Jörg M. Fegert (ESCAP Policy Division Head), Laura A. Kehoe (ESCAP Communications Editor), Benedetto Vitiello (M.D., Professor and Director of Child and Adolescent Neuropsychiatry, University of Turin), and Andreas Karwautz, Stephan Eliez, Jean-Philippe Raynaud, Eniko Kiss, Maeve Doyle, Milica Pejovic-Milovancevic, Konstantinos Kotsis, Manon Hillegers, Johannes Hebebrand, Anne Marie Räberg Christensen, Sofie Crommen and Dimitris Anagnostopoulos.

Coronavirus (SARS-CoV-2) is profoundly impacting lives around the globe. Isolation, contact restrictions and economic shutdown impose a complete change to our psychosocial environment. As the pandemic is evolving through phases, ESCAP is evaluating the impact these phases will have on child and adolescent psychiatric service provisions.

Child and adolescent psychiatrists (CAP) are forced and willing to change their way of practice through innovative approaches, such as adopting the use of digital web-based online therapy and telepsychiatry to continue treatment. Current work strategies are being re-organised so CAP can remain connected and available to their patients and families, all while maintaining good clinical practice. However, to keep the disruption to a minimum, services must remain active, we must communicate with networking partners and avoid further closure of psychiatric units.

This position statement highlights some key challenges and concerns for CAP across Europe and offer some recommendations that can be used immediately.

Challenges that CAP services are facing

• Families are forced to re-organise family life and cope with the stress of quarantine and social distancing. School shutdowns have led to home-schooling and potential postponement of exams. Parents are experiencing increased pressure to work from home, keep jobs and businesses running as well as occupy and comfort children at the same time. It also falls on the parent's shoulders to inform and explain to children about the Coronavirus pandemic, and to handle the fear and anxiety that accompanies these unknown times. Low-income families are hardest hit. There will be increased discrepancies between families with good educational background and a lot of resources and families in need of support.
• A proportion of children with acute and life-threatening psychiatric disorders require CAP inpatient treatments throughout all phases of the pandemic. In some countries, children with pre-existing mental needs, e.g. severe forms of autism, are being deprived of professional support systems meaning families and parents are left to cope on their own. Some countries have seen the closure of specialised and complex educational settings for children with developmental problems and multiple handicaps.
• Since the pandemic was announced, several countries have seen a re-organisation of hospital services, and provisional care (including re-assigning doctors and nurses not usually involved in critical care). There has been closures, partial closures or reduced services of inpatient and day-care facilities, with outpatient contacts reduced to emergency cases only. Some hospitals are unable to accept new inpatients due to the risk of infection.
• With a lot of creativity and motivation to re-organise mental healthcare, the pandemic has resulted in a massive increase in the use of telepsychiatry. However, regulations on how to reimburse these services are not in place, and this lack of structure is causing confusion. Of course, care of the patient is paramount and treatment should not be delayed. However, telepsychiatry may not be available to all persons or it may not be used in a safe and confidential environment.

Risks and concerns of patients, families and CAP

• Domestic violence and child abuse might increase due to extended periods of isolation within an abusive or unsafe home, and less intense supervision from child protection services and lacking support from peers or schools.
• The economic crisis brought by the pandemic could have long-term negative consequences leading to increased family conflict, abuse, and substance abuse.
• The pandemic is disrupting the normal bereavement processes of families. Grief and mourning of lost family members, especially in cases where contact with the infected member was restricted, could lead to feelings of guilt, adjustment problems, post-traumatic stress disorder and depression in both adults and youths.
• Severity and outcome of mental disorders could worsen because of delay in prompt diagnosis and treatment.
• The restrictions on parental visits for inpatients and their increased isolation from families and social contacts can increase the risk of depression, anxiety and suicidal behaviour. Interventions and psychoeducation to the whole family remain central for CAP but are much more difficult under these conditions.
• Even for less severe patients, continuity of care is being disrupted as routine outpatient visits are being cancelled and postponed for safety reasons.
• Unaccompanied and accompanied refugee minors are a high-risk group. Panic and fear of infection has developed as some early cases of Coronavirus have been reported in refugee institutions, shelters and camps. This population group lacks medical and psychiatric specialist care, which is a major concern.
• Telepsychiatry is increasingly being used to bridge the gap caused by social distancing regulations. Its extensive use is likely to continue once the pandemic ends. Its use has raised questions about data protection, high technical protection standards and also stressed the need for more user-friendly and easier to handle systems that can be used by all age groups regardless of abilities.

Ad hoc recommendations

These recommendations are not official guidelines.

• In most countries, National Societies since the beginning of the crisis have taken an active role to face the pandemic. They are putting forward initiatives to support the continuity of care, to guide parents, teachers, children and health professionals on how to handle the mental issues and to advocate national authorities on the bio-psycho-social impact of the crisis in the life of children and adolescents. Social media is playing a key role in distributing this information. See ESCAP Resource List.
• Crisis interventions must be accessible all the time. We recommend a first screening of patients via helplines to avoid infections. Several appointments should be arranged for patients with new onset of child psychiatric disorders and directed to adequate care.
• Keep outpatient and inpatient facilities open as much as possible following all necessary protocols to prevent transmission of the virus.
• Parents and patients in need of ongoing medication should be advised by their doctor to stock a certain amount in case of a rupture in stock. This isn’t hoarding but taking adequate measures to treat chronically ill patients. Doctors could prescribe extra prescriptions.
• CAP institutions should keep contact with patients of special needs and those patients missing out on specialised education systems to avoid disrupting current treatment programs and offer support to caregivers.
• If inpatients have reduced access to family due to hygiene restrictions, adhering to the UN-Convention of Children’s Rights, units should maintain contact with the patient’s family as much as possible. Allow digital communication with the patient’s family.
• The use of telepsychiatry approaches and online therapy or telephone consultations allows for patients to continue therapy and treatment. Using these platforms with parents can also allow the psychiatrist to offer guidance and counselling to the parents as they become more actively involved in the therapy of their child. Support is key.
• During and after the pandemic, it will be useful to analyse these interventions to determine measures of quality control and ask patients and parents through questionnaires about the usefulness of online therapy to help maintain such services in the future.
• Maintain training for child psychiatrists by switching to online training and supervision, video presentations, web-based training programs and courses, and allow their time spent in critical care (if re-assigned) to count towards their overall training program.
• In the third phase of the pandemic (return to normality), it will be important to quickly re-organise and re-establish lost treatment with patients and develop strategies for CAP to deal with the burden and strain of new patients not seen or referred during the pandemic. Offer adequate services to families to deal with the aftermath of the pandemic.

Conclusion

Despite the difficult circumstances, we applaud all persons in the healthcare professionals dealing with patients during this time. Child and adolescent mental health services continue to serve all the children they can, some on a voluntary basis, while taking protective measures to avoid spreading the virus.

ESCAP calls to national governments and EU authorities to take all the necessary decisions in every medical field and also all the financial measures to reduce negative consequences on peoples’ health and to implement lessons learned during the crisis for future service delivery.

ESCAP will continue to monitor the situation and offer advice and guidance whenever we can. We need to work as a community, to come together and think of innovative ways to re-organise and re-structure the CAP services throughout Europe. At the heart of all this, we need to ensure that all children will be protected and have the resources they need to understand what is happening now during the pandemic and to deal with its consequences when it finally comes to a close.

If you'd like to comment or assist us in our communication on this topic, please contact our editor at editor@escap.eu. 

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Page updated: 9th April 2020

Image: Martin Sanchez on Unsplash