Lessons From Boston Medical Center’s Coping Clinic

2024 marks 5 years since the debut of the Coping Clinic at Boston Medical Center, allowing dermatologists to connect pediatric patients to psychology clinicians for multidisciplinary care under one roof.In the brand-new session “Merging Behavioral Health and Pediatric Dermatologic Care,”Margaret S. Lee, MD, PhD, FAAD, Lisa Shen, MD, FAAD, and Laura Goldstein, PsyD, shared their experiences and case examples to showcase the rollout of this clinic and patient outcomes at the 2024 American Academy of Dermatology (AAD) Annual Meeting in San Diego, California.¹

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Background

Research has shown the mental health comorbidities that accompany common pediatric skin conditions such as atopic dermatitis (AD), psoriasis, and acne. In fact, 46% of teenagers with AD reported negative effects on school performance, while 8% have been diagnosed with a learning disability. Nearly 40% of pediatric patients with AD have been teased or bullied due to their skin condition.²

“Not only do skin conditions contribute to stress, depression or anxiety, but these conditions further exacerbate the skin condition with a classic example being the itch-scratch cycle of AD,” Shen said. “We've all seen patients where they say ‘the more stressed I am, the more I cannot control the scratching.’ And you can see how easily it becomes a downward spiral...negatively affecting children's self-image, daily activities, and peer interactions.”

Verbiage to Recommend Behavioral Health

Shen acknowledged that recommending behavior health is “a labor of love and not always taken well by parents or guardians.” She expressed the importance of normalizing the coexistence of behavioral health and dermatologic diagnosis, especially when stress is only going to increase with age. Shen recommends considering a behavioral health referral when the behavior is leading to scratching or picking—worsening the skin condition(s), stress is exacerbating, there are concerns about the skin condition contributing to a psychiatric condition, self-esteem is affected, or the patient is spending a disproportionate amount of time thinking about their skin condition.

“There are a few simple questions you can ask to get a gauge on mental health,” the Boston Medical Center panel assured. Questions include:

• Does your skin condition cause you to miss school?
• Doesyour skin condition get in the way of your friendships?
• Does your stress worsen your skin?
• Do you often worry about your skin?
• Do you ever feel sad or hopeless about your skin?

In an effort to get patients caretakers on board, Shen said, “Focus on behavioral modification as the end goal to improve the skin condition.”

Structure of the Coping Clinic

At Boston Medical Center, pediatric dermatologists include Shen and Lee. Goldstein serves as the pediatric psychologist. Pediatric psychiatrists and social workers are consulted as needed on a case-by-case basis. Shen, Lee, and Goldstein expressed the importance of establishing trust with colleagues so patients do not slip through the cracks during the referral process. They advised to ensure patients referred to a psychologist or psychiatrist follows up with dermatology so the patient does not feel that they are being sent for mental health services in lieu of dermatologic care. Boston Medical Center’s team also offered these services within the dermatology clinic so “psych” was not in the clinic name. Shen and Lee identified distinct roles in this model for psychiatric dx with skin manifestations, dermatologic dx with psychiatric comorbidities, and skin conditions affected by behaviors.

• Psychiatric dx with skin manifestations: dermatitis artefacta, body dysmorphic disorder, skin picking, trichotillomania, onychophagia, onychotillomania
• Dermatologic dx with psychiatric comorbidities: acne, atopic dermatitis, lichen simplex chronicus, psoriasis, alopecia areata, vitiligo, hidradenitis suppurativa
• Skin conditions affected by behaviors: atopic dermatitis exacerbated by constant scratching and acne exacerbated by picking or popping pimples

Boston Medical Center’s Coping Clinic saw 50 pediatric patients from fall 2018 through March 2023, with 31 girls and 19 boys. Their average age was 13 years old and either spoke English (n=34), Spanish (n=14), or Chinese (n=2) as their primary language. Recommendations for these patients, along with dermatologic intervention, included psychotherapy, psychoeducation, how to redirect attention, encouragement to partake in enjoyable activities. There were 2 referrals to psychiatry. Conversations on coping strategies, the itch-scratch cycle, and how to redirect attention were needed with several patients.

Case Example

Shen, Lee, and Goldstein presented a sample case from one of their Coping Clinic patients. It was a 4-year-old boy with chronic AD who scratched at his skin frequently to the point of bleeding, despite the use of topical corticosteroid medications and sedating antihistamines. His parent shared that the scratching is worse at night and he tended to scratch when frustrated or anxious. Telling him not to scratch resulted in more scratching. The family was co-sleeping due to the itch, which impacted sleep and quality of life for everyone.

For the interdisciplinary approach, the dermatology team ensured appropriate potency of anti-inflammatory medication, ruled out contact allergens, reviewed and taught non-Rx moisturizing, addressed sleep disturbance, and ruled out secondary infection. On the behavioral health side, Goldstein focused on identifying triggers of the scratching, helped establish a nighttime routine, provided psychoeducation around the itch-scratch cycle, recommended anti-itch interventions (cool compresses, moisturizer, itch basket with fidget toys and items to keep busy), and used positive reinforcement (sticker chart) for engaging in alternative behaviors.

Challenges Going Forward

At the end of the session, several attendees asked how to roll out a program like this with limited resources or rural health care limitations. Ideas among the group included reaching out to pediatric colleagues for direct connections with specialists and asking for patient/caretaker’s permission to reach out to a therapist or psychologist already working with a patient, emphasizing the importance of collaboration and teamwork.

Consider Referrals to Camp Discovery

Lee and Shen also reminded colleagues about Camp Discovery, offered by the AAD. Camp Discovery offers children living with chronic skin conditions a one-of-a-kind camp experience. And new this year, the number of locations has been expanded. Camps are provided at no cost to families by the Mark Lebwohl Camp Discovery Scholarship.

Lebwohl recently talked to Dermatology Times about Camp Discovery and said, “Camp Discovery is something that we should all be proud of. I have been active in the camp for many years. These are kids who are used to getting bullied, used to being isolated and excluded by other children. They come to a camp where everyone has skin diseases and they get along well. For many of them, it's the highlight of their year. That 1 week is the highlight of their year. The kids look forward to it.The people who work there, the counselors, the physicians, the residents who are all there, just cherish that camp.They help these kids a ton. And I think the kids help them too.”

References

1. Goldstein L, Lee M, Shen L. Merging behavioral health and pediatric dermatologic care. Presented at: 2024 American Academy of Dermatology Annual Meeting; March 8-12, 2024; San Diego, CA.
2. KobusiewiczAK, Tarkowski B, Kaszuba A, Lesiak A, Narbutt J, Zalewska-Janowska A. The relationship between atopic dermatitis and atopic itch in children and the psychosocial functioning of their mothers: A cross-sectional study. Front Med (Lausanne). 2023;10:1066495. Published 2023 Feb 16. doi:10.3389/fmed.2023.1066495