Pediatric burn injuries and subsequent wound care can be painful and distressing for children and their parents. This study tested parenting behavior as a mediator for the relationship between parental acute psychological distress and child behavior during burn wound care. Eighty-seven parents of children (1–6-years-old) self-reported accident-related posttraumatic stress symptoms (PTSS), pre-procedural anxiety, general anxiety/depression symptoms, and guilt before the first dressing change. Parent–child behavior was observed during the first dressing change. Mediation analyses identified three indirect effects. Parental PTSS predicted more child distress, mediated through parental distress-promoting behavior. Parental guilt predicted more child distress, mediated through parental distress-promoting behavior. Parental general anxiety/depression symptoms predicted less child coping, mediated through less parental coping-promoting behavior. Parents with accident-related psychological distress have difficulty supporting their child through subsequent medical care. Nature of parental symptomology differentially influenced behavior. Increased acute psychological support for parents may reduce young child procedural pain-related distress.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Oxford: Lawrence Erlbaum.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, D.C.: American Psychiatric Association.
Bakker, A., Maertens, K. J., Van Son, M. J., & Van Loey, N. E. E. (2013). Psychological consequences of pediatric burns from a child and family perspective: A review of the empirical literature. Clinical Psychology Review, 33, 361–371. https://doi.org/10.1016/j.cpr.2012.12.006.
Bakker, A., Van Loey, N. E. E., Van der Heijden, P. G., & Van Son, M. J. (2012). Acute stress reactions in couples after a burn event to their young child. Journal of Pediatric Psychology, 37, 1127–1135. https://doi.org/10.1093/jpepsy/jss083.
Bakker, A., Van Loey, N. E. E., Van Son, M. J., & Van der Heijden, P. G. (2010). Mothers’ long-term posttraumatic stress symptoms following a burn event of their child. Journal of Pediatric Psychology, 35, 656–661. https://doi.org/10.1093/jpepsy/jsp090.
Bearden, D., Feinstein, A., & Cohen, L. (2012). The influence of parent preprocedural anxiety on child procedural pain: Mediation by child procedural anxiety. Journal of Pediatric Psychology, 37, 680–686. https://doi.org/10.1093/jpepsy/jss041.
Bernard, R. S. (2001). Parent distress, parent behavior, and infant distress during pediatric immunizations. (Dissertation/Thesis), West Virginia University, Morgantown, WV. Retrieved from https://libwvu.on.worldcat.org/oclc/49054825.
Bernard, R. S., & Cohen, L. L. (2006). Parent anxiety and infant pain during pediatric immunizations. Journal of Clinical Psychology in Medical Settings, 13, 285–290. https://doi.org/10.1007/s10880-006-9027-6.
Blount, R. L., Bunke, V., Cohen, L., & Forbes, C. (2001). The Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF): Validation of a rating scale for children’s and adults’ behaviors during painful medical procedures. Journal of Pain and Symptom Management, 22, 591–599. https://doi.org/10.1016/s0885-3924(01)00303-7.
Blount, R. L., Cohen, L., Frank, N., Bachanas, P., Smith, A., Manimala, M., & Pate, J. (1997). The Child-Adult Medical Procedure Interaction Scale-Revised: An assessment of validity. Journal of Pediatric Psychology, 22, 73–88. https://doi.org/10.1093/jpepsy/22.1.73.
Blount, R. L., Corbin, S., Sturges, J., Wolfe, V., Prater, J., & James, L. (1989). The relationship between adults’ behavior and child coping and distress during BMA/LP procedures: A sequential analysis. Behavior Therapy, 20, 585–601. https://doi.org/10.1016/S0005-7894(89)80136-4.
Brown, E. A., De Young, A. C., Kimble, R., & Kenardy, J. (2018a). Review of a parent’s influence on pediatric procedural distress and recovery. Clinical Child and Family Psychology Review, 21, 224–245. https://doi.org/10.1007/s10567-017-0252-3.
Brown, E. A., De Young, A. C., Kimble, R., & Kenardy, J. (2018b). Development and validity of the Burns-Child Adult Medical Procedure Interaction Scale (B-CAMPIS) for young children. Burns. https://doi.org/10.1016/j.burns.2018.08.027.
Buskila, D., Neumann, L., Zmora, E., Feldman, M., Bolotin, A., & Press, J. (2003). Pain sensitivity in prematurely born adolescents. Archives of Pediatrics and Adolescent Medicine, 157, 1079–1082. https://doi.org/10.1001/archpedi.157.11.1079.
Caldwell-Andrews, A. A., Blount, R. L., Mayes, L. C., & Kain, Z. N. (2005). Behavioral interactions in the perioperative environment: A new conceptual framework and the development of the Perioperative Child-Adult Medical Procedure Interaction Scale. Anesthesiology, 103, 1130–1135. https://doi.org/10.1097/00000542-200512000-00005.
Campbell, L., DiLorenzo, M., Atkinson, N., & Pillai Riddell, R. (2017). A systematic review of the interrelationships among children’s coping responses, children’s coping outcomes, and parent cognitive-affective, behavioral, and contextual variables in the needle-related procedures context. Journal of Pediatric Psychology, 42, 611–621. https://doi.org/10.1093/jpepsy/jsx054.
Chambers, C., Craig, K., & Bennett, S. (2002). The impact of maternal behavior on children’s pain experiences: An experimental analysis. Journal of Pediatric Psychology, 27, 293–301. https://doi.org/10.1093/jpepsy/27.3.293.
Choiniere, M., Melzack, R., Rondeau, J., Girard, N., & Paquin, M.-J. (1989). The pain of burns: Characteristics and correlates. The Journal of Trauma, 29, 1531–1539. https://doi.org/10.1097/00005373-198911000-00013.
Cohen, L., Bernard, R. S., McClelland, C. B., & MacLaren, J. E. (2005). Assessing medical room behavior during infants’ painful procedures: The Measure of Adult and Infant Soothing and Distress (MAISD). Children’s Health Care, 34, 81–94. https://doi.org/10.1207/s15326888chc3402_1.
Cohen, L., Manimala, R., & Blount, R. L. (2000). Easier said than done: What parents say they do and what they do during children’s immunizations. Children’s Health Care, 29, 79–86. https://doi.org/10.1207/S15326888CHC2902_1.
Connor-Ballard, P. A. (2009). Understanding and managing burn pain: Part 1. The American Journal of Nursing, 109, 48–56. https://doi.org/10.1097/01.naj.0000348604.47231.68.
Cooper, J., & Pavlin, E. (1990). Altered pharmacology in thermal injury. Critical Care Report, 2, 78–84.
Dahlquist, L. M., Power, T. G., Cox, C. N., & Fernbach, D. J. (1994). Parenting and child distress during cancer procedures: A multidimensional assessment. Children’s Health Care, 23, 149–166. https://doi.org/10.1207/s15326888chc2303_1.
De Young, A. C., Hendrikz, J., Kenardy, J. A., Cobham, V. E., & Kimble, R. M. (2014). Prospective evaluation of parent distress following pediatric burns and identification of risk factors for young child and parent posttraumatic stress disorder. Journal of Child and Adolescent Psychopharmacology, 24, 9–17. https://doi.org/10.1089/cap.2013.0066.
Duke, J., Wood, F., Semmens, J., Edgar, D. W., Spilsbury, K., Hendrie, D., & Rea, S. (2011). A study of burn hospitalizations for children younger than 5 years of age: 1983–2008. Pediatrics, 127, e971–e977. https://doi.org/10.1542/peds.2010-3136.
Egberts, M. R., de Jong, A. E. E., Hofland, H. W. C., Geenen, R., & Van Loey, N. E. E. (2018). Parental presence or absence during child burn wound care procedures. Burns, 44, 850–860. https://doi.org/10.1016/j.burns.2017.11.016.
European Burns Association. (2017). EBA Practice Guidelines for Burn Care. Retrieved from http://euroburn.org/wp-content/uploads/2014/09/EBA-Guidelines-Version-4-2017-1.pdf.
Frank, N. C., Blount, R. L., Smith, A. J., Manimala, M. R., & Martin, J. K. (1995). Parent and staff behavior, previous child medical experience, and maternal anxiety as they relate to child procedural distress and coping. Journal of Pediatric Psychology, 20, 277–289. https://doi.org/10.1093/jpepsy/20.3.277.
Gee Kee, E., Kimble, R., Cuttle, L., Khan, A., & Stockton, K. (2015). Randomized controlled trial of three burns dressings for partial thickness burns in children. Burns, 41(5), 946–955. https://doi.org/10.1016/j.burns.2014.11.005.
Gee Kee, E., Stockton, K., Kimble, R., Cuttle, L., & McPhail, S. (2017). Cost-effectiveness of silver dressings for paediatric partial thickness burns: An economic evaluation from a randomized controlled trial. Burns, 43(4), 724–732. https://doi.org/10.1016/j.burns.2016.09.018.
Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Press.
Hornik, R., & Gunnar, M. R. (1988). A descriptive analysis of infant social referencing. Child Development, 59, 626–634. https://doi.org/10.2307/1130562.
Hudson, J., & Rapee, R. (2001). Parent–child interactions and anxiety disorders: An observational study. Behaviour Research and Therapy, 39, 1411–1427. https://doi.org/10.1016/S0005-7967(00)00107-8.
Jacobsen, P. B., Manne, S. L., Gorfinkle, K., Schorr, O., Rapkin, B., & Redd, W. H. (1990). Analysis of child and parent behavior during painful medical procedures. Health Psychology, 9, 559. https://doi.org/10.1037/0278-622.214.171.1249.
Jay, S. M., Ozolins, M., Elliott, C. H., & Caldwell, S. (1983). Assessment of children’s distress during painful medical procedures. Health Psychology, 2, 133–147. https://doi.org/10.1037/0278-6126.96.36.199.
Jaycox, L. H., Stein, B. D., Paddock, S., Miles, J. N., Chandra, A., Meredith, L. S., … Burnam, M. A. (2009). Impact of teen depression on academic, social, and physical functioning. Pediatrics, 124, e596–e605. https://doi.org/10.1542/peds.2008-3348.
Kehlet, H., Jensen, T. S., & Woolf, C. J. (2006). Persistent postsurgical pain: Risk factors and prevention. Lancet, 367, 1618–1625. https://doi.org/10.1016/S0140-6736(06)68700-X.
Kroenke, K., Spitzer, R. L., Williams, J. B., & Lowe, B. (2009). An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics, 50, 613–621. https://doi.org/10.1176/appi.psy.50.6.613.
Kubany, E. S., Haynes, S. N., Abueg, F. R., Manke, F. P., Brennan, J. M., & Stahura, C. (1996). Development and validation of the Trauma-Related Guilt Inventory (TRGI). Psychological Assessment, 8, 428–444. https://doi.org/10.1037/1040-35188.8.131.528.
Lovejoy, M. C., Graczyk, P. A., O’Hare, E., & Neuman, G. (2000). Maternal depression and parenting behavior: A meta-analytic review. Clinical Psychology Review, 20, 561–592. https://doi.org/10.1016/S0272-7358(98)00100-7.
MacLaren Chorney, J., Torrey, C., Blount, R. L., McLaren, C., Chen, W.-P., & Kain, Z. N. (2009). Healthcare provider and parent behavior and children’s coping and distress at anesthesia induction. Anesthesiology, 111, 1290–1296. https://doi.org/10.1097/ALN.0b013e3181c14be5.
Manimala, M., Blount, R., & Cohen, L. (2000). The effects of parental reassurance versus distraction on child distress and coping during immunizations. Children’s Health Care, 29, 161–177. https://doi.org/10.1207/S15326888CHC2903_2.
Mason, S. (1993). Young, scarred children and their mothers: A short-term investigation into the practical, psychological and social implications of thermal injury to the preschool child. Part I: Implications for the mother. Burns, 19, 495–500. https://doi.org/10.1016/0305-4179(93)90006-T.
McGarry, S., Elliott, C., McDonald, A., Valentine, J., Wood, F., & Girdler, S. (2014). Paediatric burns: From the voice of the child. Burns, 40, 606–615. https://doi.org/10.1016/j.burns.2013.08.031.
McGarry, S., Elliott, C., McDonald, A., Valentine, J., Wood, F., & Girdler, S. (2015). “This is not just a little accident”: A qualitative understanding of paediatric burns from the perspective of parents. Disability and Rehabilitation, 37, 41–50. https://doi.org/10.3109/09638288.2014.892640.
McGarry, S., Girdler, S., McDonald, A., Valentine, J., Wood, F., & Elliott, C. (2013). Paediatric medical trauma: The impact on parents of burn survivors. Burns, 39, 1114–1121. https://doi.org/10.1016/j.burns.2013.01.009.
McGrath, P. J., & Frager, G. (1996). Psychological barriers to optimal pain management in infants and children. The Clinical Journal of Pain, 12, 135–141.
Melzack, R. (1990). The tragedy of needless pain. Scientific American, 262, 27–33. https://doi.org/10.1038/scientificamerican0290-27.
Morley, J., Holman, N., & Murray, C. D. (2017). Dressing changes in a burns unit for children under the age of five: A qualitative study of mothers’ experiences. Burns, 43, 757–765. https://doi.org/10.1016/j.burns.2016.11.015.
National Health Service England. (2013). Specialised burn care. Retrieved from https://www.england.nhs.uk/wp-content/uploads/2014/04/d06-spec-burn-care-0414.pdf.
Pate, J. T., Blount, R. L., Cohen, L. L., & Smith, A. J. (1996). Childhood medical experience and temperament as predictors of adult functioning in medical situations. Children’s Health Care, 25, 281–298. https://doi.org/10.1207/s15326888chc2504_4.
Perkins, M. D., Frederick, M., & Kehlet, M. D. P. D. H. (2000). Chronic pain as an outcome of surgery: A review of predictive factors. Anesthesiology, 93, 1123–1133.
Pillai Riddell, R., Campbell, L., Flora, D. B., Racine, N., Osmun, L. D., Garfield, H., & Greenberg, S. (2011). The relationship between caregiver sensitivity and infant pain behaviors across the first year of life. Pain, 152, 2819–2826. https://doi.org/10.1016/j.pain.2011.09.011.
Pillai Riddell, R., Gennis, H., Taddio, A., & Racine, N. (2016). Are parents really that important to managing vaccination pain during infancy? Pain Management, 6, 13–17. https://doi.org/10.2217/pmt.15.54.
Pillai Riddell, R., & Racine, N. (2009). Assessing pain in infancy: The caregiver context. Pain Research and Management, 14, 27–32.
Prins, A., Ouimette, P., Kimerling, R., Cameron, R., Hugelshofer, D., Shaw-Hegwer, J., … Sheikh, J. (2003). The primary care PTSD screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9, 9–14. https://doi.org/10.1185/135525703125002360.
Racine, N. M., Riddell, P., Flora, R. R., Taddio, D. B., Garfield, A., H., & Greenberg, S. (2016). Predicting preschool pain-related anticipatory distress: The relative contribution of longitudinal and concurrent factors. Pain, 157, 1918–1932. https://doi.org/10.1097/j.pain.0000000000000590.
Rennick, J. E., Johnston, C. C., Dougherty, G., Platt, R., & Ritchie, J. A. (2002). Children’s psychological responses after critical illness and exposure to invasive technology. Journal of Developmental and Behavioral Pediatrics, 23, 133–144. https://doi.org/10.1097/00004703-200206000-00002.
Scheeringa, M. S., & Haslett, N. (2010). The reliability and criterion validity of the Diagnostic Infant and Preschool Assessment: a new diagnostic instrument for young children. Child Psychiatry and Human Development, 41, 299–312. https://doi.org/10.1007/s10578-009-0169-2.
Schoemann, A. M., Boulton, A. J., & Short, S. D. (2017). Determining power and sample size for simple and complex mediation models. Social Psychological and Personality Science, 8, 379–386. https://doi.org/10.1177/1948550617715068.
Sharar, S. R., Miller, W., Teeley, A., Soltani, M., Hoffman, H. G., Jensen, M. P., & Patterson, D. R. (2008). Applications of virtual reality for pain management in burn-injured patients. Expert Review of Neurotherapeutics, 8, 1667–1674. https://doi.org/10.1586/14737184.108.40.2067.
Slade, A. (2007). Reflective parenting programs: Theory and development. Psychoanalytic Inquiry, 26, 640–657. https://doi.org/10.1080/07351690701310698.
Spoont, M., Arbisi, P., Fu, S., Greer, N., Kehle-Forbes, S., Meis, L., & Rutks, I. (2013). Screening for post-traumatic stress disorder (PTSD) in primary care: A systematic review. Washington, D.C.: Department of Veterans Affairs.
Stockton, K. A., Harvey, J., & Kimble, R. M. (2015). A prospective observational study investigating all children presenting to a specialty paediatric burns centre. Burns, 41, 476–483. https://doi.org/10.1016/j.burns.2014.09.018.
Stoddard, F. J., Sheridan, R. L., Saxe, G. N., King, B. S., King, B. H., Chedekel, D. S., … Martyn, J. A. (2002). Treatment of pain in acutely burned children. Journal of Burn Care and Rehabilitation, 23, 135–156. https://doi.org/10.1097/00004630-200203000-00012.
Sweet, S. D., & McGrath, P. J. (1998). Relative importance of mothers’ versus medical staffs’ behavior in the prediction of infant immunization pain behavior. Journal of Pediatric Psychology, 23, 249–256. https://doi.org/10.1093/jpepsy/23.4.249.
Tabachnick, B., Fidell, L., & Osterlind, S. (2001). Using multivariate statistics. Boston: Allyn and Bacon.
Taddio, A., Katz, J., Ilersich, A. L., & Koren, G. (1997). Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet, 349, 599–603. https://doi.org/10.1016/s0140-6736(96)10316-0.
van der Kolk, B. A. (1987). Psychological Trauma. VA: American Psychiatric Association.
von Baeyer, C. L., & Spagrud, L. J. (2007). Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years. Pain, 127, 140–150. https://doi.org/10.1016/j.pain.2006.08.014.
Weinberg, K., Birdsall, C., Vail, D., Marano, M. A., Petrone, S. J., & Mansour, E. H. (2000). Pain and anxiety with burn dressing changes: Patient self-report. Journal of Burn Care and Rehabilitation, 21, 155–161. https://doi.org/10.1097/00004630-200021020-00013.
Weisman, S. J., Bernstein, B., & Schechter, N. L. (1998). Consequences of inadequate analgesia during painful procedures in children. Archives of Pediatrics and Adolescent Medicine, 152, 147–149. https://doi.org/10.1001/archpedi.152.2.147.
Young, K. D. (2005). Pediatric procedural pain. Annals of Emergency Medicine, 45, 160–171. https://doi.org/10.1016/j.annemergmed.2004.09.019.
Zhang, Z., & Yuan, K.-H. (2018). Practical statistical power analysis using Webpower and R. Granger, IN: ISDSA Press.
The authors would like to acknowledge research assistants Krittika Vongkiatkajorn and Gillian Montague for their assistance with data collection, and Jacelle Warren for statistical guidance. We would also like to thank the families that allowed us insight into their experiences, and the medical staff at the Pegg Leditschke Children’s Burns Centre who opened their unit to this research.
E.A.B received funding from the Australian Government Research Training Program Scholarship, the Children’s Hospital Foundation, and the Pain in Child Health (PICH) strategic training initiative for health research. No other authors have funding to declare.
Conflict of interest
The authors Erin A. Brown, Alexandra De Young, Roy Kimble, and Justin Kenardy declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
All procedures were in accordance with the ethical standards of the institutional research committees and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Brown, E.A., De Young, A., Kimble, R. et al. Impact of Parental Acute Psychological Distress on Young Child Pain-Related Behavior Through Differences in Parenting Behavior During Pediatric Burn Wound Care. J Clin Psychol Med Settings 26, 516–529 (2019). https://doi.org/10.1007/s10880-018-9596-1
- Accidents and injuries