There is a large unmet need for psychological support in children with visible, chronic, often severe, skin disease, which impacts greatly on children, young people (CYP) and families. Many national treatment guidelines advocate psychological support, but there is little funding or access to appropriate help. The St John’s Institute of Dermatology service at St Thomas’ Hospital treats CYP throughout the UK with disorders such as genetic skin disease, severe inflammatory disease, scarring disorders and diseases which cause visible difference. These can impact children’s self-confidence and quality of life, causing anxiety, low mood, and depression. The paediatric dermatology department, served by 10 paediatric dermatologists and eight paediatric tertiary specialist clinics, has seen an unprecedented growth in patient volume and complexity of clinical cases. A national paediatric psychodermatology service has been set up for CYP whose skin disease causes psychological impact, and those with skin conditions caused by psychological/psychiatric/neurodevelopmental comorbidities. This service has had excellent feedback from CYP/families, lowered CYP distress and reduced follow-up in general clinics/GP attendance.
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Funding was secured to provide a paediatric clinical psychologist to work in paediatric dermatology for one year at 2.5 days per week. In April 2017 a meeting was held with the paediatric dermatology HCPs to inform all user groups about referral criteria and pathways of care. Funds were identified to furnish a psychology room with sofas and toys, to provide a comfortable non-clinical setting for the CYP. Having psychology embedded alongside paediatric dermatology allowed distressed CYP immediate access to the clinical psychologist. In addition, introducing CYP to the psychologist improved engagement at future appointments and built rapport. All CYP were routinely screened using psychological outcome measures. A monthly paediatric MDT psychodermatology clinic (the complex clinic) was established for CYP whose dermatological presentations were primarily a result of psychological distress or complex needs. During the COVID-19 pandemic, all psychology input and the complex clinic were seamlessly transferred to a virtual model, which everyone found effective. Unexpected benefits were that CYP/parents were able to attend without taking time off work/school, and the CYP were more relaxed virtually and engaged freely. Psychological and social themes which emerged included bullying, grief, gender identity disorder, sexuality, body image disturbance and family-related stress. A stepped care model of psychology was used and adapted during the pandemic. All children were offered psychoeducation for managing low mood, stress and anxiety. Psychology self-help booklets were sent electronically to CYP/families and supplemented by telephone/video appointments. Children with complex needs or issues around risk were offered individual psychology appointments.
All psychology care was documented, and data were used to put the case for a permanent paediatric clinical psychologist role. This resulted in the appointment of a paediatric clinical psychologist for three days per week in September 2018. With psychology embedded in the team, a biopsychosocial model ensures that all aspects of a CYP’s health and wellbeing are considered. Consequently, CYP seen in the complex psychodermatology clinic have fewer dermatology appointments, paediatric outpatient appointments, or GP and A&E attendances, with an average of 3-4 appointments needed to resolve their issues. Since the integration of psychology into the severe eczema clinic, routine measures of mood indicate a downward trend in anxiety and depression. The MDT and one-stop clinic approach is an effective and efficient model of care. Post lockdown, psychology follow-up can be offered virtually after school to reduce impact on education. Group workshops have maximised treatment impact with minimal resources. A workshop was held to support CYP transitioning from primary to secondary school, with a parallel group for parents/carers. It featured an interactive talk from a YP with severe eczema at secondary school. A face-to-face mindfulness group was offered to improve resilience in YP, which they found beneficial but difficult to attend in person. Therefore, a virtual habit reversal workshop was provided for CYP with eczema to help them reduce scratching. CYP and their families benefitted from psychological support within a paediatric dermatology setting and felt safe with a known team.
Sustainability and Spread
The value of the paediatric psychodermatology service is recognised and a further business case will be submitted in 2022 for a band 7 full-time psychologist to grow the service to meet local and national need. As detailed, psychology has been embedded within the paediatric dermatology team to enable holistic care, encompassing the physical and psychological needs of CYP and families. The challenges with completion of feedback forms and Patient Reported Outcome Measures (PROMs) during the pandemic and virtual consultations are being addressed with digital PROMs via the DrDoctor digital platform, which texts forms and automatically uploads data to patient records. The model of care and outcome data were shared via presentation at the British Society of Paediatric Dermatology meeting (November 20) and at the Psychodermatology UK meeting (January 21). A teaching seminar in paediatric psychodermatology was presented at the Psychodermatology UK meeting, co-facilitated with Dr Ali. This session was attended virtually by over 200 delegates and had excellent feedback (score 4.8/5). The virtual habit reversal workshop highlighted that the existing habit reversal material (adapted from adult material) was not relevant to today’s CYP with eczema. Therefore, new material was developed collaboratively with CYP/families to ensure it was useful for this target group, and to develop understanding of how the intervention might fit with current clinical care pathways. This project recently won the UK Dermatology Clinical Trials Network themed research call for psychodermatology research in an open national competition. The virtual model of care has resulted in increased referrals and treatment for CYP who live outside London, which could facilitate access to MDT care for many more children and families nationwide.
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