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    Cartoons Help Derms Evaluate Kids


    Dermatologists in Wales have validated a cartoon version of the Children's Dermatology Life Quality Index (CDLQI) to assess the impact of skin disorders on a child's daily life.
    Cardiff, Wales - A cartoon dog can now help children with skin disorders tell their doctors how their skin condition and treatment affects their schoolwork, playtime, sleep, and other aspects of normal life. Dermatologists in Wales have validated a cartoon version of the Children's Dermatology Life Quality Index (CDLQI) to assess the impact of skin disorders on a child's daily life.

    "When a doctor knows more accurately the extent to which a child's life is being affected by his or her skin disease, then that information can be very helpful in informing clinical decisions relating to therapy," said Andrew Y. Finlay, M.D., professor of dermatology and chairman, department of dermatology, University of Wales College of Medicine in Cardiff. Dr. Finlay and his colleagues designed the cartoon version of the previously validated text version of the CDLQI and validated the new cartoon version in a series of studies described in a recent publication (Br J Dermatol 2003;148:285-290).

    Each of the 10 questions in the cartoon CDLQI is accompanied by a picture of a friendly cartoon dog, in a scene illustrating the question. Next to each cartoon image are four check boxes for the child's response, labeled as follows: "very much," "quite a lot," "a little," and "not at all." The child is asked to check the appropriate box.

    Evaluating Responses

    Responses are scored from 0-3, with "very much" rated as 3. A total score of 0 would indicate that the skin problem had affected the child "not at all" over the last week, whereas the maximum total CDLQI score of 30 would indicate that the child had perceived that the skin disorder over the last week had "very much" affected each aspect of daily life described in the questionnaire.

    Dr. Finlay and his colleagues administered both the cartoon version and the previously validated text version of the CDLQI to groups of children with skin disorders, and the scores of the two versions were compared. In the first of three tests performed to validate the cartoon version, 101 children aged four to 16 years (median age: 11) were recruited at an outpatient clinic and sequentially given both versions of the questionnaire to complete. Fifty children completed the cartoon version first, and 51 children completed the text version first. There was no statistical difference between the scores of the two versions (P=0.405).

    Further testing was performed under more controlled conditions. One hundred-seven children with a current skin condition were interviewed by a dermatologist in an outpatient clinic and asked to complete both versions of the questionnaire sequentially. The child's parent or guardian was present during the interview, but was not permitted to participate in completing the questionnaires.

    The order of the versions was randomized; 54 children completed the cartoon version before the text version, and 53 children completed the text version first. An investigator recorded the time spent to complete each version, and afterward asked both child and adult to indicate which format was easier to use.

    Children participating in the second testing consisted of 56 girls and 51 boys, with a median age of 11 years. Diagnosis was noted for 102 children (95 percent), and the most common diagnoses were eczema (20 children), acne (12 children), psoriasis (12 children), viral warts (11 children), and nevi (10 children).

    The mean scores of the two versions were not significantly different (P=0.427), but the mean time taken to complete the questionnaire was significantly less with the cartoon version compared to the text version (90 seconds versus 120 seconds, respectively; P<0.0001), regardless of the order in which the two versions were administered. Notably, most children (69 percent) and their parents (67 percent) found the cartoon version easier to use, and the majority of children (63 percent) and parents (68 percent) preferred it to the text version.

    Minor Skin Diseases

    Mean scores for each question were generally less than 1. "Many of the children interviewed had very minor skin diseases, including viral warts or moles, and the overall scores for these were low," said Dr. Finlay. The three questions that received the highest scores were questions evaluating how itchy/scratchy/sore the skin felt, how upset/embarrassed/self-conscious the child felt because of the skin problem, and how much the skin disorder affected the child's sleep. The mean CDLQI score was highest for children with eczema: nine points out of a possible 30. "The skin diseases that have the most impact on a child's quality of life are atopic eczema and scabies," said Dr. Finlay. "In adults, atopic eczema is also the skin disease that causes the greatest quality of life problems."

    Finally, the text and cartoon versions of the CDLQI were compared in terms of compliance by determining the rate of return of single questionnaires mailed to children who had attended an outpatient dermatological clinic within the last 12 months. Equal numbers of each version were mailed to 546 children, aged five to 16 years, with a request to complete the questionnaire and return it in the enclosed postage-paid envelope. The overall response rate was 46 percent. Compliance was similar for the two versions, with 126 returns for the cartoon version and 123 for the text version. Dr. Finlay and colleagues concluded that the cartoon version of the CDLQI is equivalent to the previously validated text version in terms of scores and compliance.

    "The lives of children with skin disease are affected in many different ways," said Dr. Finlay, "and it is important to be able to demonstrate the major impact skin disease has on the life of children." The CDLQI is an effective tool for assessing the impact of skin disorders on a child's quality of life and is available in both text and cartoon versions. The newly validated cartoon version of the CDLQI can be completed quickly and is considered by both children and their parents to be easy to use and preferable to the text version.

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