Integrating Medical and Psychological Health Care for Children with Atopic Dermatitis

Brief parenting intervention (Triple P) for families of children with eczema: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy and costs of a brief, group-delivered parenting intervention for families of children with eczema.

METHODS

A randomized controlled trial design was used. Families attending the Queensland Children's Hospital and from the community (n = 257) were assessed for eligibility (child 2-10 years, diagnosed with eczema, prescribed topical corticosteroids). Families who consented to participate (N = 59) were assessed at baseline for clinician-rated eczema severity, parent-reported eczema symptom severity, and electronically-monitored topical corticosteroid adherence (primary outcomes); and parenting behavior, parents' self-efficacy and task performance when managing eczema, eczema-related child behavior problems, and child and parent quality of life (secondary outcomes). Families were randomized (1:1, unblinded) to intervention (n = 31) or care-as-usual (n = 28). The intervention comprised two, 2-hr Healthy Living Triple P group sessions (face-to-face/online) and 28 intervention families attended one/both sessions. All families were offered standardized eczema education. Families were reassessed at 4-weeks post-intervention and 6-month follow-up, with clinician-raters blinded to condition. Costs of intervention delivery were estimated.

RESULTS

Multilevel modeling across assessment timepoints showed significant intervention effects for ineffective parenting (d = .60), self-efficacy (d = .74), task performance (d = .81), and confidence with managing eczema-related child behavior (d = .63), but not disease/symptom severity, treatment adherence or quality of life. Mean cost per participating family with parenting behavior (clinically) improved was $159.

CONCLUSIONS

Healthy Living Triple P is effective in reducing ineffective parenting practices and improving parents' self-efficacy and task performance when managing children's eczema and eczema-related behavior difficulties. There was no effect on disease/symptom severity, treatment adherence, or quality of life.

CLINICAL TRIAL REGISTRATION

ACTRN12618001332213.

The prevalence of comorbid mental health difficulties in young people with chronic skin conditions: A systematic review and meta-analysis

Chronic skin conditions can have psychosocial and somatic implications, influencing well-being and quality of life. This systematic review and meta-analysis aimed to synthesise evidence on the prevalence of comorbid mental health difficulties in 0-25-year-olds with chronic skin conditions. A secondary aim included identifying factors associated with resilience. The narrative synthesis included 45 studies. Four meta-analyses were performed with moderate-high quality studies, one for each outcome: diagnosed mental disorders; mental health symptoms; suicidal behaviour; socio-emotional and behavioural difficulties. The pooled prevalence of diagnosed mental disorders was 1.2% (95% CI = 0.2-6.1); of mental health symptoms was 22.6% (95% CI = 18.9-26.7); of suicidal behaviour was 7.8% (95% CI = 1.4-3.1); of socio-emotional and behavioural difficulties was 20.9% (95% CI = 14.7-28.8). Findings demonstrate the pooled prevalence of comorbid mental health difficulties in youth with chronic skin conditions.

Mental health interventions for atopic dermatitis: knowledge gaps, pilot programmes and future directions

Atopic dermatitis (AD) is associated with high levels of psychosocial burden, often resulting in poor mental health outcomes. Despite this association, few studies have evaluated the efficacy of mental health interventions within this population. Utilization of multidisciplinary and peer-led support, in addition to equipping patients with psychological tools, may be beneficial in improving mental health outcomes. Future research is needed to determine which interventions and formats are desired by, effective in and accessible to patients and caregivers with AD.

Impact of a Digital Atopic Dermatitis Educational Intervention on Hispanic Patients and Family Members

With the increasing incidence of atopic dermatitis (AD) in the U.S., the highest prevalence of AD being found in Hispanic countries, and the rising Hispanic-American population, educational resources on eczema focused on Spanish-speaking populations are needed more than ever. As such, the primary goal of this project was to assess the beneficial impact of an educational intervention conducted through a virtual platform for Hispanic individuals living with atopic dermatitis. Utilizing WhatsApp, the study enrolled 55 participants diagnosed with AD and/or parents of children diagnosed with AD. Participants were enrolled in a seven-day educational module with daily topics on AD health knowledge. A health knowledge survey was administered before the educational program, upon completion of the program, and one month after completion. The program found a 14% increase in AD health knowledge upon completion of the program (p < 0.001). Most importantly, there was no significant difference found between the health knowledge survey submitted at program completion and one month after completion, signaling that health knowledge taught through the course was successfully retained by participants (p = 0.29). Qualitative themes involving atopic disease were additionally explored through group discussions, including mental health and peer stigma. This study is the first of its kind in dermatology utilizing the WhatsApp format. The success of retained health knowledge regarding AD demonstrates that future virtual endeavors can be effective and accessible methods of patient education overall for populations that might not have ease of access to major medical centers.

Sleep Disturbances in Children With Atopic Dermatitis: A Scoping Review

Atopic dermatitis (AD) is associated with various quality of life concerns including poor sleep. Sleep impairments in children with AD are associated with increased risk of short stature, metabolic syndrome, mental illness and neurocognitive dysfunction. Although the association between AD and sleep disturbance is well established, the specific types of sleep disturbance in pediatric AD patients and their underlying mechanisms are not fully understood. A scoping literature review was performed to characterize and summarize the types of sleep disturbance in children (less than 18 years of age) with AD. 31 papers met inclusion criteria and extracted data were analyzed in an iterative manner. Two types of sleep disturbances were found to be more prevalent in pediatric AD patients in comparison to controls. One category was related to loss of sleep (increased frequency or duration of awakenings, increased sleep fragmentation, delayed sleep onset, decreased total sleep duration, and decreased sleep efficiency). Another category was associated with unusual behaviors during sleep (restlessness/limb movement/scratching, sleep-disordered breathing including obstructive sleep apnea and snoring, nightmares, nocturnal enuresis and nocturnal hyperhidrosis). Some mechanisms underlying these sleep disturbances include pruritus and induced scratching and increased proinflammatory markers induced by sleep loss. Sleep disturbance appears to be associated with AD. We recommend clinicians to consider interventions that may reduce sleep disturbances in children with AD. Further investigation of these sleep disturbances is needed to elucidate pathophysiology, develop additional treatments, and reduce negative impacts on the health outcomes and quality of life in pediatric AD patients.

A systematic review of parenting interventions for child chronic health conditions

This systematic review summarizes the parenting intervention literature for parents of children with chronic health conditions and evaluates intervention effects on parenting (parenting skills and parenting efficacy) and child (behaviour, illness severity/control and quality of life) outcomes. Systematic searches using seven electronic databases (including CINHAL, MEDLINE and PsycINFO) were used to identify relevant papers published in English between 1997 and 2017, and reference lists were searched for additional relevant articles. Ten papers reporting on eight separate studies met inclusion criteria: three studies evaluated stand-alone parenting interventions, while the remaining five studies included parenting components in broader interventions that also targeted medically oriented aspects of illness management. Results suggest that parenting interventions may lead to improved parent self-efficacy, parenting behaviour, illness severity/control, child quality of life and child behaviour; however, intervention effects were mixed and confined to parent-report outcome measures. A paucity of studies using rigorous randomized controlled trial study designs limits the conclusions that can be drawn regarding intervention efficacy. Achieving adequate enrolment and retention of families in parenting intervention trials appears to be problematic within these clinical groups. Larger samples and more diverse clinical populations will support the reliability of future evaluations of parenting interventions in this context and improve generalizability of results.

Predictors of treatment success in children with difficult to treat atopic dermatitis using a personalized integrative multidisciplinary (PIM) treatment programme

BACKGROUND

A 6-week personalized integrative multidisciplinary treatment programme (PIM) was developed for children with difficult to treat AD who appeared unresponsive to treatment according to current guidelines.

OBJECTIVE

The aim of the present study was to identify clinical and psychosocial characteristics that predict long-term treatment success after PIM.

METHODS

Treatment was considered successful when there was a 75% reduction on the Self-Administered Eczema Area and Severity Index and/or little impact of AD on daily life, measured with the Children's Dermatology Life Quality Index (score ≤ 6), 6 months after the end of PIM. PIM is a personalized, integrative, multidisciplinary treatment programme with clearly defined goals and strategies, addressing atopic, paediatric, mental health comorbidities and general well-being, for children and adolescents aged 8- to 18 years. Multivariate logistic regression models were constructed using a backward selection procedure. Questionnaires were used to assess psychosocial characteristics; clinical data was extracted from medical records.

RESULTS

In total, 79 children/adolescents with difficult to treat AD completed PIM and long-term treatment results were available for 74 children/adolescents. The majority (77%) of children/adolescents demonstrated long-term treatment success with PIM. Predictors of long-term treatment success (adjusted ORs) included maternal disease acceptance OR (95% CI) 1.84 (1.15-2.94). A group (23%) of mostly females OR (95% CI) 0.10 (0.02-0.54) with multiple somatic complaints OR (95% CI) 0.88(0.80-0.97), from families where the mother has anxiety for the use of topical corticosteroids OR (95% CI) 0.62(0.40-0.94), is less likely to obtain long-term treatment success.

CONCLUSION

Most children and adolescents with difficult to treat AD, seemingly unresponsive to conventional treatment according to current guidelines, are able to improve with PIM. Psychosocial and family but not clinical variables, predicted long-term treatment success after participating in PIM.

Bidirectional relationships between psychological health and dermatological conditions in children

Dermatological conditions are common among children. They are a frequent cause of presentation to health care services and a leading contributor to burden of disease. Evidence supports the notion that bidirectional relationships exist between children’s physical and psychological health, whereby the child’s dermatological condition can impact their psychological health and well-being, while, in the reverse direction, psychological factors (eg, stress) can impact the severity and course of the child’s skin disease. The psychological impact of dermatological conditions in childhood needs to be taken into account during the assessment, planning, and treatment phases of management. Likewise, the potential effect of children’s emotional and behavioral difficulties on management, particularly in terms of the impact on parents’ ability to implement their child’s treatment plan, should be considered. This literature review summarizes the current evidence for the relationships between three common chronic dermatological conditions of childhood – atopic dermatitis, psoriasis, and urticaria – and psychological adjustment and quality of life in childhood. Overall, a general paucity of research in the pediatric context – combined with limitations in terms of study design, variability in operationalization of constructs, and heterogeneity in measurement of outcomes – makes it difficult to draw firm conclusions in this area. Based on the available research, implications for successful long-term management of these conditions are discussed in terms of integrating psychological and parenting support with medical management to improve adherence, reduce disease severity, and improve quality of life for children and their families.

Psychosomatic factors of atopic dermatitis exacerbation

BACKGROUND

The aim of this study was to estimate whether the stress, lack of social support, and poor emotional relationships influence the recurrence of AD in adults.

METHODS

Case-control study comprised 66 outpatients with AD and 132 controls with different skin diseases believed to be slightly influenced by psychosomatic factors. Participants were treated at the Department of Dermatology - Military Medical Academy and City Department for Skin and Venereal Diseases from January to June 2014. Stressful life events were assessed using the Paykel's Interview for Recent Life Events. The attachment relationship and perceived social support were assessed with the Experiences in Close Relationships Scale and with the Multidimensional Scale of Perceived Social Support, respectively. Univariate and multivariate logistic regression analyses were applied.

RESULTS

AD patients had significantly higher anxiety scores when initiating a close emotional relationship and when avoiding an affective attachment (OR = 1.49; CI = 1.13-1.97; P = 0.005 and OR = 1.63; CI = 1.16-2.30; P = 0.005, respectively). Perceived social support from family and friends was significantly lower among cases compared to controls (OR = 0.93; CI = 0.88-0.98; P = 0.009 and UO = 0.94; CI = 0.89-0.99; P = 0.027, respectively).

CONCLUSIONS

AD patients had higher anxiety scores, and those with low social support tended to have more frequent disease recurrence. The number of stressful life events did not differ between studied groups.

Effectiveness of alpine climate treatment for children with difficult to treat atopic dermatitis: Results of a pragmatic randomized controlled trial (DAVOS trial)

BACKGROUND

Alpine climate treatment has historically been used in Europe to treat atopic dermatitis (AD), but no randomized trials have been conducted to provide evidence for its effectiveness.

OBJECTIVE

To investigate the long-term effectiveness of alpine climate treatment for children with difficult to treat AD.

MATERIALS & METHODS

A pragmatic, open, randomized controlled trial was conducted. Children diagnosed with AD that was considered difficult to treat, aged between 8 and 18 years and willing to be treated in Switzerland were randomized to a six-week personalized integrative multidisciplinary treatment period in a clinical setting in the alpine climate (Switzerland) or an outpatient setting in moderate maritime climate (Netherlands). Study assessments were conducted at the Wilhelmina Children's Hospital; an electronic portal was used for the collection of questionnaire data. Primary outcomes were disease activity (SAEASI), quality of life (CDLQI) and catastrophizing thoughts (JUCKKI/JU) 6 months after intervention. Other assessments were immediately and 6 weeks after intervention. Subgroup analyses concerned asthma-related outcomes. Children were randomly assigned to either the intervention or control group using a covariate adaptive randomization method, taking age and asthma diagnosis into account. Children, parents and healthcare professionals involved in treatment were not blinded to group assignment. Data were analysed according to intention-to-treat with linear mixed-effects models for continuous outcomes. The trial is registered at Current Controlled Trials ISCRTN88136485.

RESULTS

Between 14 September 2010 and 30 September 2014, 88 children were enrolled in the trial, 84 children were randomized (41 assigned to intervention, 43 to control) of whom 77 completed the intervention (38 of 41 (93%) intervention, 39 of 43 (91%) control) and 74 completed follow-up (38 of 41 (93%) intervention, 36 of 43 (84%) control). Six months after intervention there were no significant differences between the groups on disease activity (SAEASI mean difference -3.4 (95%CI -8.5 to 1.7)), quality of life (CDLQI mean difference -0.3 (95%CI -2.0 to 1.4)) and catastrophizing thoughts (JUCCKI/JU subscale mean difference -0.7 (95%CI -1.4 to -0.0)). Immediately and 6 weeks after intervention, disease activity and quality of life were significantly different in favour of alpine climate treatment. Mean differences on SAEASI were -10.1 (95%CI -14.5 to -5.8) and -8.4 (95%CI -12.2 to -4.6) and on CDLQI -1.9 (95%CI -3.3 to -0.5) and -1.5 (95%CI -2.8 to -0.3) immediately and 6 weeks after the intervention, respectively. There were no long-term differences on asthma-related outcomes. Five serious adverse events occurred during the study period, which were not thought to be related to the treatment.

CONCLUSIONS & CLINICAL RELEVANCE

For children with difficult to treat AD, there was no additional long-term benefit of alpine climate treatment, in contrast to the short-term, compared to an outpatient treatment programme in moderate maritime climate, using a personalized integrative multidisciplinary treatment approach.

Multidisciplinary interventions in the management of atopic dermatitis

Atopic dermatitis (AD) is the most common pediatric skin disease. AD has a significant effect on patient and family quality of life caused by intense pruritus, sleep disruption, dietary and nutritional concerns, and psychological stress associated with the disease and its management. Multidisciplinary approaches to AD care have been developed in appreciation of the complex interplay among biological, psychological, behavioral, and dietary factors that affect disease control and the wide range of knowledge, skills, and support that patients and families require to effectively manage and cope with this condition. Common components of multidisciplinary treatment approaches include medical evaluation and management by an AD specialist, education and nursing care, psychological and behavioral support, and nutritional assessment and guidance. Models of care include both clinical programs and structured educational groups provided as adjuncts to standard clinical care. Available evidence suggests beneficial effects of multidisciplinary interventions in improving disease severity and quality of life, particularly for patients with moderate-to-severe disease. Additional research is needed to identify the best candidates for the various multidisciplinary approaches and evaluate the cost-effectiveness of these programs.

Patient Burden of Atopic Dermatitis

Atopic dermatitis is associated with significant patient burden, with impacts from symptoms and visible physical manifestations of the disease. Consequences include detrimental effects on quality of life (QoL), sleep, self-esteem, interpersonal relationships, participation in leisure and sports, and attendance or performance at school or work. Patients also spend a significant amount of time on treatments and care. Worsening severity of disease appears to be associated with a higher risk of impaired QoL, and pharmacologic and educational interventions that improve disease severity appear to, for the most part, simultaneously improve QoL.

Child behaviour problems and childhood illness: development of the Eczema Behaviour Checklist

BACKGROUND/OBJECTIVES

Children with atopic dermatitis are at increased risk of both general behaviour problems, and those specific to the condition and its treatment. This can hamper the ability of parents to carry out treatment and manage the condition effectively. To date, there is no published instrument available to assess child behaviour difficulties in the context of atopic dermatitis management. Our aim was to develop a reliable and valid instrument to assess atopic dermatitis-specific child behaviour problems, and parents' self-efficacy (confidence) for managing these behaviours.

METHODS

The Eczema Behaviour Checklist (EBC) was developed as a 25-item questionnaire to measure (i) extent of behaviour problems (EBC Extent scale), and (ii) parents' self-efficacy for managing behaviour problems (EBC Confidence scale), in the context of child atopic dermatitis management. A community-based sample of 292 parents completed the EBC, measures of general behaviour difficulties, self-efficacy with atopic dermatitis management and use of dysfunctional parenting strategies.

RESULTS

There was satisfactory internal consistency and construct validity for EBC Extent and Confidence scales. There was a negative correlation between atopic dermatitis-specific behaviour problems and parents' self-efficacy for dealing with behaviours (r = -.53, p < .001). Factor analyses revealed a three-factor structure for both scales: (i) treatment-related behaviours; (ii) symptom-related behaviours; and (iii) behaviours related to impact of the illness. Variation in parents' self-efficacy for managing their child's atopic dermatitis was explained by intensity of illness-specific child behaviour problems and parents' self-efficacy for dealing with the behaviours.

CONCLUSIONS

The new measure of atopic dermatitis-specific child behaviour problems was a stronger predictor of parents' self-efficacy for managing their child's condition than was the measure of general child behaviour difficulties. Results provide preliminary evidence of reliability and validity of the EBC, which has potential for use in clinical and research settings, and warrant further psychometric evaluation.

A Review of Multidisciplinary Interventions in Atopic Dermatitis

Multidisciplinary interventions have been developed for patients with atopic dermatitis (AD) and their families, with the aim of improving outcomes such as disease control, adherence, and quality of life. We reviewed the content of different multidisciplinary approaches to intervention for AD and evidence for their impact on key outcome measures. We also provided data from our multidisciplinary outpatient program for pediatric AD. Studies included in the review suggest benefits of multidisciplinary interventions as models of treatment or adjuncts to standard medical care, with a positive impact on outcomes including disease severity and itching/scratching. There were limitations to existing studies, including heterogeneous methods used to assess quality of life outcomes across studies and lack of controlled studies assessing the outcome of clinical care programs. Further research will be useful in assessing the impact of multidisciplinary interventions on important outcomes such as treatment adherence and sleep, identifying the elements of multidisciplinary interventions that are most critical for improved outcomes, and identifying the best candidates for multidisciplinary intervention approaches.

Psoriasis in childhood: effective strategies to improve treatment adherence

Psoriasis is a relatively common chronic inflammatory skin disease in children for which there is no cure. Most children have mild disease that can be managed with topical therapy as opposed to phototherapy or systemic therapy. Despite the mild presentation of psoriasis in most children, the disease can have a significant impact on quality of life due to the need for ongoing treatment, the frequently visible nature of the cutaneous manifestations, and the social stigma that is associated with psoriasis. Adherence to treatment, in particular topical therapy, is often poor in adults and compromises response to therapy and medical provider management strategies. Multiple factors that may contribute to nonadherence in adults with psoriasis have been identified, including lack of education on the disease and expectations for management, issues related to ease of use and acceptability of topical medications, and anxiety regarding possible medication side effects. There is currently no published data on adherence in the pediatric psoriasis population; however, poor adherence is often suspected when patients fail to respond to appropriate therapy. General strategies used to assess adherence in other pediatric disease populations can be applied to children with psoriasis, and interventions that reflect experience in other chronic dermatologic disorders such as atopic dermatitis may also be helpful for medical providers caring for children with psoriasis.

Atopic dermatitis in children: management of pruritus

Children with chronic atopic dermatitis (AD)-related itch require a comprehensive treatment approach that addresses the underlying cause of pruritus, as well as symptoms and complications that extend beyond the physical domain. In small children and infants, the short-term complications of quality of life disturbance and sleep dysfunction are closely associated with the course of adolescent development. In addition, the physical damage that results from uncontrolled pruritus and scratching can lead to disease chronification. Therefore, the rapid relief of acute pruritic flares, followed by the long-term maintenance of symptom-free skin, should be prioritized in AD treatment, in an effort to avoid the emotional, social and physical chronic manifestations described above. Alleviation of AD symptoms with fourth-generation topical anti-inflammatory agents like methylprednisolone aceponate is an appropriate choice of therapy for children and infants, due to its optimized therapeutic index and versatility in formulation. Especially in AD, supplemental disease management education should be considered, to address the psycho-social needs of children (and their families) suffering from pruritus.

Eczema and sleep and its relationship to daytime functioning in children

Chronic childhood eczema has significant morbidity characterised by physical discomfort, emotional distress, reduced child and family quality-of-life and, of particular note, disturbed sleep characterised by frequent and prolonged arousals. Sleep disturbance affects up to 60% of children with eczema, increasing to 83% during exacerbation. Even when in clinical remission, children with eczema demonstrate more sleep disturbance than healthy children. Notably, disturbed sleep in otherwise healthy children is associated with behavioural and neurocognitive deficits. Preliminary evidence suggests that disturbed sleep in children with eczema is also associated with behavioural deficits while the impact on neuropsychological functioning remains unexplored. In conclusion, a disease which affects up to 20% of children in some countries and may produce long-term behavioural and neurocognitive deficits merits further evaluation using standardised tests of sleep, behaviour and neurocognition.

The relationship between sensory hypersensitivity and sleep quality of children with atopic dermatitis

This study aims to investigate the impact of sensory hypersensitivity in children with atopic dermatitis (AD) and to evaluate a possible relationship between sensory hypersensitivity, sleep quality and disease severity in AD. Fifty-seven AD patients and 37 healthy children, aged 3-10 years, participated in this study. Disease severity was assessed using the Severity Scoring of Atopic Dermatitis (SCORAD) Score. The sensory profile was assessed using the Short Sensory Profile (SSP) and sleep characteristics were evaluated using the Children's Sleep Habits Questionnaire (CSHQ). The AD group demonstrated significantly worse sleep quality compared with the controls in the following CSHQ subscales: sleep duration; parasomnias; sleep disordered breathing and daytime sleepiness. Sensory hypersensitivity was correlated with lower sleeping quality. Severity Scoring of Atopic Dermatitis Scores was positively correlated with sleep anxiety and with parasomnias. Sensory hypersensitivity and disturbed sleep patterns were common in the children with AD that participated in this study. A possible common underlying mechanism of hyper-arousability may account for both phenomena. Evaluation of AD children should also refer to their sensory processing abilities and sleep habits to create optimal intervention programs that will be better focused on the child and family needs.

The need for interdisciplinary pediatric sleep clinics

The purpose of this study was to describe the function and structure of an interdisciplinary outpatient pediatric sleep clinic. In addition, the frequency of individual and comorbid sleep diagnoses, the prevalence of comorbid medical or psychiatric disorders, and the types of treatment recommendations and referrals provided to patients at the end of their clinic visits was examined. Over a 4-month period, 265 consecutive patients were evaluated in the sleep clinic by trainees, nurses, and attendings in pulmonary medicine, neurology, and psychology. Obstructive sleep apnea was the most common diagnosis, followed by behavioral insomnia of childhood. Over half of the patients had a comorbid medical diagnosis, and 31% had a comorbid psychiatric diagnosis. Polysomnography was the most common recommendation, with 38% of patients receiving at least one behavioral recommendation. The results of this descriptive study support the need for an interdisciplinary approach to pediatric sleep medicine, providing broad training to trainees of all disciplines while improving the clinical care for children with sleep problems.