Systematic Review: Psychosocial Interventions for Children and Young People With Visible Differences Resulting From Appearance Altering Conditions, Injury, or Treatment Effects

Cross-condition risk and protective factors for psychosocial distress in parents and carers of children and young people with appearance-affecting conditions and injuries

Alongside typical parenting challenges, initial condition-specific research suggests thadifferent experiences and support needs.t parents of children with different visible differences may experience similar psychosocial difficulties. Despite this, large-scale cross-condition research to identify risk and protective factors for parental distress and psychosocial adjustment has been lacking. Two hundred and nine parents and carers of children with a range of visible differences completed an online survey comprised of standardised outcome measures, study-specific measures, and open-ended questions. Multiple regression modelling identified possible risk and protective factors, and data collected via open-ended questions were analysed using content analysis. Findings support themes previously identified in small-scale cross-condition qualitative research with parents of children with visible differences. Risk factors for parental negative affect and stress included parental reports of the noticeability of their child's visible difference and teasing. Protective factors included good parent-child communication, self-compassion, knowledge of their child's condition and satisfaction with treatment. The risk and protective factors identified provide important insight into the experiences of this parent population and indicate possible avenues for psychosocial intervention.

Body image and psychosocial outcomes in youth and young adults with differences of sex development: a multi-method study

OBJECTIVE

Differences of sex development (DSD) can affect the physical health, appearance, and psychosocial functioning of affected individuals, but little is known about how subjective appearance perceptions (body image) impact psychosocial outcomes. This study evaluated body image and its associations with psychosocial outcomes including quality of life, resilience, and psychosocial adjustment.

METHODS

This cross-sectional, multi-method study assessed body image and psychosocial outcomes including quality of life, adjustment, and resilience in 97 youth and young adults with DSD (mean age = 17 ± 3.7 years; 56% assigned female in infancy) using psychometrically sound instruments. A subsample (n = 40) completed qualitative interviews.

RESULTS

Quantitative results indicated that overall, participants were satisfied with their physical appearance, although less so with their primary sex characteristics. Body image dissatisfaction was associated with poorer psychosocial adjustment, quality of life, and resilience. Qualitatively, youth and young adults reported a variety of perceptions, both positive and negative, related to their body image and the impact of living with a DSD condition. Themes identified included appearance management; effects of DSD on body image; diagnostic factors and features; attitudes about diagnosis; and treatment.

CONCLUSIONS

Body image is significantly associated with psychosocial outcomes in youth and young adults with DSD, with qualitative findings highlighting both positive and negative body image experiences. Results have implications for clinical care including screening for appearance concerns, normalization of appearance variations, and intervention development to better support healthy body image and psychosocial functioning in youth and young adults with DSD.

More than my appearance: a pilot evaluation of the expand your Horizon Online functionality-based writing programme for adults with visible differences

Background

Adults with conditions that affect their appearance, known as visible differences, can experience appearance concerns, social anxiety, and depression. Interventions have been developed for this population to facilitate adjustment and coping skills; however, they have limited evidence of efficacy. The Expand Your Horizon [Alleva, J. M., Martijn, C., Van Breukelen, G. J., Jansen, A., & Karos, K. (2015). Expand Your Horizon: A programme that improves body image and reduces self-objectification by training women to focus on body functionality. Body Image, 15, 81-89. https://doi.org/10.1016/j.bodyim.2015.07.001] online functionality-based writing programme was adapted for adults with visible differences.

Method

A pilot randomised controlled trial with a wait-list control group was carried out to assess preliminary intervention efficacy and gain information about the acceptability and feasibility of the programme. Forty-four adults aged 21-63 years (M = 40.21; SD = 12.05) with visible differences took part. Various facets of body image (i.e. functionality appreciation and body appreciation) as well as depression and anxiety were assessed immediately pre- and post-intervention and at three-months.

Results

Participants reported enjoying the programme, felt that the format was acceptable, and it significantly increased functionality appreciation, which was maintained at three-months. However, there were no improvements in body appreciation, depression, and anxiety.

Conclusions

In future, a full trial should be carried out with an active control group.

Stakeholders' Views on Information Needed in a Patient Decision Aid for Microtia Reconstruction

OBJECTIVE

To assess which information about microtia and the possible reconstructive options health care providers (HCPs), patients and parents believe should be included in a patient decision aid (PtDA).

DESIGN

A mixed-methods study comprised of an online survey of HCPs and focus group discussions with patients and parents.

PARTICIPANTS

Survey respondents were members of the International Society for Auricular Reconstruction (ISAR). Focus group participants were patients with microtia and their parents, recruited through the microtia outpatient clinic at Amsterdam UMC, and through a Dutch patient organization for cleft and craniofacial conditions.

METHODS

An online, investigator-made survey was sent to ISAR members in December 2021. Semi-structured focus group discussions were held in February 2022. Quantitative results were summarized, and qualitative results were thematically grouped.

RESULTS

Thirty-two HCPs responded to the survey (response rate 41%). Most respondents (n = 24) were plastic surgeons, who had a median of 15 years of experience (IQR: 7-23 years). Two focus groups were held with a total of five patients and two parents. HCPs, patients and parents generally agreed on the information needed in a PtDA, emphasizing the importance of realistic expectation management. Patients and parents also considered psychosocial and functional outcomes, patient experiences, as well as patients' involvement in decision-making important.

CONCLUSIONS

A PtDA for microtia reconstruction should target all patients with microtia, and include information on at least technique-related information, expected esthetic results, possible adverse effects, psychosocial and functional outcomes and patient experiences. Preference eliciting questions should be developed for both pediatric patients and their parents.

'It's not meant to be for life, but it carries on': a qualitative investigation into the psychosocial needs of young retinoblastoma survivors

OBJECTIVE AND DESIGN

Retinoblastoma (Rb) is a rare childhood eye cancer, with 45% of individuals impacted by heritable disease and the remainder impacted non-heritably. The condition can leave survivors with life-long psychological and social challenges. This qualitative study examined the psychosocial needs of teenagers and young adults living beyond Rb.

SETTING

A qualitative, exploratory study was conducted using focus groups with teenagers and interviews with young adults. Participants were recruited via the Childhood Eye Cancer Trust and the two national Rb treatment centres in the UK. Reflexive thematic analysis was used to analyse data using exploratory and inductive methods.

PARTICIPANTS

32 young survivors of Rb (10 heritable, 21 non-heritable, 1 unknown; 23 unilateral, 9 bilateral) aged between 13 and 29 years (12 male, 20 female).

RESULTS

Data were rich and spanned the life course: three key themes were generated, containing eight subthemes. Theme 1 describes participants' experiences of childhood and trauma, including survivor guilt, memories from treatment and impact on personality. Theme 2 focuses on the challenges of adolescence, including the psychological impact of Rb, the impact on identity, and the sense of normality and adaptation to late effects. The third theme considered adulthood and the development of acceptance, a state of being widely considered unachievable during childhood, as well as the 'work' needed to feel supported, including seeking out information, peer support and therapeutic strategies.

CONCLUSIONS

This study provides in-depth insight into the experiences of life beyond Rb. Findings highlight the need for specific psychosocial interventions informed by codesign.

Congenital melanocytic naevus (CMN) through the lens: Using photo-elicitation interviews to explore adjustment in adolescents with a rare birthmark condition

Adolescents with the rare birthmarks congenital melanocytic naevi (CMN) experience physical and psychosocial challenges, many of which stem from looking different from the 'norm'. However, some adjust and have positive experiences. Understanding the lived experiences of adolescents who have adjusted to CMN can provide a holistic picture of adjustment and inform the development of support and interventions for others with the condition. Open, participant-driven photo-elicitation interviews were conducted with four White females (15-17 years) who self-identified as having adjusted to CMN. Participants chose five photographs which were used to guide the interviews (47-80 min). Interpretative phenomenological analysis (IPA) was used to analyse the transcribed interview data. Three superordinate themes were identified: 'Accepting My 'True' Self' (1), 'I am Not Alone in This' (2), and 'Developing as a Person' (3). The themes related to accepting CMN as part of their identity, developing a positive body image (e.g., body appreciation, broad conceptualisations of beauty, body image flexibility), feeling supported and accepted by family, friends, and others with CMN, and developing adaptive coping skills. Findings suggest positive body image may be important for adjustment and can be determined by an individual. The benefits of using photo-elicitation within appearance research are discussed.

Psychosocial Interventions for Children and Young People With Visible Differences Resulting From Appearance-Altering Conditions, Injury, or Treatment Effects: An Updated Systematic Review

OBJECTIVE

Children and young people with visible differences can experience psychosocial difficulties, such as anxiety and teasing by others. Interventions targeting difficulties have previously been reviewed by Jenkinson et al. This review aimed to identify and critically assess recent studies evaluating the effectiveness of psychosocial interventions for children and young people with visible differences on psychosocial wellbeing, self-esteem, and social experiences and compare the findings with Jenkinson et al. using a replacement review process.

METHODS

Inclusion criteria are as follows: studies with participants aged 0-18 years with visible differences; investigating a psychosocial intervention; including comparison with an alternative intervention, control group, or pre- and post-intervention; and including a quantitative measure assessed pre- and post-intervention. Exclusion criteria are as follows: participants with body dysmorphic disorder or appearance changes due to eating disorders or obesity and studies not written in English. MEDLINE, AMED, and PsycInfo were searched and grey literature was included. Results were reviewed against eligibility criteria, data were extracted, and studies were evaluated using the Cochrane Risk of Bias 2 tool.

RESULTS

Using Jenkinson et al. as one source of studies, 24 studies were included evaluating a range of interventions such as social interaction skills training, residential social camps, and cognitive behavioral therapy. Risk of bias was high in 20 studies and of some concern in four studies.

CONCLUSION

There is some evidence of the effectiveness of hypnotherapy, a relaxation response resiliency program, integrative body-mind-spirit group, and therapeutic patient education, but more rigorous research is needed to confirm their impact on psychosocial outcomes.

A clinical and biologic review of congenital melanocytic nevi

Congenital melanocytic nevi (CMN) are the result of aberrations in the mitogen-activated protein kinase signal transduction pathway caused by postzygotic somatic mutations. The estimated incidence of newborns with CMN is 1%-2%. The main complications of CMN include proliferative nodules, melanomas, and neurocutaneous melanosis, and the latter two are the most troublesome issues to address. Treatments are primarily taken into account for aesthetic purposes and the reduction of melanoma risk. Due to the much lower incidence of malignant transformation observed in recent studies than in previous data, clinical management paradigms for CMN patients have gradually shifted towards conservative observation and close monitoring. Surgery and lasers are still the main treatments, and targeted therapy may be a promising strategy to help manage complications. With the increase in awareness of mental health, increasing focus has been placed on the quality of life (QoL) and psychological issues of both CMN patients and their parents. Recent studies have revealed that families coping with CMN might endure intense pressure, a major loss in QoL, and psychological problems after diagnosis and during treatment. Here, we sought to present an overview of genetic basis, complications, treatments, and psychological issues related to CMN and hope to provide better management for patients with CMN.

The role of the clinical psychologist within a cleft service

Clinical psychologists are core members of UK cleft services. This paper outlines the variety of ways in which clinical psychologists work across the lifespan to promote the psychological wellbeing of those born with a cleft and their families. In the context of dental or orthodontic treatment, this involves a combination of early intervention and advice, psychological assessment or specialist psychological therapy for individuals experiencing dental anxiety or anxiety regarding the appearance of their teeth. This paper therefore aims to highlight the varying roles which clinical psychologists play in the provision of cleft-related dental care, often alongside multidisciplinary colleagues.

Experiences and impact of the UK lockdown amongst adults who have a facial visible difference

Globally, COVID-19 has been shown to have had a wide ranging and significant impact on individuals' daily living, and physical and mental health. However, there are some groups of individuals who may encounter unique challenges with regards to COVID-19 and whose experiences have not been investigated thus far. Therefore, this study aimed to understand the experiences of adults with a facial visible difference in relation to COVID-19 and lockdown. Semi-structured interviews were conducted with 21 adults with a variety of facial visible differences (e.g., cleft lip/palate, facial scars, skin conditions) and analyzed using inductive reflexive thematic analysis. This analysis generated three themes (Escaping the external gaze; Existing feelings manifesting in new challenges; COVID-19 taking priority). The results of this study suggest that the first U.K. lockdown from the COVID-19 pandemic created significant challenges for some individuals with a facial visible difference, and ongoing restrictions and social distancing measures might be particularly challenging for those who experience anxiety around social encounters. These findings highlight the importance of providing appropriate and accessible support for people with facial differences during lockdown and as restrictions ease.

Predictors of Adolescents' Response to a Web-Based Intervention to Improve Psychosocial Adjustment to Having an Appearance-Affecting Condition (Young Person's Face IT): Prospective Study

BACKGROUND

Adolescents with a condition affecting their appearance that results in a visible difference can be at risk of psychosocial distress and impaired adjustment. Evidence for the effectiveness of existing interventions in improving psychosocial outcomes is limited, and relevant treatment can be difficult to access. Young Person's Face IT (YPF), a self-guided web-based intervention, has demonstrated potential in reducing social anxiety in adolescents with a visible difference. However, more knowledge is needed about the variables that contribute to variations in intervention effects to identify those who may benefit most from YPF.

OBJECTIVE

This study aimed to investigate demographic, psychosocial, and intervention-related variables as predictors of overall intervention effects after adolescents' use of YPF.

METHODS

We used longitudinal data collected as part of a larger, ongoing mixed methods project and randomized controlled trial (ClinicalTrials.gov NCT03165331) investigating the effectiveness of the Norwegian version of YPF. Participants were 71 adolescents (mean age 13.98, SD 1.74 years; range 11-18 years; 43/71, 61% girls) with a wide range of visible differences. The adolescents completed primary (body esteem and social anxiety symptoms) and secondary (perceived stigmatization, life disengagement, and self-rated health satisfaction) outcome measures at baseline and postintervention measurement. The predictor variables were demographic (age and gender), psychosocial (frequency of teasing experiences related to aspects of the body and appearance as well as depressive and anxiety symptoms), and intervention-related (time spent on YPF) variables.

RESULTS

Two-thirds (47/71, 66%) of the adolescents completed all YPF sessions and spent an average of 265 (SD 125) minutes on the intervention. Backward multiple regression analyses with a 2-tailed P-value threshold of .20 revealed that several variables were retained in the final models and predicted postintervention outcome changes. Body esteem was predicted by age (P=.14) and frequency of teasing experiences (P=.09). Social anxiety symptoms were predicted by gender (P=.12), frequency of teasing experiences (P=.03), depressive and anxiety symptoms (P=.08), and time spent on YPF (P=.06). Perceived stigmatization was predicted by age (P=.09), gender (P=.09), frequency of teasing experiences (P=.19), and depressive and anxiety symptoms (P=.06). Life disengagement was predicted by gender (P=.03), depressive and anxiety symptoms (P=.001), and time spent on YPF (P=.14). Self-rated health satisfaction was predicted by age (P=.008). However, the results were limited by relatively low explained postintervention variance, ranging from 1.6% to 24.1%.

CONCLUSIONS

This study suggests that adolescent boys, adolescents who experience higher levels of psychosocial distress related to their visible difference, and adolescents who spend sufficient time on YPF may obtain better overall intervention effects.

'Scars: How Our Wounds Make Us Who We Are': Improving appearance-based stigma, conceptualisation of beauty and body esteem through a documentary

Introduction

Those with an altered appearance as a result of injury, health condition or treatment can face stigma, which may contribute to adverse psychosocial outcomes. However, current research tends to focus on supporting individuals themselves to cope, rather than targeting societal stigma. This study aimed to reduce societal stigma towards this group, through the use of a documentary about people with scars.

Methods

146 adults completed questionnaires before and after viewing the documentary.

Results

After viewing, participants had reduced self-reported intentions to behave in a stigmatising way towards those with visible differences, broader conceptualisation of beauty, and more positive body-esteem. Qualitative data also suggested further positive impacts.

Conclusion

Those with visible differences (for example scars) are subject to societal stigmatisation which perpetuates psychological and social problems. Therefore, alleviating social stigma through the media, as demonstrated through the documentary in this study, may improve the lives of those living with visible differences.

Lay Summary

People with an altered appearance or scars as a result of injury, health condition or treatment can face stigma, which may contribute to harmful psychological and social outcomes. However, current research tends to focus on supporting affected individuals themselves to cope, rather than targeting societal stigma. This study aimed to find out whether a documentary about people with scars was successful at reducing viewers' stigma towards this group. A group of 146 adults completed questionnaires before and after viewing the documentary. After viewing, questionnaires indicated that participants had reduced intentions to behave in a stigmatising way towards those with visible differences. Furthermore, they also viewed a broader range of appearances as beautiful and felt more positive about their own bodies. Comments and feedback from participants also suggested further positive impacts. Those with visible differences (for example scars) are subject to societal stigmatisation which can cause and worsen mental health problems. Therefore, alleviating social stigma through the media, as demonstrated through the documentary in this study, may improve the lives of those living with visible differences.

Adolescents and parents' perception of Young Person's Face IT: An online intervention for adolescents struggling with conditions affecting their appearance

Objective

A visible difference in appearance caused by a congenital or acquired condition can negatively affect adolescents' psychosocial well-being. Young Person's Face IT (YPF) is an online intervention based on cognitive behavioural therapy and social skills training, developed to help adolescents who struggle with adjusting to a visible difference. The objective of the present study was to explore adolescents' and parents' perceptions of the intervention's relevance and usefulness in supporting young people with appearance-related psychosocial concerns.

Methods

Participants were adolescents (N = 76, aged 11-18) and parents (N = 15), recruited in a larger randomised controlled trial aiming at evaluating YPF. This qualitative study with descriptive data includes adolescents' ratings on YPF's usefulness, and interview data from adolescents and parents on their experiences with YPF. The interviews were analysed using a thematic approach.

Results

Results indicated that YPF was experienced as useful and relevant. Interviews showed that adolescents felt validated through the programme's content, discovered that other young people had similar experiences and felt that YPF could contribute to changing self-perceptions for the better. However, results could not confirm whether perceived usefulness led to the development and use of new social skills in real-life situations.

Conclusion

This study offers new perspectives on the relevance and usefulness of YPF in supporting adolescents with appearance-related psychosocial concerns. Findings suggest that updates and modifications are required so that YPF stays relevant and useful for adolescents in need of support.

Trial registration number

NCT03165331.

Towards a better understanding of the social stigma of facial difference

Facial difference (FD) is not only an individual experience; it is inherently social, reflecting interactions between social norms and individual attitudes. Often FD is stigmatized. In this paper, we employ a widely used stigma framework, namely the social stigma framework put forth by Pryor and Reeder (2011), to unpack the stigma of FD. This framework posits that there are four forms of stigma: public stigma, self-stigma, stigma by association, and structural stigma. We first discuss the social and psychological literature on FD as it pertains to these various forms of stigma. We then describe coping approaches for FD stigma. Lastly, we delineate evidence-based methods for addressing the various forms of FD stigma, such that future efforts can more effectively tackle the stigma of facial difference.

Is it safe? Exploring positive and negative outcome changes following a web-based intervention for adolescents distressed by a visible difference (YP Face IT)

Despite the importance of making sure that psychological interventions are safe, research including both positive and negative effects of novel internet-delivered support is scarce. The aim of our study was to explore whether, and in what way, a new intervention for adolescents distressed by a visible difference (YP Face IT; YPF, Norwegian version) led to positive and/or negative outcome changes. Participants were 79 adolescents (62.00% girls; M_age = 13.84, SD = 1.73), with a visible difference. All had access to the YPF programme and answered questionnaires assessing social anxiety and body esteem pre- and post-intervention. Analyses included calculations of statistical as well as clinically significant and reliable changes. Results showed that fewer participants reported clinical levels of social anxiety and low body esteem after access to YPF. Results also indicated that participants who had a positive pre- to post-intervention change had lower levels of perceived self-worth pre-intervention, and spent more time on the intervention than those with a negative pre- to post change. Three participants showed a clinically significant negative and reliable change in social anxiety or body esteem from pre- to post-intervention. However, based on an examination of these participants' characteristics, preliminary findings support the safety of YPF.

Cost‐effectiveness analysis of a psychosocial web‐based intervention for adolescents distressed by a visible difference: Results from a randomized controlled trial in Norway

Adolescents with a visible difference to the face or body (e.g., due to a congenital condition, illness, or injury), may be at risk of elevated psychological distress. Young Person's Face IT (YPF), a web-based psychosocial intervention, has displayed effectiveness, but no previous study has specifically evaluated its cost-effectiveness. The aim of our study was to investigate whether YPF could be a cost-effective alternative for psychosocial support to adolescents distressed by a visible difference, relative to care-as-usual (CAU). Within the context of a randomized controlled trial in Norway, 102 participants (43% boys) were allocated to intervention (n = 55) or waiting list control group (n = 47). Mean age was 13.9 years (SD = 1.71; range 11-18), and all self-identified as experiencing distress related to a visible difference. Participants answered questionnaires including measures of health-related quality of life and social anxiety at baseline and 3-month follow-up. A health economic evaluation using the method of cost-utility analysis was performed, including quality-adjusted life-years (QALYs). Results indicated that the incremental cost-effectiveness of YPF was 63,641 Norwegian kroner per QALYs gained, which is well within the acceptability threshold in the Norwegian healthcare sector. Hence, YPF could potentially be considered a cost-effective intervention for adolescents experiencing distress related to a visible difference, but more research is needed that includes comparisons of YPF to other health- and societal resources and long-term follow-ups. Our study also constitutes an addition to research as, compared to interventions for somatic diseases, there is a lack of studies exploring the cost-effectiveness of psychological interventions.

The role of burn camp in the recovery of young people from burn injury: A qualitative study using long-term follow-up interviews with parents and participants

BACKGROUND

Children and adolescents recovering from burn injury are at heightened risk of psychosocial problems. An integrative form of psychosocial intervention is burn camp. However, evidence about burn camp effectiveness is equivocal.

OBJECTIVES

This study examined the role of therapeutic camp experiences in the recovery journeys of children and adolescents who had experienced burn injury and been treated in a tertiary pediatric hospital in Brisbane, Australia.

METHODS

Retrospective semi-structured interviews were conducted with youths and parents. Inductive reflexive thematic analysis was used with pooled interview data.

RESULTS

The participants were eight youths who attended at least one burns camp (between 2009 and 2019) and 15 parents of youth campers. An overwhelming majority (96%) reported a positive experience of camp, that they would return, and that they recommended the camp to other youth with burns. The four strengths of the camp experience were fun, adventurous activities; social relatedness (friendships, socializing); camp setting and experience; and acceptance. The four impacts of the camp on youth campers were normalizing ("I'm not the only one", shared experience); social support (making new friendships, social confidence, mentoring others); psychological recovery (happier, mentally stronger, more resilient, independence building); and confidence (increased self-confidence, increased social confidence, leadership development).

CONCLUSIONS

Although this is the first known research about burn camp in Australia, the findings are similar to a handful of other qualitative studies about burn camp experiences and impacts. Recommendations include future research on aspects of camp experiences that contribute to targeted outcomes, the role of staff and previous camp participants as mentors, and comparisons with other psychosocial interventions for youth burn survivors.

The psychosocial needs of adolescent and young adult kidney transplant recipients, and associated interventions: a scoping review

Background

Renal transplantation is considered the gold standard treatment for end-stage kidney disease. Adolescent and young adult kidney transplant recipients have the highest rate of graft loss amongst transplanted patients. It is largely accepted this is due to psychosocial and behavioural difficulties, which impact adherence to prescribed therapies. This phenomenon is not isolated to a particular healthcare system having been observed in multiple countries across different continents. It is a global issue of concern. We sought to review the psychosocial needs of these patients, and the interventions designed to meet these needs.

Methods

A scoping review was conducted based on Arksey and O’Malley’s six-stage framework. Eligibility criteria included primary studies of any type that investigated the psychosocial needs of adolescent and/or young adult renal transplant recipients or studies which examined interventions designed to address these needs. Search strategies were developed and conducted on PsycINFO, PubMed, Embase, and CINAHL. Articles meeting the inclusion criteria were critically reviewed using a descriptive-analytical narrative method.

Results

Thirty-nine studies met our inclusion criteria, 30 of which related to psychosocial needs, and the remainder examined psychosocial interventions. Four main themes were derived from our analysis of psychosocial needs literature, as follows: the need for (1) emotional support, (2) acceptance, (3) direction, (4) equality in healthcare. 2 main themes emerged from analysis of psychosocial intervention literature, namely: psychosocial (1) capability, (2) assessment. Despite the evidence that graft health is strongly associated with psychosocial wellbeing, findings revealed a significant lack of literature investigating how best to meet psychosocial needs. Trends were observed amongst intervention studies, namely interventions of novel and non-evidenced based design, with the aim of improving medication adherence through organisational strategies and education. However, literature regarding psychosocial needs showed non-adherence to therapies was not simply a result of disorganisation or lack of understanding, but rather, was founded on a recipient’s idiosyncratic relationship with their prescribed therapies e.g., psychological, social or financial reasons for non-adherence.

Conclusions

Future research should be directed at investigating the efficacy of evidence-based interventions that empower the individual patient to overcome their specific barrier to an optimal relationship with their therapies.

Acceptability and feasibility of an online psychosocial intervention for Dutch adolescents with a visible difference: A mixed-methods study

Adolescents with a visible difference can experience difficult social situations, (e.g., people staring or making unwanted comments) and are at risk for mental health problems. Unfortunately, interventions for adolescents with a visible difference experiencing appearance-related distress are scarce and lack an evidence-base. This study tests the acceptability and feasibility of YP Face IT, an innovative online psychological intervention using social skills training and cognitive behavioural therapy, to Dutch adolescents. Adolescents aged 12-17 with a visible difference and access to an internet-enabled computer or tablet participated. They completed YP Face IT (eight sessions) and questionnaires were administered pre- and post-intervention. After completing YP Face IT, participants were interviewed to assess the acceptability and feasibility of YP Face IT and study procedures. Overall, 15 adolescents consented to participation, one person dropped out after one session. Most adolescents appreciated the intervention and all would recommend it to other adolescents experiencing appearance-related distress. Everyone reported learning experiences after following the sessions. Some struggled with motivation, but reminders by the website and research team were helpful. The Dutch YP Face IT intervention may be acceptable and the current study design is feasible to use. An RCT should be conducted to assess the effectiveness of the intervention.

Physical, Psychological, and Social Outcomes in Pediatric Burn Survivors Ages 5 to 18 Years: A Systematic Review

Acute pediatric burn injuries often result in chronic sequelae that affect physical, psychological, and social outcomes. To date, no review has comprehensively reported on the impact of burn injuries across all three domains in school-aged children. The aim of this systematic review was to identify published literature that focuses on the impact of burn injuries on physical, psychological, or social functioning, and report upon the nature of study characteristics and their outcomes. We included literature published after 1980, focusing on burn outcomes in children aged 5 to 18 years. Each eligible study was systematically reviewed and primary outcomes were classified into outcome domains based on existing frameworks. Fifty-eight studies met inclusion criteria, and reported on physical (n = 24), psychological (n = 47), and social (n = 29) domains. The majority of the studies had sample sizes of <100 participants, burn size of <40%, and findings reported by parents and/or burn survivors. Only eight of 107 different measures were used in three or more studies. Parents and burn survivors generally reported better physical and social outcomes and worse psychological functioning compared to non-burn populations. Physical disabilities were associated with psychological and social functioning in several studies. Follow-up data reported improvements across domains. This review demonstrates the importance of physical, psychological, and social status as long-term outcomes in burn survivors. Mixed findings across three outcome domains warrant long-term research. Findings of this review will guide the foundation of comprehensive burn and age-specific instruments to assess burn recovery.

Reducing social anxiety in adolescents distressed by a visible difference: Results from a randomised control trial of a web-based intervention

A visible difference to the face or body may challenge adolescents' adjustment and engagement in life activities, where some require psychosocial support. However, evidence is limited for whether existing interventions for this adolescent group reduce social or appearance-related distress. We therefore conducted a parallel-group, randomised control trial to evaluate the effectiveness of Young Person's Face IT, a self-guided web-based psychosocial intervention developed for adolescents with a visible difference who experience distress. Adolescents (N = 189, aged 11-18) from two countries (Norway and the Netherlands), were randomly allocated to an intervention group or care as usual (CAU). Outcomes were body esteem, social anxiety, perceived stigmatisation, and life disengagement. Compared with CAU, participants who completed Young Person's Face IT showed reductions in social anxiety symptoms (η_p² = 0.06). No significant improvements were found for the other outcomes. This study endorses web-based psychosocial support in reducing social anxiety in adolescents distressed by a visible difference. Future studies are needed to confirm the effectiveness of Young Person's Face IT and to explore potential long-term effects.

Assessing the usability and acceptability of Face IT@home: an online CBT intervention for people with visible differences

To increase access to support, an online psychosocial support tool for adults with visible differences was adapted for use without referral or supervision. This intervention combines a cognitive behavioural and social skills model of support. This study aimed to assess the usability and acceptability of Face IT@home as a self-help intervention. Eighty-one participants were recruited (32 with visible differences). Stage 1 included 14 participants (11 female, all with visible differences) who viewed two sessions of Face IT@home and undertook a semi-structured telephone interview. Stage 2 consisted of 14 think-aloud sessions (13 female, none with visible differences) with participants, supervised by researchers. Stage 3 employed 53 participants (47 female; 19 with visible differences), to view one session of Face IT@home and complete an online survey to evaluate usability and acceptability. User interviews, think-aloud studies and questionnaires identified usability and acceptability factors of Face IT@home that make it fit for purpose as a self-help tool. Participants suggested some changes to the Face IT@home program to improve usability. Participants reported that Face IT@home was a useful tool for people with visible differences and could be effective. The CBT-based model was considered a useful approach to addressing psychosocial concerns. The online self-help format will increase access to psychological support for adults with visible differences.

Key learning aims

(1)

Recruiting hard-to-engage groups to online psychosocial interventions: Experiences from an RCT study targeting adolescents with a visible difference

Online interventions have the potential to reach individuals who are otherwise difficult to engage due to stigma and sensitive topics. However, these individuals also tend to be hard to recruit in clinical trials, a crucial step in order to provide evidence-based interventions. This highlights a need for more information about efficient recruitment strategies for difficult-to-engage groups. The present study aimed to share the systematised experiences of recruiting adolescents with a visible difference to an online psychosocial intervention RCT. With the intention to recruit 160 participants (age 12-17), recruitment efforts were nationwide and included multiple arenas (e.g., hospitals, schools, social media), and methods (e.g., in-consultation, targeted letters, posters). Ultimately, 102 participants were recruited, and results showed that recruitment involving patient organisations, hospital departments, and specialised resource centres were most successful in reaching participants. The most efficient recruitment strategy was targeted letters sent home to eligible patients/members, as 78% of the participants were recruited this way. Media and social media recruitment efforts yielded comparatively few participants. No participants were recruited through schools and educational health care services, primary health care services, or municipal and regional authorities. Our results are discussed in relation to barriers with recruiting difficult-to-engage groups to RCTs, providing useful recruitment tools to future similar studies. For instance, future studies are recommended to utilise targeted approaches over general population approaches. Also, results from recruitment efforts should routinely be reported, as this ultimately will provide more general strategies for effective recruitment and support studies in reaching recruitment goals.

Psychosocial Experiences in Children With Congenital Melanocytic Nevus on the Face and Their Parents Throughout the Tissue Expansion Treatment

ABSTRACT

Large congenial melanocytic nevus (LCMN) on the head and face can have negative psychological effects on children and possibly also parents. Patients and their families experience prolonged periods of stress during tissue expansion treatment. The purpose of this study was to evaluate the psychological impact of LCMN on children and parents and explore their fluctuations of psychological status during treatment. Psychosocial status was evaluated in 30 children with LCMN on the head and face and a control group of 56 sex- and age-matched children using the Child Behavior Checklist and the Inventory of Subjective Life Quality for Child and Adolescents. The parents of both groups were also evaluated using the Symptom Checklist-90, the Hospital Anxiety and Depression Scale, and the Perceived Stress Scale. Psychological assessments were performed before expander implantation, before lesion resection, and after operation. Results indicated that children with LCMN were more prone to social problems, withdrawal, and aggressive behavior. Furthermore, their psychological problems increased after entering to school. Parents of children with LCMN had high levels of emotional problems and stress. Continuous expansion resulted in the psychosocial status of both children and parents to reach the worst levels during the period before lesion resection. Six months after surgery, most of these psychosocial effects reduced to levels lower than before surgery. Additionally, we identified several risk factors, namely sex, number of operations, being in education, employment status of mother, and family pressures. Large congenial melanocytic nevus on head and face have considerable psychological impact on children and their parents throughout the tissue expansion treatment. This study demonstrates the need for appropriate psychological screening and interventions.

"Have We Done Enough?" A Cross-condition Exploration of the Experiences of Parents Caring for A Child with an Appearance-affecting Condition or Injury

Children and young people (CYP) with appearance-affecting conditions/injuries report common pervasive psychosocial difficulties, regardless of cause, nature or extent of their visible differences. Parents or carers can also experience psychosocial difficulties and challenges specific to having CYP with a visible difference. Current literature is confined to exploring condition-specific concerns of parents, typically in more prevalent appearance-affecting conditions/injuries, whilst the experiences of parents of CYP with other visible differences are unknown. Thirty-one interviews (parents n = 20, health and support professionals n = 11) and 4 parent focus groups (n = 25) were conducted. Three overarching themes were constructed: "Appearance does(n't) matter" describes the impact of having a child with a socially undesirable appearance; "Being 'battle' ready" reflects parents' desire to arm their child with resources to manage challenges, whilst "Walking the tightrope" reflects parents' lack of clarity about how best to approach this. Findings highlight shared and common cross-condition psychosocial difficulties among parents and carers.

Investigating the presence of peer bias against ptosis in young children

PURPOSE

To investigate the presence of peer bias directed at young children aged 3-6 years of age and the age at which this bias emerges.

METHODS

Children (3-6 years) completed an individual testing session involving two tasks: (1) a paired photograph task examined the effect of the appearance of ptosis on children's preferences in two different social situations (toy sharing and birthday party); (2) a ranking task investigated whether different grades of ptosis are evaluated differently by children of different ages.

RESULTS

A total of 217 children were included. The paired photograph task showed that with increasing age, subjects were less likely to invite children with ptosis to share a toy or attend their birthday party. Three-year-olds did not show a bias against peers with ptosis; however, 4- to 6-year-olds did chose significantly fewer children with an apparent ptosis across both social situations. The ranking task highlighted that 6-year-olds viewed a grade 3 ptosis significantly more negatively than 3- and 4-year-olds; however, there was no effect of age on the rankings given to other grades of ptosis.

CONCLUSIONS

Bias against ptosis emerges at about 4 years of age and is still evident at 6 years.

Appearance Concerns, Psychosocial Outcomes, and the Feasibility of Implementing an Online Intervention for Adolescents Receiving Outpatient Burn Care

The current study assessed the prevalence of appearance concerns, psychosocial difficulty, and use of an appearance-focused social and psychological support resource (Young Person's Face IT; YPF) within a population of teens (12-17 year-olds) receiving outpatient burn care with the goal to assess the feasibility of routine use of the resource in outpatient burn care. The study sample included 78 patients ages 12 to 17 receiving outpatient care for burns at one hospital. Appearance concerns were measured via the Burn Outcomes Questionnaire Appearance Subscale, the Appearance Subscale of the Body Esteem Scale for Adolescents, and a 2-part question which asked participants directly about appearance concerns related to the burn injury. A large majority (70.0%) of study participants reported appearance concerns on at least one appearance measure and girls reported more burn-related appearance concerns compared with boys. Psychosocial difficulty was measured via the Pediatric Symptom Checklist-17 (PSC-17) and measures of social functioning were collected and compared within the sample by burn size, burn location, sex, and appearance concerns. Internalizing symptoms were prevalent on the PSC-17 (18.6% risk) and decreased self-worth and increased social anxiety symptoms were significantly associated with having appearance concerns. Although interest in YPF was high (78.3%), actual use of the resource among those who signed up to pilot it (n = 46 participants) was low (19.4% use). Results indicate that there is a need for and interest in appearance-focused social anxiety resources for adolescents with burn injuries such as YPF, but more research is needed to understand its feasibility in clinical practice.

Investigating online psychological treatment for adolescents with a visible difference in the Dutch YP Face IT study: protocol of a randomised controlled trial

INTRODUCTION

This paper outlines the study protocol for the Dutch Young People (YP) Face IT Study. Adolescents with a visible difference (ie, disfigurement) often experience challenging social situations such as being stared at, receiving unwanted questions or being teased. As a consequence, some of these adolescents experience adverse psychosocial outcomes and appearance-related distress. To address this appearance-related distress, an online psychotherapeutic intervention, YP Face IT, has been developed. YP Face IT uses social interaction skills training and cognitive-behavioural therapy. The Dutch YP Face IT Study tests whether this intervention is effective in reducing social anxiety and improving body esteem.

METHODS AND ANALYSIS

Participants are adolescents aged 12-18 with a visible difference and experiencing appearance-related distress. In this two-armed randomised controlled trial, 224 adolescents will be randomised to care as usual or YP Face IT. Adolescents will complete questionnaires at baseline, at 13 weeks and at 25 weeks. Primary outcomes are differences in social anxiety and body esteem between YP Face IT and care as usual. Secondary outcomes are differences in aspects of self-worth, perceived stigmatisation, health-related quality of life, life engagement, appearance-related distress and depressive symptoms between the two groups.

ETHICS AND DISSEMINATION

Research ethics approval was obtained from the medical ethics review committee in Rotterdam (reference number MEC-2018-052/NL63955.078.18). Findings will be disseminated through academic peer-reviewed publications, conferences and newsletters to patient associations and participants of the study.

TRIAL REGISTRATION NUMBER

The Netherlands Trial Register (NL7626).

Australian health professionals' perspectives of psychosocial adjustment to visible differences: A qualitative analysis of pediatric populations

Living with a visible difference (e.g., disfigurement) can compromise a child's psychological wellbeing. Although some children can adjust well, others can develop a range of appearance-related issues such as social anxiety, low self-esteem, and body dissatisfaction. However, current research fails to confirm what factors contribute to appearance-related distress, and what factors buffer the consequences of living with a visible difference. Semi-structured qualitative interviews were conducted with 16 Australian specialist health professionals who care for children with visible differences. Interviews explored the type of appearance-related psychosocial concerns presented to a pediatric hospital, perspectives on the impact of appearance-related distress, as well as factors and processes that health professionals perceive influence adjustment. Data were subjected to inductive thematic analysis. Rich evidence was offered by health professionals, which demonstrated deep understanding of the psychological wellbeing of their patients. Three themes were identified: Mind, Body, and Soul; Stages of Life; and Individual Differences. Findings highlighted the complexity of appearance-related distress, with individual differences in adjustment, and the powerful impact it can have on a child's short and long-term psychosocial wellbeing. The importance of reaching consensus in the conceptualisation and measurement of psychological wellbeing is stressed, and key domains associated with adjustment are proposed.

Efficacy and cultural appropriateness of psychosocial interventions for paediatric burn patients and caregivers: a systematic review

Background

Paediatric burns are highly painful and traumatising injuries that are overrepresented among Aboriginal and Torres Strait Islander people. Paediatric burn patients’ pain remains poorly managed by pharmacological interventions, leading to increased anxiety, distress, and trauma in patients and their caregivers. Non-pharmacological psychosocial interventions have been suggested as effective in reducing pain and psychological morbidities among paediatric burn patients and their caregivers; however, their degree of effectiveness and appropriateness for Aboriginal and Torres Strait Islander people is unclear.

Methods

A non-date restricted systematic review was conducted through four databases. Studies published in English assessing psychosocial interventions on paediatric burn patients’ physical pain along with theirs and/or their caregiver’s anxiety, distress, or trauma symptoms were identified and included in this review. Included studies were assessed for their ability to reduce one of the outcomes of interests and for their reflection of Aboriginal and Torres Strait Islander peoples’ perspectives of health.

Results

Of the 3178 identified references, 17 were eligible. These include distraction based techniques (n = 8), hypnosis/familiar imagery (n = 2), therapeutic approaches (n = 4), and patient preparation/procedural control (n = 3). Distraction techniques incorporating procedural preparation reduced pain, while discharge preparation and increased ‘patient control’ reduced patient and caregiver anxiety; and internet based Cognitive Behaviour Therapy reduced short-term but not long-term post-traumatic stress symptoms. No interventions reflected Aboriginal and Torres Strait Islander peoples’ perspectives of health; and few targeted caregivers or focused on reducing their symptoms.

Conclusions

The development and assessment of psychosocial interventions to appropriately meet the needs of Aboriginal and Torres Strait Islander paediatric burn patients is required.

Opening a Pandora's Box that can't be salvaged: Health professionals' perceptions of appearance-related care in an Australian pediatric specialist hospital

Many children and young people struggle adjusting to the psychosocial consequences (e.g., body dissatisfaction, social anxiety, and stigmatisation) of visible differences (or disfigurement). As appearance-affecting conditions often require specialist multidisciplinary team care, health professionals are in a unique position to offer psychosocial support and intervention. However, there is a dearth of literature on how appearance-related concerns are managed in pediatric hospital settings. Sixteen Australian specialist health professionals participated in semi-structured qualitative interviews to address this gap. Interviews explored current appearance-related psychosocial service provision, barriers in accessing appearance-related care, and perceptions of online platforms to deliver specialist support and intervention. Thematic analysis demonstrated four themes: We can do it better, Capability versus availability, Online generation, and Putting appearance on the agenda. This research highlighted the potential value of online platforms to increase accessibility to specialist appearance-related care, the need for more psychosocial resources to be integrated into appearance-related specialities, prioritising the development of low to medium appearance-related support and intervention, increasing the appearance-related knowledge of health professionals and families, and the need for more holistic approaches in routine care.

A Web-Based Self-Help Psychosocial Intervention for Adolescents Distressed by Appearance-Affecting Conditions and Injuries (Young Persons' Face IT): Feasibility Study for a Parallel Randomized Controlled Trial

BACKGROUND

Disfigurement (visible difference) from wide-ranging congenital or acquired conditions, injuries, or treatments can negatively impact adolescents' psychological well-being, education and health behaviours. Alongside medical interventions, appearance-specific cognitive behavioural and social skills training to manage stigma and appearance anxiety may improve psychosocial outcomes. YP Face IT (YPF), is a Web-based seven session self-help program plus booster quiz, utilising cognitive behavioural and social skills training for young people (YP) struggling with a visible difference. Co-designed by adolescents and psychologists, it includes interactive multimedia and automated reminders to complete sessions/homework. Adolescents access YPF via a health professional who determines its suitability and remotely monitors clients' usage.

OBJECTIVE

To establish the feasibility of evaluating YPF for 12-17 year olds self-reporting appearance-related distress and/or bullying associated with a visible difference.

METHODS

Randomized controlled trial with nested qualitative and economic study evaluating YPF compared with usual care (UC). Feasibility outcomes included: viability of recruiting via general practitioner (GP) practices (face to face and via patient databases) and charity advertisements; intervention acceptability and adherence; feasibility of study and data collection methods; and health professionals' ability to monitor users' online data for safeguarding issues. Primary psychosocial self-reported outcomes collected online at baseline, 13, 26, and 52 weeks were as follows: appearance satisfaction (Appearance Subscale from Mendleson et al's (2001) Body Esteem Scale); social anxiety (La Greca's (1999) Social Anxiety Scale for Adolescents). Secondary outcomes were; self-esteem; romantic concerns; perceived stigmatization; social skills and healthcare usage. Participants were randomised using remote Web-based allocation.

RESULTS

Thirteen charities advertised the study yielding 11 recruits, 13 primary care practices sent 687 invitations to patients on their databases with a known visible difference yielding 17 recruits (2.5% response rate), 4 recruits came from GP consultations. Recruitment was challenging, therefore four additional practices mass-mailed 3,306 generic invitations to all 12-17 year old patients yielding a further 15 participants (0.5% response rate). Forty-seven YP with a range of socioeconomic backgrounds and conditions were randomised (26% male, 91% white, mean age 14 years (SD 1.7)); 23 to YPF, 24 to UC). At 52 weeks, 16 (70%) in the intervention and 20 (83%) in UC groups completed assessments. There were no intervention-related adverse events; most found YPF acceptable with three withdrawing because they judged it was for higher-level concerns; 12 (52%) completed seven sessions. The study design was acceptable and feasible, with multiple recruitment strategies. Preliminary findings indicate no changes from baseline in outcome measures among the UC group and positive changes in appearance satisfaction and fear of negative evaluation among the YPF group when factoring in baseline scores and intervention adherence.

CONCLUSIONS

YPF is novel, safe and potentially helpful. Its full psychosocial benefits should be evaluated in a large-scale RCT, which would be feasible with wide-ranging recruitment strategies.

TRIAL REGISTRATION

ISRCTN registry ISRCTN40650639; http://www.isrctn.com/ISRCTN40650639.

The Use of a Brief Measure to Assess Longitudinal Changes in Appearance Concerns for Youth Recovering From Burn Injuries

Burns are among the most common injuries to children, and, although survival rates have improved, many burn survivors are left with scars and/or other visible differences, which may be associated with anxiety, depression, and/or low self-esteem. A better understanding of the prevalence and persistence of these problems in child and adolescent burn survivors might lead to an expanded paradigm of care and possibly to better outcomes. The present study provides longitudinal prevalence data for the Appearance Concerns (AC) subscale of the parent-reported Burn Outcomes Questionnaire (BOQ) for 5- to 18-year-old children and identifies patient characteristics associated with higher risk for appearance concerns. Subjects were 799 pediatric burn survivors who were assessed prospectively using the parent-reported BOQ5-18, which was administered soon after their discharge from acute care and again every 3 to 6 months for up to 4 years. Approximately 20% of all youth were reported to have appearance concerns over the first 2 years, after which the rate declined gradually, falling to around 10% after 3 years. This study showed that such concerns were prevalent and persistent years after burn injuries and suggested that larger burns, facial burns, and country of origin outside of the United States were all associated with higher scores on the AC subscale. These findings highlight the importance of assessing appearance concerns in the long-term care of young burn survivors and suggest that the BOQ5-18 AC subscale could be used to identify individuals with heightened appearance concerns and to measure their response to interventions.

The provision of specialist psychosocial support for people with visible differences: A European survey

A substantial body of research has demonstrated the challenges commonly facing people with visible differences (disfigurements) and explored the potential benefits offered by specialist psychosocial support and intervention for those who are negatively affected. However, little is known about the availability of such support in Europe for people whose appearance is in any way different to 'the norm'. This survey of 116 psychosocial specialists from 15 European countries, working with a range of patient groups, has shown a tendency for specialists to prioritise Cognitive-behavioural-based approaches, amongst a wide range of other approaches and interventional techniques. It indicates variations in the availability of support, and a perceived need for improved access to interventions, additional training, and greater awareness of the psychosocial issues associated with visible differences.

Psychosocial Functioning of Children in a Craniofacial Support Group

Objective:

To describe psychosocial functioning before and after participation in support groups for pediatric patients with craniofacial diagnoses and their families.

Design:

Baseline and postgroup outcomes and comparison to test norms.

Setting:

Urban children’s hospital.

Participants:

Patients (N = 138) were 54% female, primarily Latino (83%), aged 7 to 18 years (mean = 10.4, standard deviation = 2.8), and had public insurance (72%). Patients had isolated cleft lip/palate (54%), craniofacial syndromes (19%), craniofacial microsomia/microtia (14%), or other diagnoses (12%). Caregivers (n = 138) were mostly mothers (80%).

Intervention:

Support groups focused on peer normalization, social skills, and coping for patients with craniofacial diagnoses.

Main Outcome Measure:

Selected scales of the Behavior Assessment System for Children–Second Edition completed by patients and caregivers (51% Spanish; 49% English).

Results:

While in the average range, caregivers reported significantly higher baseline clinical concerns and patients and caregivers reported lower positive scales compared to test norms. Postgroup, patients reported significantly lower social stress than peer norms. Caregivers reported higher postgroup clinical scales, but no differences from test norms in the positive scales. In comparing pre to postgroup means, all but one scale showed significant improvement. The largest effect sizes were for higher self-reported self-esteem ( d = 0.49) and lower caregiver-reported depression ( d = 0.54) in their children.

Conclusions:

Although greater clinical concerns were reported compared to test norms, baseline and postgroup functioning was in the average range. Patients and caregivers reported significantly improved psychosocial functioning following group participation, particularly for adaptive skills and self-esteem.

An evaluation of the impact of a burn camp on children and young people's concerns about social situations, satisfaction with appearance and behaviour

INTRODUCTION

This evaluation aimed to assess the impact of a burn camp on children and young people's concerns about social situations, satisfaction with appearance and behaviour.

METHODS

Young people completed the Perceived Stigmatisation Questionnaire (PSQ), Social Comfort Questionnaire (SCQ) and Satisfaction with Appearance Scale (SWAP) one month before camp (n=23), on the last day of camp (n=21) and at a three-month follow-up (n=13). Parents completed the Strengths and Difficulties Questionnaire (SDQ) one month before camp (n = 22) and at follow-up (n=12). Parents and young people also completed open-ended questions before camp and at the follow-up.

RESULTS

Results in this evaluation were mixed. While parents' reported scores on the SDQ were poorer after camp, young people's reported outcomes on all three measures improved at the end of camp. PSQ and SWAP scores were maintained and improved, respectively, at the follow-up. Qualitative responses were generally consistent with these scores. Significant improvements were found between the scores before camp and at the three-month follow-up for both the SWAP and PSQ. These results indicate that the burn camp may help to improve young people's satisfaction with their appearance and concerns about social situations. However, there was no comparison group and there was a significant loss of participants at follow-up.

CONCLUSION

Burn camps may therefore offer a range of psychosocial benefits to young people with burn injuries. This was the first evaluation to demonstrate a positive impact of a burn camp on satisfaction with appearance and concerns about social situations using outcome measures validated with the burns population.

[Psychological Health of Children with Chronic Physical Illness and their Parents - Results from Meta-Analyses]

Psychological Health of Children with Chronic Physical Illness and their Parents - Results from Meta-Analyses The present paper summarizes results from meta-analyses on psychological well-being of children with chronic physical illnesses and their parents. At the beginning, we discuss potential reasons for psychological effects of a chronic physical illness on children and adolescents as well as their parents. We then summarize results of meta-analyses of studies that compared aspects of mental health of children with a chronic physical illness and their parents with families of healthy children. Depressive symptoms, anxiety, and internalizing symptoms in general were most elevated in children with chronic fatigue syndrome and chronic headache while externalizing symptoms were most elevated in young people with epilepsy, chronic headache, and cerebral palsy. Depression and anxiety was less elevated in the ill children than in their parents. Parents of children with HIV-infection/AIDS and cerebral palsy reported the highest levels of distress, followed by parents of children diagnosed with cancer and spina bifida. Conclusions are drawn for future research and practice.

Recruiting young people with a visible difference to the YP Face IT feasibility trial: a qualitative exploration of primary care staff experiences

BACKGROUND

Qualitative research methods embedded within feasibility trials are of significant value as they can provide important information for a definitive trial, often unable to be fulfilled by quantitative methods alone. In addition, such information can aid researchers running other trials or evaluating interventions on a similar topic. Aim This study aimed to explore GP and nurses' experiences of recruiting to a trial exploring the feasibility of evaluating YP Face IT, a novel online psychosocial intervention to support young people with appearance-altering conditions.

METHODS

During the recruitment period, a focus group with participating GPs and nurses explored recruitment challenges. In addition, at the end of the recruitment period, telephone interviews were conducted with eight GPs and nurses involved in recruiting to the study, in order to inform a definitive trial of YP Face IT. Transcripts were subjected to thematic analysis. Findings Despite reporting that the study was valuable and interesting, interviewees struggled to recruit in-consultation. They appeared to lack confidence in raising the sensitive issue of a visible difference and adopted strategies to avoid mentioning the topic. Participants felt the nature of the target population, as well as pressures of the primary care environment presented challenges to recruitment, but welcomed YP Face IT as an intervention that could address unmet support needs. Primary care staff may benefit from training to help them raise the subject of a visible difference with young people in order to identify those that require additional support.

Psychological adjustment to craniofacial conditions (excluding oral clefts): A review of the literature

OBJECTIVE

A congenital craniofacial anomaly (CFA) is expected to impact upon several domains of psychological, emotional and social functioning, yet no recent reviews have comprehensively summarised the available literature. Further, existing reviews tend to draw upon literature in the field of cleft lip and palate, and do not give substantive attention to other types of CFAs.

DESIGN

A review of 41 papers published between January 2000 and March 2016 pertaining to psychological adjustment to CFAs.

MAIN OUTCOME MEASURES

Findings are presented according to key psychological domains: General Psychological Well-being, Quality of Life, Behaviour, Emotional Well-being, Social Experiences, Appearance, and Treatment-Related Experiences.

RESULTS

Current literature offers a contradictory picture of adjustment to CFAs. Psychological adjustment appeared to be comparable to norms and reference groups in approximately half of the papers related to non-syndromic CFAs, while more variation was found across domains among samples with syndromic CFAs. Associations were found between adjustment, physical health and cognitive function in several papers. The review identified a number of gaps in the literature, such as the inclusion of a wide range of diagnoses within research samples.

CONCLUSIONS

This review demonstrates the complexity of findings, both within and across domains, and highlights a number of methodological challenges.

Perspectives of health professionals on the psychosocial impact of an altered appearance among adolescents treated for cancer and how to improve appearance-related care

An altered appearance can impact the psychosocial well-being of adolescent cancer patients, yet patient reports imply a dearth of appearance-related support. Using a two-phase qualitatively driven mixed method design, 62 health professionals from a range of UK oncology care settings provided data relating to their views on the impact of appearance changes on adolescent patients (aged 12-18 years), of delivering appearance-related care, and their training needs. Integrated findings were divided into two main outcomes. The first comprises health professionals' perceptions of the psychosocial and behavioral impacts of appearance-related distress in their patients and their experiences of interventions that prevent or ameliorate appearance concern. The second illustrates personal barriers (among health professionals, adolescents, and parents) and organizational barriers that inhibit the delivery of appearance-related support, together with suggestions about how these may be overcome. The needs of patients are extensive and varied, but due to the barriers identified can be poorly addressed. Nonetheless, some practitioners are utilizing a variety of interventions supported by theory and/or evidence of their success in other clinical areas. Recommendations are made for the content, design, and coordination of interventions for adolescents and for the content of education programs to meet the training needs identified by participants.

Study protocol of the YP Face IT feasibility study: comparing an online psychosocial intervention versus treatment as usual for adolescents distressed by appearance-altering conditions/injuries

INTRODUCTION

A significant number of adolescents suffer extensive and enduring difficulties such as social anxiety, body image dissatisfaction, low self-esteem and bullying as a result of conditions or injuries that affect their appearance (eg, craniofacial and skin conditions, treatment side effects and scarring). Evidence-based psychosocial interventions to meet their specific needs are currently lacking. YP Face IT, developed by the UK's Centre for Appearance Research in collaboration with clinical experts and young people, is an innovative online psychosocial intervention designed to offer this group immediate support, advice and coping strategies. It has been endorsed by young people, their parents/carers, GPs, clinical psychologists and health professionals working with those affected by appearance-related conditions.

METHODS AND ANALYSIS

Young people aged 12-17 with an appearance-altering condition/injury that self-identify as experiencing appearance-related distress, teasing or bullying will be invited to participate via GP practices and UK charities. Consenting participants will be randomised to the intervention (YP Face IT) or the treatment as usual (TAU) control group. Outcome measures will be completed by young people and their parents/carers at baseline, 13, 26 and 52 weeks. Primary outcome measures will be the Body Esteem Scale and the Social Anxiety Scale for Adolescents. Participants will complete other health-related outcome measures and resource use questionnaires for health economic analysis. We will assess recruitment rates, acceptability of the YP Face IT programme, adherence and retention to treatment, questionnaire completion rates, variation of TAU in Primary Care and the feasibility of GP practice staff supervising young people's use of YP Face IT.

ETHICS AND DISSEMINATION

This feasibility trial protocol (V.1, 3 March 2014), received a favourable ethical opinion from the NRES Committee South West-Frenchay (reference number 14/SW/0058). Findings will be disseminated through academic peer-reviewed publications, conferences and to participating GP practices and charities supporting those with conditions affecting appearance.

TRIAL REGISTRATION NUMBER

ISRCTN40650639; Pre-results.

Adverse childhood experiences and trauma informed care: the future of health care

Adverse childhood experiences (ACEs) are related to short- and long-term negative physical and mental health consequences among children and adults. Studies of the last three decades on ACEs and traumatic stress have emphasized their impact and the importance of preventing and addressing trauma across all service systems utilizing universal systemic approaches. Current developments on the implementation of trauma informed care (TIC) in a variety of service systems call for the surveillance of trauma, resiliency, functional capacity, and health impact of ACEs. Despite such efforts in adult medical care, early identification of childhood trauma in children still remains a significant public health need. This article reviews childhood adversity and traumatic toxic stress, presents epidemiologic data on the prevalence of ACEs and their physical and mental health impacts, and discusses intervention modalities for prevention.

Developing young person's Face IT: Online psychosocial support for adolescents struggling with conditions or injuries affecting their appearance

A participatory action approach with potential users and clinical experts was employed to design and evaluate the acceptability of young person’s Face IT (YP Face IT), an online intervention incorporating cognitive behavioural therapy and social skills training for adolescents with appearance-related anxiety as a result of a visible difference. Workshops with adolescents and clinicians informed a prototype YP Face IT which underwent a usability analysis by 28 multidisciplinary health professionals and 18 adolescents, before 10 adolescents completed it at home. Acceptability data obtained online and via interview were analysed using content analysis. Participants found YP Face IT acceptable and believed it would provide much needed and easy access to psychosocial support. They requested that it should be made widely available either as a self-management tool requiring minimal supervision from a health professional or to compliment therapist-led care.