Theoretical models of the psychological impact of skin disease during childhood

Most theoretical models of child and family adaptation to chronic illness use a stress and coping model adapted from Lazarus and Folkman (1984) to explain the impact of a chronic illness on children and their families. For example, Wallander and Varni's (1998) model predicts that disease-related variables (such as severity or visibility), functional independence and psychosocial stressors can be seen as risk factors, whereas intrapersonal factors (such as coping style), social-ecological factors and stress processing are all seen as resistance factors.

However, most of the research studies to date have been cross-sectional, descriptive studies. Unfortunately, these research designs may not capture the complexity of the processes that may be involved, particularly when trying to understand relationships between people and causal processes. For example, the reciprocal relationship between a mother and her child, particularly when it involves both the mother and child's psychological and physical state, is a very complex one and has sometimes been oversimplified. It is not possible to disentangle the direction of causality in a cross-sectional study and this means that a degree of caution is required when interpreting many studies. A biopsychosocial model, such as the one described by Howlett (1999), which takes into account the influences that biological, social and psychological factors have on both the child and his or her carer, and the possibility of reciprocal causal patterns is the most useful way of trying to understand the interrelationship of these factors.

However, the exact nature of the risk factors that are important predictors of which children adjust well to their condition and which children do develop psychological difficulties are not well understood. Whilst intuitively, severity of the condition would seem to be a good predictor, this is not always supported by research. The very concept of severity is quite a complex one - some conditions are considered 'severe' because they are life threatening, such as cancer, whilst others may not be life threatening but do have a big impact on 'quality of life' and are therefore severe in a different way. Skin conditions are rarely severe in the sense of 'life threatening' in children. However, they often have a very big impact on the child's quality of life and that of his or her family, and may be seen as 'severe' in terms of the impact on day-to-day life. It has become clear that there is no simple relationship between the severity of a condition as assessed 'objectively' by a clinician and psychological adjustment.

The visibility of the child's condition is also thought to have an impact on the child's adjustment to their condition. Many skin conditions are immediately apparent to other people and children, and their families have to manage the reaction of other people to the child's condition on a daily basis. Papadopoulos et al. (2000) compared the impact of acne which was mainly on a young person's body with acne mostly on the face, and showed that the visible, facial acne sufferers had lower self-esteem and that their body image was more affected than if it was on their body.

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