The provision of specialist psychosocial support for people with visible differences: A European survey

The acceptability of early psychological interventions for adults with appearance concerns after burns

INTRODUCTION

Appearance concerns are common following burns. However, there is a lack of research investigating early psychological interventions for appearance concerns. This qualitative study explored the acceptability of early psychological interventions for appearance concerns after burns.

METHODS

Fifteen adults (nine female; 18-56 years) with appearance concerns were interviewed within three months post-burn to explore their views about the acceptability of early psychological interventions for these concerns. Interviews were audio-recorded and transcribed. Template analysis informed data collection and analysis.

RESULTS

Three themes represented participants' views about the acceptability of early psychological interventions for appearance concerns: (1) early psychological interventions are absent; (2) early psychological interventions are acceptable within a therapeutic relationship (to manage upsetting emotions and thoughts about appearance, with therapists who are experienced in supporting burns patients); and (3) ambivalence and obstacles exist (e.g., difficulties accepting help, minimising injuries or concerns, and time restrictions following hospital discharge).

CONCLUSION

Early psychological interventions for appearance concerns following burns are likely to be acceptable for some patients. However, ambivalence and potential barriers remain to be addressed. Embedding early psychological interventions for appearance concerns into routine burn care could increase acceptability through normalisation.

More than my appearance: a pilot evaluation of the expand your Horizon Online functionality-based writing programme for adults with visible differences

Background

Adults with conditions that affect their appearance, known as visible differences, can experience appearance concerns, social anxiety, and depression. Interventions have been developed for this population to facilitate adjustment and coping skills; however, they have limited evidence of efficacy. The Expand Your Horizon [Alleva, J. M., Martijn, C., Van Breukelen, G. J., Jansen, A., & Karos, K. (2015). Expand Your Horizon: A programme that improves body image and reduces self-objectification by training women to focus on body functionality. Body Image, 15, 81-89. https://doi.org/10.1016/j.bodyim.2015.07.001] online functionality-based writing programme was adapted for adults with visible differences.

Method

A pilot randomised controlled trial with a wait-list control group was carried out to assess preliminary intervention efficacy and gain information about the acceptability and feasibility of the programme. Forty-four adults aged 21-63 years (M = 40.21; SD = 12.05) with visible differences took part. Various facets of body image (i.e. functionality appreciation and body appreciation) as well as depression and anxiety were assessed immediately pre- and post-intervention and at three-months.

Results

Participants reported enjoying the programme, felt that the format was acceptable, and it significantly increased functionality appreciation, which was maintained at three-months. However, there were no improvements in body appreciation, depression, and anxiety.

Conclusions

In future, a full trial should be carried out with an active control group.

An ACT self-help intervention for adults with a visible difference in appearance: A pilot feasibility and acceptability randomized controlled study

Individuals living with a visible difference in appearance experience high levels of social anxiety, yet self-help interventions for this heterogeneous population are not available. We conducted a pilot trial of a novel Acceptance and Commitment Therapy (ACT) based self-help intervention.Individuals with anxiety about having a visible difference in appearance (n = 284) were randomized to an ACT-based four-week intervention (n = 145) or a waitlist control condition (n = 139). We collected pre and follow-up (four-weeks after the completion of the intervention) data. Primary outcomes included social anxiety and impairments in functioning. Psychological flexibility (PF) was also examined. ANCOVAs, controlling for pre scores, indicated significant improvements in functioning by the intervention group. No significant differences were observed for anxiety and PF between conditions at follow-up. Drop out was 68% for the intervention and 41% for the control group, with no differences in the groups in age, origin, gender, or type of visible difference. Participants in the intervention group found the intervention almost equally, useful (77%) and helpful (73%). An ACT-based self-help intervention can alleviate distress related to visible difference in appearance. More sophisticated designs are needed now, to collect idiographic and longitudinal data and examine personalized changes across time in this population.

Experiences and impact of the UK lockdown amongst adults who have a facial visible difference

Globally, COVID-19 has been shown to have had a wide ranging and significant impact on individuals' daily living, and physical and mental health. However, there are some groups of individuals who may encounter unique challenges with regards to COVID-19 and whose experiences have not been investigated thus far. Therefore, this study aimed to understand the experiences of adults with a facial visible difference in relation to COVID-19 and lockdown. Semi-structured interviews were conducted with 21 adults with a variety of facial visible differences (e.g., cleft lip/palate, facial scars, skin conditions) and analyzed using inductive reflexive thematic analysis. This analysis generated three themes (Escaping the external gaze; Existing feelings manifesting in new challenges; COVID-19 taking priority). The results of this study suggest that the first U.K. lockdown from the COVID-19 pandemic created significant challenges for some individuals with a facial visible difference, and ongoing restrictions and social distancing measures might be particularly challenging for those who experience anxiety around social encounters. These findings highlight the importance of providing appropriate and accessible support for people with facial differences during lockdown and as restrictions ease.

Predictors of Adolescents' Response to a Web-Based Intervention to Improve Psychosocial Adjustment to Having an Appearance-Affecting Condition (Young Person's Face IT): Prospective Study

BACKGROUND

Adolescents with a condition affecting their appearance that results in a visible difference can be at risk of psychosocial distress and impaired adjustment. Evidence for the effectiveness of existing interventions in improving psychosocial outcomes is limited, and relevant treatment can be difficult to access. Young Person's Face IT (YPF), a self-guided web-based intervention, has demonstrated potential in reducing social anxiety in adolescents with a visible difference. However, more knowledge is needed about the variables that contribute to variations in intervention effects to identify those who may benefit most from YPF.

OBJECTIVE

This study aimed to investigate demographic, psychosocial, and intervention-related variables as predictors of overall intervention effects after adolescents' use of YPF.

METHODS

We used longitudinal data collected as part of a larger, ongoing mixed methods project and randomized controlled trial (ClinicalTrials.gov NCT03165331) investigating the effectiveness of the Norwegian version of YPF. Participants were 71 adolescents (mean age 13.98, SD 1.74 years; range 11-18 years; 43/71, 61% girls) with a wide range of visible differences. The adolescents completed primary (body esteem and social anxiety symptoms) and secondary (perceived stigmatization, life disengagement, and self-rated health satisfaction) outcome measures at baseline and postintervention measurement. The predictor variables were demographic (age and gender), psychosocial (frequency of teasing experiences related to aspects of the body and appearance as well as depressive and anxiety symptoms), and intervention-related (time spent on YPF) variables.

RESULTS

Two-thirds (47/71, 66%) of the adolescents completed all YPF sessions and spent an average of 265 (SD 125) minutes on the intervention. Backward multiple regression analyses with a 2-tailed P-value threshold of .20 revealed that several variables were retained in the final models and predicted postintervention outcome changes. Body esteem was predicted by age (P=.14) and frequency of teasing experiences (P=.09). Social anxiety symptoms were predicted by gender (P=.12), frequency of teasing experiences (P=.03), depressive and anxiety symptoms (P=.08), and time spent on YPF (P=.06). Perceived stigmatization was predicted by age (P=.09), gender (P=.09), frequency of teasing experiences (P=.19), and depressive and anxiety symptoms (P=.06). Life disengagement was predicted by gender (P=.03), depressive and anxiety symptoms (P=.001), and time spent on YPF (P=.14). Self-rated health satisfaction was predicted by age (P=.008). However, the results were limited by relatively low explained postintervention variance, ranging from 1.6% to 24.1%.

CONCLUSIONS

This study suggests that adolescent boys, adolescents who experience higher levels of psychosocial distress related to their visible difference, and adolescents who spend sufficient time on YPF may obtain better overall intervention effects.

Adolescents and parents' perception of Young Person's Face IT: An online intervention for adolescents struggling with conditions affecting their appearance

Objective

A visible difference in appearance caused by a congenital or acquired condition can negatively affect adolescents' psychosocial well-being. Young Person's Face IT (YPF) is an online intervention based on cognitive behavioural therapy and social skills training, developed to help adolescents who struggle with adjusting to a visible difference. The objective of the present study was to explore adolescents' and parents' perceptions of the intervention's relevance and usefulness in supporting young people with appearance-related psychosocial concerns.

Methods

Participants were adolescents (N = 76, aged 11-18) and parents (N = 15), recruited in a larger randomised controlled trial aiming at evaluating YPF. This qualitative study with descriptive data includes adolescents' ratings on YPF's usefulness, and interview data from adolescents and parents on their experiences with YPF. The interviews were analysed using a thematic approach.

Results

Results indicated that YPF was experienced as useful and relevant. Interviews showed that adolescents felt validated through the programme's content, discovered that other young people had similar experiences and felt that YPF could contribute to changing self-perceptions for the better. However, results could not confirm whether perceived usefulness led to the development and use of new social skills in real-life situations.

Conclusion

This study offers new perspectives on the relevance and usefulness of YPF in supporting adolescents with appearance-related psychosocial concerns. Findings suggest that updates and modifications are required so that YPF stays relevant and useful for adolescents in need of support.

Trial registration number

NCT03165331.

Is it safe? Exploring positive and negative outcome changes following a web-based intervention for adolescents distressed by a visible difference (YP Face IT)

Despite the importance of making sure that psychological interventions are safe, research including both positive and negative effects of novel internet-delivered support is scarce. The aim of our study was to explore whether, and in what way, a new intervention for adolescents distressed by a visible difference (YP Face IT; YPF, Norwegian version) led to positive and/or negative outcome changes. Participants were 79 adolescents (62.00% girls; M_age = 13.84, SD = 1.73), with a visible difference. All had access to the YPF programme and answered questionnaires assessing social anxiety and body esteem pre- and post-intervention. Analyses included calculations of statistical as well as clinically significant and reliable changes. Results showed that fewer participants reported clinical levels of social anxiety and low body esteem after access to YPF. Results also indicated that participants who had a positive pre- to post-intervention change had lower levels of perceived self-worth pre-intervention, and spent more time on the intervention than those with a negative pre- to post change. Three participants showed a clinically significant negative and reliable change in social anxiety or body esteem from pre- to post-intervention. However, based on an examination of these participants' characteristics, preliminary findings support the safety of YPF.

Cost‐effectiveness analysis of a psychosocial web‐based intervention for adolescents distressed by a visible difference: Results from a randomized controlled trial in Norway

Adolescents with a visible difference to the face or body (e.g., due to a congenital condition, illness, or injury), may be at risk of elevated psychological distress. Young Person's Face IT (YPF), a web-based psychosocial intervention, has displayed effectiveness, but no previous study has specifically evaluated its cost-effectiveness. The aim of our study was to investigate whether YPF could be a cost-effective alternative for psychosocial support to adolescents distressed by a visible difference, relative to care-as-usual (CAU). Within the context of a randomized controlled trial in Norway, 102 participants (43% boys) were allocated to intervention (n = 55) or waiting list control group (n = 47). Mean age was 13.9 years (SD = 1.71; range 11-18), and all self-identified as experiencing distress related to a visible difference. Participants answered questionnaires including measures of health-related quality of life and social anxiety at baseline and 3-month follow-up. A health economic evaluation using the method of cost-utility analysis was performed, including quality-adjusted life-years (QALYs). Results indicated that the incremental cost-effectiveness of YPF was 63,641 Norwegian kroner per QALYs gained, which is well within the acceptability threshold in the Norwegian healthcare sector. Hence, YPF could potentially be considered a cost-effective intervention for adolescents experiencing distress related to a visible difference, but more research is needed that includes comparisons of YPF to other health- and societal resources and long-term follow-ups. Our study also constitutes an addition to research as, compared to interventions for somatic diseases, there is a lack of studies exploring the cost-effectiveness of psychological interventions.

Reducing social anxiety in adolescents distressed by a visible difference: Results from a randomised control trial of a web-based intervention

A visible difference to the face or body may challenge adolescents' adjustment and engagement in life activities, where some require psychosocial support. However, evidence is limited for whether existing interventions for this adolescent group reduce social or appearance-related distress. We therefore conducted a parallel-group, randomised control trial to evaluate the effectiveness of Young Person's Face IT, a self-guided web-based psychosocial intervention developed for adolescents with a visible difference who experience distress. Adolescents (N = 189, aged 11-18) from two countries (Norway and the Netherlands), were randomly allocated to an intervention group or care as usual (CAU). Outcomes were body esteem, social anxiety, perceived stigmatisation, and life disengagement. Compared with CAU, participants who completed Young Person's Face IT showed reductions in social anxiety symptoms (η_p² = 0.06). No significant improvements were found for the other outcomes. This study endorses web-based psychosocial support in reducing social anxiety in adolescents distressed by a visible difference. Future studies are needed to confirm the effectiveness of Young Person's Face IT and to explore potential long-term effects.

An Acceptance and Commitment Therapy Prototype Mobile Program for Individuals With a Visible Difference: Mixed Methods Feasibility Study

Background

Mobile apps may offer a valuable platform for delivering evidence-based psychological interventions for individuals with atypical appearances, or visible differences, who experience psychosocial appearance concerns such as appearance-based social anxiety and body dissatisfaction. Before this study, researchers and stakeholders collaboratively designed an app prototype based on acceptance and commitment therapy (ACT), an evidence-based form of cognitive behavioral therapy that uses strategies such as mindfulness, clarification of personal values, and value-based goal setting. The intervention also included social skills training, an established approach for increasing individuals’ confidence in managing social interactions, which evoke appearance-based anxiety for many.

Objective

In this study, the authors aim to evaluate the feasibility of an ACT-based app prototype via the primary objectives of user engagement and acceptability and the secondary feasibility objective of clinical safety and preliminary effectiveness.

Methods

To address the feasibility objectives, the authors used a single-group intervention design with mixed methods in a group of 36 participants who have a range of visible differences. The authors collected quantitative data via measures of program use, satisfaction ratings, and changes over 3 time points spanning 12 weeks in outcomes, including selected ACT process measures (experiential avoidance, cognitive defusion, and valued action), scales of appearance concerns (appearance-based life disengagement, appearance-fixing behaviors, appearance self-evaluation, and fear of negative appearance evaluation), and clinical well-being (depression and anxiety). Semistructured exit interviews with a subsample of 12 participants provided qualitative data to give a more in-depth understanding of participants’ views and experiences of the program.

Results

In terms of user engagement, adherence rates over 6 sessions aligned with the upper boundary of those reported across mobile mental health apps, with over one-third of participants completing all sessions over 12 weeks, during which a steady decline in adherence was observed. Time spent on sessions matched design intentions, and engagement frequencies highlighted semiregular mindfulness practice, mixed use of value-based goal setting, and high engagement with social skills training. The findings indicate a good overall level of program acceptability via satisfaction ratings, and qualitative interview findings offer positive feedback as well as valuable directions for revisions. Overall, testing for clinical safety and potential effectiveness showed encouraging changes over time, including favorable changes in appearance-related life disengagement, appearance-fixing behaviors, and selected ACT measures. No iatrogenic effects were indicated for depression or anxiety.

Conclusions

An ACT-based mobile program for individuals struggling with visible differences shows promising proof of concept in addressing appearance concerns, although further revisions and development are required before further development and more rigorous evaluation.

Assessing the usability and acceptability of Face IT@home: an online CBT intervention for people with visible differences

To increase access to support, an online psychosocial support tool for adults with visible differences was adapted for use without referral or supervision. This intervention combines a cognitive behavioural and social skills model of support. This study aimed to assess the usability and acceptability of Face IT@home as a self-help intervention. Eighty-one participants were recruited (32 with visible differences). Stage 1 included 14 participants (11 female, all with visible differences) who viewed two sessions of Face IT@home and undertook a semi-structured telephone interview. Stage 2 consisted of 14 think-aloud sessions (13 female, none with visible differences) with participants, supervised by researchers. Stage 3 employed 53 participants (47 female; 19 with visible differences), to view one session of Face IT@home and complete an online survey to evaluate usability and acceptability. User interviews, think-aloud studies and questionnaires identified usability and acceptability factors of Face IT@home that make it fit for purpose as a self-help tool. Participants suggested some changes to the Face IT@home program to improve usability. Participants reported that Face IT@home was a useful tool for people with visible differences and could be effective. The CBT-based model was considered a useful approach to addressing psychosocial concerns. The online self-help format will increase access to psychological support for adults with visible differences.

Key learning aims

(1)

Recruiting hard-to-engage groups to online psychosocial interventions: Experiences from an RCT study targeting adolescents with a visible difference

Online interventions have the potential to reach individuals who are otherwise difficult to engage due to stigma and sensitive topics. However, these individuals also tend to be hard to recruit in clinical trials, a crucial step in order to provide evidence-based interventions. This highlights a need for more information about efficient recruitment strategies for difficult-to-engage groups. The present study aimed to share the systematised experiences of recruiting adolescents with a visible difference to an online psychosocial intervention RCT. With the intention to recruit 160 participants (age 12-17), recruitment efforts were nationwide and included multiple arenas (e.g., hospitals, schools, social media), and methods (e.g., in-consultation, targeted letters, posters). Ultimately, 102 participants were recruited, and results showed that recruitment involving patient organisations, hospital departments, and specialised resource centres were most successful in reaching participants. The most efficient recruitment strategy was targeted letters sent home to eligible patients/members, as 78% of the participants were recruited this way. Media and social media recruitment efforts yielded comparatively few participants. No participants were recruited through schools and educational health care services, primary health care services, or municipal and regional authorities. Our results are discussed in relation to barriers with recruiting difficult-to-engage groups to RCTs, providing useful recruitment tools to future similar studies. For instance, future studies are recommended to utilise targeted approaches over general population approaches. Also, results from recruitment efforts should routinely be reported, as this ultimately will provide more general strategies for effective recruitment and support studies in reaching recruitment goals.

Designing an mHealth Intervention for People With Visible Differences Based on Acceptance and Commitment Therapy: Participatory Study Gaining Stakeholders' Input

Background

Given their growing popularity, mobile health (mHealth) apps may offer a viable method of delivering psychological interventions for people with an atypical appearance (ie, visible difference) who struggle with appearance-related distress. Acceptance and Commitment Therapy (ACT), a third-wave cognitive behavioral approach, has been used effectively in mHealth and is being increasingly applied clinically to common psychosocial difficulties associated with visible differences. We planned to design an ACT-based mHealth intervention (ACT It Out) for this population.

Objective

The aim of this study is to gain key stakeholder input from user representatives and psychological clinicians to optimize the intervention’s design for future development and uptake. To do so, we explored considerations relating to mHealth as a delivery platform for adults with visible differences and elicited stakeholders’ design preferences and ideas based on initial author-created content.

Methods

Within a participatory design framework, we used a mix of qualitative methods, including usability sessions and a focus group in a face-to-face workshop, and interviews and textual feedback collected remotely, all analyzed using template analysis. A total of 6 user representatives and 8 clinicians were recruited for this study.

Results

Our findings suggest that there are likely to be strengths and challenges of mHealth as an intervention platform for the study population, with key concerns being user safeguarding and program adherence. Participants expressed design preferences toward relatable human content, interactive and actionable features, flexibility of use, accessibility, and engaging content.

Conclusions

The findings offer valuable design directions for ACT It Out and related interventions, emphasizing the need to carefully guide users through the intervention while acknowledging the limited time and space that mHealth affords.

Australian health professionals' perspectives of psychosocial adjustment to visible differences: A qualitative analysis of pediatric populations

Living with a visible difference (e.g., disfigurement) can compromise a child's psychological wellbeing. Although some children can adjust well, others can develop a range of appearance-related issues such as social anxiety, low self-esteem, and body dissatisfaction. However, current research fails to confirm what factors contribute to appearance-related distress, and what factors buffer the consequences of living with a visible difference. Semi-structured qualitative interviews were conducted with 16 Australian specialist health professionals who care for children with visible differences. Interviews explored the type of appearance-related psychosocial concerns presented to a pediatric hospital, perspectives on the impact of appearance-related distress, as well as factors and processes that health professionals perceive influence adjustment. Data were subjected to inductive thematic analysis. Rich evidence was offered by health professionals, which demonstrated deep understanding of the psychological wellbeing of their patients. Three themes were identified: Mind, Body, and Soul; Stages of Life; and Individual Differences. Findings highlighted the complexity of appearance-related distress, with individual differences in adjustment, and the powerful impact it can have on a child's short and long-term psychosocial wellbeing. The importance of reaching consensus in the conceptualisation and measurement of psychological wellbeing is stressed, and key domains associated with adjustment are proposed.

Anxiety and depression in adolescents with a visible difference: A systematic review and meta-analysis

Living with a visible difference can entail challenging social situations, associated with psychosocial symptoms. However, it is not clear whether adolescents with a visible difference experience more anxiety and depression than unaffected peers. We aim to determine whether adolescents with a visible difference experience more symptoms of anxiety and depression than unaffected peers. A literature search was conducted in Embase, Medline Ovid, Web of Science, Cochrane CENTRAL, PsycINFO Ovid, and Google Scholar. Meta-analyses were done using random-effects models to calculate a standardised mean difference. Analyses for subgroups were used to study causes of visible difference. Eleven studies were identified (n = 1075, weighted mean age = 15.80). Compared to unaffected peers, adolescents with a visible difference experience more symptoms of anxiety (SMD = 0.253, 95 % CI [0.024, 0.482], p = .030), but not depression (SMD = 0.236, 95 % CI [-0.126, 0.599], p = .202). Adolescents with a skin condition did not experience more symptoms of anxiety (SMD = 0.149, 95 % CI [-0.070, 0.369], p = .182) or depression (SMD = 0.090, 95 % CI [-0.082, 0.262], p = .305) when compared to unaffected peers. Overall, more symptoms of anxiety are found in adolescents with a visible difference compared to peers. No differences in anxiety or depression were found for skin differences. Screening for anxiety is recommended.

Sex differences in perceived stigmatization, body image disturbance, and satisfaction with facial appearance and speech among adolescents with craniofacial conditions

Youth with craniofacial conditions often have appearance and speech differences and are vulnerable to social stigmatization and body image disturbances. Given sociocultural pressures for female attractiveness, adolescent girls with craniofacial conditions may be especially vulnerable to body dissatisfaction and appearance-related social stigmatization, though such sex differences have been infrequently studied in this population. This study aimed to: (1) examine sex differences in body image disturbance, satisfaction with speech and facial appearance, and perceived stigmatization among adolescents with craniofacial conditions; and (2) evaluate whether stigmatization perceptions are predictive of body image disturbance and satisfaction with facial appearance and speech. Using a cross-sectional design, 110 adolescents from two craniofacial centers completed measures of body image disturbance, satisfaction with speech and facial appearance, and perceived stigmatization. Females reported significantly greater levels of body image disturbance and lower satisfaction with facial appearance compared to males. There were no significant sex differences for satisfaction with speech or perceived stigmatization. Perceived stigmatization was a significant predictor of body image disturbance, and satisfaction with facial appearance and speech while controlling for sex, body mass index, and age. Interventions to prevent and/or address body image and stigmatization concerns are clinically indicated for both sexes.

Psychosocial Interventions Targeting Recovery in Child and Adolescent Burns: A Systematic Review

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Opening a Pandora's Box that can't be salvaged: Health professionals' perceptions of appearance-related care in an Australian pediatric specialist hospital

Many children and young people struggle adjusting to the psychosocial consequences (e.g., body dissatisfaction, social anxiety, and stigmatisation) of visible differences (or disfigurement). As appearance-affecting conditions often require specialist multidisciplinary team care, health professionals are in a unique position to offer psychosocial support and intervention. However, there is a dearth of literature on how appearance-related concerns are managed in pediatric hospital settings. Sixteen Australian specialist health professionals participated in semi-structured qualitative interviews to address this gap. Interviews explored current appearance-related psychosocial service provision, barriers in accessing appearance-related care, and perceptions of online platforms to deliver specialist support and intervention. Thematic analysis demonstrated four themes: We can do it better, Capability versus availability, Online generation, and Putting appearance on the agenda. This research highlighted the potential value of online platforms to increase accessibility to specialist appearance-related care, the need for more psychosocial resources to be integrated into appearance-related specialities, prioritising the development of low to medium appearance-related support and intervention, increasing the appearance-related knowledge of health professionals and families, and the need for more holistic approaches in routine care.

Promoting Psychosocial Adjustment in Individuals Born With Cleft Lip and/or Palate and Their Families: Current Clinical Practice in the United Kingdom

Objectives:

The importance of psychosocial aspects of care has received growing recognition in recent years. However, the evidence base for psychosocial intervention remains limited. Specialist clinicians working in cleft lip and/or palate (CL/P) services hold a wealth of knowledge and experience yet to be elicited. The aims of this study were to identify common psychosocial challenges and potential risk and/or protective factors for psychosocial distress from the perspective of specialist clinicians and to establish the types of interventions currently being delivered in practice.

Design:

Individual interviews with 17 clinical nurse specialists and 19 specialist clinical psychologists, representing all 16 UK CL/P surgical sites. Data were analyzed using inductive content analysis.

Results:

Numerous psychosocial challenges affecting individuals with CL/P and their families were identified across the life span. Risk factors were predominantly contextual in nature, while protective factors appeared amenable to intervention. Participants drew upon a range of therapeutic models and approaches to guide formulation and intervention, while acknowledging the lack of evidence to support these approaches in CL/P populations specifically.

Conclusions:

Findings have important implications for the way in which psychosocial support for CL/P and related conditions is delivered and evaluated. A framework for the standardized assessment of holistic individual and familial well-being is proposed. Suggestions for increasing the evidence base for specific psychosocial interventions are made, including enhanced family functioning; social, emotional, and appearance concerns; treatment decision-making; and screening for psychosocial and developmental issues.

Cosmetic camouflage improves quality of life among patients with skin disfigurement: A systematic review

This study systematically reviewed the impact of cosmetic camouflage use on different psychosocial outcomes in patients with disfiguring skin disorders. Electronic databases and reference lists were searched in February 2018 for studies reporting the impact of cosmetic camouflage on different quality of life (QoL) outcomes. Eighteen studies met the inclusion criteria: six randomized controlled trials, two quasi-experimental studies, nine single group 'before and after' interventions, and one comparative study with single post-intervention measurement. Quality appraisal of included studies was undertaken using the Joanna Briggs critical appraisal tools. While the studies varied in design, those included in this review indicated significant improvement in QoL after the use of cosmetic camouflage. The mean reduction in Dermatological Life Quality Index scores ranged from 1.4 to 6.4 signifying improvement in QoL of participants after treatment with cosmetic camouflage. Cosmetic camouflage can be an effective therapy in improving QoL among patients with skin disfigurement.

Acceptance and Commitment Therapy for People Experiencing Appearance-Related Distress Associated With a Visible Difference: A Rationale and Review of Relevant Research

People may have a visibly different appearance due to various causes, such as congenital conditions, injury, disease, or medical treatment. Some individuals with a visible difference experience social anxiety and isolation, body image dissatisfaction, shame and self-stigma, psychological trauma, and challenges managing their condition. In this article, we synthesize the relevant literature and present the theoretical rationale for the application of Acceptance and Commitment Therapy (ACT), a third-wave behavioral therapy combining mindfulness skills and value-driven action, to those experiencing distress relating to an unusual or altered appearance. We also outline how ACT may be tailored to the specific considerations of this population and recommend next steps in researching its acceptability and clinical effectiveness.