Psychological and educational interventions for atopic eczema in children Edited (no change to conclusions)
Psychological and educational interventions have been used as an adjunct to conventional therapy for children with atopic eczema to enhance the effectiveness of topical therapy. This is an update of the original Cochrane review.
To assess the effect of psychological and educational interventions for atopic eczema in children.
We updated our searches of the following databases to January 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2012, Issue 12), MEDLINE (from 1946), EMBASE (from 1974), OpenGrey, and PsycINFO (from 1806). We also searched six trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs).
Randomised controlled trials of psychological or educational interventions, or both, used to assist children and their carers in managing atopic eczema.
Data collection and analysis
Three authors independently applied eligibility criteria, assessed trial quality, and extracted data. A lack of comparable data prevented data synthesis, and we were unable to conduct meta‐analysis because there were insufficient data.
We included 10 RCTs, of which 5 were new to this update; all interventions were adjuncts to conventional therapy and were delivered in primary‐ and secondary‐care settings. There were 2003 participants in the 9 educational interventions and 44 participants in the 1 psychological study. Some included studies had methodological weaknesses; for example, we judged four studies to have high risk of detection bias, attrition bias, or other bias. Our primary outcomes were participant‐rated global assessment, reduction in disease severity (reported as objective SCORAD (SCORing Atopic Dermatitis)), and improvement in sleep and quality of life. No study reported participant‐rated global assessment or improvement of sleep.
The largest and most robust study (n = 992) demonstrated significant reduction in disease severity and improvement in quality of life, in both nurse‐ and dermatologist‐led intervention groups. It provided six standardised, age‐appropriate group education sessions. Statistically significant improvements in objective severity using the SCORAD clinical tool were recorded for all intervention groups when compared with controls. Improvements in objective severity (intervention minus no intervention) by age group were as follows: age 3 months to 7 years = 4.2, 95% confidence interval (CI) 1.7 to 6.8; age 8 to 12 years = 6.7, 95% CI 2.1 to 11.2; and age 13 to 18 years = 9.9, 95% CI 4.3 to 15.5. In three of five studies, which could not be combined because of their heterogeneity, the objective SCORAD measure was statistically significantly better in the intervention group compared with the usual care groups. However, in all of the above studies, the confidence interval limits do not exceed the minimum clinically important difference of 8.2 for objective SCORAD.
The largest study measured quality of life using the German 'Quality of life in parents of children with atopic dermatitis' questionnaire, a validated tool with five subscales. Parents of children under seven years had significantly better improvements in the intervention group on all five subscales. Parents of children aged 8 to 12 years experienced significantly better improvements in the intervention group on 3 of the 5 subscales.
This update has incorporated five new RCTs using educational interventions as an adjunct to conventional treatment for children with atopic eczema. We did not identify any further studies using psychological interventions. The inclusion of new studies has not substantially altered the conclusions from the original review. The educational studies in both the original review and this update lack detail about intervention design and do not use a complex interventions framework. Few use an explicit theoretical base, and the components of each intervention are not sufficiently well described to allow replication. A relative lack of rigorously designed trials provides limited evidence of the effectiveness of educational and psychological interventions in helping to manage the condition of atopic eczema in children. However, there is some evidence from included paediatric studies using different educational intervention delivery models (multiprofessional eczema interventions and nurse‐led clinics) that these may lead to improvements in disease severity and quality of life. Educational and psychological interventions require further development using a complex interventions framework. Comparative evaluation is needed to examine their impact on eczema severity, quality of life, psychological distress, and cost‐effectiveness. There is also a need for comparison of educational interventions with stand‐alone psychosocial self‐help.
Steven J Ersser, Fiona Cowdell, Sue Latter, Eric Gardiner, Carsten Flohr, Andrew Robert Thompson, Karina Jackson, Helen Farasat, Fiona Ware, Alison Drury
Plain language summary
Psychological and educational interventions for atopic eczema in children
Atopic eczema is an itchy, inflammatory skin condition, which affects the quality of life of children with eczema and their parents or carers. It affects large and increasing numbers of children worldwide. Psychological and educational approaches have been used to complement medication in managing eczema, for example, by using simple psychological techniques to manage itching and scratching or sleep disturbance. Educational interventions, provided to individuals and groups by nurses or teams of specialists in hospital or community settings, have been used to help parents and children to understand the condition and their role in managing it successfully. However, the effect of these approaches has not been systematically measured.
We included 10 studies in this review: 5 were in the original review, and 5 were newly incorporated in this update.
Nine studies were educational and predominantly parent‐focused (total number of participants n = 2003), and the tenth was a child‐centred psychological intervention (n = 44).
The main finding of this review is that there is currently only limited research evidence about the effect of educational and psychological approaches when used alongside medicines for the treatment of childhood eczema. Included studies provided a range of interventions, from a single 15‐minute consultation to a comprehensive series of sessions delivered to groups of parents over a period of 12 hours. Details of the interventions used and the educational theory base are generally poorly described. Outcome measures varied between studies.
Although it is not possible to draw definitive conclusions from this review, several studies using educational interventions demonstrated improvements in eczema severity and quality of life for both children and families. In particular, two studies showed promise. One large study (n = 992) using a multi‐disciplinary group education intervention in a hospital setting showed modest improvements in disease severity and quality of life. The single study using psychological approaches indicated that relaxation methods reduced the severity of eczema when compared to discussion only.
There is a need for further research into this subject, and priority should be given to comparing the relative cost effectiveness of health professionals educating parents either in teams or by nurses alone. There is also a need for comparison with stand‐alone self‐help. The most appropriate timeframe for evaluating the effect of interventions should be considered.
Steven J Ersser, Fiona Cowdell, Sue Latter, Eric Gardiner, Carsten Flohr, Andrew Robert Thompson, Karina Jackson, Helen Farasat, Fiona Ware, Alison Drury
Implications for practice
This review draws on evidence from 10 trials. It is interesting that the studies focused on interventions directed at the parent rather than the child, particularly when 'atopic schools' offering multi‐disciplinary therapeutic patient education, involving both parents and children, are becoming more common (Barbarot 2013). Based on the Chinn 2002; Moore 2009; Niebel 2000; and Schuttelaar 2010 studies, there is limited evidence that parental education delivered by nurses who are caring for children with atopic eczema may improve the clinical severity of the atopic eczema when used as an adjunct to conventional treatment. Details of the precise nature of educational activity within nurse‐led clinics are limited; consideration needs to be given to this issue and its reporting. Evidence from the robust GADIS (German Atopic Dermatitis Intervention Study) multicentre study (Staab 2006) of multi‐disciplinary intervention using an eczema school curriculum indicates that children and their parental carers may benefit from structured education, albeit using a complex intervention. There appear, in consequence, to be two main service delivery models ‐ nurse‐led and multi‐disciplinary ‐ in operation; however, we have no comparative evaluation of their relative effectiveness, either clinically or in terms of cost. Furthermore, reliable conclusions cannot be drawn on the effectiveness of psychological and complementary approaches, namely biofeedback and hypnotherapy, from one satisfactory but small study.
Since the management of atopic eczema requires an adaptation in health and illness behaviour and effective actions by the carer, it is logical to develop and evaluate both psychological and educational strategies as an adjunct to conventional therapy. It is surprising that despite the wide range of psychological interventions available, few have been subject to application, and there has been little robust evaluation. Educational interventions directed towards parents also appear to be worthy of development and robust testing, with attention given to finding both effective and resource‐efficient models. Current case‐based indications of good practice in prominent dermatology departments reveal recognition of the potential of such approaches (e.g. Lawton 2005). Educational interventions require careful consideration of both the content of learning and of the most effective process, including who is best placed to teach affected people, at what frequency and duration, and whether or not educational technology should be employed. Nine of the 10 RCTs focused on parental education and used a variety of intervention formats.
An important issue for consideration is the scope and limits of the application and effectiveness of psychological interventions that have been used with adults could be used with children and their parents. The adult studies provide some additional, useful and relevant information on both interventions and their evaluation, which was not found within the child studies under review. For example, although based on small studies, there are indications that the habit reversal technique used in conjunction with conventional treatment may improve atopic eczema outcomes (Melin 1986; Norén 1989). However, its application to children will depend on the child's developmental stage. Similarly, Ehlers 1995 showed that although a combined approach (patient education and cognitive‐behavioural treatment) led to a significantly larger improvement in atopic dermatitis than intensive patient education or conventional dermatological treatment, such treatment will be limited to some older children of the appropriate developmental stage. In contrast, those educational studies that have sought to improve effective health behaviour through adult education have direct applicability to parental carers of children with atopic eczema. For example, Gradwell 2002 showed that a single 20‐minute appointment with a nurse to demonstrate the use of therapies (as well as the standard consultant appointment and follow‐up) was useful in improving the participants' understanding of the treatments. Therefore, there may be some limited scope to explore psychological interventions as an additional therapy for children of the appropriate developmental stage. There may also be opportunities to apply the interventions used to teach adults with atopic eczema to the parents of children with atopic eczema.
This review suggests that there is scope for both multi‐disciplinary teams and suitably qualified individual clinicians, such as nurses, as well as psychologists, to deliver educational interventions in conjunction with conventional therapy. In some countries, such as the UK, nurse‐led clinics provide an opportunity for focused intervention. In countries such as Germany, the eczema school multi‐disciplinary model is more established. There is scope to debate the relative merits of these different service delivery models that employ suitably qualified professionals to deliver both psychological and educational interventions. There is also scope to study how educational activity can most effectively be integrated with the resource efficient provision of conventional dermatological therapy.
Implications for research
A relatively small number of studies fulfilled our inclusion criteria, and of these, we assessed only three as at low risk of bias. As such, there are significant opportunities to improve research design to evaluate psychological and educational interventions for children with atopic eczema and the reporting standards of such studies.
It is important that in the development of future trials, those people who will actually use the intervention are involved at an early stage (Medical Research Council 2008). Interventions should have a robust and explicit theoretical base (NICE 2013), and consideration should be given to duration and frequency.
The Harmonising Outcome Measures for Eczema (HOME) initiative concluded that the core outcomes that all eczema‐related RCTs should report on are clinical signs, symptoms, long‐term control of flares, and quality of life (Schmitt 2012). At the HOME III meeting (HOME 2013), it was agreed that EASI should be the instrument for measuring signs of eczema. It is advised that self‐efficacy measures are incorporated particularly as this is likely to be a key mediator in changing the health behaviour of parents caring for children with eczema (Ersser 2013). Quality of life, for both the child and their family, and sleep are also important measures (HOME 2013). Consideration needs to be given to clinically meaningful time frames for applying selected outcome measures to assess sustained change.
Useful information to inform the design of more robust trials may be obtained from this review of existing studies examining the delivery of psychological and educational interventions to the parents of children with atopic eczema and those adult studies discussed above. These include ensuring the following:
- the use of (and reporting of) adequate methods of random allocation and allocation concealment;
- the use of validated outcome measures (for validity and reliability, for use with the appropriate populations under study); and
- the pursuit of loss to follow up is addressed within the study design.
In addition, given the nature of the interventions and outcomes examined in this review, there is scope to consider a wider range of research designs other than RCTs within any subsequent reviews, since these may help us to better understand the behavioural nature and effects of educational and psychological interventions.
In conclusion, there is significant scope to undertake intervention development and then design robust trials to evaluate theoretically based psychological and educational interventions, which may enhance the management of atopic eczema in children.Get full text at The Cochrane Library
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