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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 186-189

Role of virtual psychosocial interventions in coping with mental health challenges of children during the pandemic


Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission07-Mar-2021
Date of Decision29-Jul-2021
Date of Acceptance09-Aug-2021
Date of Web Publication31-Aug-2021

Correspondence Address:
Dr. Prahbhjot Malhi
Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_82_21

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  Abstract 

Background: The morbidity and mortality rates associated with the COVID-19 infection among children, fortunately, continue to be low; nevertheless, children are experiencing several pandemic-related mental health risks. Clinical Description: DK, a 9-year-old boy, was referred to the pediatrics department of a tertiary care center for compulsive oxygen saturation checking behaviors that developed a few weeks after the sudden demise of his maternal grandfather due to the COVID-19 infection. A diagnosis of adjustment disorder with emotional and behavioral problems was made as per the Diagnostic and Statistical Manual of Mental Disorder-5 criteria. Management: A comprehensive management plan was drawn out that focused on encouraging the parents to engage in productive and meaningful conversations regarding death being a permanent event in the life cycle. The child was asked to draw so that he could share his feelings and was also taught “belly breathing” that used a script of 4 counts in and 4 counts out by sharing child-orientated educational videos. The family was asked to chalk out a structured routine with time for creative artwork besides completing academic assignments. Follow-up after a month of therapy revealed an overall improvement in behavior, increased interactions with teachers and peers, and decline in compulsive checking of oxygen saturation levels. Conclusions: There is a need to expand digital treatment options for children, especially during times of public health emergencies, by using online psychoeducation resources, mental health apps, and conducting online therapy sessions.

Keywords: Adjustment disorder, artwork, cinema therapy, COVID-19, death, grief, virtual interventions


How to cite this article:
Bharti B, Malhi P. Role of virtual psychosocial interventions in coping with mental health challenges of children during the pandemic. Indian Pediatr Case Rep 2021;1:186-9

How to cite this URL:
Bharti B, Malhi P. Role of virtual psychosocial interventions in coping with mental health challenges of children during the pandemic. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Sep 26];1:186-9. Available from: http://www.ipcares.org/text.asp?2021/1/3/186/325100

The COVID-19 pandemic and its resultant repercussions including a nationwide lockdown, physical distancing, decreased social interactions, economic hardships, and job insecurities have resulted in increased parental and family stress.[1] In addition to the high morbidity and mortality associated with the COVID-19 infections, children and adolescents are also experiencing several adverse effects associated with the mandatory stay-at-home instructions. The decision to close schools has resulted in millions of Indian children being left without access to playgrounds, extracurricular activities, and social connections with teachers and peers. Schooling their children at home has become a daunting prospect for families. Research indicates that forced confinements of families at home have increased mental tension, irritability, family conflicts, impaired parenting, and decreased subjective well-being of both parents and children.[2]

We share the story of a young boy who developed compulsive behaviors and intense irrational fears after the death of his grandfather from COVID-19. Assessment was conducted by parental and child interviews and administration of questionnaires through video conferencing. We want to highlight the fact that psychosocial interventions can be successfully implemented through the virtual platform and smartphone consultations, even in these challenging circumstances.


  Case Description Top


DK, a 9-year-old boy, was referred to the pediatrics department of a tertiary care center for abnormal behavior. The child had started compulsively checking his own oxygen saturation multiple times in a day, a behavior that developed a few weeks after the sudden demise of his maternal grandfather due to the COVID-19 infection. He had also become clingy and repeatedly sought reassurance from his parents that he was infection-free. History further revealed that the child had become withdrawn and displayed extreme agitation and distress at hearing any news related to any fatality from the coronavirus infection. The mother reported disturbed sleep, but no change in the appetite of the child. During the interviews, the child revealed his deep attachment to his grandfather, unresolved grief, and feeling of loss. Prior to this, the child was academically bright and studied in Class 4. There was no significant history of any psychosocial difficulties in the past.

The mother confided that she too was struggling to cope with the unexpected death of her father and also battling with guilt of survival. She actively avoided talking about his demise, lest it evoke sadness. Her overall negative affect and preoccupation with her own grief had impaired her ability to provide the supportive care that the child needed. Moreover, increased demands of looking after the household and working remotely from home added to her distress. Social isolation, limited social support from an extended family, and lack of structure that was usually provided by school further contributed to the child's and family's difficulties.


  Management and Outcomes Top


All interactions and assessments were conducted through video-conferencing over several detailed sessions with the mother, child, and family. These lasted for approximately 45 min to an hour. Initially, daily sessions were conducted for a week, followed by alternate day sessions for the next week [Figure 1]. The Screen for Child Anxiety-Related Emotional Disorders (SCARED), Parent version, was used to assess anxiety problems. The child score on the somatic subdomain of the SCARED was above the cutoff score, thereby indicating elevated anxiety in these domains.[3] A diagnosis of adjustment disorder with emotional and behavioral problems was made as per the Diagnostic and Statistical Manual of Mental Disorder-5 criteria.
Figure 1: Timeline

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A management plan was drawn out that focused on encouraging the parents to engage in a productive and meaningful conversation with DK regarding death being a permanent event in a person's life cycle. Several Disney and Pixar movies (i.e., Coco, Lion King, and Big hero 6) were suggested as one way of initiating a conversation about processing death and grief, in a child-friendly way.[4] Second, since DK liked to draw and create stories, he was asked to share his feelings through the medium of line drawings. The child initially drew a boy crying copiously and it was assumed that he was projecting his feelings onto the paper and sharing his grief [Figure 2]. In order to focus on the positive and happy memories, the child was asked to draw all the activities that he had enjoyed doing with his grandfather. This time he drew and recounted an enjoyable evening that he and his grandfather had spent together fixing his bicycle [Figure 3]. DK was also taught “belly breathing” that used a script of 4 counts in and 4 counts out by sharing child orientated educational videos (available on the Homebase.org website), along with the reasons why mindful breathing was necessary.[5] The family was encouraged to chalk out a structured routine for the child with time for creative artwork, besides completing academic assignments. Follow-up after a month of therapy revealed an overall improvement in behavior, increased interactions with teachers and peers, a decline in the compulsive behavior, and reduced anxiety scores on SCARED.[3]
Figure 2: Drawings of the child before therapy

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Figure 3: Drawings recalling happy memories with grandfather

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  Discussion Top


Recent research has highlighted numerous pandemic-related mental health risks for children. A study from China found that nearly 23% and 19% of 2330 students (Grades 2–6) reported depressive and anxiety symptoms, respectively. Students who were worried about being affected by COVID-19 and not optimistic about the epidemic had significantly higher depression scores.[1] Emerging research suggests that prolonged social and physical distancing can increase feelings of loneliness among children and adolescents as it curtails their peers and social interactions. A recently published review (63 studies, n = 51,576) found a clear relationship between loneliness and future mental health problems in children and adolescents, especially depression, up to 9 years later.[6] It is possible that the social distancing measures of the COVID-19 have disproportionately affected families with preexisting mental health vulnerabilities and aggravated their psychosocial problems. Disruptions in daily routines and school closure have added to the distress of children as school routines and peer relationships are important coping mechanisms for all young people, and especially for those who are at high risk for mental health problems.

Since school reopening is still uncertain, forced isolation is likely to persist. In such a scenario there is a need for clinical services to scale up and offer intervention and preventive services. It is important to recognize that parental stress can also impact child well-being. Lee surveyed 405 American parents with at least one child (0–12 years) and found that one-third of them reported changes in their children's behavior (increased sadness and loneliness), subsequent to the pandemic. This change and increased mental health difficulties were attributed to several reasons, including disruption in daily routine and social isolation in an abusive home leading to increased maltreatment. A significant proportion of parents also confessed to feeling depressed and experiencing severe anxiety themselves due to economic uncertainty, stress, and death of close friends or relatives.[7]

Adjustment disorders are frequently diagnosed mental health disorders in children and the diagnosis is generally considered in patients who respond to a recent identifiable stressor with acute and dysfunctional emotional or behavioral response that cause significant academic and social functional impairment and are not accounted by another mental disorder. The response to the stressor varies widely and can include, but not confined to, excessive worry, repetitive and distressing thoughts, and acting out. The response needs to occur within 3 months of the onset of the stressor.[8] These disorders are amenable to the management by tele-counselling. Several intervention strategies used to enhance coping and adjust with loss include cinema therapy, artwork, and mindful breathing. Cinema education or movie therapy helps in initiating conversations about challenging events and distressful experiences, such as death, managing grief, and negative emotions. In Indian homes, death is often a taboo topic and discussing the death of animated characters in a movie may serve as a way to start difficult conversations about real-life deaths.[4] The movie “Inside-out” explicitly addresses how the emotion of sadness is needed as much as joy for growth and holistic health. Art in therapy is also used with children to share feelings, relieve distress, and acknowledge that sadness, uncertainty, and anxiety are normal emotions that are evoked during difficult and unprecedented times.[9] Clinical applications of mindful-based intervention practices such as deep breathing exercises have been shown to decrease symptoms of anxiety, depression, and maladaptive behaviors in children and adolescents in many studies.[6] The sesame street animated Muppet clips demonstrate ways in which young children can manage negative feelings such as anxiety, anger, and disappointment through various strategies.

Pediatricians need to provide anticipatory guidance to parents to help their children cope with various challenges faced during these unprecedented times. The present case illustrates how psychosocial interventions can be implemented through video conferencing using online psychoeducation resources and therapy sessions. A few randomized controlled trials have found that internet-based psychotherapeutic interventions are viable and effective options for treating depressed adolescents.[10] There is a scope to expand digital treatment for children, especially during public health emergencies. In the near future, there may be a shift in mental health-care provision toward online prevention, care, and management.



Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents have given his consent for images and other clinical information to be reported in the journal. The parents understand that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Xie X, Xue Q, Zhou Y, et al. Mental health status among children in home confinement during the coronavirus disease 2019 outbreak in Hubei Province, China. JAMA Pediatr 2020;174:898-900.  Back to cited text no. 1
    
2.
Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.  Back to cited text no. 2
    
3.
Birmaher B, Brent DA, Chiappetta L, et al. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. J Am Acad Child Adolesc Psychiatry 1999;38:1230-6.  Back to cited text no. 3
    
4.
Tenzek KE, Nickels BM. End-of-life in Disney and Pixar films: An opportunity for engaging in difficult conversation. Omega (Westport) 2019;80:49-68.  Back to cited text no. 4
    
5.
Mathis ET, Dente E, Biel MG. Applying mindfulness-based practices in child psychiatry. Child Adolesc Psychiatr Clin N Am 2019;28:209-20.  Back to cited text no. 5
    
6.
Loades ME, Chatburn E, Higson-Sweeney N, et al. Rapid systematic review: The impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. J Am Acad Child Adolesc Psychiatry 2020;59:1218-39.e3.  Back to cited text no. 6
    
7.
Lee J. Mental health effects of school closures during COVID-19. Lancet Child Adolesc Health 2020;4:421.  Back to cited text no. 7
    
8.
Zelviene P, Kazlauskas E. Adjustment disorder: Current perspectives. Neuropsychiatr Dis Treat 2018;14:375-81.  Back to cited text no. 8
    
9.
Weiskittle RE, Gramling SE. The therapeutic effectiveness of using visual art modalities with the bereaved: A systematic review. Psychol Res Behav Manag 2018;11:9-24.  Back to cited text no. 9
    
10.
Topooco N, Berg M, Johansson S, et al. Chat- and internet-based cognitive-behavioural therapy in treatment of adolescent depression: Randomised controlled trial. BJPsych Open 2018;4:199-207.  Back to cited text no. 10
    


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