psychological aspects of injury--for the patient, the family, and the provider. This chapter seeks to delineate these variables in an effort to promote effective identification of the emotional components of injury and facilitation of necessary interventions in promoting positive overall injury outcomes.

Practice parameters for the assessment and treatment of children and adolescents with posttraumatic stress disorder

These practice parameters review the current state of knowledge about posttraumatic stress disorder (PTSD) in children and adolescents. The parameters were written to aid clinicians in the assessment and treatment of children and adolescents with PTSD symptoms. A literature search and extensive review were conducted in order to evaluate the existing empirical and clinical information in this regard. Expert consultation was also solicited. The main findings of this process were that a wide variety of stressors can lead to the development of PTSD symptoms in this population; that the specific PTSD symptoms manifested may vary according to the developmental stage of the child and the nature of the stressor, and for this reason, the diagnostic criteria for PTSD in adults may not adequately describe this disorder in children and adolescents; that several factors seem to mediate the development of childhood PTSD following a severe stressor; and that most of the therapeutic interventions recommended for children with PTSD are trauma-focused and include some degree of direct discussion of the trauma. Controversies and unresolved issues regarding PTSD in children are also addressed.

Relationship between parental emotional states, family environment and the behavioural adjustment of pediatric burn survivors

The purpose 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 problems 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, 1-5 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 problem CBCL scores. i.e. troubled (T > or = 60) or untroubled (T<60). One-way ANOVA tests revealed no significant differences between the two groups in the way parents reacted to trauma (IES) and parental depression (BDI). Significant differences (p<0.01) were revealed between the two groups on FES subscales. The parents of the untroubled group scored higher on 'Cohesion' and 'Organization' and lower on 'Conflict'. These parents also scored higher (p< or =0.05) 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 he a part of the rehabilitation of the burned child.

Long-term psychosocial adaptation of children who survive burns involving 80% or greater total body surface area

OBJECTIVE

To examine the psychosocial adjustment of survivors of massive pediatric burn injuries, the change in adjustment across time, and the impact on parents.

BACKGROUND

Patients/parents were assessed at regular intervals postburn using standardized tests of adjustment. Patients who could not be included in standardized longitudinal assessments were administered questionnaires by mail/telephone.

METHODS

The Child Behavior Checklist, the Teacher Report Form, the Youth Self Report Form, and the Parenting Stress Index were utilized to assess adjustment.

RESULTS

On all objective measures, the group of survivors and their parents were within normal limits. Adjustment neither improved nor deteriorated over time.

CONCLUSION

Children who survive massive burn injuries can achieve positive psychosocial adaptation.