Journal of Child Psychology and Psychiatry 53:1 (2012), pp 56–63 doi:10.1111/j.1469-7610.2011.02431.

Prevalence, comorbidity and course of trauma

reactions in young burn-injured children
Alexandra C. De Young,1 Justin A. Kenardy,1 Vanessa E. Cobham,2 and
Roy Kimble3
1
School of Psychology and Centre of National Research on Disability and Rehabilitation Medicine, University of
Queensland, Herston, Qld; 2School of Psychology, University of Queensland, St Lucia, Qld; 3The Centre for Children’s
Burns and Trauma Research, Queensland Children’s Medical Institute, University of Queensland and Department of
Paediatrics and Child Health, Royal Children’s Hospital, Herston, Qld, Australia

Background: Infants, toddlers and preschoolers are the highest risk group for burn injury. However, to
date this population has been largely neglected. This study examined the prevalence, onset, comorbidity
and recovery patterns of posttrauma reactions in young children with burns. Methods: Parents of 130
unintentionally burned children (1–6 years) participated in the study. The Diagnostic Infant Preschool
Assessment was conducted with parents at 1 and 6 months postinjury. Results: The majority of chil-
dren were resilient. However, 35% were diagnosed with at least one psychological disorder, there was a
high rate of comorbidity with posttraumatic stress disorder, and 8% of children did not experience
recovery in distress levels over the course of 6 months. Conclusions: These outcomes are likely to have
serious repercussions for a young child’s medical and psychosocial recovery as well as their normal
developmental trajectories. It is recommended that screening, prevention and early intervention
resources are incorporated into paediatric health care settings to optimise children’s psychological
adjustment following burn injury. Keywords: Preschool children, trauma, burns, posttraumatic stress
disorder, psychological disorder, prevalence, onset, comorbidity.

associated with acute and long-term social, emo-

Introduction
Unintentional injuries are one of the leading causes
of death, hospitalisation and disability for children
worldwide (World Health Organisation, 2008). Burns
are a common type of injury (World Health Organi-
sation, 2008) and are among the most serious as
they often share characteristics of both acute and
chronic medical illness. Young children are the
highest risk group for burn injury (Australian Insti-
tute of Health and Welfare, 2009) with an estimated
4,600 Australian children under 5 years old pre-
senting to emergency departments annually for
burns treatment (Kidsafe NSW, 2010).
Burns often meet the criteria for a traumatic event
(American Psychiatric Association, 2000) and are not
only distressing at the time of injury but can be a
source of ongoing stress for both the child and entire
family. In the acute period, burns can be life
threatening and extremely painful. Treatment during
the early phase involves repeated, painful and inva-
sive medical procedures, hospitalisation and/or
regular visits to hospital and scar management. In
the longer term, children can be faced with years of
rehabilitation and reconstructive surgery and may
need to adjust to permanent disfigurement or func-
tional impairment.
Psychological outcome studies have indicated that
in addition to the physical consequences, burns are
Conflict of interest statement: No conflicts declared.
tional and behavioural difficulties. Research has
shown that following burn injury approximately 6%–
47% of children and adolescents develop acute
stress disorder (ASD; Fukunishi, 1998; Saxe et al.,
2005), posttraumatic stress disorder (PTSD; Landolt,
Buehlmann, Maag, & Schiestl, 2009) and anxiety
(Stoddard, Norman, Murphy, & Beardslee, 1989).
Additionally, youth with burns have been shown to
experience significantly more depressive symptom-
atology (Rivlin & Faragher, 2007), behavioural and
social problems (Blakeney et al., 1993) and dimin-
ished adaptive behaviours (Meyer, Blakeney,
LeDoux, & Herndon, 1995) in comparison to controls
or normative data. Meyer et al. (2007) have demon-
strated the potential long-lasting psychological im-
pact of burns, reporting a current psychiatric
disorder prevalence rate of 45.5% in a sample of
young adults who were burned as children. Further,
burn-injured children with PTSD are also at greater
risk of impaired health-related quality of life (Landolt
et al., 2009).
Despite infants and preschoolers being at espe-
cially high risk for burn injury, this population has
been largely neglected. The only known study to use
a developmentally sensitive diagnostic interview
found that 29% of burn victims aged between 12 and
48 months were experiencing acute stress symp-
toms within the first month of injury (Stoddard et al.,
2006). Research using the Child Behaviour Checklist
has found 2- to 3-year-old children evaluated a

 2011 The Authors. Journal of Child Psychology and Psychiatry  2011 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
doi:10.1111/j.1469-7610.2011.02431.x
mean of 1.2 years postburn, were experiencing
significantly more depressive behaviours, somatic
complaints and sleep problems in comparison to the
normative sample (Meyer, Robert, Murphy, &
Blakeney, 2000).
To date, as far as we are aware no studies with
young burn victims and only two studies with trau-
matised preschoolers have specifically investigated
comorbidity and onset of trauma reactions
(Scheeringa & Zeanah, 2008; Scheeringa, Zeanah,
Myers, & Putnam, 2003). These studies have shown
that comorbidity with PTSD is common. First, in a
mixed trauma sample, Scheeringa et al. (2003)
found comorbidity prevalence rates of 75% for
oppositional defiant disorder (ODD), 63% for sepa-
ration anxiety disorder (SAD), 38% for attention-
deficit/hyperactivity disorder (ADHD) and 6% for
major depressive disorder (MDD). Children diag-
nosed with PTSD had significantly higher rates of
comorbid ODD and SAD in comparison to children in
either the trauma group with no PTSD or healthy
control group. Following Hurricane Katrina, Schee-
ringa and Zeanah (2008) reported that of the pre-
school children with PTSD, 61% also had ODD, 21%
had SAD, 33% had ADHD and 43% had MDD. The
researchers also found that all new onset non-PTSD
disorders following the storm were associated with
PTSD symptomatology.
It is important to note that the majority of children
who have an unintentional burn injury do not
experience adverse outcomes (Kent, King, & Coch-
rane, 2000; Tarnowski, Rasnake, Gavaghan-Jones,
& Smith, 1991). Longitudinal research with older
children with unintentional injuries, including
burns, has shown that the course of posttrauma
responses is variable and tends to follow three dis-
tinct recovery trajectories: resilient (i.e. initial mild,
transient disruption in functioning), recovery (i.e.
initial elevated symptoms that disrupt normal func-
tioning but decline to baseline levels over time) and
chronic (i.e. clinical levels of acute and ongoing
symptoms; Le Brocque, Hendrikz, & Kenardy, 2010).
Le Brocque et al. (2010) identified that children with
burns were significantly more likely to be in the
chronic trajectory group than in the resilient group.
In contrast to research with injured adults (deRoon-
Cassini, Mancini, Rusch, & Bonanno, 2010),
evidence was not found for a fourth delayed onset
trajectory (Le Brocque et al., 2010).
In sum, paediatric burn injury is a global public
health concern with existing research showing that
burns have the potential for long-lasting physical
and psychological consequences. However, further
research is warranted as there are several method-
ological issues that make comparisons between
studies difficult (e.g. inconsistent assessment time
frames within and across studies). Additionally, as
far as we are aware, there have been no prospective
longitudinal studies that have reported the psycho-
logical morbidity, comorbidity and recovery patterns
 2011 The Authors. Journal of Child Psychology and Psychiatry  2011 Association for Child and Adolescent Mental Health.
Trauma reactions in young burned children 57
following burn injury in young children. This repre-
sents an important gap in knowledge given that
burns are most common in children under 5 years
old.
The purpose of this longitudinal study was to
confirm and extend the existing research by exam-
ining posttrauma reactions in young children who
require medical treatment for unintentional burn
injury. The specific aims were to: (a) document the
prevalence and onset of psychological morbidity in
young children at 1 and 6 months following burn
injury, (b) examine the comorbidity between PTSD
and other concurrent and new onset psychological
reactions, and (c) explore the course and patterns of
recovery in children’s posttrauma psychological
reactions over 6 months. We hypothesised that a
small minority of children (approximately 6%–35%)
would have a diagnosable psychological disorder
within the first 6 months of injury (H1). Additionally,
it was predicted that PTSD would have a high rate of
comorbidity with SAD and ODD; and PTSD symp-
tomatology at 1 month would be associated with the
development of new onset non-PTSD diagnoses at
6 months (H2). Finally, it was hypothesised that the
majority of children would be resilient or experience
natural recovery in trauma symptoms. However,
approximately 10% of children would not experience
a significant decline in PTSD symptoms (PTSS) or
emotional and behavioural symptoms over 6 months
(H3).
Methods
Participants
Data for this study were collected as part of a larger
longitudinal research project investigating the psycho-
social impact of burn injury in preschoolers and their
parents. To date, this cohort of children has been
described in one other study (De Young, Kenardy, &
Cobham, 2011). Participants were parents of children
aged 1–6 years who had sustained an unintentional
burn injury. All children who were receiving treatment
as either an inpatient or outpatient at a specialist burns
centre in Australia were potentially eligible, irrespective
of burn severity. Exclusion criteria were: (a) parent’s
English was insufficient to complete interviews or
questionnaires, (b) injury was a result of suspected
child abuse or neglect, and/or (c) child had a pervasive
developmental disorder.
A total of 329 children were eligible for inclusion in
the study; however, only 196 (60%) were able to be
approached before the child was discharged from the
outpatient unit. One hundred and seventy-seven
parents (90%) consented to participate in the study;
however, 47 (27%) subsequently dropped out before the
1-month assessment (25 = too busy; 7 = no reason
given; 6 = could not be contacted; 5 = stressful time
and 4 = minor injury/no concerns). Thus, the total
sample consisted of 130 consenting participants (73%)
who completed the interview 1-month postaccident
(M = 38.39 days, SD = 8.69). Of these participants, 125
(96%) completed the 6-month interview [M = 199.64
58 Alexandra C. De Young et al.
days (SD = 16.21)] and 5 (4%) were lost to follow-up
(2 = could not be contacted; 2 = no reason given;
1 = too distressing).
Measures
Diagnostic Infant Preschool Assessment. The
Diagnostic Infant Preschool Assessment (DIPA; Schee-
ringa & Haslett, 2010) is a semistructured diagnostic
interview conducted with the primary caregiver of chil-
dren aged 1–6 years. The DIPA includes empirically
validated developmental modifications and provides a
categorical diagnosis or continuous measure of Diag-
nostic and Statistical Manual of Mental Disorders (fourth
edition, DSM–IV–TR). To meet a categorical diagnosis,
children must have impairment in one or more domains
of functioning (i.e. parent–child relationship, sibling
relationships, daycare/school, peer relationships or
ability to act appropriately outside the home). The
PTSD, MDD, ADHD, ODD, SAD and specific phobia
modules were used in this study. For these modules,
the DIPA has demonstrated acceptable test–retest reli-
ability for continuous measures (a = .67–.87) with the
exception of MDD (a = .40), and fair to good kappa
reliabilities (j = .38–.66; Scheeringa & Haslett, 2010).
Burn severity. Injury severity information was
obtained from the child’s medical record. Burn severity
was measured using percentage total body surface
(%TBSA) burned (Lund & Browder, 1944) and whether
the child needed to be hospitalised.
Procedure
Eligible families were approached and invited to par-
ticipate in the study either while the child was still in
hospital or during visits to the outpatient clinic. Fol-
lowing written informed consent, participating parents
were contacted 1 and 6 months later to complete the
DIPA. Due to many families not living within driving
distance, the DIPA was conducted over the phone.
Interviews were conducted by a graduate psychologist
who had received training on assessment in young
children. Any diagnostic issues were discussed regu-
larly with the research team. The study was approved
and conducted in accordance with the University of
Queensland Human Ethics Committee and Royal Chil-
dren’s Hospital Ethics Committee.
Data analysis
The Statistical Package for Social Sciences (SPSS), Win-
dows Version 17 (Chicago, Illinois, USA) was used for all
analyses. Prior to analysis, data were screened for accu-
racy of entry and missingness, and outliers and proba-
bility distributions were also examined. Differences
between participants with complete and incomplete
data were examined using t-tests and chi-square tests.
The likelihood ratio chi-square statistic was used to
assess the relationship between PTSD and current and
new onset comorbid diagnoses. Where more than 25%
of cells had expected frequency counts with <5, Fi-
scher’s exact test was substituted. If odds ratios could
 2011 The Authors. Journal of Child Psychology and Psychiatry  2011 Association for Child and Adolescent Mental Health.
J Child Psychol Psychiatry 2012; 53(1): 56–63
not be calculated because of missing cell information,
risk ratios were reported instead.
To examine recovery patterns, children were cate-
gorised into one of three PTSD trajectory groups based
on findings by Le Brocque et al. (2010): ‘resilient’ (no
PTSD at either time point), ‘recovery’ (PTSD at 1 month
but not at 6 months), ‘chronic’ (PTSD diagnosis at 1 and
6 months) and an additional group: ‘delayed onset’
(received a new-onset PTSD diagnosis at 6 months).
A series of mixed design analyses of variance (ANOVAs)
using general linear modelling were used to assess
changes in children’s PTSS and emotional and
behavioural functioning over time within the fixed PTSD
trajectory groups. Age, gender, %TBSA and child trau-
ma history were entered as covariates. The analyses
were followed up with post hoc comparisons between
the fixed trajectory groups at each time point and
between time points for each group. Bonferroni’s
correction for multiple comparisons was applied and
the bonferroni corrected p-value is reported in text
where applicable. For each of the effects in the model,
the effect size g2 was calculated. Guidelines for inter-
preting the effect size followed recommendations by
Kinnear and Gray (2008), with small g2 < .06, medium
g2 between 0.06 and .14, and large g2 ‡ .14. The sig-
nificance level for all tests was set at p < .05 for two-
sided tests.
Results
Sample characteristics
Demographic details and medical information for the
130 participants with complete T2 interviews are
presented in Table 1. The majority (80%) of children
were under 3 years old. Burns were at the lower end
of the severity spectrum (%TBSA range = 1%–27%).
Parents reported the most traumatic part for their
child was one of the following: the actual burn injury
(55%), dressing changes (27%), both the burn and
dressings (15%), the hospital experience (2%) and
skin graft (1%). Twenty-two children (17%) had pre-
viously experienced one or more potentially trau-
matic events [hospitalisation or invasive medical
procedure (13%), previous burn injury (2%), animal
attack (2%), near drowning (1%)]. Three per cent of
the sample was Indigenous Australian. No signifi-
cant differences were found for child gender, parent
age, parent employment status or burn size between
children with completed interviews at each time
point and those without. Children with complete and
incomplete assessment data at each time point also
did not differ significantly on total symptom scale
scores on the DIPA.
Prevalence and onset of psychological morbidity
The most commonly experienced symptoms, partic-
ularly within the first month, were excessive clingi-
ness (58%), active avoidance of trauma reminders
(52%), irritability and temper tantrums (50%), psy-
chological distress around reminders (40%), sleep
doi:10.1111/j.1469-7610.2011.02431.x Trauma reactions in young burned children 59

Table 1 Sample characteristics frequently diagnosed with MDD. According to parent

report, the majority of emotional and behavioural
n (%)
disorders were new onset within the first month of
Child their child’s burn injury (Table 2). Specific phobia
Male 68 (52) and ADHD had the highest rates of new onset at
Female 62 (48)
6 months.
Age (years), M (SD) 2.70 (1.54)
Burn type
Scald 53 (41)
Contact 51 (39)
Comorbidity
Fire/flames 13 (10) There was a high rate of comorbidity with PTSD
Chemical/electrical 4 (3)
(Table 2). Children with PTSD at 1 month were sig-
Friction 9 (7)
Burn severity nificantly more likely to have comorbid MDD, Fish-
% TBSAa, M (SD) 3.24 (4.30) er’s exact test, p = .004, risk ratio = .23; ODD,
Hospitalised 27 (21) v2(1) = 29.87, p < .001, OR = 17.32, CI = 5.60–
Participating parent 53.59; SAD, v2(1) = 29.87 p < .001, OR = 17.32,
Mother 121 (93)
CI = 5.60–53.59; and a specific phobia, v2 (1) = 6.96,
Age (years), M (SD) 32.93 (5.57)
Marriedb 79 (67) p = .012, OR = 8.48, CI = 1.56–46.11. At 6 months,
Employedb 73 (62) children with PTSD were significantly more likely to
Education levelb have comorbid ADHD, v2(1) = 14.50, p < .001,
Less than year 12 21 (17) OR = 22.71, CI = 4.58–112.62; ODD, v2(1) = 32.99,
Completed year 12 18 (15)
p < .001, OR = 50.00, CI = 11.16–224.08; and SAD,
Trade/college certificate 31 (26)
University degree 48 (41) v2(1) = 11.51, p = .001, OR = 13.38, CI = 3.19–
56.04. PTSD was comorbid with at least one of the
%TBSA, percentage total body surface area burned. above disorders 73% of the time at 1 month and 85%
a
%TBSA data were not available for 3 children. bData were not of the time at 6 months.
available for 12 parents.
Next, analyses were conducted to examine new
onset non-PTSD morbidity at 6 months, conditional
disturbance (40%), disobedience (35%), nightmares on a diagnosis of PTSD at 1 month. PTSD at 1 month
(30%), difficulties sitting still (29%) and increased was associated with an increased likelihood of hav-
aggression (27%). The prevalence and onset rates for ing a new non-PTSD diagnosis at 6 months,
emotional and behavioural disorders are presented v2(1) = 7.94, p = .011, OR = 4.81, CI = 1.62–14.29.
in Table 2. At 1 month 35% of children and 27% at Additionally, all children with a new-onset non-PTSD
6 months met criteria for a psychological disorder. diagnosis at 6 months had a minimum of one PTSS
PTSD, ODD and SAD were the most commonly at 1 month and significantly more PTSS (M = 5.94,
diagnosed disorders. Based on findings reported SD = 3.47) in comparison to children with no new
previously on this sample (De Young et al., 2011), onset disorders at 6 months [M = 2.73, SD = 2.56,
the preschool PTSD criteria proposed for the DSM–V t(17.46) = )3.55, p = .002, Cohen’s d = 1.05].
was used to diagnose PTSD in this study. However,
for comparison, PTSD rates using the DSM–IV cri-
PTSD trajectories
teria are also included in Table 2. The most common
phobias were of medical personnel (e.g. doctors, Investigation of PTSD trajectory patterns indicated
nurses), needles or fear of injury. Children were least that the majority of children [90 (72%)] could be

Table 2 Prevalence, new onset and comorbidity of psychiatric disorders in children 1 and 6 months postburn

1 Month 6 Months

Comorbid Comorbid
Rates New onset postburn w/PTSDa Rates New onset 6 months w/PTSDa

PTSDa 33 (25) 33 (100) – 13 (10) 3 (23) –

PTSD-DSM–IV 6 (5) 6 (100) – 1 (1) 0 (0) –
MDD 4 (3) 4 (100) 4 (12) 0 (0) 0 (0) 0 (0)
ADHD 7 (5) 2 (29) 4 (12) 8 (6) 5 (63) 5 (39)
ODD 21 (16) 18 (86) 16 (49) 17 (14) 3 (18) 10 (77)
SAD 21 (16) 21 (100) 16 (49) 10 (8) 3 (30) 5 (39)
Specific phobia 6 (5) 3 (50) 5 (15) 12 (10) 8 (67) 2 (15)
Any disorder 45 (35) 41 (91) 24b (73) 34 (27) 18 (53) 11b (85)

Values are given as n (%). DSM–IV, Diagnostic and Statistical Manual of Mental Disorders, fourth edition; PTSD, posttraumatic
stress disorder; MDD, major depressive disorder; ADHD, attention-deficit/hyperactivity disorder; ODD, oppositional defiant
disorder; SAD, separation anxiety disorder.
a
Proposed PTSD criteria for preschool children. bExcluding PTSD cases from ‘any disorder’.

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60 Alexandra C. De Young et al. J Child Psychol Psychiatry 2012; 53(1): 56–63

classed as having a resilient trajectory. Of the
remaining children, 22 (18%) were categorised into
the recovery trajectory group, 10 (8%) in the chronic
group and 3 (2%) in the delayed onset PTSD group.
Further evaluation of the 3 children with delayed
onset PTSD indicated they had subthreshold PTSS at
1 month. Due to the small group size and missing
questionnaire data for these children, the delayed
onset group was not included in the following anal-
yses. Means and interaction effects for the mixed
design ANOVAs are presented in Table 3. Age, gen-
der, %TBSA and child trauma history were included
in the initial analyses; however, no significant main
effects or interactions were found for any of these
variables. Therefore, these variables were not
included in the final model.
Beginning with PTSS over time as the dependent
variable, analyses indicated a large significant
interaction effect between time and group, F(2,
119) = 30.36, p < .001, g2 = .34. Post hoc tests
indicated that at 1 month, children in the chronic
group had significantly more PTSS than the recovery
(p = .045) and resilient group (p < .001) and the
recovery group had significantly more PTSS than
children in the resilient group (p < .001). There was a
significant reduction in PTSS across the 6 months
for children in the resilient and recovery groups
(p < .001), although children in the recovery group
had a significantly higher mean number of symp-
toms at 6 months in comparison to the resilient
group (p < .001). Children in the chronic group did
not experience any significant reduction in symp-
toms (p = .725) and were experiencing significantly
more PTSS than children in the other two groups at
6 months (p < .001). These results support the
validity of the trajectories.
Oppositional defiant disorder and SAD symptoms
also followed a similar pattern to PTSS, with children
in the chronic PTSD group continuing to have ele-
vated symptom levels, in comparison to the other two
groups. Furthermore, symptoms for children in this
group did not decrease significantly over the course
of 6 months postinjury (Table 3). For depression
symptoms, all children experienced a significant
decline over 6 months; however, the chronic group
had significantly more symptoms at 6 months in
comparison to the other two groups (p < .001). For
ADHD symptoms, there was only a significant med-
ium main effect for PTSD group, F(2, 119) = 18.39,
p < .001, g2 = .12, where children in the chronic
group had significantly more ADHD symptoms than
the other two groups at both time points and expe-
rienced no decline in symptom levels. Overall, these
findings suggest that children with persistent PTSD
also experience a range of elevated emotional and
behavioural difficulties that do not recover naturally
over time.
Discussion
Preschool children are a particularly high risk group
for burn injury. However, due to the common mis-
conception that young children are unlikely to be
affected by trauma and the lack of empirically vali-
dated and developmentally sensitive diagnostic cri-
teria and assessment measures, this population has
received little clinical and research attention. This
prospective study aimed to build on from our previ-
ous diagnostic paper (De Young et al., 2011), by
documenting the prevalence, onset, comorbidity and
recovery patterns of posttrauma reactions in young
burn victims. Together the findings from both stud-
ies show that preschool children are a vulnerable
population that can no longer be neglected.
The findings from this study make several impor-
tant contributions to the literature on paediatric
burn injury as well as trauma in young children
more generally. First, the results indicate that it is
common and normal for children to experience ele-
vated distress levels in the first month of injury, but
in many cases these early symptoms naturally
resolve. However, consistent with Hypothesis 1,
these findings show that young burn victims are at
risk of adverse emotional and behavioural outcomes,
with 35% of children diagnosed with at least one
psychological disorder within the first 6 months of
injury. PTSD, ODD and SAD were the most com-
monly diagnosed disorders.
The PTSD prevalence rate at 1 month (25%) was
comparable to the only other study that has reported
on acute stress reactions (29%) in burned children
under the age of 4 years (Stoddard et al., 2006).

Table 3 Course of emotional and behavioural symptoms over 6 months within the PTSD trajectory groups

DIPAa 1 Month 6 Months Interaction

Resilient Recovered Chronic Resilient Recovered Chronic F g2

PTSD 1.79 (1.72) 6.45 (1.71) 8.10 (2.51) 0.71 (1.10) 2.23 (1.57) 7.90 (2.69) 30.36** .34
MDD 0.51 (0.89) 2.82 (1.62) 3.50 (2.01) 0.24 (0.71) 0.73 (1.03) 2.50 (1.43) 20.39** .20
ADHD 1.39 (2.17) 1.91 (2.37) 5.30 (3.06) 1.27 (2.38) 1.36 (2.48) 6.40 (3.81) 2.96 .05
ODD 0.61 (1.26) 2.91 (2.14) 4.90 (2.96) 0.51 (1.11) 1.59 (2.09) 4.90 (2.18) 8.69** .12
SAD 0.52 (0.91) 2.14 (1.36) 2.10 (0.88) 0.38 (0.92) 0.77 (1.11) 2.50 (1.72) 10.75** .15

Values are given as M (SD). DIPA, Diagnostic Infant Preschool Assessment; PTSD, posttraumatic stress disorder; MDD, major
depressive disorder; ADHD, attention-deficit/hyperactivity disorder; ODD, oppositional defiant disorder; SAD, separation anxiety
disorder.
a
Resilient: n = 90; recovered: n = 22; chronic: n = 10.

 2011 The Authors. Journal of Child Psychology and Psychiatry  2011 Association for Child and Adolescent Mental Health.
doi:10.1111/j.1469-7610.2011.02431.x
Rates of ODD and SAD were in line with rates
reported for children exposed to Hurricane Katrina
(Scheeringa & Zeanah, 2008). Lower than expected
rates were found for MDD. This may reflect parental
difficulties in observing depressive symptoms in
young children. Alternatively, young children may be
developmentally less likely to experience depression
following trauma (Scheeringa & Zeanah, 2008). It is
interesting to note that the rates for PTSD, ODD and
SAD are high given that the majority of children in
this sample had minor injuries (M %TBSA = 3.24%).
One possible explanation is that children with minor
injuries who are treated as outpatients have less
contact with hospital staff and are less likely to
receive the same level of psychological support (e.g.
music therapist, social worker, psychologist) and
follow-up as children with moderate to severe burns.
It is also possible that there are other aspects,
besides the objective features of injury severity,
which are scary or traumatic for young children (e.g.
having to go to hospital, separated from caregiver
during treatment).
Second, consistent with Hypothesis 2 and previ-
ous research (Scheeringa & Zeanah, 2008; Schee-
ringa et al., 2003), this study also found high rates of
comorbidity with PTSD, especially for ODD and SAD.
Additionally, children with PTSD at 1 month were
4.8 times more likely to develop a new non-PTSD
psychological disorder by 6 months. Further all
children with new-onset morbidity at 6 months had
PTSD symptomatology at 1 month. These results are
in concordance with two studies, one with children
(Scheeringa & Zeanah, 2008) and one with adults
(McMillen, North, Mosley, & Smith, 2002), that both
found that new onset disorders following a natural
disaster did not occur without the presence of PTSS.
McMillen et al. (2002) have argued that this finding
suggests that PTSD contributes to the development
of other psychiatric disorders. Most recently, Milot,
Éthier, St-Laurent, and Provost (2010) also found
some support for the proposal that PTSD may con-
stitute a mechanism in the development of other
psychiatric disorders, as their research indicated
that trauma symptoms fully mediated the relation-
ship between maltreatment and internalising
and externalising behaviours in preschool aged
children.
Whilst no quantitative data were collected, we
hypothesise that the increased rates of ODD and
SAD found in this study could also be due to changes
in parenting behaviours in response to the child’s
initial distress (e.g. more noncontingent rewards,
decreased consequences for inappropriate behav-
iour, overprotective). Scheeringa and Zeanah (2008)
have also speculated that the presence of SAD may
be explained by a young child’s unique dependence
on their caregiver for protection following trauma
and that ODD may be due to an overlap in hypera-
rousal symptoms with PTSD (e.g. irritability or
outbursts of anger).
 2011 The Authors. Journal of Child Psychology and Psychiatry  2011 Association for Child and Adolescent Mental Health.
Trauma reactions in young burned children 61
The high rates of comorbidity with PTSD provide
further support for concerns that children who
exhibit high emotion and deregulated behaviour may
receive a number of erroneous primary diagnoses
such as ADHD and ODD instead of PTSD following
trauma (Scheeringa & Zeanah, 2008). Additionally,
of the children who met criteria for ADHD, 2 children
(29%) at 1 month and 5 children (63%) at 6 months
received a new-onset ADHD diagnosis postinjury.
This also raises questions about whether the new
onset rates are reflecting a new ADHD like syndrome
that is more representative of a manifestation of
traumatic stress rather than classical ADHD. Given
that it is particularly difficult to accurately identify
internalised PTSS in young children (e.g. avoidance
of thoughts), there is a high risk that the more easily
observable disruptive symptoms are mistakenly
targeted for treatment without understanding the
concurrent underlying PTSD symptomatology
(Scheeringa & Zeanah, 2008). Comorbidity during
early childhood is a particularly complex issue,
especially given that this is a time when ODD and
SAD often first present. More research is clearly
warranted to further understand PTSD psychiatric
comorbidity in young children.
Third, in line with recovery patterns reported by Le
Brocque et al. (2010), the results from this study
suggest that young children may also show distinct
individual variation in trauma responses following
burn injury. Using a priori categories, the majority of
children were classified as resilient (72%) with mild
distress symptoms in the acute period that were
within normal levels and improved significantly by
6 months. The 18% of children classified as having a
recovery trajectory had moderate to severe initial
elevations in psychological distress but appeared to
recover well over the course of 6 months, as dem-
onstrated by a significant reduction in PTSD, MDD,
ODD and SAD symptoms. Of concern, and consis-
tent with Hypothesis 3, a small but clinically signif-
icant group of children (8%) not only retained a PTSD
diagnosis but also experienced elevated emotional
and behavioural difficulties that did not improve or
return to baseline levels of functioning. Even the
18% in the recovered group were left with a mean of
2.23 PTSS after 6 months. It has been established
that caregiver report alone is a substantial under-
estimate of PTSD symptomatology in young children
(Scheeringa, Wright, Hunt, & Zeanah, 2006). Thus, it
appears that if left untreated, trauma during early
childhood may follow a chronic and unremitting
course for a clinically significant subset of children.
This can have significant ramifications for a young
child’s healthy emotional, social, physical, and
behavioural development.
Limitations and future directions
There are limitations of this study that need to be
considered. The design of this study did not incor-
62 Alexandra C. De Young et al. J Child Psychol Psychiatry 2012; 53(1): 56–63

porate a healthy control group. It could therefore be
argued that the new-onset psychological disorder
prevalence rates (e.g. ODD, SAD) are a reflection of
typical behaviours seen in this age group rather
than as a result of trauma per se (Scheeringa &
Zeanah, 2008). However, the rates of new onset dis-
orders were comparable across age groups (i.e. 1–3
vs. 4–6) and the prevalence rates of disorders
reported in this study are higher than those reported
in nonpsychiatric samples (Egger & Angold, 2006).
Additionally, all interviews were conducted over the
telephone and by the one interviewer who was
therefore not blind to initial PTSD status. However,
the decision to conduct the DIPA over the telephone
was based on research which has found high
agreement between face-to-face and telephone
administered versions of the Anxiety Disorders
Interview Schedule for children for DSM–IV parent
version (ADIS–C–IV–Parent; Lyneham & Rapee,
2005). Finally, these findings may not generalise to
more severe burn injuries, other trauma types (e.g.
intentional injury, interpersonal trauma), different
cultural or socioeconomic backgrounds or other
caregivers (e.g. fathers).
To increase the generalisability of existing find-
ings, further research is needed with preschool
children from different trauma populations, should
include healthy control or comparison groups and
follow children over longer time frames. In particu-
lar, research is needed to identify the risk and pro-
tective factors that predict what trajectory pathway a
child is likely to follow after medical trauma. The
ability to identify and predict distinct recovery pat-
terns following trauma has important implications
for the early identification of children who may be at
risk (Le Brocque et al., 2010).
children, SAD and ODD commonly follow or emerge
concurrently with the onset of PTSD. Following on
from this, medical and mental health professionals
need to be aware that young traumatised children
are at risk of adverse outcomes and need to screen
for a range of emotional and behavioural difficulties,
not just PTSD. Additionally, it is essential to screen
for trauma and traumatic stress symptoms in chil-
dren who present with new onset disruptive
behavioural problems. Within the treatment context,
it is important to minimise the psychological impact
of potentially traumatic events where possible dur-
ing the acute phase (e.g. allowing child and parent to
stay together, effective pain management), to provide
early psychological prevention to high risk children,
and once diagnoses are entrenched after the acute
phase to provide quality evidence-based treatment.
In conclusion, a clinically significant minority of
children are at risk of long-term adverse psycholog-
ical outcomes following burn injury. It is therefore
recommended that all young children who present
for treatment of burns are screened for trauma
reactions and that prevention and early intervention
resources are routinely incorporated into paediatric
burns settings.
Acknowledgements
This research was supported by the Cressbrook Com-
mittee & Royal Children’s Hospital Foundation Post-
graduate Scholarship and Australian Post Graduate
Award. The authors thank Professor Michael Schee-
ringa for his advice and support during various stages
of the project and constructive feedback on this article.
The authors also thank Ms Joan Hendrikz for her time
and helpful statistical advice.

Conclusion
There are several important diagnostic, assessment
and treatment implications from this study. First,
from a diagnostic perspective, we propose that the
DSM–V makes revisions to the existing PTSD asso-
ciated features section to indicate that in preschool
Correspondence to
Alexandra C. De Young, CONROD, University of
Queensland, Level 1 Edith Cavell Building, Royal Bris-
bane and Women’s Hospital, Herston, Qld 4029, Aus-
tralia; Tel: +61 7 3346 4890; Fax: +61 7 3346 4603;
Email: adeyoung@uq.edu.au

Key points
• Infants, toddlers and preschoolers are the highest risk group for burn injury.
• The majority of young children do not experience adverse psychological outcomes.
• However, a clinically significant minority are at risk of PTSD and comorbid emotional and behavioural diffi-
culties that may follow a chronic and debilitating course.
• These outcomes can have serious short and long term consequences for a young child’s medical and psy-
chosocial recovery and normal developmental trajectories.
• It is recommended that screening, prevention and early intervention resources are incorporated into paedi-
atric burns settings to optimise young children’s psychological adjustment following burn injury.

 2011 The Authors. Journal of Child Psychology and Psychiatry  2011 Association for Child and Adolescent Mental Health.
doi:10.1111/j.1469-7610.2011.02431.x
References
American Psychiatric Association (2000). Diagnostic and sta-
tistical manual of mental disorders (4th edn, Text Revision).
Washington, DC: Author.
Australian Institute of Health and Welfare (2009). A picture of
Australia’s children 2009. Cat. No. PHE 112. Canberra:
AIHW.
Blakeney, P., Meyer, W., Moore, P., Broemeling, L., Hunt, R.,
Robson, M., & Herndon, D. (1993). Social competence and
behavioral problems of pediatric survivors of burns. Journal
of Burn Care & Rehabilitation, 14(1), 65–72.
De Young, A.C., Kenardy, J.A., & Cobham, V.E. (2011).
Diagnosis of posttraumatic stress disorder in preschool
children. Journal of Clinical Child and Adolescent Psychol-
ogy, 40, 1–10.
deRoon-Cassini, T.A., Mancini, A.D., Rusch, M.D., & Bonanno,
G.A. (2010). Psychopathology and resilience following trau-
matic injury: A latent growth mixture model analysis.
Rehabilitation Psychology, 55, 1–11.
Egger, H.L., & Angold, A. (2006). Common emotional and
behavioral disorders in preschool children: Presentation,
nosology, and epidemiology. Journal of Child Psychology and
Psychiatry, 47, 313–337.
Fukunishi, I. (1998). Posttraumatic stress symptoms and
depression in mothers of children with severe burn injuries.
Psychological Reports, 83, 331–335.
Kent, L., King, H., & Cochrane, R. (2000). Maternal and child
psychological sequelae in paediatric burn injuries. Burns,
26, 317–322.
Kidsafe NSW. (2010). Burns and Scalds Prevention. Available
from: http://www.kidsafensw.org/homesafety/burns_scalds_
prevention.htm [last accessed 3 June 2011].
Kinnear, P.R., & Gray, C.D. (2008). SPSS 15 made simple.
Hove/New York: Psychology Press.
Landolt, M.A., Buehlmann, C., Maag, T., & Schiestl, C. (2009).
Brief report: Quality of life is impaired in pediatric burn
survivors with posttraumatic stress disorder. Journal of
Pediatric Psychology, 34, 14–21.
Le Brocque, R.M., Hendrikz, J., & Kenardy, J.A. (2010). The
course of posttraumatic stress in children: Examination of
recovery trajectories following traumatic injury. Journal of
Pediatric Psychology, 35, 637–645.
Lund, C., & Browder, N. (1944). The estimation of areas of
burns. Surgery Gynecology and Obstetrics, 79, 352–358.
Lyneham, H.J., & Rapee, R.M. (2005). Agreement between
telephone and in-person delivery of a structured interview
for anxiety disorders in children. Journal of the American
Academy of Child and Adolescent Psychiatry, 44, 274–282.
McMillen, C., North, C., Mosley, M., & Smith, E. (2002).
Untangling the psychiatric comorbidity of posttraumatic
stress disorder in a sample of flood survivors. Comprehen-
sive Psychiatry, 43, 478–485.
Meyer, W.J., Blakeney, P., LeDoux, J., & Herndon, D.N. (1995).
Diminished adaptive behaviors among pediatric survivors
of burns. Journal of Burn Care and Rehabilitation, 16, 511–
518.
 2011 The Authors. Journal of Child Psychology and Psychiatry  2011 Association for Child and Adolescent Mental Health.
Trauma reactions in young burned children 63
Meyer, W.J., Blakeney, P., Thomas, C.R., Russell, W., Robert,
R.S., & Holzer, C.E. (2007). Prevalence of major psychiatric
illness in young adults who were burned as children.
Psychosomatic Medicine, 69, 377–382.
Meyer, W.J., Robert, R., Murphy, L., & Blakeney, P.E. (2000).
Evaluating the psychosocial adjustment of 2- and 3-year-old
pediatric burn survivors. Journal of Burn Care and Rehabil-
itation, 21, 179–184.
Milot, T., Éthier, L.S., St-Laurent, D., & Provost, M.A. (2010).
The role of trauma symptoms in the development of behav-
ioral problems in maltreated preschoolers. Child Abuse and
Neglect, 34, 225–234.
Rivlin, E., & Faragher, E.B. (2007). The psychological sequelae
of thermal injury on children and adolescents: Part 1.
Developmental Neurorehabilitation, 10, 161–172.
Saxe, G., Stoddard, F., Chawla, N., Lopez, C.G., Hall, E.,
Sheridan, R.L. et al. (2005). Risk factors for acute stress
disorder in children with burns. Journal of Trauma and
Dissociation, 6, 37–49.
Scheeringa, M.S., & Haslett, N. (2010). The reliability and
criterion validity of the Diagnostic Infant and Preschool
Assessment: A new diagnostic instrument for young chil-
dren. Child Psychiatry and Human Development, 41, 299–
312.
Scheeringa, M.S., Wright, M.J., Hunt, J.P., & Zeanah, C.H.
(2006). Factors affecting the diagnosis and prediction of
PTSD symptomatology in children and adolescents. Ameri-
can Journal of Psychiatry, 163, 644–651.
Scheeringa, M.S., & Zeanah, C.H. (2008). Reconsideration of
harm’s way: Onsets and comorbidity patterns of disorders in
preschool children and their caregivers following Hurricane
Katrina. Journal of Clinical Child and Adolescent Psychology,
37, 508–518.
Scheeringa, M.S., Zeanah, C.H., Myers, L., & Putnam, F.W.
(2003). New findings on alternative criteria for PTSD in
preschool children. Journal of the American Academy of
Child and Adolescent Psychiatry, 42, 561–570.
Stoddard, F.J., Norman, D.K., Murphy, J.M., & Beardslee,
W.R. (1989). Psychiatric outcome of burned children and
adolescents. Journal of the American Academy of Child and
Adolescent Psychiatry, 28, 589–595.
Stoddard, F. J., Saxe, G., Ronfeldt, H., Drake, J. E., Burns, J.,
Edgren, C., & Sheridan, R. L. (2006). Acute stress symptoms
in young children with burns. Journal of the American
Academy of Child & Adolescent Psychiatry, 45(1), 87–93.
Tarnowski, K.J., Rasnake, L.K., Gavaghan-Jones, M.P., &
Smith, L. (1991). Psychosocial sequelae of pediatric burn
injuries: A review. Clinical Psychology Review, 11, 371–398.
World Health Organisation. (2008). World report on child injury
prevention. Available from:http://whqlibdoc.who.int/
publications/2008/9789241563574_eng.pdf [last accessed
3 June 2011].
Accepted for publication: 20 April 2011
Published online: 14 June 2011