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.

Impact of public exhibition on the perception of birthmarks

BACKGROUND

The importance of photographs in social media, the steep rise in popularity of tattoos, and the prominence of individuals with visibly different skin in fashion are likely to be changing the landscape of self- and public perception of birthmarks. Study objectives were to assess the impact of a photoshoot and public exhibition on the self-perception of individuals with extensive birthmarks, and to explore the viewing public's reactions.

METHODS

Thirty individuals with congenital melanocytic nevi (CMN) were recruited internationally. Each had a professional photoshoot portrait with their skin exposed, resulting in a public exhibition in London entitled "How do you C Me Now?" Participants/parents completed pre- and post-questionnaires relating to self-perception and the impact of their birthmarks on behavior. Over 8000 members of the public viewed the exhibition, 464 completing an on-site questionnaire on its effects.

RESULTS

All participants/parents rated the experience as positive, valuable and helpful. Scores on self-appreciation and self-confidence were significantly higher after the photo shoot. Members of the general public overwhelmingly reported the exhibition increased their positive feelings towards people with birthmarks. The majority of public respondents also reported that the exhibition made them feel better about their own skin and about their looks in general.

CONCLUSION

This unique exhibition and the associated research has provided a striking new perspective on potential psychological interventions for individuals with birthmarks.

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.

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.

"Will You Still Feel Beautiful When You Find Out You Are Different?": Parents' Experiences, Reflections, and Appearance-Focused Conversations About Their Child's Visible Difference

To investigate parents' reflections and experiences of having a child born with an appearance-altering condition, interviews with 33 parents of children born with rare craniofacial conditions were analyzed using inductive thematic analysis. Three themes emerged: "Managing emotions: A dynamic process," "Through another lens: External reminders of difference," and "Awareness of difference: Approaching the child." Findings suggest that although parents learned to accept and love their child's visible difference, external factors such as appearance-altering surgery and other people's reactions activated difficult emotions in parents. Parents struggled to decipher whether and when to raise appearance-related issues with their child, and how this could be done without distressing the child. Anticipatory guidance that facilitates positive appearance-focused conversations both within and outside the home seems to be needed. Parenting skills could also be strengthened by preparing parents for social reactions to the child's visible difference, and their child's changed appearance following surgery.

The Face Image Meta-Database (fIMDb) & ChatLab Facial Anomaly Database (CFAD): Tools for research on face perception and social stigma

Investigators increasingly need high quality face photographs that they can use in service of their scholarly pursuits-whether serving as experimental stimuli or to benchmark face recognition algorithms. Up to now, an index of known face databases, their features, and how to access them has not been available. This absence has had at least two negative repercussions: First, without alternatives, some researchers may have used face databases that are widely known but not optimal for their research. Second, a reliance on databases comprised only of young white faces will lead to science that isn't representative of all the people whose tax contributions, in many cases, make that research possible. The "Face Image Meta-Database" (fIMDb) provides researchers with the tools to find the face images best suited to their research, with filters to locate databases with people of a varied racial and ethnic backgrounds and ages. Problems of representation in face databases are not restricted to race and ethnicity or age - there is a dearth of databases with faces that have visible differences (e.g., scars, port wine stains, and cleft lip and palate). A well-characterized database is needed to support programmatic research into perceivers' attitudes, behaviors, and neural responses to anomalous faces. The "ChatLab Facial Anomaly Database" (CFAD) was constructed to fill this gap, with photographs of faces with visible differences of various types, etiologies, sizes, locations, and that depict individuals from various ethnic backgrounds and age groups. Both the fIMDb and CFAD are available from: https://cliffordworkman.com/resources/.

"It's tough because I see that it's upsetting her…": A qualitative exploration of parents' perceptions of talking with their adolescents about having a visible difference

Many adolescents live with a visible difference that affects their lives in profound ways, but studies investigating parents' perceptions of raising appearance issues during conversations with their adolescent are lacking. As part of a larger study exploring the effectiveness of a web-based intervention (YP Face IT), semi-structured interviews were conducted with 18 parents of adolescents with a visible difference. Thematic analysis revealed four overarching themes: (1) Conversational settings; (2) Understanding adolescents' feelings and thoughts; (3) Providing parental guidance and encouragement; and (4) When the dialogue becomes difficult. Results showed that parents resorted to specific settings when instigating conversations about appearance, such as when their adolescents expressed a need for emotional care, were perceived to be upset, or whilst managing their condition. The choice of setting was also important as some parents generally felt uncomfortable raising appearance issues with their adolescent, for fear of fueling appearance concerns. Results further suggest that open communication can enable parents to stay informed about their adolescent's psychosocial adjustment to a visible difference. These results stress the need to make available support to facilitate open communication about appearance-related topics between parents and adolescents.

The effectiveness of interventions to improve psychosocial outcomes in parents of children with appearance-affecting health conditions: A systematic review

BACKGROUND

Although many cope well, the impact of supporting a child with an Appearance-Affecting Health Condition (AAHC) can place a significant demand on parents. As such, it is vital that families have access to appropriate psychosocial support to reduce any potential difficulties. Although previous reviews have explored the effectiveness of psychosocial interventions for parents of Children and Young People (CYP) with general health conditions, the evidence of effectiveness remains limited. Further, little is known about the effectiveness of such interventions specifically among parents of CYP with AAHCs. This review aimed to identify and assess the evidence of effectiveness of psychosocial interventions among parents of CYP with AAHCs.

METHODS

Database searches were conducted using MEDLINE, PsychARTICLES, PsychINFO, CINAHL Plus, the British Nursing Database and the Cochrane Library. Results were reviewed against the inclusion criteria and data were extracted. Methodological quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool, and a narrative synthesis was conducted.

RESULTS

Fifteen studies, evaluating 10 interventions, were included and overall seven interventions were found to be effective (effect sizes and methodological quality varied).

CONCLUSIONS

This review finds moderate to strong evidence of effectiveness of the Triple P Positive Parenting Program, the Early Family Intervention Program and general parent education/training interventions. These findings offer useful insights relating to the delivery of current support, as well as for the development of future parent and family interventions. Finally, recommendations for future intervention evaluation studies in this area are made.

The parent and child experience of childhood vitiligo: An interpretative phenomenological analysis

Vitiligo is a chronic and visible skin condition involving depigmentation with half of those with the condition developing it before the age of 20. This study sought to gain an experiential understanding of the impact of vitiligo on children and their parents. Interpretative phenomenological analysis was used, and semi-structured interviews were conducted with four child-parent dyads (eight participants). Analysis of the participants' accounts revealed four overarching themes (Continuing Burden, The Significance of Visible Difference, Uncertainty and Unpredictability, and Coping), with 12 subthemes. There were some subtle differences between the parents and children. Both parents and child participants described the condition as posing a continuing burden with most participants reporting experiencing unwanted attention and being concerned about future relationship impact. Some parents described experiencing a sense of resignation to the condition, whereas all the children described a greater sense of acceptance. Nevertheless, acceptance seemed fragile, and parents were concerned that their children needed assistance in developing self-confidence. The findings represent the first in-depth analysis of childhood vitiligo.

Cancer and changes in facial appearance: A meta-ethnography of qualitative studies

INTRODUCTION

Living with an altered facial appearance as a result of treatment for cancer requires considerable psychological adjustment. As such it is essential that health care professionals understand the lived experience of people affected. This systematic review provides a meta-ethnography of studies that have explored the experience of changed facial appearance as a result of cancer.

METHODS

A search of four databases (Web of Science, CINAHL, PsycInfo, and Scopus) took place using terms relating to qualitative research, cancer, and changed facial appearance. Thirteen studies were identified, appraised, and included in the synthesis. The findings and interpretations within the studies were subject to meta-ethnography procedures so as to elicit novel cross-cutting themes.

FINDINGS

The experience of changed facial appearance after cancer was clustered into three contexts. In the context of the disease, subthemes were the primacy of survival, the changing relationship with the disease, and the impact of the care team on the experience of changed appearance. In the context of the social world, subthemes were positive reactions, negative reactions, and coping strategies. In the context of the self, subthemes were the self under attack, self-to-self relating, the self in the world, and rebuilding the self.

CONCLUSIONS

The findings indicate that health care professionals must conduct holistic assessments, so as to fully recognize and where necessary address the impact upon self. The meta-ethnography shows that the experience of facial appearance change following cancer is complex and requires awareness of a number of theoretical areas including identity construction, social support, stigmatization, and the specific literature on visible difference. Statement of contribution What is already known on this subject? Changed facial appearance after cancer can cause significant social difficulties and impact on the sense of self. The experience of managing the specific dual challenges of cancer and altered facial appearance is not clearly understood. Recent studies that have focused specifically on the experience of changes in appearance after cancer have been limited in scope and transferability. What does this study add? To our knowledge, this is the first meta-ethnography to bring together the literature on the impact of altered facial appearance following cancer. Patients may feel unable to talk about appearance with health care professionals because it is seen as a frivolous issue. Clinicians should facilitate open, person-centred opportunities for patients to discuss the impact of changed appearance and where necessary facilitate access to support.

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.

A mixed methods evaluation of medical tattooing for people who have experienced a burn injury

INTRODUCTION

There are no existing studies examining the psychological merits of using facial medical tattooing (MT) following burn injury. This study evaluated an MT service supported by The Katie Piper Foundation. It examined accessibility, satisfaction and whether there were improvements in quality of life (QoL).

METHODS

Thirty-five service-users were invited to participate in a cross-sectional online survey. Twenty-five (71%) responded (24 women; age range = 21-64 years), and of these five (4 women; age range = 26-59 years) also participated in telephone interviews, which were analysed using descriptive thematic analysis.

FINDINGS

The service was largely considered easy to access (22/25) and convenient (25/25). Most service-users (22/25) were satisfied with the results of MT. Some areas of dissatisfaction were described, by a minority of service-users, including: the procedure being painful (1/25); the tattoo being below expectation or fading over time (3/25). The majority reported that MT had improved confidence (22/25); mood (19/25); and ability to socialise (19/25). The procedure improved some service-users' ability to carry out essential activities (14/25) and enjoyable activities (16/25). The qualitative responses provided during interview, indicated that all respondents found the procedure useful to their adjustment, although a minority (3/5) found it painful and also commented on fading (1/5). All described MT as contributing to a sense of increased normality.

CONCLUSIONS

MT had the largest impact on emotional wellbeing and interpersonal domains of QoL. MT services should now improve awareness of the procedure, lobby for further support to provide wider access to the procedure, and routinely use measures assessing psychosocial outcomes.

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.

'I want the way I look to matter less': A case study describing psychological aspects of changing appearance

There is a need for a better understanding of psychological processes when appearance is changed dramatically through surgery. The aim of this article is to shed light on how complex the process of changing appearance can be, and highlight the importance of including a psychological perspective to the treatment offered to children and adolescents with a visible condition affecting appearance. In order to illustrate some psychological aspects involved in a change of appearance, the case study of a young woman born with a cleft palate is presented. Through orthognathic surgery, an operation that changes the relationship and position of the upper and lower jaw, this young woman experienced a dramatic change in appearance. As a result of a new attractive appearance, she experienced new and different social interactions, which challenged her in surprising ways. Unexpectedly, an unknown past of childhood sexual abuse was triggered by romantic experiences due to her new appearance, and she developed signs of post-traumatic stress disorder (PTSD) and depression. This article presents central themes from the therapy and clinical interventions, which were mainly based on a solution-oriented and cognitive framework, and considers how the change of appearance affected the way this young woman behaved, felt and thought about herself after the surgery. Clinical implications of the case are discussed and their relevance to another research field - dramatic weight loss among those suffering from obesity - is suggested.