Introduction

Clinicians and researchers have written about the possible interactions of psychological and social factors in atopic dermatitis (AD) since the 1940s. In their seminal work, Alexander & French [1] included eczema amongst the classic psychosomatic disorders. Since that time, the conceptualization of psychosomatic disorders has shifted away from a primarily psychological aetiology towards a more complex interactional model, whereby psychological stress at a child and family level interacts with an innate predisposition for the disease. Research in the field has been hampered by methodological problems such as biased samples, lack of appropriate controls, subjective research instruments and laxity in the dermatological diagnosis. Nevertheless, it is accepted that psychosocial factors have an important influence on the disease process, and attention to these factors must be included in the management.

The interaction between AD and psychosocial factors is complex, and various aspects need to be considered.

• How the child’s personality/temperament and the parents’ coping styles interact with the eczema.
  
• How the chronicity and severity of the eczema impact on the psychological well-being of the child and the parents.
  
• How the child with eczema responds to stress and whether there are eczematous flares related to the stress response.

Reference

1 Alexander F, French T. Studies in Psychosomatic Medicine. New York: Ronald Press, 1948.

Interaction Between Atopic Dermatitis and Psychological Symptoms in the Child

There is good evidence that psychological morbidity is increased in children and young people with moderate to severe AD across all age groups. Preschool-aged children with moderate to severe AD, when compared to controls, were found to have significantly increased rates of behavioural problems, including clinginess/dependency, fearfulness and sleep difficulty [1]. School-aged children with AD have been shown to have twice the level of psychological disturbance compared to controls [2]. A very large cross-sectional population-based survey in Norway found significantly higher rates of mental distress in students aged 13–19 with AD compared to healthy adolescents [3].

It has been difficult to elucidate the nature or mechanism of interaction between psychological symptoms and dermatitis. Early research postulated a link between a particular emotional conflict or personality profile and eczema. However, the few controlled studies have not confirmed this theory [4] and it has been impossible to determine whether the psychological profile described (increased anxiety, sensitivity, insecurity, perfectionism, difficulty in expressing emotions) was a predisposing factor or a result of the eczema.

There has been more success in demonstrating the effects of stress [5]. There is increasing evidence to suggest that stress has a direct effect on the neuroendocrine and immune systems (See Psychoneuroimmunology below). It is also thought that scratching may be a mediating behaviour: itchiness, and therefore scratching, tends to increase when a child is experiencing more stress [6,7]. Scratching is also a frequent cause of parental exasperation and negative attention. Some children will learn to use scratching as a way of getting attention or provoking parents, so that it becomes a focus of family tension. The interaction between stress and disease severity can be bidirectional and mutually reinforcing: stress increases disease severity, which in turn increases stress.

Atopic dermatitis affects very young children at a crucial stage of their psychological development. It is important therefore to consider whether the attachment relationship between the infant or child and its primary caregiver (usually mother) is affected. This was examined in a group of 30 preschool children by Daud et al. [1]. The AD group was found to be at least as securely attached as controls. Mothers were found to demonstrate warm and empathic responses towards their children, despite their own high level of distress. This study, based on a largely middle-class, well-educated sample, was one of the first to contradict previous observations of negative mother–child interactions, and the only reported study to use well-validated measures to examine attachment. Despite this positive finding, psychotherapists emphasize the additional strain imposed by severe AD on the mother–infant relationship. Pauli-Pott et al. [8] found a higher level of maternal anxious protectiveness towards their AD infants compared to controls and also a high level of maternal hopelessness in severe cases. If these patterns of infant–maternal interaction become entrenched and long-standing, they can have a negative impact on a child’s emotional development.

In school-aged children, missed days from school, poor self-image and preoccupation with symptoms may affect academic performance. Visible skin disease will make children self-conscious and may elicit unkind comments from peers. The disfigurement literature attests to the important role of the family in maintaining a child’s self-esteem. Although little specific work has been done on adolescents with AD, the acne literature [9] would suggest concerns about the impact on identity and self-esteem, particularly in vulnerable young people. Skin conditions may contribute to adolescent depression, which is common, especially in girls [10].

Factors indicating the presence of an important psychological component include maternal reports of poor bonding or extreme anxiety or hopelessness about their infants’ AD and, for older children, bullying and social isolation at school and academic underachievement. Self-perception of disfigurement and depressed mood are of particular importance in adolescents.

References

1 Daud L, Garralda M, David TJ. Psychosocial adjustment in preschool children with atopic eczema. Arch Dis Child 1993;69:670–6.

2 Absolon CM, Cottrell D, Eldridge SM et al. Psychological disturbance in atopic eczema: the extent of the problem in school-aged children. Br J Dermatol 1997;137:241–5.

3 Saunes M, Smidesang I, Holmen TL, Johnsen R. Atopic dermatitis in adolescent boys is associated with greater psychological morbidity compared with girls of the same age: the Young-HUNT study. Br J Dermatol 2007:156:283–8.

4 Buske-Kirschbaum A, Jobst S, Wustmans A, Kirschbaum C, Raum W, Hellhammer D. Psychosom Med 1997;59:419–26.

5 King RM, Wilson GV. Use of a diary technique to investigate psychosomatic relations in atopic dermatitis. J Psychosom Res 1991;35:697–706.

6 Gupta MA, Gupta AK. Psychiatric and psychological co-morbidity in patients with dermatologic disorders. Am J Clin Dermatol 2003;4(12):833–42.

7 Gil KM, Keefe FJ, Sampson HA, McCaskill CC, Rodin J, Crisson JE. The relation of stress and family environment to atopic dermatitis symptoms in children. J Psychosom Res 1987;31:673–84.

8 Pauli-Pott U, Caruia Beckmann D. Infants with atopic dermatitis: maternal hopelessness, child-rearing attitudes and perceived infant temperament. Psychother Psychosom 1999;68:39–45.

9 Chamlin SL. The psychosocial burden of childhood atopic dermatitis. Dermatol Ther 2006;19:104–7.

10 Angold A, Costello EJ. The epidemiology of depression in children and adolescents. In: Goodyer IM (ed) The Depressed Child and Adolescent, 2nd edn. Cambridge Child and Adolescent Psychiatry series. Cambridge: Cambridge University Press, 2001: 143–78.

Psychological Impact on the Family

In common with other studies of chronic illness, parents of children with atopic dermatitis tend to report increased levels of stress. Moore et al. [1] found that compared to looking after a child with asthma, caring for a child with AD was associated with greater parental sleep disturbance, which correlated with anxiety levels and maternal depression scores. Su et al. [2] found that the negative impact on the family was higher for severe AD than for diabetes mellitus, partly because of the sleep disruption. Co-sleeping with children is more common in AD than in most families. Parents complain of frequent awakenings and decreased sleep efficiency.

Maternal distress, including low mood, guilt, self-blame and worry, is frequently reported. Mothers of children with AD are less frequently employed outside the home [3] and report increased social isolation because of their child’s illness. Worries about allergens and anticipation of negative reactions from others may affect their pattern of socializing.

Atopic dermatitis can affect family life at an emotional, social and financial level. A young child who is often irritable and fussy, or clingy and wanting to be held, can be very trying. Dealing with constant scratching is a source of exasperation. Children may also resist difficult topical treatments, causing added parental stress and a worsening of the disease. Mothers have reported feeling conflicted over discipline [3], which is not uncommon in parents dealing with childhood illness. Inconsistent discipline in turn leads to behavioural problems.

The negative impact on families has been documented by quality of life (QOL) questionnaires [4], some of which have been developed specifically for AD [5–8]. Quality of life studies indicate a correlation between severity of AD and impact on family life and document the high negative impact on QOL in AD compared to other skin diseases [9].

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