Eur. J. Pediat. Dermatol.                                                                                       Contents vol. 9, 1999
9, 101-4, 1999

The psychological consultation for pediatric dermatology patient.
What "indicators" to observe?

Andreoli E., Foglio Bonda P.G., Mozzetta A., Paradisi M.*
Servizio di Psicologia Clinica e Psicoterapia Psicosomatica
*VII Div. Dermatologia Pediatrica
Istituto Dermopatico dell'Immacolata, IRCCS, Rome (Italy)

Summary Several studies and researches indicate how interdependent are the psychological and physical health of a person in every moment of his life, but above all during the time of his/her development. In any case, the feeling of uneasiness in children or adolescents affected by skin diseases assumes great significance for what the level of perception of their own reality is concerned. This is the reason why it is very important to give an evaluation concerning the presence of some behaviours (the so called indicators) that suggest the possibility of a psychological component in any case of skin disorders during childhood or adolescence. The psychological component may influence the offspring and the course and even affect the outcome of the therapy of the disease or may represent more or less direct consequence of it. On the basis of our long experience in a pediatric dermatology ward we would like to call your attention to this list of such behaviours that we have found more significant in order to suggest the dermatologist the need of a psychological consultation.

Key words Skin diseases, psychological consultation, psychosomatic disturbances, somatopsychic disturbances.

Several studies and researches indicate how interdependent are the psychological and physical health of a person in every moment of life, but above all during the infantile and adolescent periods of development (1, 2).
We can speak of a psychological component in a dermatological disease, when: *a situation of psychological disturbance contributes to the manifestation of skin disease (psychosomatic disturbances); *the dermatological disease negatively influences the psychological health (somatopsychic disturbances) -3, 4-.
In every case, the feeling of uneasiness that the child or adolescent affected by a dermatological disease experience is completely unique. Beginning with the physical pathology, this feeling of uneasiness can give rise to dysphoric emotional reactions and/or unsuitable behaviour and/or heteroaggressiveness and autoaggressiveness that, even if not always necessarily "serious", assume, in general, considerable meaning.
For this reason it is indispensable to evaluate, in any case of infantile and adolescent skin diseases (as alopecia areata, vitiligo, atopic dermatitis, psoriasis, urticaria or acne), the presence of those signs that indicate the possibility that exists a psychological component that could have influenced the offspring and/or the course of the disease (5).
However, when the child manifests negative emotional reactions and/or negative conduct relative to events, or towards personal, familial, interpersonal, scholastic or environmental dynamics, it is necessary to understand how to manage the skin disease, not only from the medical point of view but also from the one of its consequences in the psychosocial environment.
This should be done so that the experience of the disease doesn’t influence negatively, through these consequent psychological and/or relational problems (6), the course of the illness and the global development of the subject.
This investigation is not however specifically the task of the dermatologist who, consequently, when he thinks it is necessary, will ask for a consultation with the psychologist.
To decide on the effectiveness of this collaboration, the dermatologist, during the visit, can look for the presence of a sign/signs of problematic behaviour and/or dynamics in the child/adolescent, in his/her parents or in their relationship. The presence of these signs ("indicators") could result in the belief that there is a particular psychic uneasiness and, consequently, the need for a psychological consultation (7).
We present a list of the most significant behavioural or conduct patterns that suggest the dermatologist the need to refer the child or adolescent to a psychological consultation, sharing them in five groups.
Main indicators to evaluate the need for a psychological consultation are as follows:

1- The presence of "extreme behaviours", not only negative but also positive. It is therefore very important to pay particular attention to observe not only the children whose behaviour is currently defined "terrible" or "unbearable", but also those children that are described as "perfect" or as "a child who never give problems". In fact while the former can display their difficulties by means of inadequate behaviour, the latter can dissimulate their psychological uneasiness by adapting themselves totally to the requests, real or presumed, of the familial or scholastic background or escaping the situations, potentially stressing and anxiogenous as well.
Among those "extreme behaviours" we want to underline the presence of: *the attitude to renounce to one’s own wishes and needs and/or to express one’s own emotions or drives’ energies, in order to make sure the love and appreciation of the others, especially those meaningful; *exaggerated and methodical behaviours of opposition and/or aggressiveness, toward themselves and/or the others, including autolesionistic responses, for instance to scratch until bleeding, to pull out eyebrow or hair, etc.; *behaviours of excessive and rigid devotion to the scholastic engagements, apart the results that in any case are inferior to their actual capacities; *clear disinterest toward the interpersonal relationships or excessive and everlasting need of interaction, as mean to avoid either those experiences that the subject thinks that may be anxiogenous and problematic, or the effort to express his own potentialities.

2- The presence of a stressing event or a long standing situation of stress. It is important to remember that we can speak of stress in those cases when the subjects have the sensation to be under pressure in consequence of the presence of some realities (personal, interpersonal, social or environmental) that determine in themselves an alert situation and make any effort in order to face it with every capacity.
The stress may be originated not only by negative events or situations, but also by positive ones (for instance, to win a competition may represent a stress event because the child doesn’t know if he can maintain the same results in the future).
The period of time ("temporal window") considered to make hypothesis about the existence of a link between stressing event or situation and skin disease doesn’t go over six months before the onset of the disease.
We think it is important to remind that not always what is subjectively lived as stressing by the child may be the same in the adult. That is why it is particularly difficult for the parents to determine the cause of the uneasiness (for example, the separation of the parents of a mate to whom the child doesn’t appear particularly linked may be a stressing event because he can think that something similar may happen to him as well).

3- A clear incoherence between the modalities of the development of the subject and those typical of his age. For example, the child is too "advanced" or on the contrary he goes back to already overtaken behaviour or he doesn’t go on or has notable problems in different areas of his own reality, particularly in those: *of the personal autonomy as, for example, in dressing; eating; practising daily activities; etc.; *of sleep. For instance, difficulties in the moment to fall asleep; the need of someone’s presence when goes to bed; fear to sleep alone; frequent awakening; nightmares; etc.; *of nourishment. For example, the need to be feed; or the go back to the use of the feeding bottle; appetite very scarce or exaggerated; either absolute rejection or exclusive demand of a particular nourishment; etc.; *the sphincteric control that is inadequate, either for a lack of acquisition or for the return of behaviours already overtaken of enuresis or encopresis, during the night or day; or for the child's request to maintain or use again the napkin.
Sometimes behaviours obsessive or of opposition may also be present, as for example, the refusal to go to the toilet; ritualistic behaviours that are clearly in contrast with the rules of good manners; etc.;
*of the motion development, referred to the control ad co-ordination of movement;
*of the verbal communication. For instance, the articulation; the precision of language; the contents’ extreme poorness or copiousness; etc.;
*the acquisition of specific competences as, for example, the capacity of reading, writing and making calculation;
*of the interests and/or sexual behaviours, in which habits completely inadequate to the age are present; for instance, questioning, readings or autoerotic behaviours that are excessive and compulsive; poses clearly seductive; anticipate sexual experiences; etc.

4- The presence of clear difficulties in social and scholastic areas, as those in:
*the interpersonal relationships, that are strongly inadequate and problematic with main persons of one’s own background, such as parents, brothers, teachers and friends. Those relationships are defined by cold emotions; exaggerate need of protection, dependence or autonomy; requests clearly inadequate to the child’s age; excessive rivalry or dependence to brothers. This is also applied to the child’s interaction with mates and other children, as for example, total disinterestedness or exaggerate need to stay with them; or excessive interest for TV, PC, video-games, school activity, track-and-field sports, reading, ... that allows him to remain isolated;
*the social adaptation; for example, incapacity to understand social rules and/or refusal of follow them; methodical lies or tendency to take things belonging to others; etc.;
*the scholastic learning and progress, that are clearly reduced in consideration with the potentialities of the subject and that may be accompanied by behaviours (crying; fear and or refusal to go to school; lack of participation to school activities) and/or somatic symptoms (headache, vomiting, anticipate awakening, nightmares, anorexia), that constitute expressions of uneasiness in relation to the scholastic ambience, unless we can clearly exclude an organic aetiology.

5- The presence of inadequate attitudes and feelings related to the skin disorders as:
*the negation or the excessive stressing of the meaning that the skin problem may have. An example of this is a teen-ager who affirms that to be affected by a form of universalis alopecia areata isn't a real problem for her; or, at the contrary, a young boy who doesn't want to go out with friends cause his acne;
*the sense of guilt that the patient has related to onset, to the course or to the consequences of the skin problem. For example, reproving himself for the time, work and money that the parents spend for specialist visits; or because sees them worried and sorry for him;
*to attribute to the skin problem a particular meaning as when the child feel himself responsible for an eventual presence of disturbed behaviours and/or dynamics personal or domestic; when he tries to create an excessive interest of everybody for his skin problem; or when he seeks to justify his school difficulties or tries to solve some difficult relationship of his parents by means of his pathology.

We think that the evaluation of those "indicators" could be useful to the dermatologist to assess in a global way the situation of the child or adolescent, to establish the need for a psychological consultation.
We report a simple schedule in which we have summarised the five groups of "indicators", and at side the space in which one can to put a mark to report the presence of someone of them, while they are pointed out during the examination, so it will be easier to evaluate the opportunity to ask the psychologist for a consultation.
To manage to assess with good accuracy the timeliness of a psychological consultation looks to us of main importance, in as much as that allows the dermatologist to offer to the ill child and adolescent a specialistic treatment that could contribute to stimulate a best answer to dermatological therapy.
Meanwhile, it allows us to avoid a psychological screening of all the patients that, in addition to request a long period of time and plenty of energies, could result unnecessary and have a negative effect either for the child and/or his/her parents.

Address to: Dott. E. Andreoli
Servizio di Psicologia Clinica e Psicoterapia Psicosomatica
Ististuto Dermopatico dell'Immacolata - IRCCS
Via dei Monti di Creta - Rome (Italy)

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