Attitudes and Perceptions of School-Aged Children Toward Alopecia Areata

Although not life-threatening, alopecia areata (AA) is associated with increased rates of depressive symptoms and anxiety in children.¹ This study investigates how schoolchildren, from kindergarten (K) through grade 8, perceive those with AA and the associated social ramifications.

After receiving institutional review board approval, we developed a study participant group of 123 school children, grades K through 8, separated by grade. Half the subjects were interviewed as individuals and half as pairs, and all were shown a photograph of a child with AA (Figure). The investigators observed and recorded the initial subjects’ reactions. Responses to a series of questions regarding their attitudes toward the photograph were analyzed to assess differences in children’s attitudes toward those with AA across grade level, sex, and interview format (individual vs pair). Statistical significance was assessed using the Pearson χ² test and Fisher exact test, with a type 1 error rate of 0.05.

When initially viewing the photograph of a child with AA, children in grades K through 3 were more likely to show discomfort; 20% were visibly uncomfortable (n = 19), often looking away from the photograph. Another 27% displayed expressions of surprise and shock (n = 26). None of the children in grades 5 through 8 revealed any apparent discomfort. Those interviewed in pairs were 3 times more likely to express discomfort. When asked how they would feel if one of their classmates lost their hair, all subjects across all grade levels responded with the majority answer of “sad.” Children interviewed in pairs were 3 times more likely to admit they would be “scared” or “shocked.”

When the children were asked if they thought the child with AA was sick or dying, 42% of those in grades K through 3 (n = 41) and 54% in grades 5 through 8 (n = 14) thought the child was sick, and 21% in grades K through 3 (n = 20) thought they were dying. Those in grades K through 3 were 6 times more likely than older children to think that the child was dying. A common theme in all age groups was that the children were curious and wanted to know “what happened?”

When the children were asked if they would be afraid to get close to someone with AA, children in grades K through 3 were 5 times more likely than older children to state that they would be afraid (37%; n = 36). A total of 88% of the older children (grades 5-8; n = 23) stated that they would not be afraid. Boys were more likely than girls to admit being afraid of getting close to someone with AA.

The most significant differences in survey responses were seen across grade levels, implying that children’s developmental age has a strong impact on their view of others with AA. This was demonstrated by a consistent natural transition in responses at around the third grade, artificially dividing these children’s opinions into younger (grades K-3) and older (grades 5-8) opinions of AA.

Younger children were much more likely to display apparent discomfort when viewing the photograph and believe the child to be dying or contagious. This demonstrates an evolving concept of illness with age, with younger children more likely to view hair loss as deadly and transmittable, leading to isolation of younger children with AA.

There were few differences in perception based on sex. Students were assessed in pairs to discover potential components of peer influence on the negative views of others. One notable difference in pair responses was increased expression of surprise and shock at seeing a photograph of someone with AA. For most questions, individuals within a pair tended to agree, suggesting that children are likely to influence each other when in groups, implying an element of peer pressure in singling out someone who is perceived as different.

Our findings emphasize the importance of recognizing how the change in appearance associated with AA can affect how a child is viewed by peers. Previous studies have shown that appearances can be the greatest factor in social isolation of school-age children, especially girls.² Negative peer views of appearance have been associated with decreased rates of peer acceptance and popularity and increased disruptive behavior.²

By understanding how children perceive and react to hair loss, health care professionals will be better equipped to counsel children, families, and teachers about AA. The following key educational points from our study that should be shared with the patient, family, and school to help avoid isolation caused by AA:

1. AA is not life-threatening; the child is healthy;

2. AA is not contagious; and

3. Children at all grade levels are curious; we should educate them about AA.

Corresponding Author: Andrew Hankinson, MD, Penn State College of Medicine, The Milton S. Hershey Medical Center, 107 Townhouse Rd, Hershey, PA 17033 (Carlohank@gmail.com).

Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: McMillan, Miller.

Acquisition of data: McMillan, Miller.

Analysis and interpretation of data: Hankinson, McMillan, Miller.

Drafting of the manuscript: Hankinson, McMillan, Miller.

Critical revision of the manuscript for important intellectual content: Hankinson, Miller.

Study supervision: Hankinson, Miller.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by the Hershey Chapter of the Children’s Miracle Network.

Role of the Sponsors: The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; or in the preparation, review, or approval of the manuscript.