Children With Atopic Dermatitis More Prone to Depression, Internalizing Behaviors

Children with severe atopic dermatitis were shown to be at nearly 2-fold greater risk of both depression and internalizing behaviors, with mild disease also associated with internalizing behaviors in those as young as 4 years of age.

Severe atopic dermatitis (AD) may increase risk of depression and internalizing behaviors in children and adolescents, with mild disease also noted as a contributing factor. Study findings were published in JAMA Dermatology.

As ​​the most common inflammatory skin disease globally, AD affects up to 20% of pediatric populations. Notably, the condition’s association with adverse mental health outcomes, particularly anxiety, depression, and suicidality, may present a significant risk of underdiagnosis and undertreatment in children, highlighted researchers, as these age groups often present with subtle symptoms.

“Childhood and adolescence are particularly critical times for the development of mental illness and are characterized by rapid fluctuations of severity across short intervals,” they added. “The heterogeneous, waxing, and waning nature of AD makes it important to examine disease course over time to account for variations in disease activity and severity.”

Seeking to evaluate the association between AD and symptoms of depression and internalizing behaviors at multiple points across childhood and adolescence, they conducted a longitudinal, population-based birth cohort study of data derived from the Avon Longitudinal Study of Parents and Children (ALSPAC) between September 6, 1990 and December 31, 2009.

Children enrolled in ALSPAC were followed from birth for a mean (SD) duration of 10.0 (2.9) years, with annual period prevalence of AD assessed at 11 points from 6 months to 18 years of age (N = 11,181; 5721 male [51.2%]).

Primary outcomes of symptoms of depression and internalizing behaviors were measured by child-reported responses to the Short Moods and Feelings Questionnaire (SMFQ) at 5 points from 10 to 18 years of age and the maternal report of the Emotional Symptoms subscale of the Strength and Difficulties Questionnaire (SDQ) at 7 points from 4 to 16 years of age, respectively.

Researchers also assessed the role of potential mediating factors, including asthma/rhinitis, sleep, and inflammation, in the association between AD and the mental health outcomes.

Of the study cohort, the annual period prevalence of active AD decreased from 19.1% to 14.5% from 3 to 18 years of age. Among those reporting active AD, the proportion of those reporting moderate or severe symptoms during the prior 12 months ranged from 21.8% to 40.1%.

Regarding the period prevalence of adverse mental health outcomes, symptoms of depression ranged from 6.0% to 21.6% and internalizing behaviors ranged from 10.4% to 16.0%.

After adjusting for potential confounders, including child sex, age, and race/ethnicity, severe AD was associated with a more than 2-fold increased risk of symptoms of depression (adjusted OR [aOR], 2.38; 95% CI, 1.21-4.72) and a 1.9 times greater risk of internalizing symptoms (aOR, 1.90; 95% CI, 1.14-3.16).

Researchers noted that sleep quality mediated some of the association between severe AD and the mental health outcomes, but it was not explained by differences in sleep duration, asthma/rhinitis, or levels of inflammatory markers (interleukin 6 and C-reactive protein).

Furthermore, patients with mild and moderate AD were not associated with symptoms of depression, but they were significantly associated with internalizing behaviors beginning as early as 4 years of age (mean increased odds of 29%-84% across childhood in adjusted models).

“The large and increasing burden of pediatric mental illness highlights the importance of clinician awareness of the psychosocial needs of children and adolescents with AD,” concluded researchers.


Kern C, Wan J, LeWinn KZ, et al. Association of atopic dermatitis and mental health outcomes across childhood. JAMA Dermatol. Published online September 1, 2021. doi:10.1001/jamadermatol.2021.2657

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