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Children and adolescents with atopic dermatitis (AD) -- which of all kids in the U.S. -- have an increased risk of behavioral problems and clinically significant symptoms of impaired mental health compared with their peers without AD.

Some of the common reported in these young patients include psychosocial distress, anxiety, depression, conduct disorder, attention deficit-hyperactivity disorder (ADHD), and learning disability, with a dose-dependent relationship between prevalence of mental health disorder and severity of the skin disease.

Indeed, of 2013-2017 U.S. National Health Interview Survey data found that 26.7% of children ages 4 to 17 with AD had a mental disorder with impairment compared with 17.7% of children without AD (P<0.001), for an excess risk of 11 per 1,000 children, noted Joy Wan, MD, MSCE, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and co-authors. Furthermore, mental disorder with impairment was nearly twice as likely to be severe in children with AD versus those without AD (10.9% vs 6.2%, P<0.001).

"Within the subgroup of children without ADHD, only 6% of children with AD had severe mental health impairment in contrast to 11% among all children with AD; this suggests that ADHD accounts for a large proportion of the severe mental health symptoms detected," Wan and team wrote.

Although the between AD and impaired mental health are not well understood, symptoms of AD, such as and chronic itch, may mediate this relationship, Wan told 番茄社区app.

A prospective analysis reported identified ADHD (13.8%), sleep disturbances (10.7%), depression (7.5%), anxiety (11%), behavioral problems (5.5%), and learning disability (8.2%) in over 2,000 children ages 2 to 17 in the Pediatric Eczema Elective Registry (PEER) cohort. Median age at AD diagnosis was 9 months; almost half of patients had asthma or seasonal allergies, and 38% had moderate to severe/very severe disease. Children with learning disability had a significantly higher median Patient Oriented Eczema Measure (POEM) score compared with those without learning disability.

In addition, in an analysis of data from the , a longitudinal birth cohort study of 4,898 urban children, sleep disturbance and AD were each independently associated with higher odds of several behavioral problems.

In those with AD, adjusted odds of having mean behavioral scores at the 75th or greater percentile were increased by 51% at 5 years, 62% at 9 years, and 44% at 15 years. Children whose AD persisted at ages 5, 9, and 15 years had a significantly increased risk of behavioral problems at 15 years (adjusted risk ratio 1.17, 95% CI 1.01-1.35). "AD in children aged 5 years who did not have behavioral problems was associated with behavioral problems at ages of 9 and 15 years, [suggesting] that AD preceded the onset of behavioral problems," the authors wrote.

After adjusting for multiple confounding variables, children with AD were approximately 35% to 40% more likely than those without AD to worry, fight, physically attack, or threaten others, the authors noted, with "significant 2-way interactions ... between AD and sleep as predictors of underactivity, being threatening, being sullen, and nervousness."

Outcomes on the Child Behavior Checklist subscales over the three waves showed that AD was associated with anxious/depressed behavior, attention problems, and aggressive behavior at age 5. These persisted at ages 9 and 15, with the addition of withdrawn behavior and social problems such as speech problems, clinginess, trouble interacting with other children, and poor coordination.

"Internalizing behaviors, such as worrying, nervousness, and lying, can impact both social and emotional functioning," the authors noted, adding that violent behaviors could have obvious negative societal ramifications, although given the fairly low effect sizes, the absolute risk of these behaviors is low overall in AD patients.

"Multidisciplinary skin and behavioral approaches should be tailored to manage pediatric AD patients, especially those with early-onset and persistent AD and those with sleep disturbance," they added.

Impairments in conduct, emotions, peer relationships, and attention may be under-recognized in clinical practice, observed Wan and co-authors in their cross-sectional study. Additionally, affected patients may not report or seek help for these problems, despite their detrimental effects on quality of life.

Only about half of children with severe mental health problems had seen a mental health professional, and of the 88% who had seen a general practitioner in the last year, only 45% had done so due to emotional or behavioral issues. However, similarly low rates of mental health care were reported by children with severe mental health impairment who did not have eczema, Wan and team observed.

As for screening for mental health problems, Karan Lal, DO, of UMass Memorial Medical Center in Worcester, Massachusetts, told 番茄社区app, "For patients with moderate to severe chronic atopic dermatitis, I often recommend the Patient Health Questionnaire for adolescents."

"Short of using formalized assessments to screen for things such as depression, anxiety, and ADHD, simply asking our patients how they're feeling, how they're doing in school, and how they're functioning at home is easily implemented and a good place to start to try to identify any children at risk for more worrisome mental health concerns," Wan told 番茄社区app.

In addition to asking open-ended questions, "children and adolescents with moderate-severe AD would likely benefit from more regular screening for behavioral problems by their primary care provider and/or referred child behavioral health specialist," said Jonathan Silverberg, MD, PhD, MPH, of George Washington University School of Medicine and Health Sciences in Washington, D.C.

As for treatment approaches for this subgroup of pediatric patients, more data are needed, he noted. "I suspect that any therapy that results in good long-term control of AD signs and symptoms could potentially have downstream benefits at reducing behavioral problems. Topical crisaborole (Eucrisa) is approved in children down to age 6 months. Currently, injectable dupilumab (Dupixent) is approved in children down to age 6 years."

In addition to , nonpharmacologic interventions including , aromatherapy, and habit reversal behavioral therapy may also alleviate .

Lal noted that medications like doxepin (Sinequan) work well for sleep disturbances in kids with AD and also improve mood. "This medication is used to treat depression and anxiety, but is also a potent anti-pruritic agent. I have also seen patients do well on dupilumab in terms of disease control, which in turn improves their mental health issues because their AD is more manageable."

Data on this specific outcome are scarce, said Wan. Clinical trials of newer AD treatments such as the biologics are increasingly examining mental health as secondary outcomes, finding that improvements in mental health can parallel improvements in AD, she added. It is important that these types of outcomes continue to be included in future trials and that studies of nonpharmacologic therapies in children with AD and mental health issues are also undertaken, she said.

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