Behavioral Health Management in Children with Atopic Eczema

Atopic dermatitis (AD) is an inflammatory skin condition affecting up to 20% of children. For some children, the condition improves, however in others the symptoms may worsen and become a life-long condition to manage. One of the most difficult, and crucial, aspects of managing pediatric AD is helping children develop the ability to resist the urge to scratch. Once scratched, the skin develops a lesion and the resulting inflammatory process increases the itchy, pruritic sensation, igniting the often torturous itch-scratch cycle.

Consequences of AD

Children with AD are often living in situations with bi-directional stress, where the stress and anxiety of AD can reduce parenting effectiveness, in turn worsening challenging behaviors and child emotional distress, perpetuating a cycle of family distress and acute AD symptoms. Children with chronic sleep disruption (due to AD pruritis) or emotional stress (due to physical discomfort and conflict with parents) are at higher risk of learning/attention problems which can further increase the stress of parents. Emotional distress and sleep disruption can activate inflammatory responses, setting off the itch-scratch cycle. As these children age and become adolescents, they can be at higher risk of anxiety and depression as they manage typical developmental struggles including hormonal changes, emotional sensitivity, and peer and family conflicts.

Strategies for managing AD

Medical strategies to decrease skin inflammation include using medications such as topical steroids or calcineurin inhibitors and promoting skin hydration through daily baths and use of lotions. Preventative measures to reduce skin irritation as well as reduce emotional distress can help reduce the frequency and intensity of the pruritis, further decreasing the urge to scratch and stopping the cycle. Allergy testing, through skin tests or food challenges, can be helpful in identifying irritants to reduce or eliminate contact with.

A family-systems behavioral health approach views the child a member of a family and community system and seeks to address concerns from a holistic perspective. In addition to working with the family on strategies to promote wellness for the individual and the family, this approach also considers if community environments (such as schools, daycares, etc) understand AD and have the willingness and ability to accommodate the child’s needs while in that setting.

Combining medical and behavioral models is known as integrative care, where teams of specialists work together from different areas of expertise towards a common goal. For example, a physician may provide education and prescribe medical treatments for AD, while a psychologist may teach distraction and relaxation techniques to cope with itching. Nurses on the team may provide hands-on teaching about treatments to children and families, and therapists may work with the family to address household dynamics that may impede effective management of AD. By approaching the situation from multiple angles, the child and family become equipped with a variety of robust options to manage AD which in turn promotes overall well-being due to decreased pain and systems dysfunction.

The role of parents in managing AD

It is important to take the child’s developmental age into account when creating an integrative care plan. Younger children will rely almost completely on parents to recognize and intervene around itching behaviors. Older children may be able to recognize itching but require coaching to apply appropriate management strategies. As with any chronic illness, teens may express reluctance (or even refusal) to manage their symptoms as they attempt to master the role of autonomy and require carefully structured support from providers and parents to increase adherence without increasing conflict.

When parents maintain a calm, positive approach to managing scratching behaviors and doing routine AD healthcare, children adopt more favorable impressions towards managing their own health as they age. Similarly, if parents are anxious and distressed around AD care, and they use harsh tones when correcting scratching behavior, AD symptoms may become worse due to stress and children may attempt to hide scratching behaviors to avoid being yelled at. Distraction, or identifying an alternate way to safely relieve the itch, is often a more effective intervention than simply telling the child to stop scratching.

Therapeutic interventions

For many reasons, a family may decide to employ professional help to manage the effect of AD on both the individual as well as the larger family system. There are many different types of therapeutic tools and approaches that can be employed; depending on the unique needs of an individual or family, one or several of the below approaches may be beneficial.

Cognitive-behavioral therapy (CBT) connects thoughts and behaviors and uses specific techniques to develop coping skills. Acceptance and commitment therapy seeks to clarify values and coals, and develop strategies using mindfulness to increase self-efficacy and decrease perceived stress. Parenting and behavioral management training centers around developing reasonable behavioral expectations and strategies for increasing desired behaviors and decreasing unwanted behaviors through consistent application of rewards and consequences. Biofeedback uses medical monitoring devices to allow children to see their physiologic responses to relaxation techniques, which reinforces their understanding of the mind/body connection. Sleep consultation interventions examine the behavioral and physiological factors that can interfere with sleep, and identify therapy or medications to address the identified concerns. Group therapy can help reduce a child’s perception of isolation and increase social skills, and incorporation art or other common childhood activities can make group participation less threatening. And finally, a psychiatric consultation can be used to identify medications to improve sleep or reduce anxiety and depression.

Conclusion

Atopic dermatitis can significantly reduce quality of life for children as well as their caregivers and the larger family unit. The resulting bidirectional stress increases the likelihood of acute symptom flare-ups, further distressing the individual and family system. By employing an interdisciplinary team to provide integrative health care, patients and families can employ a holistic set of interventions to increase adaptive functioning and decrease the negative effects of AD.

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