The impact of skin conditions on selfesteem

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It is hard for a child to grow up with a skin condition and for this not to have some impact on their self-esteem. However, the variation in the impact on self-esteem cannot be entirely attributed to the severity of the child's condition, because it is very dependent on psychological factors and the child's beliefs about their condition. It is possible for a child with very damaged skin to report high levels of self-esteem and vice versa; for a young person with very trivial skin blemishes to report a considerable impact on self-esteem.

Self-esteem has been most studied in relation to acne and studies have clearly demonstrated that adolescents with acne do have lower self-esteem than non-affected adolescents (Papadopoulos et al., 2000; Smith, 2001). Unfortunately, one of the more effective types of medication used for acne has been linked with concerns about depression and suicide in young people, although the evidence as to the drug's causal role in this is not clear as yet. Given the high rate of depression and suicidal ideation amongst adolescents in general, and adolescents with acne in particular, the treatment with isotretinoin needs to be carefully monitored to ensure fluctuations in mood are identified and if necessary can be modified (Hull & D'Arcy, 2003).

Young children are not usually self-conscious about their appearance, but self-consciousness tends to increase as the child grows up and most adolescents are acutely self-conscious. As a child gets older they have to leave the safe confines of the family home and manage the transition first to nursery or playgroup, then to primary school and then to secondary school. These transitions can be extremely difficult for a child with a skin condition who has to cope with other people's reaction to their skin including considerable amounts of curiosity and intrusive comments. Most young people or adults who have grown up with a skin condition can recall extremely unpleasant and traumatic episodes of being teased or excluded as a consequence of their skin condition (Richardson, 1997).

Unlike adults, young children will often stare openly at a child who looks different, and will sometimes make hurtful comments or ask questions in quite a disin-hibited way. In addition, they will often react with disgust or horror without any attempt to disguise their reaction because it may upset the person concerned. Young children have been shown to have clear preferences for children who look attractive and so a child who is visibly different can easily feel rejected or excluded by his or her peers (Sigelman et al., 1986). Managing these types of reactions can be very difficult for a young child with a skin condition and may result in them becoming increasingly self-conscious. This will obviously have an impact on the child's self-esteem but can also set up a 'negative mind set' which results in the child becoming increasingly sensitive to other's comments and at worst withdrawing from or avoiding social situations because of this.

It is important for teachers and parents to help dispel some of the fears that other children or parents may have about the child's skin condition. Common mis-perceptions are that the condition may be contagious or may be very painful if the skin looks red or inflamed. Before the child starts at school it is important for the parent to meet with the child's teacher to explain the condition and to provide information about it, particularly if it is very rare or if the condition may be affected by factors within the school, such as temperature or sitting on a carpet. If appropriate, the teacher can spend some time with the whole class helping them to understand the condition and promoting friendships.

All schools should have anti-bullying policies in place and should have plans to help reduce bullying in school. However, there is considerable variation in how well these are implemented and how proactive schools are in promoting and managing differences within the school. There are some excellent training packages available for teachers from organisations, such as Kidscape, as well as Changing Faces and the National Eczema Society.

Nonetheless, the child will face some incidents of teasing and may well find it helpful to develop strategies for managing these incidents. There has been very little research specifically on evaluating such interventions for children with skin disorders. However, Bradbury (1996), and Kish and Lansdown (2000) have evaluated programmes for children with disfigurements of various origins. These concentrate on developing social skills to help children manage social situations more confidently, as it is often the case that children may approach a situation without much confidence and be more likely to expect a negative reaction. They also help children to develop self-protection strategies, such as imagining a force field around themselves which can deflect negative comments. Whilst these programmes have not been evaluated formally, they do appear to help improve the child's sense of mastery over teasing incidents and improve their self-esteem.

Older children, particularly young adolescents, can also use some of the stress management techniques and cognitive-behavioural therapy techniques used for adults (Stangier & Ehlers, 2000). Some of the habit reversal techniques that have been found to be useful for adults can be applied to children, but they do need some adaptation to make them useful and may not be so successful since they rely on high levels of motivation (Bridgett et al., 1996).

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