A Quantitative, Cross-sectional Study of Depression and Self-esteem in Teenage and Young Adult Burn Victims in Rehabilitation
Burns can have a negative physiological and emotional impact, particularly among teenage victims. To assess the presence of depression and level of self-esteem, a cross-sectional study was conducted among 63 teenage and young adult burn victims ages 12 to 20 years undergoing physical and psychological rehabilitation at the Outpatient Unit for Plastic Surgery and Burns at the Central Institute of the Clínicas Hospital of the Faculty of Medicine of the University of São Paulo, São Paulo, Brazil.
Assessment instruments included Beck’s Depression Inventory (BDI) and the Rosenberg Self-Esteem Scale (RSE). Internal consistency within and between the two scales was established via Cronbach’s-a coefficient. All variables were analyzed using descriptive statistics, and the statistical difference between means was compared using Student’s t-test. The majority of participants were female (38, 60.3%) and unmarried (59, 93.7%) with a mean total body surface area (TBSA) burn of 23.84%. Most burns (58, 92.10%) were the result of accidents and were located on the trunk (47, 74.6%), head (43, 68%), arms (41, 65%), hands (38, 60%), neck (34, 54%), and forearm (29, 46%). Participants had received physical and psychological rehabilitation for an average of 124.74 months (SD 63.67) from a multidisciplinary team.
The majority of participants (33, 52.4%) reported functional and aesthetic after-effects and appraised their scar as visible (51, 81.0%). BDI results showed low levels or absence of depression (mean = 7.63, SD 8.72; scale 0 = no depression to 63 = serious depression); the RSE showed adequate levels of self-esteem (mean = 8.41, SD 4.74; scale 0–30, where higher scores indicate worst levels of self-esteem). Burn location did not affect depression (BDI: P = 0.26) or self-esteem (RSE: P = 0.21). However, depression and self-esteem were more significant in participants who were not able to work and/or go to school than in those who were (BDI: P = 0.04 and self-esteem RSE: P = 0.03). Contrary to the initial hypothesis, this population of teenage burn victims did not experience depression and low self-esteem compared with the normal population described in the literature, which may demonstrate the importance of multidisciplinary rehabilitation programs.
Potential Conflicts of Interest: This paper was presented at Guarulhos University in May 2012 as a requirement for obtaining a Master’s degree.
The teenage period marks the emergence of primary and secondary sexual characteristics, body and hormonal changes, and growth; at the end of this process, the individual reaches adult physical maturity.1 Even though each teenager has his/her own individual reactions to this period of life, some common characteristics include the need to become independent from parents, the acquisition of a personal identity or lifestyle within a certain group, an increased emphasis on and acceptance of one’s own body image, and the establishment of sexuality, the ego, a vocation, and moral identity.2,3 In this context, physical appearance and the development of the muscular and skeletal frame become important. Body structure as it relates to group acceptance influences socialization and the establishment of self-affirmation and self-confidence.2,3
A cross-sectional study4 in a population sample of normal adolescents (17,082 girls and 15,922 boys) of secondary school age suggests that the physical changes of puberty determine the reformulation of the body schema — ie, a reorganization of the person’s mental representation of him/herself — and, subsequently, constant concern with general body image. According to the study, in normal teens the distance sensed between the idealized and real body image can elicit a feeling of anguish and may render the teenager prone to depression. Other studies confirm the incidence of depression and even suicidal tendencies in this age group. A longitudinal study5 conducted among 4,500 adolescent students and a cross-sectional study6 with 763 high school students showed adolescents with lower self-esteem, greater impulsivity, problems of family cohesion, and less social support are more prone to suicide.
A longitudinal study7 that included eight assessments across a 14-year period of a national probability sample of 7,100 individuals ages 14–30 years that examined the normative self-esteem trajectory in adolescence and adulthood concluded self-esteem is susceptible to change and may be low during the teenage years when compared with the population of adults; this age bracket is a critical period for the healthy development of self-esteem. Individual variation can be attributed to emotional stability, a sense of command, individual conscience, and health.
Transverse and longitudinal studies have reported persons with burns describe pain, paraesthesia, anxiety, depression, post-traumatic stress, and feeling suicidal, along with physical problems arising from scar contractions and social problems such as unemployment.8-16 With an increase in the number of persons surviving burns, rehabilitation plans have been developed to deal with the repercussions of physical sequelae generated by burns, such as contractures, loss of muscle, heterotopic ossifications, amputations, pain, neuropathies, and psychological disorders, along with aesthetic sequelae (with no functional disorder).17 In addition, burn patients face social problems such as difficulty returning to work, unemployment,18,19 and financial problems.20 Blades et al21 studied construction of a scale for assessing the health status of burn patients and concluded that the location of the burn such as the face or hands can be an important factor in psychological disorders. Similarly, according to a longitudinal study14 that followed 86 former patients treated for severe burn injuries an average of 9 years previous showed that unemployment can negatively affect psychological adjustment.
Rehabilitation to help burn patients reach their maximum potential following injury and increase their chances for the return of physical, social, and psychological functions13,16 has become a priority8 so the patient can regain status in the family, social unit, and at work.22
A teenage burn victim faces the physical and psychological changes associated with his/her age, exacerbated by the injury itself. Few studies have been conducted regarding the psychological impact of this trauma on Brazilian teenage and young adult populations. The aim of this study is to assess the presence of depression and also the level of self-esteem of teenagers who are going through the process of post burn rehabilitation and determine whether the location of the burn (hand or head) or current work situation is a factor in psychological conditions.
Participants. A cross-sectional field study with quantitative analysis was conducted between August and December 2011. All teenagers and young adults between 12 and 20 years of age who had burns (any total body surface area [TBSA] of the burn), whose primary language was Portuguese, and who were undergoing physical and psychological rehabilitation in the outpatient unit of the Burns Unit at the Clínicas Hospital of the Faculty of Medicine of the University of São Paulo were invited and eligible to participate. There were no other qualifying criteria.
Sociodemographic and clinical instrument. Participant social and demographic information was collected from data reported by the patient or guardian in the medical file and included date of birth, education, occupation, cause and TBSA of the burn, etiologic agent, visibility of burn, presence of physical sequelae, and presence of aesthetic sequelae (sequelae without functional disorder).
Beck’s Depression Inventory (BDI). The BDI distinguishes different degrees of depression.22 The instrument consists of 21 statements, each with four options regarding symptoms and attitudes, with intensity options ranging from 0 to 3. Scores <10 indicate no or minimal depression; 10–18, slight to moderate depression; 19–29, moderate to serious depression; and 30–63, serious depression.23 The Brazilian version as validated by Gorenstein et al24.25 (internal consistency 0.81) was used. All of the data obtained through the BDI26 were supplied by the participants who completed the instrument.
Rosenberg’s Self-Esteem Scale (RSE). Self-esteem is a person’s positive or negative view of him/herself.27 The RSE was created in the 1960s; it was culturally adapted and validated for Brazilian culture by Dini et al.28 This instrument contains 10 items (five negative and five positive statements) and uses a Likert scale ranging from 0 to 3 (fully agree, agree, disagree, fully disagree, respectively). The point score may range from 0 to 30; higher point scores show worse levels of self-esteem.29,30 Participants completed the RSE survey instrument.30
Cronbach’s-a coefficient. The analysis of Cronbach’s-a coefficient to assess the internal consistency of the BDI and RSE Scale (to ensure instrument reliability and suitability in this population sample) was performed.
Procedure. Before or after the medical visit, the adolescents were sent individually to a room to guarantee privacy, and the study instruments were provided for completion. A researcher stayed in the room in the event any explanation was required. Participants’ legal guardians could accompany the participant but not provide answers. This procedure took approximately 30 minutes.
Ethical procedures. Study approval was obtained from the Ethics Commission for Analysis of Research Projects of the Clínicas Hospital of the Faculty of Medicine of the University of São Paulo (approval number 0331/11). All eligible patients were invited to participate in the survey. The study purpose and procedures were explained to the patients and their legal guardians, and signed informed consent was obtained with the assurance of privacy and anonymity before the questionnaires were completed.
Data collection and analysis. Researchers collected, scored, analyzed, and interpreted the data. All data were stored and analyzed using the Statistical Package for the Social Sciences (SPSS)®, version 18.0. (IBM, Seattle, WA). Cronbach’s-a was 0.7. Descriptive statistics were used for clinical and demographic variables as well as the questionnaire answers. Student’s t-test was used to quantify statistical difference between the means calculated from the responses; level of significance of up to 5 (P <0.05) was established. The null hypothesis (H0) that no differences would be found between the means for the different variables was used. For data analysis, location of burn lesion and work/study situation variables were considered. Location was classified according to the presence or absence of burns on the hands or head specifically, along with other body regions. Work and/or study activity was divided into categories of not performing such activities (unwaged/people who do not study or work) and performing work and/or study activities (freelance work, formal or informal work, trainees, and students).
All of the 63 potential participants agreed to be included. All adolescents were receiving treatment for physical and psychological rehabilitation for an average of 124.74 months (SD 63.97) or 10.39 years (SD 5.32) with follow-up by a multidisciplinary team. Participants were mostly female (38, 60.3%), not married (59, 93.7%), and 12 to 20 years old (mean 15.95, standard deviation [SD] 2.88). The mean body surface burned was 23.84, with accidents the main cause of injury (58, 92.10%). The average age of occurrence of the burn was 5 years, 6 months, 18 days (ie, 66.68 months, SD 60.33); thus in most cases, the trauma occurred during childhood. The majority of participants (33, 52.4%) reported functional and aesthetic after-effects of just the burn area, and most (51, 81.0%) described their scar as visible.
Fire caused the majority of burns (36, 57.10%), followed by scalding (20, 31.7%). Alcohol (25, 39.7%) was the main causative substance (in Brazil, alcohol is routinely used as a cleaner and barbecue igniting agent), followed by hot water (12, 19%). The body areas most affected by burns included the trunk (47, 74.6%), head (43, 68.3%), arms (41, 65.10%), hands (38, 60.3%), neck (34, 54%), and forearm (29, 46%).
Internal consistency between all instruments used was good (>0.7). Alpha values were 0.88 for BDI and 0.74 for RSE.
BDI. The mean BDI score was 7.63 (SD 8.72), suggesting that, at most, participants were not or only slightly depressed. Most participants (34) scored all BDI items as 0. The largest portion of answers (10, 15.90%) corresponding to a score of three was for item 11 (“I no longer get irritated by things that used to irritate me”). Item 8 (“I am critical of myself for my weaknesses and errors”) and item 2 (“I always blame myself for my faults”) were scored 1 and 2, respectively (20.6 of answers). Item 14 score of 2 (“I am concerned about getting old or unattractive”) and score of 3 (“I think there have been permanent changes to my appearance that make me unattractive”) had frequencies of 12.70 and 25.90, respectively (see Table 1).
RSE scale. Participant answers yielded a mean score of 8.41 (SD 4.74), showing that, in general, this group has an adequate degree of self-esteem. The mean RSE score was 8.41 (SD 4.74); most of the teenagers surveyed fully agreed or agreed with the positive items on the RSE (see Table 2). Even though items 2, 5, 6, and 9 show greater percentages of participant disagreement, item 8 is worthy of attention; 30.2 and 41.3, respectively, of the subjects say they “fully agree” or “agree” with the statement “I wish I could have more respect for myself,” demonstrating characteristics that may be native to all teenagers (self-criticism, insecurity, and preoccupation),2,3 not just burn victims (see Table 2).
Burn location. The average BDI and RSE scores for teenagers who had sustained burns on their head (n = 43) versus those who did not (n = 20) were statistically the same (BDI: P = 0.26; RSE: P = 0.21) (see Table 4). The scores also were not statistically significantly different between persons who did (n = 38) compared to those who did not (n = 25) sustain burns on their hands (BDI: P = 0.10; RSE: P = 0.28) (see Table 5). In this study population, a history of burns on the head or hands did not affect levels of depression and self-esteem.
Work and/or school activity performance. Persons who were able to perform work and/or school activities (n = 53) had an average BDI score of 6.83 (SD 8.36) and an average RSE of 8.09 (SD 4.99), compared to 11.90 (SD 9.78) and 10.10 (SD 2.69), respectively, for persons who were not able to perform these activities (n = 10). These differences were statistically significant (BDI: P = 0.04 and RSE: P = 0.03) (see Table 6). The reasons why study participants were unable to perform work and/or school activities was not explored. This study did not analyze the relation of consequence (depression and self-esteem were caused by inability to work or inability to work was caused by depression), but it has shown these variables are related. It also was not possible to assess if the variable depth of the burn influences the ability to work due to lack of information and standardization of language in the patient’s file.
The purpose of this study was to assess the presence of depression and the level of self-esteem among teenagers and young adults going through post-burn rehabilitation and determine whether the location of the burn (hand or head) or current work situation influences psychological conditions. Both the BDI and RSE had good internal consistency (Cronbach’s-a coefficient >0.7).
The most frequently cited cause of injury was fire and the most common causative agent was alcohol. Liquid alcohol is widely used in Brazil as a cleaning agent and as fuel for barbecue grills. Such activities often involve children and teens, putting them at risk for burn injuries.31
Results of the BDI (mean 7.63, SD 8.72) show a lack of depression or, at most, a slight degree of depression. In a cross-sectional study. Gorenstein et al25 used the BDI among 270 healthy Brazilian university students. The mean score in that student group was 8.5 (SD 7.0), slightly higher than the average in this study. Even though 52.4 of the teenagers and young adults in this study reported aesthetic effects and functional consequences and the average TBSA burned was high (23.84), most (73.3) were not depressed or at most showed a low level of depression, and most had a high level of self-esteem. Similar results were reported in a cross-sectional study32 of 115 adults with burn injuries in Brazil.
In a cross-sectional study among an American population comprising 121 burn victims with a mean age of 17.9 years, Orr et al33 used the BDI and RSE and concluded that social support, especially from friends, is an important variable in post burn trauma psychological adaptation. Social support bears upon levels of self-esteem, depression, and body image.
In the current study, depression and self-esteem scores were not significantly different between teenagers and young adults who did or did not have burns involving their head or hands. However, significant differences in depression and self-esteem scores were observed between those who were and those who were not able to work and/or go to school. These results concur with those by Orr et al,33 who showed that social activities play a part in a young burn victim’s re-adaptation into society.
The presence of functional or aesthetic sequelae or the visibility of the scar did little to affect depression or self-esteem. Such results could suggest the use of the coping mechanism. In a cross-sectional study34 that supports these findings, 149 participants who had been treated for a severe burn injury and had been discharged from acute treatment for their burn injuries at least 3 months earlier completed several instruments. The Posttraumatic Growth Inventory (PTGI) is a 21-item scale assessing the positive legacy of trauma using a Likert scale where 1 = change not experienced at all to 5 = change occurred to a very large degree. The Self-Report Inventories Assessing Coping (CBQ) is a 33-item, Likert scale questionnaire in which answer options ranged from 1 = strategy not applied at all to 4 = strategy frequently applied. The Social Support (F-SozU-14) included 14 items that measure perceived social support, and features a Likert scale where 1 = absolutely right to 5 = not true enough. The study concluded some changes that occur after a catastrophic event, especially in relationships, appreciation of life, spirituality, and direction of life, can be positive. It also was determined that the presence of coping strategies with a mean of active coping (mean = 2.45, SD 0.44) higher than avoidant coping (mean = 1.05, SD 0.95) and high level of social support (mean = 4.02, SD 0.82) may be decisive for influencing positive changes individuals may experience.
This study sample reflected the particularities inherent in Brazil’s socioeconomic conditions as demonstrated in a cross-sectional study35 in which 584 Latin American children and adolescents from 5 to 17 years of age were interviewed. Because parents need to work, some teens assume household responsibilities (eg, organizing the home, food preparation, care of siblings) at a young age.36 The authors believe the necessity imposed by the economic scenario of the country creates mechanisms of independence earlier in Brazilian teens compared to adolescents in different social situations.
Rehabilitation therapy is not a reality throughout Brazil, where the focus is on acute care. Access to the institutions that provide rehabilitation is limited. It is worth noting the country is divided geographically into five regions; the division of health services is not egalitarian, with extreme concentration in the Southeast. This presents an additional obstacle to patients receiving rehabilitation services who live in other areas.
In the present study, the sample size was a limiting factor; studies involving larger samples are recommended. Direct comparisons between teenagers and young adults with and without a history of burn injury would be useful. Other limiting factors included the lack of information and standardization of language on the patient’s file with incomplete information about the depth and extend of the original burn injury. Additional research is sorely needed to improve methods of understanding, assessing, and treating comorbid depression and low self-esteem following burn injury, at the very least to better understand the success of current rehabilitation therapy.
Because of the trauma that changes the ability to perform daily activities, as well as physical function and appearance, self-esteem and depression should be assessed in persons who sustain burn injuries. This is especially true among teenage and young adult patients where natural changes during adolescence generate conditions conducive to the development of depression and low self-esteem. Although the majority of participants in this study had good self-esteem and depression scores, some individual scores, such as those dealing with feelings of personal fault and appearance, seem to warrant intervention. Thus, it is necessary to apply these instruments as part of the rehabilitation process to ensure successful re-adaptation of the patient to society and to improve general quality of life.
At the time this manuscript was written, Ms. Nicolosi was a Master’s degree candidate, University of Guarulhos, Guarulhos. Brazil. She is now a University Professor, Health Department of the Nove de Julho University, São Paulo, Brazil. Dr. de Carvalho is a nurse, Plastic Surgery division, Faculty of Medicine, University of São Paulo, São Paulo, Brazil; and University Professor, University of Guarulhos. Dr. Sabatés is Head Teacher, University of Guarulhos. Please address correspondence to: Júlia Teixeira Nicolosi, RN, MSN; email: email@example.com.
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