Skin disease is very common among children and young people. For example, up to 20% of young children develop eczema and the majority of young people develop some symptoms of acne temporarily during adolescence (McHenry et al., 1995; Smithard et al., 2001). However, there is surprisingly little research on the psychological impact of skin disease in childhood and the focus of most research in paediatric psychology has been on life-threatening conditions, such as cancer. Despite the lack of research, there is widespread acknowledgement of the impact of skin disease on the psychological well-being and quality of life of children, and increasing awareness of the importance of understanding the psychological impact of skin disorders on children and their families (Howlett, 1999).
This chapter will start by outlining some key issues in understanding the relationship between skin disorders and psychological factors for children. This includes the importance of considering both a developmental and systemic framework for childhood problems, and potential difficulties that may arise in communicating with a child about sensitive topics, such as how they feel about their appearance. The chapter will then describe current theoretical models of the psychological impact of physical disease on children and their families, and how these inform our understanding of the impact of skin disease. The next section will review research on the impact of skin conditions on the relationship between a mother and her baby or child, and the impact of skin conditions on the child's self-esteem. Finally, intervention strategies and methods of improving the psychological outcome for children and their families will be reviewed.
In order to understand the impact of skin disease on children it is essential to consider both the child's developmental stage and the context in which they live. The impact of a skin condition will vary considerably depending on the age and level of independence of the child. Young children are entirely dependent on their parents for their healthcare and a young child's response to a skin condition is therefore likely to both be influenced by, and have a strong influence on, the response of their parents. However, as the child grows up, they will be more strongly influenced by their peer group and become less dependent on their parents. As a consequence of this, the implications for a child with, for example, severe eczema at the age of 2 years are very different from the implications for an adolescent of age 14. Whilst for the 2-year-old child, their relationship with their parent and the parent's skills in managing the condition may be very important factors, for the adolescent, the important issues are more likely to be related to their self-esteem, their sense of belonging to their peer group and their own ability to care for their skin.
In most families, the child's mother acts as the main carer for the child and this seems to be particularly true for families where a child has a physical illness (Sloper, 2000). Research has therefore focused on the relationship between the child and his or her mother. For this reason, mothers are referred to as the main carers throughout this chapter. However, it is likely that the many of the same findings may also apply to fathers if they were in the main caring role in a family.
The developmental stage of the child will also affect the best way to communicate with the child about concerns regarding their skin. Very young children are unlikely to be able to put their concerns into words and it is often necessary to rely on parental report or to use pictures or drawings as a way of communicating. However, as the child gets older and becomes more independent, they will often prefer to talk about concerns without their parent present. In particular, adolescents may appear non-communicative if seen with their parents, but will often talk much more freely about their concerns if seen on their own. It is important for anyone working with children with skin conditions to be flexible about how they see the child and his or her family in order to ensure they are able to communicate as effectively as possible with the child. Nonetheless, the sensitive nature of the child's concerns may make it very hard for them to discuss these in a brief consultation with someone they do not know well and they may be reluctant to report concerns spontaneously.
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