Evidence-Based Interventions for Chronic Itch
Rare & Resilient Resources Webinar 4
Evidence Based Interventions for Chronic Itch: Rare & Resilient Webinar 4
Caitlin Shneider, Tyler Bradley, Video Narrator, Emily Ventura, Walter Perez
Caitlin Shneider 00:00
Well, I’m excited to see everybody again today for the fourth session of our webinar series. And today we are going to be focused on talking about evidence based, non-pharmacological interventions for chronic itch. Which is a big fancy way of saying, “What has the research shown to be helpful for reducing itch in other disease groups?” And so just as an agenda of what we’re going to talk about today, we’ll start like we did last time with a quick review covering the highlights of what we talked about last week. And then we will dive right into what the literature and what the publication of data has been shown to say about interventions that are not specific to use of medicine.
So things that are targeting factors like what we’ve been talking about, to reduce itch intensity and frequency. And much of what we’ll focus on today is really focusing on behavioral factors. So we’ll talk about the principles of behavior and behavior change, and then specifically dive into two particular behavioral interventions called habit reversal, and distraction. And then at the end, we’ll briefly touch on chronic itch and scratching in infancy.
So just reviewing what we talked about last week, as you might remember, last week was thinking about thinking, and we were specifically talking about the role of our thoughts on the itch sensation and scratching behavior. And so we talked about that the literature has shown that there are two types of thinking patterns that are associated with itch. Particularly that thoughts that emphasize a negative meaning of that itch sensation and thoughts that emphasize the acceptance of the itch experience have been associated with the experience of itch.
More specifically, that thoughts that emphasize this negative meaning has been shown to be associated with more itch, and therefore more scratching. And by contrast, thoughts that are more acceptance based, seem to be associated with decreased itch, and therefore decrease scratching. And throughout the series, we really talked about this in the context of this idea of a light dimmer switch. That these biological, psychological, and behavioral factors are controlling the intensity of that itch, making it brighter, stronger, or turning it down and reducing it. And last week, we also presented this idea of the cognitive triangle showing the connection between the way that we think and how we feel and how that impacts our behavior.
We specifically talked about this in the context of that example, as if you were to see someone you know, walking down the street waving to you. And when you wave, or when you wave to them, they don’t wave back, and sort of the thoughts that go through your mind and how that makes you feel, and then how you respond back to that person or what you do the next time you see them, which was just illustrating how our thoughts are related to the way that we feel and how that then influences the way that we respond in the world and how we behave.
And we talked about ways in which our thinking sometimes acts almost like these glasses, where it’s adding something to our environment that’s not there, or it’s it’s not representing the world as it is there’s something being added. We talked about that in the context of thinking traps. We reviewed a number of these thinking traps, which are ways in which some information is being left out. So we talked about all or nothing thinking, sort of like black and white thinking. We talked about ways in which only certain types of information is getting through.
We talked about magnification and catastrophizing. And this is one we spent some time talking about, that kids with chronic pain and kids with chronic itch often experience catastrophizing, which is feeling helpless in the context of their itch or pain, magnifying that experience, and then being stuck on those thoughts, which can lead to rumination, just kind of constant worry, and that can look look a number of different ways. And we talked about a number of different approaches that have been shown to be helpful to address these types of thinking to be able to reduce the intensity and frequency of itch, specifically two kinds.
One we talked about was Cognitive Behavioral Therapy or CBT. The other was Acceptance and Commitment Therapy or ACT. And that both of these strive to either change the thoughts that go through our mind, or to change our relationship to those thoughts. And so for CBT, we’re looking to change those thoughts and we talked about two ways of doing that.
One of which we talked about was kind of like playing a detective. It is something that you might do with your child of trying to spot the thinking trap, figuring out what happened, figuring out what clues support the thinking trap or might go against it. And then, for older children, talking about that thought record of really getting specific about what happened, what emotions did we feel, what thoughts were going through our mind, and being able to assess information that might support the thought that went through our mind and what information might not support that, to be able to ultimately come up with a thought that is more balanced, and be able to integrate pieces of information that our mind not mind might not consider.
And then ACT is not changing the thought, but specifically changing our relationship to that thought. So we talked about that, oftentimes, kids that have a chronic or chronic disease, a lot of the thoughts that go through their mind and their worries are things that are true, and that cannot be changed. And that using this approach is sometimes more appropriate and more helpful, in that we are accepting thoughts and allowing ourselves to let those thoughts go. And we used a couple of examples like putting that thought on a leaf and letting it float down the stream or tying it to a balloon and letting the balloon float up into the sky, so we talked about these two different ways of thinking.
Caitlin Shneider 06:47
And so throughout the series, we’ve referenced this model, really as a framework of pruritus is this process that happens in our body. One of the symptoms of that is the experience of itch, which ultimately leads to the scratching behavior. And we’ve been talking about biological, psychological, and behavioral factors that influence the itch and the scratching.
So last week, we were really focused on psychological factors, so specifically the way that we think. And this week, as I sort of highlighted, what we’re really going to focus on is behavioral factors. So we’ve covered biological psychological, and today is really going to be the behavioral focus. So diving in, there are a number of studies that have looked specifically at interventions that do not use a drug or a medicine, to look at how they might impact the experience of itch and scratching behavior. And they have suggested that there are data to show that each of these things have been associated with decreased it.
So that includes education, so learning about the experience of itch. And I’m going to present these briefly, but then we’re going to talk more about each of these more specifically. So education about itch. Psychotherapy related to the experience of chronic itch, stress reduction and relaxation training, habit reversal and distraction and then a number of topical, topical things that can be put on top of the skin. And so habit reversal and distraction are the ones that we’re going to spend most of our time talking about today, and are really behavioral in their approach.
Caitlin Shneider 08:45
So as a quick overview, as before we dive into this, we might notice, education is similar to what we’ve been doing throughout this webinar, right. It is understanding the experience of itch. What are factors that contribute to that? And that is what many investigations have tested, specifically these things. So education about chronic itch, information about ways to manage stress and ways to relax muscles, information about daily skincare, thinking about triggers or things that happen before the experience of itch, talking about the itch-scratch cycle, which we’ve talked about, developing alternatives to scratching, which we’re going to talk about today, sleep problems, talking about more medical topics, general nutrition.
There are studies to show that providing this education has been associated with reduced itch and itch intensity, whether alone, but then also sometimes in combination with therapy to support that. There are data to also support, as we’ve talked about, just related to what we were discussing last week, that therapy has also been shown to be associated with decreased itch intensity and frequency. We talked about that the most common ways of doing that and the the data has supported therapy from a CBT perspective or an ACT perspective, so changing the thoughts or changing the relationship to thoughts.
There’s also something called mindfulness based stress reduction, which has also been shown to be helpful
But the purpose of being in therapy is really twofold. One of which is to change the perception of itch. So really working on the individual’s experience of that itch and the thoughts that go through their mind. But then also addressing stress associated with itch related topics or areas of concern and how that gets in the way at school, at home, with friends, and really striving to reduce stress in that way, as well. And just like we spent a whole session on in session two, there’s data to show that reducing stress and relaxing has been shown to decrease itch and scratch. So progressive muscle relaxation, which we’ve talked about.
There’s something called autogenic training, which is very similar to progressive muscle relaxation, but instead of tightening and releasing each muscle group at a time, what you’re doing is directing your attention to that part of the body and imagining it to relax. So I think about it kind of like a combination of progressive muscle relaxation with guided imagery. It’s using your imagination to relax those parts of the muscles, thinking about the skin being very cool, thinking about the skin as being calm.
And there’s some mixed evidence and data to show that aromatherapy, specifically with essential oils, has been helpful in reducing itch experience, sometimes with massage. So there’s some mixed evidence for that as it reduces stress as well. And so what we’re what we’re going to spend most of our time today talking about are these behavioral interventions, which, as I mentioned, are habit reversal and distraction.
Caitlin Shneider 12:17
So as we talk about behavior, it’s important to first understand what are the principles that guide child behavior and human behavior in general? And so these might be very familiar to you, or they might be totally new. An I think it’s helpful for us to think about them as we’re learning some of these some of these skills. So what we know is that the way we behave is influenced by what happens around us. So there are things that happen that make our behavior continue. And there are things that happen that make our behavior stop or discontinue.
And we call things that cause our behavior, to increase things that are reinforcing. They are reinforcement. And things that cause our behavior to decrease or stop are punishment. And so when we think about ways in which we try to shape behavior or change behavior, I think about it in this way. So if we look at this table, we can separate it by what’s reinforcing and what’s punishing. And so you’ll see at the top, in the first column, we add something, and in the second column, we take something away. And then in the first row, we are trying to increase behavior. In the second row, we’re trying to decrease behavior. So let’s say we’re trying to get a behavior to increase, so we would only look at the top right, reinforcing good behavior to increase
We could add something pleasant to be a positive reinforcement. And we’re going to walk through an example of that. Or we could take away something that is unpleasant or undesirable, to get that behavior to occur again. And on the flip side, if we wanted to be behavior to stop or discontinue, we would want to add a punishment, right, something that is going to make that discontinue. So we could add something undesirable, or unpleasant or we could take something away, that is pleasant or enjoyable. So let’s that’s very abstract. Let’s talk about this in the context of an example. A classic: eating vegetables, right, trying to get our kids to eat their vegetables
. So here’s an example. Your kid ate their vegetables. I think many of us would want that behavior to continue. We want that to occur again. So that would mean that if we’re looking at this chart, we’re looking at the top row again, right. We want this behavior to continue, so we can add something desirable, a positive reinforcement, or we can take something away that is undesirable to get it to occur again. So an example of something that would be a positive reinforcement, something we’re adding might be positive attention from a parent.
Parent attention is one of the most reinforcing, outcomes, aspects of, of child behavior. So smiling, giving high fives, saying “Great job!” is very reinforcing. Related to that, providing praise for behavior that we liked, has also shown to be really effective. And being really specific about what we liked, “Great job eating your vegetables. I liked that you ate your vegetables when I asked”, being really intentional and specific, and then sometimes giving a reward. So you can give a sticker, a toy, something like that. You’re adding something desirable to get that behavior to happen again.
On the flip side, if we were to do a negative reinforcement, so to take something away that is undesirable, we could take away chores, for example. “Because you ate your vegetables, you don’t need to wash the dishes tonight”, or an older for an older child, “Because you eat your vegetables, you can stay out 30 minutes later”, or something like that, taking away a curfew, something that is undesirable. On the flip side, maybe instead of eating vegetables, your child puts their head down on the table and starts crying. Don’t want that one to continue.
We want them to eat their eat their vegetables, right. We’ve probably seen this face a couple of times. And so what we want is the bottom half of this. We don’t want this behavior to continue. So we’re either going to add something undesirable, or we’re going to take away something that is desirable. So an example of a positive punishment, something we’re adding, might be that we reprimand or we discipline and say, you know, “You need to eat your vegetables”. We might add consequences. “If you don’t eat your vegetables, you now need to wash the dishes and take the trash out.” And we might add like rules or restrictions.
These are examples of things that you would add as a way of punishing a behavior. And on the flip side, a negative punishment, which would be taking things away, might be taking away toys, or taking away the tablet or taking away special privileges being able to go to the park. “But you didn’t eat your vegetables, so we’re not going to go to the park.” And I see a bunch of people smiling haha and it seems like maybe this is familiar, I’m guessing. Yes. So this is not new to you. And I didn’t, I didn’t expect that it would be super new, but it’s sometimes helpful to review.
So when we think about trying to change behavior, we also want to think about ways in which it is helpful. And just as I was mentioning, when we think about changing behavior, we want to be really clear about what we want and what we don’t want. Because oftentimes when we give general statements like “Good job”, or “No don’t do that”, kids are not sure specifically what we mean. So we want to make sure that we’re saying, “Good job eating your vegetables”, or “No, don’t touch the speaker” or whatever it might be.
We also know that to change behavior, the way in which it is most helpful is for the response to be immediate right after the behavior occurs. So as soon as you see something you like, immediately providing that positive and specific reinforcement or attention. We also know that making sure it’s consistent is important in trying to shape behavior, in making sure that every time something happens, a child knows to expect that something… there will be a consequence, if they know the behavior shouldn’t occur, or there is something reinforcing it for it to continue to occur.
And essentially what we’re trying to do is change contingencies, so that way children know what to expect. And related to that idea of being consistent, we want to make sure that when we are shaping behavior, that all the adults in their life are working together. So multiple caregivers, teachers at school, other adults that might watch them. I think as we talk through these examples, some of this might seem to make a lot of sense, but it can be really tricky sometimes.
And as we we talked about, parent attention can be one of the most reinforcing aspects of a child’s world. So, one of the examples that that I often highlight is say that your child, or a child does something that they’re not supposed to. And the immediate reaction of the parent is to yell at them, or to look at them and give them the stare of “Oh, don’t do that.” And sometimes that can actually be very reinforcing, because parent attention is something that often gets behaviors to go up. So it’s important to try and think carefully about what is the purpose of the behavior, and how is the response making it happen again, or making it stop.
Caitlin Shneider 20:32
So we’ll talk about habit reversal, keeping all of those things in mind, which, as as you might remember, is something that the data have shown to be associated with decreased itch and decreased scratching. And what habit reversal is, is this idea of teaching children how to replace an undesirable behavior with something else, a competing behavior that is incompatible with the other behavior. So they can’t do both at the same time, essentially teaching them to replace that behavior.
This is often used for kids that have hair pulling, or they pick their skin, or they have tics, but it’s also been shown to be potentially pretty effective in working with kids that have chronic scratching. So when we think about this, and we remember the itch scratch cycle, so from that first webinar, this sensation of itch leads us to scratch, which causes that barrier damage. And the more that this barrier damage, which is the skin gets damaged, the greater the itch sensation goes up and then we go round and round and round, right. And that stress throughout this exacerbates this whole thing. But if we’re able to replace scratch with something else, we might be able to interrupt this cycle, and therefore reduce the itch sensation. And so that ties exactly into this model we’ve been talking about, right.
If we can change this behavioral factor, we might be able to reduce it and reduce scratching. So as we talked about, one of the ways that this works is that we replace scratching with another behavior that they can’t do at the same time. And then afterwards, we change the contingencies. We’re changing what happens to get that behavior to occur again, and help them do that behavior over and over again. And so the way that habit reversal has been done in a number of studies, is to first develop the child’s awareness of their scratching behavior
. I think one of the webinars we were talking, after it was over, just about how some of this is so automatic, that we don’t, kids don’t even notice that they’re scratching. So the first step of this is developing awareness of times that they are scratching. And then from that, practicing, as we said, a competing response or behavior that is incompatible with scratching, something you cannot do at the same time, reinforcing that behavior, and then engaging the child in something else. And so ways in which you might start are developing awareness.
Oftentimes, the studies have used something like this, which is identifying what is happening before the itch and the scratch and then what is happening afterwards. What is happening in the environment that is causing the scratch to continue? So that way, we can understand that and shift that. And, as, as we said, the first step is increasing their awareness. Oftentimes, especially with young kids, parents need to support this. And so I pulled this example and I’m going to send this to the team to post online. There’s a little workbook that’s been designed for kids about ways in which kids and their parents can work together to try and increase their awareness of when they’re scratching.
And so this is an idea of ways to work together, of ideas that that a parent can do with the child to help them. So “Circle the ways in which a grown up can help you be aware of your scratching and cross out the ones you don’t want.” So “Touch my hand”, might circle that. “Punish me”, probably not. “Make a secret signal”, you can make a secret signal with your child that can represent “Oh, you’re scratching”. “Yell at me”, probably not. And I think one of the things that is important in this as well is that we really want the attention to the scratching be behavior to be neutral. Right.
If we’re giving lots of positive attention to the behavior, based on what we just talked about, would we expect that the behavior goes up? Goes down? Doesn’t change? What do we think? If we are giving….yeah, exactly right. If we’re giving lots of positive attention to scratching, it’s gonna go up. And what we know is that if we give negative attention to the scratching, oftentimes kids will start to then hide it, and not….. keep it from you, which makes this a little bit more challenging to do. And so we really want to focus on just neutral attention, not judging them, not shaming them, just “Oh, you’re scratching” or like “Use the signal that you came up with” to help them start to develop more awareness.
Caitlin Shneider 25:52
The second part of this is developing that competing response. So practicing something that they could do that is incompatible with scratching. And what the studies have often used, is encouraging kids to clench their fists for 30 seconds, instead of scratching. And then if after 30 seconds, the itch continues, to press a fingernail against the area, or to pinch the area. Some other studies have shown grabbing an object instead of clenching a fist. But these are two ways of responding to the itch sensation in a different way than scratching to reduce that barrier damage, and hopefully disrupt that itch scratch cycle.
And again, this is much easier said than done in, in practice. After practicing a competing behavior, as we talked about, we want to reinforce it to happen again. And so what we would expect over time, is that the itch goes down, which would be negatively reinforcing, something they don’t like is taken away. But in the meantime, while that is happening, it’s important for parents to positively reinforce the behavior. And so finding ways to add things that are pleasant immediately after to get that behavior to continue, until we’re able to see this decrease itch sensation.
So sometimes with kids, we will use like a sticker chart. So every time they do it, they get to put a sticker on their chart. And then you know, this is kind of a long one, but sometimes you can do shorter ones. “You get 10 stickers, and then we get to go pick out something else”, as a way to help kids stick to this. And this can be especially helpful for for, I would say more like older children.
Caitlin Shneider 28:01
And then the last thing that is important after that is engaging the child in another activity, getting them distracted, away from that sensation of itch. So this is also pulled from that little workbook that I mentioned, that comes up with different ideas of things to do after practicing that competing response and reinforcing the behavior. And this is also tied to what has been shown in shown in the literature of what has been shown to be effective for reducing itch and scratching behaviors. That specifically directing kids attention away from itch to something that is more positive or pleasant, is associated with decreased itch and scratching, likely because it increases relaxation, and it decreases opportunities for stress.
Studies have shown that distraction that engages multiple senses, so like seeing and hearing something or touching something and seeing something have shown to be more helpful. And again, that is supported by by parents and adults. And just like we were talking about the idea of taking attention away from something that is unpleasant, so changing the behavior, of where they’re directing their attention, can decrease itch and decreased scratch. This is also very consistent with what we know from the chronic pain literature, so what has been shown to be helpful for kids that experienced chronic pain.
And we would expect that, given the shared neural pathway between itch and scratch. So we know that for kids that experience chronic pain, there are often a number of different ways that parents respond. And these are three ones that are are common: protective parent responses, which often sounds like the optimal parent response. We want to protect our kids. But sometimes this is almost thought of more as overprotective, so enabling and accommodating certain behaviors. So saying, like, “You don’t have to do your homework because you have pain today” or “You don’t have to go to school today, because you have pain today” or “You don’t have to do chores”, kind of like this over protective accommodating response, which has been shown to be associated with increased pain.
Another common response from parents is a minimizing response, which is exactly what it sounds like, sort of diminishing their experience, “It’s not that bad”, “There’s nothing I can do about it. Stop making a fuss.” which has also been shown to be associated with more pain and more negative outcomes. And then this last common response is this idea of distraction, which is just what we were talking about, of checking in with the child and encouraging them to participate in another activity and reassuring them that they’re going to be okay.
And so just as I mentioned, this protective parent response has really been associated with more… with worse psychological as well as sort of daily functioning outcomes. We think that it’s possible that this response really communicates parent anxiety about their experience. So suggesting that their pain is very severe, and requires limitation of their daily activities, which, you know, might be something that is the case for, for parents of children that experience chronic itch.
We haven’t really looked at this yet. There’s they’re not studies that have started to look at this. And the same is true for minimizing responses, that we have seen that there’s a relationship between the way that parents respond to pain and their experience of pain. It’s possible that parents saying, “Don’t worry about it. Don’t make a fuss about it” actually allows the child or encourages the child to magnify their experience to try and get attention from their parent. And this distract response or encouraging them to persist in other activities, while kind of keeping an eye on them, communicates to the child that their experience is manageable.
That they don’t have to limit their daily activities, that they can keep going on. And so kids have been shown to be able to do more on a day to day basis when parents respond in this way. And so as I mentioned, this hasn’t really been looked at in kids that experienced chronic itch yet. I think there’s one study that has just started to look at this in patients that have burn injury. And so we don’t know if this might be the case for kids that experienced chronic itch or not. But given the similarities between chronic pain and chronic itch, it’s possible that what we know from chronic pain could be relevant for this group.
Caitlin Shneider 33:07
And then talking about topical solutions that can also be associated with reduced itch. Studies have shown that keeping skin moisturized has been associated with this, which I’m guessing you guys have heard before. Keeping skin cool or sometimes even numbing the area has been shown to be associated with decreased itch intensity. So oftentimes, particularly for kids with chronic pain, they’ll spray like a numbing cream on the area or a numbing spray.
There’s one or two studies that have talked about a wet pajama treatment, where they put kids’ pajamas in cold water, and then wring them out as a way to cover the skin in a cooler temperature. And then studies that have been done in kids with chronic pain have shown that actually touching the skin overtop of the areas that have the itch sensation or in other areas have been shown to decrease itch sensation as it sort of provides competing information to the brain.
And so it reduces the itch signals in that way. So one of the things that kids with chronic pain use is something called a Buzzy bee or not chronic pain, but kids that have more acute pain is a Buzzy bee, which I’ll just show you really quickly is something that’s very cool, that can sort of numb the skin.
Video Narrator 34:47
Hi, I’m Dr. Amy Baxter, emergency pediatrician and inventor of Buzzy. Thank you for your purchase. Here’s how to use your Buzzy. Buzzy comes with two wings, the Buzzy vibration unit, two AAA batteries already installed and instructions. To begin using your Buzzy simply attach the wings and the back and press or strap to the injection area. Make sure the ice wings are frozen solid. Ice mels after 10 minutes at room temperature, so keep it between other ice packs during transportation. Press down the switch at the top.
For injections placed Buzzy for 30 to 60 seconds directly where the injection will go. Immediately before the injection move Buzzy up a few centimeters, so that it is active and vibrating between the brain and the pain during the shot. In clinical settings clean Buzzy and wings.
Caitlin Shneider 35:42
So this often how Buzzy can be used for chronic pain, more for acute setting, so like getting a shot. But that idea of introducing something cool and providing that tactile stimulation, so Buzzy vibrating kind of like a bee would, has been shown to potentially help with itch as well. And so when we think about some of these strategies, particularly habit reversal and distraction, they can be helpful for kids that are school age and above.
But we we introduced this idea of what might be helpful for kids that experience chronic itch that are younger than that? And what we know is that there aren’t studies yet that have looked at this in terms of what can be helpful for infants that experience chronic itch. However, there are studies that have been done for kids that experience chronic pain.
And so it’s possible that some of the things that have been shown to be helpful for infants with chronic pain could be helpful for infants with chronic itch. So we know that when kids experience chronic pain, breastfeeding can be particularly helpful in reducing pain. It’s thought that it’s a combination of factors, that idea of skin to skin contact, a sweet taste and then distraction, the idea of sucking, all of those together are thought to reduce the infant’s distress and stress in that moment, which as we talked about reducing stress is going to reduce that itch experience.
So it’s possible that breastfeeding is helpful for infants that experience chronic itch. Similarly, that idea for non nutritive sucking, so sucking on a pacifier, some studies have shown that sucking on a pacifier that’s dipped in sugar or has some sort of sweet sucrose attached to it, particularly for infants with chronic pain, has been shown to be helpful.
And as I mentioned, that idea of skin to skin contact has also been shown to be helpful in reducing infant stress, which is, as we know is associated with their experience of pain and potentially related to that idea of chronic itch for infants that experience chronic itch. So what we can pull together from this is that there are some interventions that have been looked at for kids that experience chronic itch. Again, they’re conducted in other groups, so primarily in kids that experience dermatological conditions, so things like atopic dermatitis.
But it’s possible that they could be helpful for kids that experience itch as a result of PFIC. We don’t yet know that. But that is a place to start. And I want to make sure that we take some time to be able to talk about questions or things that come up as as we think about this. And before we dive in next week to talking about the process of finding a therapist. So I will pause there, but want to open it up to questions, comments.
Yes, so Emily, put in the chat, asked “Any experiences or studies that look at infant massage?”
Caitlin Shneider 39:10
For itch, or for chronic pain?
Emily Ventura 39:15
Sorry, I guess either. Just drawing on an experience I had working in the NICU as a nurse. With a lot of the fussy babies, infant massage was something that was really common for distraction, and then for pain and whatnot. So I didn’t know if you’ve seen any of that in you know, the evidence that you’ve been reviewing or and anything related to chronic pain?
Caitlin Shneider 39:40
Sure. I think that’s a great, great point. I haven’t seen that in my review of the literature, but I’m also not an expert on infant pain management. So that’s certainly possible and that might be included in some of the studies that have looked specifically at distraction. That idea of massage, so it’s distraction, but it’s also sort of that tactile stimulation and directing the brain’s attention away from the area of pain, so that certainly could be.
Emily Ventura 40:09
Tyler Bradley 40:13
I had a sort of a question comment on the…what was it…bringing reinforcement and distraction and talking about that with say, like a teacher, that the child may have or another, like if they go to daycare, and they’re a little younger. Is that as simple as like bringing that worksheet and asking the teacher to also fill it out or do you have any other tips for parents that might help them in kind of describing what they’re looking… what they’re asking for?
Caitlin Shneider 40:45
Yeah that’s a great question. And actually, is included in that workbook that I mentioned. There’s a whole handout on to talk to teachers about. And I think to your point, we, we want to be consistent and get everybody on the same page. And so it would be including the teacher in whatever the signal might be to help the child realize that they’re scratching, so that the teacher can help that help them as well. I think the challenges of of working in a classroom setting is that the response might have to be different. I mean, there’s usually at least 15, 20 other kids, so they may not be able to respond in the same way that you might be able to in the home.
But I think at minimum, asking the teacher to to be able to help the child notice at school when they’re scratching, and have a conversation with the teacher about what realistically they might be able to do in a classroom setting and what they can’t. But there is a specific handout in that workbook I mentioned, specifically for teachers.
Tyler Bradley 41:47
Gotcha. Awesome. Thank you. Walter?
Walter Perez 41:59
I just want to say thank you, again, this was awesome. It’s almost like a Parenting 101 little webinar, as it applies to what we’re talking about, but I think there’s a lot of pointers that we can walk away with. So I just want to say thank you. And I really appreciate your your teaching on the whole habit reversal. And it makes a lot of sense to me, you know, because and when you think about habits, you just can’t take them away. Like bad habits, for example, just can’t take them away, you got to replace them. Right. And so I really appreciate you saying that. And it’s a good reminder for all of us. So thank you for that.
Caitlin Shneider 42:32
Yeah, absolutely. And I think you’re you’re spot on. So much of this applies to just child behavior in general. It’s not necessarily specific to kids that experience chronic itch. But we can use that to think about what is happening in the environment that maybe can that perpetuates the scratching behavior to occur and think about ways in which we can change that, to be able to help them develop an alternative response. And I, as we’ve been talking about throughout this series, so much of this is easier said than done.
This makes it seem like “Oh, well just have them do something else instead”, that’s a very over simplistic way of thinking about this. And so I want, I want to make sure that we emphasize that this, again, takes time it takes practice. This is so that you all have education and understanding about some ideas of ways that might be able to reduce scratching, but as we talked about working with somebody who’s a professional to be able to implement this in the context of your family can be really helpful. And so that’s what we’ll talk about next week is how to find somebody that can help with some of these things and implementing them.
Tyler Bradley 43:44
And you said…did you say the workbook…are you going to give that to us to…to distribute? Gotcha. Okay. So for people on this call, we’ll add that to our website. And then if you’re listening to the audio recording, hopefully by the time you’re listening, this will be on the Rare and Resilient Webinars page to download.
Emily Ventura 44:05
Yeah, I’ll send that to you.
Walter Perez 44:08
Just want to add to give you props as well, Caitlin, because I think the word that just came to mind as you were talking about your whole webinar series, I think is you’re bringing intentionality to all this. I think, you know, you mentioned you might already know some of these things, but I think that we’ll end up doing certain things without realizing it. But I think when it comes to handling the pain, the itch, we have to be intentional about it. And I really appreciate the encouragement you’re giving, whether you’re being direct or indirect on that. Being intentional as parents is what’s going to help us kind of win the battle, I think and so thank you for that.
Caitlin Shneider 44:42
Yeah, absolutely. I think I think you all have so much power to help to help your to help your kids and just as you said, it starts with you and they’re very lucky to have you.
Emily Ventura 44:56
Well, and as Walter,,, I’m delayed in my driving…Walter to beat me to it. But we have I have a similar thought process. Walter, you mentioned intentionality. And I’m also thinking of mindfulness and patience. And I’m specifically thinking of the example you shared with clenching, clenching the fists, teaching your child to clench their fists, and I’m thinking about, “Okay, well, maybe that doesn’t work the first time.” But that seems like for habit reversal, you might need to try it a few times before you’ll really get the outcome that you’re looking for. It’s just habit reserve reversal.
And so I’m thinking of, if I put myself in that position as a parent, just allowing myself to be patient with that process. And it piggybacks off of what Walter was saying, with intentionality. It’s a lot of just like, reminders for us that it is going to be challenging, but these types of tips if, you know, create consistency, and you know, just just keep at it, have some patience, I think we’ll see some success.
Caitlin Shneider 45:58
Yeah, yeah, I appreciate that perspective. And I think that that connects so well, to what we’ve been talking about. That it it will take practice. It probably won’t work on the first try, just like we talked about, you know, stepping outside tomorrow and trying to run 26.2 Miles. Not feasible for me, I don’t know about for you.
But it will take some practice. And I think to your point, that idea of being able to be patient and keep that larger goal in mind, might be something that’s really helpful is keeping an eye on what the goal is, and ways in which you are taking steps towards that, even if it doesn’t feel like that in the moment and feeling really frustrated that maybe it didn’t go the way that you prefer, and finding ways to say, “Okay, we tried it once. That’s one more time than we’ve done in the past. That’s a step. It’s a step in the right direction.”
And being able to work with somebody that can support you in that experience, I think is really helpful. Because, as we said, it sounds so much easier in practice and then sometimes once you get into it, it can be challenging and finding somebody that can guide you through that and also support you, I think can be helpful.
Tyler Bradley 47:10
Okay, awesome. If there are no other comments or questions, we can get ready for Thursday’s webinar. If you have not registered for that one yet, you have to register separately. That link was an email that I sent today, and on our website on the Rare and Resilient Resources page. And if you’re listening to the audio recording again, please go register for webinar five.
Caitlin Shneider 47:37
And for those that plan to join, if you have had experiences looking for a provider, or have had roadblocks or specific questions, please feel free to bring them. My goal is not to take up the whole hour talking to you about how to find a therapist. I want to give you enough information, so it’s helpful. But I’m going to use that poll everywhere that we’ve used in the past and create an anonymous portal for folks to share specific questions about the process or concerns. So if there are things that have been barriers or challenges, and you feel comfortable opening them up in this space, I just want you to know that that I’m going to create that space for you next on Thursday.
Tyler Bradley 48:20
Emily Ventura 48:22
Thank you so much.
Caitlin Shneider 48:24
Tyler Bradley 48:25
All right. Hopefully we’ll see everybody on Thursday.
Caitlin Shneider 48:28
Yes, see you Thursday.
For Rare Disease Day 2023, we offered a webinar series called “Rare & Resilient Resources: A New Perspective On Coping With Pruritus”. This is the fourth webinar in the series. This installment covers evidence-based interventions for chronic itch.
To understand behavioral interventions, we must understand the key principles of behavior change: we can increase positive behavior by reinforcing it, and we can decrease negative behavior by adding punishment. In this webinar, we explore how we can utilize these key principles along with two types of evidence-based behavioral interventions, habit reversal and distraction, to help manage itch. Tune-in to learn the steps for practicing habit reversal and distraction at home and at school, along with age-specific itch interventions for young infants/babies.
Host: Caitlin Shneider
Caitlin is a Clinical Psychology Doctoral student at Georgia State University. Caitlin studies the influence of child pain catastrophizing and parent response to pain on psychosocial and functional outcomes for youth, giving her a unique perspective on dealing with pruritus.