Screening for Psychosocial Dysfunction in Pediatric
Dermatology Practice
Paula K. Rauch, MD*; Michael S. Jellinek, MD*; J. Michael Murphy, EdD*; Lawrence Schachner, MD**; Ronald Hansen, MD†; Nancy B. Esterly, MD††; Julie Prendiville, MD~; Sandra J. Bishop, MA*; Marilyn Goshko, EdM*
The Pediatric Symptom Checklist, a brief psychosocial screening questionnaire, was used in a multi-center study of pediatric dermatology clinics (n=377). Overall rates of positive screening indicated that approximately 13% of patients screened positive, a rate similar to findings in primary care pediatric settings. Examining the sample in greater detail demonstrated that children whose dermatologic disorder is perceived to have a greater impact on their appearance are at higher risk for psychosocial dysfunction.
Introduction From infancy through senescence, we experience the world through our skin. Skin is the ultimate physical boundary that can be stroked, stimulated, bruised or broken and is always out there to be seen. Although the psychological importance of skin is complex, there have been relatively few studies of skin disorders, with most of these focused on particular disorders. One reason for the lack of research is that pediatric dermatology practices are not easy to study since they tend to see a high volume of patients who are seen only briefly and often only in consultation after referral from their primary pediatricians. Furthermore, the skin conditions are usually not viewed as
life-threatening, perhaps minimizing chological importance for the child.
Child Psychiatry Service, Massachusetts General Hospital, Boston, MA; ** Department of Dermatology, Cutaneous Surgery and Pediatrics,
Division of Pediatric
Dermatology, University
of Miami School of
Medicine, Miami, FL;†Department of Internal Medicine, Dermatology and Pediatrics, University of Arizona Health Sciences Center, Tucson, AZ; &dag er;&dag er; Departments of Dermatology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI; ~Department of Dermatology, Wright State University, Dayton, Ohio. Correspondence to: Paula K. Rauch, MD, Child Psychiatry Service, Massachusetts General Hospital, 15 Parkman Street ACC 725, Bos—
ton, MA 02114
Phone: 617-726-2724.
perceived
psy-
The primary goals of the current study were 1) to arrive initial assessment of the level of psychosocial dysfunction in the school-age pediatric dermatology population, using data from two general pediatric outpatient practices as a comparison group, and 2) to determine whether certain subgroups of pediatric dermatology patients are at increased risk of psychosocial dysfunction. As of this writing, there are no published studies of the psychological functioning of school-aged children seen in pediatric dermatology practice. There have been studies of the psychological aspects of childhood skin disorders, but these have tended to focus on specific subgroups of the pediatric dermatology population, either by diagnosis (e.g. at an
acne, *
the
atopic dermatitis/eczema, vitiligo), or by age group
(most of the studies are confined to adolescents).
study of vitiligo patients,’1 transitions, such as moving to a new or community, beginning at a new school, demonstrated greater psychosocial distress with respect to their impaired For example, in children who faced
a
small
appearance, while those children who exhibited a sense of competency (through sports, academics or artistic skill) seemed most resilient. The vitiligo study examined only 13 patients of school age and used a lengthy, unstructured 493
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on April 14, 2015
interview technique to arrive at their findings. Anecdotal studies of children with atopic dermatitis2,3 highlight the interplay between skin symptomatology, emotional wellbeing and parent-child interaction. The largest study of atopic dermatitis4 evaluated 40 children of all ages and found an association between emotional stressors in the family and symptom severity. Applying the method of this study in clinical practice is impractical because family evaluations are too time-consuming and require psychiatric expertise not readily available in most pediatric derma-
tology settings.
In the adolescent and young adult popula-
tion, there is evidence suggesting patients with the severe
forms of
acne
have
more
anxiety
and
most
depressive
symptoms as compared to unaffected individuals, those with lesser manifestations of the skin condition, or patients who have responded well to acne treatment. 5-7 Whether this is cause or effect is unknown. The aim of the current study was to assess a large number of patients while not disrupting high volume pediatric dermatological practices with time-consuming or cumbersome psychological instruments. We elected to use the Pediatric Symptom Checklist (PSC) (Table 1), an easily scored questionnaire completed in less than five minutes by parents while in the waiting room.’ The PSC is a 35item, one page questionnaire designed to screen schoolaged children for psychosocial dysfunction in pediatric practice settings. In establishing the validity of the PSC instrument, parental ratings were found to be a reliable measure of the child’s psychosocial functioning as compared with data generated from other respondents. The PSC was validated by comparison to longer questionnaires9 and comprehensive psychiatric evaluation for both middle 10 and lower-middle&dquo; class pediatric outpatients. In middle class practice settings, the PSC identifies between 12% and 14% of school age children as being sufficiently dysfunctional to require further evaluation.’,&dquo; Children living in poverty, experiencing acute stress, or being raised by a single parent have PSC positive rates in the 20%-30% range. 10-12 Using the PSC as a screening measure is ideal for a high volume specialty practice because it identifies a group of patients in need of referral rather than providing cumbersome diagnostic information that is irrelevant to a nonpsychiatric clinician. Methods The PSC
.
parents of school-aged chil-
presented and hospital-based outpatient pediatric dermatology practices in Illinois (N.E.), Wisconsin (N.E.), Florida (L.S.), and Arizona (R.H.). Parents were asked to complete the questionnaire voluntarily without it becomdren in
was
private
Table 1. Pediatric symptom checklist
to
ing part of the child’s permanent record. Questionnaires were given consecutively to parents of children 6-12 years old on regular clinic days at each site. Over 98% of parents readily accepted the questionnaire and signed the consent form at each of the sites. In addition to the 35 PSC questions, the forms included age, socioeconomic data, a question about whether the child had received counseling in the previous year, and a parental rating of the impact of the skin condition on the child’s appearance (&dquo;Hardly at All,&dquo; &dquo;Somewhat,&dquo; &dquo;A lot&dquo;). Physicians were asked to assign a dermatologic diagnosis for each case. The PSC is scored by assigning 0, l, or 2 points for each symptom rating of &dquo;never,&dquo; &dquo;somewhat,&dquo; and &dquo;often&dquo;
494
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on April 14, 2015
and summing the accumulated points. The is 28, with PSC scores of 28 and higher designated as positive. A positive score indicates a level of dysfunction warranting further evaluation. Socioeconomic status (SES) was calculated using Hollingshead’3 criteria which combine each parent’s education and occupation into an equation that results in a score, that is then recoded into social classes ranging from one through five, with one being the highest socioeconomic group and five the lowest. For questionnaires which did not provide occupation and education data for both parents, SES was not calculated on the basis of one parent’ss data only. Subjects for whom ewe did not have both education and occupation data for at least one parent could not have socioeconomic status calculated. The comparison group was drawn from two general outpatient pediatric practices which had served as sites in earlier studies&dquo;,&dquo; of the PSC.
respectively, cutoff
score
Pediatric
Symptom Checklist (PSC) Using the PSC score of 28, 12.7% (n=48) of the dermatological patients received positive PSC screening scores. The PSC positive rate did not differ significantly by gender ( 15.1 % for males vs. 11.0% for females) nor by minority/ non-minority designation (13.2% for minority children; 10.1 % for non-minorities). PSC positive rates showed a marginally significant trend to vary in the different practice sites (AZ=18.8%, FL=16.1%; IL=12.0%; WI=6.2%; X2=7.3, p, .10) (see Table 2). In the comparison sample, the overall PSC positive rate was 14%, very close to the overall rate found in the dermatological practices. In the comparison sample, as in the dermatological sample, there were no significant differences in PSC positive rates according to gender or minority status. The mean PSC score in the dermatological sample was 16.1 1: 9.5 which was actually significantly lower (t=2.9; p < .01) than the mean PSC score in the
comparison sample ( 18.2 ± 9.2). Results Data were collected on 377 English speaking subjects who were 6 to 12 years of age (x=8.9). Of these subjects 218 (58%) were female and 159 (42%) were male. We had racial/ethnic data on 276 (73%) of the children; of these, 208 (75%) were non-minority and 68 (25%) were minority (11.2% African-American, 8.7% Hispanic, and4.7% Asian American or mixed). We had scorable SES data for 313 (83%) of the cases. The full range of occupational statuses’-9 were found in the dermatological samples, with a mean of 5.3 ± 2.5 (SD). Using the recoded occupational categories, 83 families (27%) were coded lower-lower middle class, 152 (49%) were coded middle class, and 78 families (25%) were coded upper middle class. In the comparison group there were 300 subjects and they did not differ significantly from the dermatological sample on the basis of age (x=8.9), or percent minority (23%). The comparison sample did have a slightly higher percentage of males (52%; X2 5.4; p < .05). Mean SES (6.5 ± 1.7) in the comparison sample was also significantly higher (T=6.91; p < .001) than in the =
dermatological sample. Chi-square analyses suggested that the principal difference between the two samples was in the significantly (X2 61.3; p < .0001 ) lower percentage of lower SES families in the comparison sample (LO SES=3% comparison sample vs. 27% dermatological =
sample). The percentage of upper middle class (HI SES) was similar in both samples, 35% in the comparison sample vs. 25% in the dermatological sample. families
Socioeconomic Status
Categorical analyses
showed that PSC
positive
rates
significantly associated with SES class for both dermatological and control samples. In the dermatological sample, the rate of positive screening scores with the PSC was about twice as high in middle class families (9.2%) were
than in upper middle class families
(5.1 %),
and twice
as
high again (19.3%) in lower class families (X2=9.1; p < .01). A three-way ANOVA showed an F that was significant overall (F=8.4; p
.20). Mean PSC scores for the diagnostic groups were also not significantly different (Fg ~=1.2, p > .20).
Discussion The overall frequency of positive PSC scores (i.e., children who screened at high risk for psychosocial dysin pediatric dermatology practice was virtually the same as the rate found in general pediatric practices of comparable SES, with an overall PSC positive rate of 13.0%. In the dermatology sample, nearly half (44%) of the PSC positive subjects had been rated by their parents as having skin disorders that had a lot of impact on their appearance. Alternately, of the subjects whose parents rated the impact on appearance as &dquo;a lot,&dquo; more than a quarter (27.8%) were PSC positive, as compared with about 10% for each of the groups who rated appearance as less affected. The strong association between psychosocial dysfunction and greater perceived impact on appearance is statistically and clinically significant. The importance of
function)
496
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on April 14, 2015
appearance in adolescence is a generally accepted aspect of development, while it is often assumed that appearance assumes lesser importance for school-aged children. Since the current data are based on parental rather than selfassessments, one has to wonder what the child’s own view of the impact of his/her skin disorder on appearance would be and if it would be similar to the parent’s assessment. Nonetheless, the data indicate that impact on appearance, as assessed by parents, defines a group of children at high risk in their psychosocial functioning, and demonstrate a significant role for appearance in the emotional well-being of the school-aged child. Further, more than a quarter of all parents (28%), regardless of the PSC score, rated the skin disorder as seriously affecting the child’s appearance. This surprisingly high rate suggests that, in contrast to a physician, a parent’s untrained and emotional eye is acutely sensitive to the changes in appearance of a child’s skin. Unlike the parent, the physician is trained to see a disorder in terms of etiology and prognosis, and since in most dermatology patients these are benign and good, physicians may become quite tolerant of non-disfiguring lesions. The pediatrician or dermatologist’s objective perspective then may make it difficult to appreciate the parent’s (or patient’s) level of anxiety and concern. The results of this study highlight parents’ extraordinary sensitivity to appearance and indicate that it must be taken into consideration by practitioners. The validity of the PSC is indirectly supported by the
expected finding that a greater percentage of psychosocially dysfunctional children as opposed to nondysfunctional children had received some counseling. However, this should not be interpreted as suggesting that most high risk children have already received further psychosocial assessment. In the high risk group, 75% of the children had not been in counseling, and therefore had not
References 1. Hill-Beuf A, Porter JD. Children coping with impaired appearance: Social and psychologic influences. Gen Hospital Psychiatry 1984; 6:294-301. 2. Solomon CR, Gagnon C. Mother and child characteristics and involvement in dyads in which very young children have eczema. J Devel Behav Pediatr 1987; 8:213-20. 3. Koblenzer CS, Koblenzer PJ. Chronic intractable atopic eczema. Its occurrence as a physical sign of impaired parent-child relationships and psychologic developmental arrest: Improvement through insight and education. Arch Dermatol 1988; 124:1673-7. 4. Gil KM, Keefe FJ, Sampson HA, et al. The reaction of stress and family environment to atopic dermatitis symptoms in children. J Psychosom Res 1987; 31:673-84. 5. Van der Meeren HL, van der Schaar WW, van den Hurk CM. The psychological impact of severe acne. Cutis 1985; 36:84-6. 6. Rubinow DR, Peck GI, Squillace KM, et al. Reduced anxiety and depression in cystic acne patients after successful treatment with oral isotretinoin. J Am Acad Dermatol 1987; 17:25-32. 7. Wu SK, Kinder BN, Trunnell TN, et al. Role of anxiety and anger in acne patients: a relationship with the severity of the disorder. J Am Acad Dermatol 1988; 12:325-33. 8. Jellinek MS, Murphy JM. Screening for psychosocial disorders in pediatric practice. AJDC 1988; 142:1153-7. 9. Jellinek MS, Murphy JM, Bums B. Brief psychosocial screening in outpatient pediatric practice. J Pediatr 1986; 109:371-8. 10. Jellinek MS, Murphy JM, Robinson J, et al. The pediatric symptom checklist: screening school age children for psychosocial dysfunction. J Pediatr 1988; 112:201-9. 11. Murphy JM, Jellinek MS. Screening for psychosocial dysfunction in economically disadvantaged and minority group children: further validation of the Pediatric Symptom Checklist. Amer J Orthopsychiatry 1988; 58:450-6. 12. Murphy JM, Jellinek MS. Final Report, NIMH Contract #86MO43903401d - The further development of a brief psychosocial screening instrument for pediatric practice. Washington, D.C. National Institute of Mental Health, 1986. 13. Hollingshead AB. Four factor index of social status. New Haven, Connecticut: Department of Sociology, Yale University, 1975.
received the additional assessment that their PSC
positive scores warrant. Conclusion Based on this sample, pediatricians and dermatologists who treat children with skin disorders face about the same level of psychosocial dysfunction as is seen in a general pediatric population. Children whose disorder affects appearance are more likely to have positive screening scores. Although more of these children have had some counseling in the past year, most still have not. The comprehensive care of children with dermatological disorders requires attention to psychosocial issues and further research.
497
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on April 14, 2015
Dermatology Practice
Paula K. Rauch, MD*; Michael S. Jellinek, MD*; J. Michael Murphy, EdD*; Lawrence Schachner, MD**; Ronald Hansen, MD†; Nancy B. Esterly, MD††; Julie Prendiville, MD~; Sandra J. Bishop, MA*; Marilyn Goshko, EdM*
The Pediatric Symptom Checklist, a brief psychosocial screening questionnaire, was used in a multi-center study of pediatric dermatology clinics (n=377). Overall rates of positive screening indicated that approximately 13% of patients screened positive, a rate similar to findings in primary care pediatric settings. Examining the sample in greater detail demonstrated that children whose dermatologic disorder is perceived to have a greater impact on their appearance are at higher risk for psychosocial dysfunction.
Introduction From infancy through senescence, we experience the world through our skin. Skin is the ultimate physical boundary that can be stroked, stimulated, bruised or broken and is always out there to be seen. Although the psychological importance of skin is complex, there have been relatively few studies of skin disorders, with most of these focused on particular disorders. One reason for the lack of research is that pediatric dermatology practices are not easy to study since they tend to see a high volume of patients who are seen only briefly and often only in consultation after referral from their primary pediatricians. Furthermore, the skin conditions are usually not viewed as
life-threatening, perhaps minimizing chological importance for the child.
Child Psychiatry Service, Massachusetts General Hospital, Boston, MA; ** Department of Dermatology, Cutaneous Surgery and Pediatrics,
Division of Pediatric
Dermatology, University
of Miami School of
Medicine, Miami, FL;†Department of Internal Medicine, Dermatology and Pediatrics, University of Arizona Health Sciences Center, Tucson, AZ; &dag er;&dag er; Departments of Dermatology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI; ~Department of Dermatology, Wright State University, Dayton, Ohio. Correspondence to: Paula K. Rauch, MD, Child Psychiatry Service, Massachusetts General Hospital, 15 Parkman Street ACC 725, Bos—
ton, MA 02114
Phone: 617-726-2724.
perceived
psy-
The primary goals of the current study were 1) to arrive initial assessment of the level of psychosocial dysfunction in the school-age pediatric dermatology population, using data from two general pediatric outpatient practices as a comparison group, and 2) to determine whether certain subgroups of pediatric dermatology patients are at increased risk of psychosocial dysfunction. As of this writing, there are no published studies of the psychological functioning of school-aged children seen in pediatric dermatology practice. There have been studies of the psychological aspects of childhood skin disorders, but these have tended to focus on specific subgroups of the pediatric dermatology population, either by diagnosis (e.g. at an
acne, *
the
atopic dermatitis/eczema, vitiligo), or by age group
(most of the studies are confined to adolescents).
study of vitiligo patients,’1 transitions, such as moving to a new or community, beginning at a new school, demonstrated greater psychosocial distress with respect to their impaired For example, in children who faced
a
small
appearance, while those children who exhibited a sense of competency (through sports, academics or artistic skill) seemed most resilient. The vitiligo study examined only 13 patients of school age and used a lengthy, unstructured 493
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on April 14, 2015
interview technique to arrive at their findings. Anecdotal studies of children with atopic dermatitis2,3 highlight the interplay between skin symptomatology, emotional wellbeing and parent-child interaction. The largest study of atopic dermatitis4 evaluated 40 children of all ages and found an association between emotional stressors in the family and symptom severity. Applying the method of this study in clinical practice is impractical because family evaluations are too time-consuming and require psychiatric expertise not readily available in most pediatric derma-
tology settings.
In the adolescent and young adult popula-
tion, there is evidence suggesting patients with the severe
forms of
acne
have
more
anxiety
and
most
depressive
symptoms as compared to unaffected individuals, those with lesser manifestations of the skin condition, or patients who have responded well to acne treatment. 5-7 Whether this is cause or effect is unknown. The aim of the current study was to assess a large number of patients while not disrupting high volume pediatric dermatological practices with time-consuming or cumbersome psychological instruments. We elected to use the Pediatric Symptom Checklist (PSC) (Table 1), an easily scored questionnaire completed in less than five minutes by parents while in the waiting room.’ The PSC is a 35item, one page questionnaire designed to screen schoolaged children for psychosocial dysfunction in pediatric practice settings. In establishing the validity of the PSC instrument, parental ratings were found to be a reliable measure of the child’s psychosocial functioning as compared with data generated from other respondents. The PSC was validated by comparison to longer questionnaires9 and comprehensive psychiatric evaluation for both middle 10 and lower-middle&dquo; class pediatric outpatients. In middle class practice settings, the PSC identifies between 12% and 14% of school age children as being sufficiently dysfunctional to require further evaluation.’,&dquo; Children living in poverty, experiencing acute stress, or being raised by a single parent have PSC positive rates in the 20%-30% range. 10-12 Using the PSC as a screening measure is ideal for a high volume specialty practice because it identifies a group of patients in need of referral rather than providing cumbersome diagnostic information that is irrelevant to a nonpsychiatric clinician. Methods The PSC
.
parents of school-aged chil-
presented and hospital-based outpatient pediatric dermatology practices in Illinois (N.E.), Wisconsin (N.E.), Florida (L.S.), and Arizona (R.H.). Parents were asked to complete the questionnaire voluntarily without it becomdren in
was
private
Table 1. Pediatric symptom checklist
to
ing part of the child’s permanent record. Questionnaires were given consecutively to parents of children 6-12 years old on regular clinic days at each site. Over 98% of parents readily accepted the questionnaire and signed the consent form at each of the sites. In addition to the 35 PSC questions, the forms included age, socioeconomic data, a question about whether the child had received counseling in the previous year, and a parental rating of the impact of the skin condition on the child’s appearance (&dquo;Hardly at All,&dquo; &dquo;Somewhat,&dquo; &dquo;A lot&dquo;). Physicians were asked to assign a dermatologic diagnosis for each case. The PSC is scored by assigning 0, l, or 2 points for each symptom rating of &dquo;never,&dquo; &dquo;somewhat,&dquo; and &dquo;often&dquo;
494
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on April 14, 2015
and summing the accumulated points. The is 28, with PSC scores of 28 and higher designated as positive. A positive score indicates a level of dysfunction warranting further evaluation. Socioeconomic status (SES) was calculated using Hollingshead’3 criteria which combine each parent’s education and occupation into an equation that results in a score, that is then recoded into social classes ranging from one through five, with one being the highest socioeconomic group and five the lowest. For questionnaires which did not provide occupation and education data for both parents, SES was not calculated on the basis of one parent’ss data only. Subjects for whom ewe did not have both education and occupation data for at least one parent could not have socioeconomic status calculated. The comparison group was drawn from two general outpatient pediatric practices which had served as sites in earlier studies&dquo;,&dquo; of the PSC.
respectively, cutoff
score
Pediatric
Symptom Checklist (PSC) Using the PSC score of 28, 12.7% (n=48) of the dermatological patients received positive PSC screening scores. The PSC positive rate did not differ significantly by gender ( 15.1 % for males vs. 11.0% for females) nor by minority/ non-minority designation (13.2% for minority children; 10.1 % for non-minorities). PSC positive rates showed a marginally significant trend to vary in the different practice sites (AZ=18.8%, FL=16.1%; IL=12.0%; WI=6.2%; X2=7.3, p, .10) (see Table 2). In the comparison sample, the overall PSC positive rate was 14%, very close to the overall rate found in the dermatological practices. In the comparison sample, as in the dermatological sample, there were no significant differences in PSC positive rates according to gender or minority status. The mean PSC score in the dermatological sample was 16.1 1: 9.5 which was actually significantly lower (t=2.9; p < .01) than the mean PSC score in the
comparison sample ( 18.2 ± 9.2). Results Data were collected on 377 English speaking subjects who were 6 to 12 years of age (x=8.9). Of these subjects 218 (58%) were female and 159 (42%) were male. We had racial/ethnic data on 276 (73%) of the children; of these, 208 (75%) were non-minority and 68 (25%) were minority (11.2% African-American, 8.7% Hispanic, and4.7% Asian American or mixed). We had scorable SES data for 313 (83%) of the cases. The full range of occupational statuses’-9 were found in the dermatological samples, with a mean of 5.3 ± 2.5 (SD). Using the recoded occupational categories, 83 families (27%) were coded lower-lower middle class, 152 (49%) were coded middle class, and 78 families (25%) were coded upper middle class. In the comparison group there were 300 subjects and they did not differ significantly from the dermatological sample on the basis of age (x=8.9), or percent minority (23%). The comparison sample did have a slightly higher percentage of males (52%; X2 5.4; p < .05). Mean SES (6.5 ± 1.7) in the comparison sample was also significantly higher (T=6.91; p < .001) than in the =
dermatological sample. Chi-square analyses suggested that the principal difference between the two samples was in the significantly (X2 61.3; p < .0001 ) lower percentage of lower SES families in the comparison sample (LO SES=3% comparison sample vs. 27% dermatological =
sample). The percentage of upper middle class (HI SES) was similar in both samples, 35% in the comparison sample vs. 25% in the dermatological sample. families
Socioeconomic Status
Categorical analyses
showed that PSC
positive
rates
significantly associated with SES class for both dermatological and control samples. In the dermatological sample, the rate of positive screening scores with the PSC was about twice as high in middle class families (9.2%) were
than in upper middle class families
(5.1 %),
and twice
as
high again (19.3%) in lower class families (X2=9.1; p < .01). A three-way ANOVA showed an F that was significant overall (F=8.4; p
.20). Mean PSC scores for the diagnostic groups were also not significantly different (Fg ~=1.2, p > .20).
Discussion The overall frequency of positive PSC scores (i.e., children who screened at high risk for psychosocial dysin pediatric dermatology practice was virtually the same as the rate found in general pediatric practices of comparable SES, with an overall PSC positive rate of 13.0%. In the dermatology sample, nearly half (44%) of the PSC positive subjects had been rated by their parents as having skin disorders that had a lot of impact on their appearance. Alternately, of the subjects whose parents rated the impact on appearance as &dquo;a lot,&dquo; more than a quarter (27.8%) were PSC positive, as compared with about 10% for each of the groups who rated appearance as less affected. The strong association between psychosocial dysfunction and greater perceived impact on appearance is statistically and clinically significant. The importance of
function)
496
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on April 14, 2015
appearance in adolescence is a generally accepted aspect of development, while it is often assumed that appearance assumes lesser importance for school-aged children. Since the current data are based on parental rather than selfassessments, one has to wonder what the child’s own view of the impact of his/her skin disorder on appearance would be and if it would be similar to the parent’s assessment. Nonetheless, the data indicate that impact on appearance, as assessed by parents, defines a group of children at high risk in their psychosocial functioning, and demonstrate a significant role for appearance in the emotional well-being of the school-aged child. Further, more than a quarter of all parents (28%), regardless of the PSC score, rated the skin disorder as seriously affecting the child’s appearance. This surprisingly high rate suggests that, in contrast to a physician, a parent’s untrained and emotional eye is acutely sensitive to the changes in appearance of a child’s skin. Unlike the parent, the physician is trained to see a disorder in terms of etiology and prognosis, and since in most dermatology patients these are benign and good, physicians may become quite tolerant of non-disfiguring lesions. The pediatrician or dermatologist’s objective perspective then may make it difficult to appreciate the parent’s (or patient’s) level of anxiety and concern. The results of this study highlight parents’ extraordinary sensitivity to appearance and indicate that it must be taken into consideration by practitioners. The validity of the PSC is indirectly supported by the
expected finding that a greater percentage of psychosocially dysfunctional children as opposed to nondysfunctional children had received some counseling. However, this should not be interpreted as suggesting that most high risk children have already received further psychosocial assessment. In the high risk group, 75% of the children had not been in counseling, and therefore had not
References 1. Hill-Beuf A, Porter JD. Children coping with impaired appearance: Social and psychologic influences. Gen Hospital Psychiatry 1984; 6:294-301. 2. Solomon CR, Gagnon C. Mother and child characteristics and involvement in dyads in which very young children have eczema. J Devel Behav Pediatr 1987; 8:213-20. 3. Koblenzer CS, Koblenzer PJ. Chronic intractable atopic eczema. Its occurrence as a physical sign of impaired parent-child relationships and psychologic developmental arrest: Improvement through insight and education. Arch Dermatol 1988; 124:1673-7. 4. Gil KM, Keefe FJ, Sampson HA, et al. The reaction of stress and family environment to atopic dermatitis symptoms in children. J Psychosom Res 1987; 31:673-84. 5. Van der Meeren HL, van der Schaar WW, van den Hurk CM. The psychological impact of severe acne. Cutis 1985; 36:84-6. 6. Rubinow DR, Peck GI, Squillace KM, et al. Reduced anxiety and depression in cystic acne patients after successful treatment with oral isotretinoin. J Am Acad Dermatol 1987; 17:25-32. 7. Wu SK, Kinder BN, Trunnell TN, et al. Role of anxiety and anger in acne patients: a relationship with the severity of the disorder. J Am Acad Dermatol 1988; 12:325-33. 8. Jellinek MS, Murphy JM. Screening for psychosocial disorders in pediatric practice. AJDC 1988; 142:1153-7. 9. Jellinek MS, Murphy JM, Bums B. Brief psychosocial screening in outpatient pediatric practice. J Pediatr 1986; 109:371-8. 10. Jellinek MS, Murphy JM, Robinson J, et al. The pediatric symptom checklist: screening school age children for psychosocial dysfunction. J Pediatr 1988; 112:201-9. 11. Murphy JM, Jellinek MS. Screening for psychosocial dysfunction in economically disadvantaged and minority group children: further validation of the Pediatric Symptom Checklist. Amer J Orthopsychiatry 1988; 58:450-6. 12. Murphy JM, Jellinek MS. Final Report, NIMH Contract #86MO43903401d - The further development of a brief psychosocial screening instrument for pediatric practice. Washington, D.C. National Institute of Mental Health, 1986. 13. Hollingshead AB. Four factor index of social status. New Haven, Connecticut: Department of Sociology, Yale University, 1975.
received the additional assessment that their PSC
positive scores warrant. Conclusion Based on this sample, pediatricians and dermatologists who treat children with skin disorders face about the same level of psychosocial dysfunction as is seen in a general pediatric population. Children whose disorder affects appearance are more likely to have positive screening scores. Although more of these children have had some counseling in the past year, most still have not. The comprehensive care of children with dermatological disorders requires attention to psychosocial issues and further research.
497
Downloaded from cpj.sagepub.com at NORTH CAROLINA STATE UNIV on April 14, 2015
