How paediatric psycho‐oncology is changing during the COVID‐19 epidemic in Italy: New approaches

1.

The city of Turin, located in Piedmont, north‐west Italy, is the fourth largest city in Italy with almost 900 000 citizens in the municipality and 2 200 000 if we consider the city plus the surrounding area of its 315 municipalities. Since the end of April 2020, Piedmont and more specifically the metropolitan city of Turin, has been one of the mostly highly affected areas by the COVID‐19 pandemic with more than 20 000 cases throughout Piedmont and almost 10 000 in Turin alone. It has had the fourth highest number of positive cases in the country. ¹ International research ² , ³ , ⁴ is demonstrating that this particular coronavirus mainly affects older people and therefore cannot be considered a paediatric concern as such. This is also confirmed by Italian data that estimates the incidence of positive cases among children (age 0‐18) stands at around 1.2%. ⁵ , ⁶ Nonetheless, the epidemic has a potentially devastating indirect impact on the paediatric oncology population and the family as a whole. First, in consideration of their immunodepression, young patients are weaker and less able to fight infection. Second, they are already undergoing a psychological stressful condition due to the intense treatments they are receiving on a daily basis. Third, patient and caregiver are now being forced to tolerate social and relational isolation that is much stricter than they would be required to experience under normal circumstances. Finally, off‐treatment patients may suffer from feelings of anxiety if they find themselves reliving the limitations and fears they experienced during the course of treatment (fear of infection, isolation, use of extensive precautions).

Located in the municipality of Turin, the Department of Paediatric Oncology of the Regina Margherita Children's Hospital is the baseline validated Hub ⁷ for the entire Piedmont and Aosta Valley and one of the main centres at national level (about 8% of total diagnoses in Italy). ⁸ Its Psycho‐oncology Unit, manages more than 150 new diagnoses per year, providing highly‐structured psychological support to child and adolescent patients and their families. Psycho‐oncologists also take care of patients who have concluded their therapy (“off‐therapy patients” who make up around 40 per year) as well as mediating the complex relationships: patients and their families, doctors and educational services (hospital school, social services and volunteers). The entire range of psychological activities is regulated by formalized protocols that help professionals orient their interventions which are currently organized in three levels: (1) preventive (diagnosis communication with psycho‐oncologist and oncologist and preliminary interviews with patients and families), (2) diagnostic‐therapeutic, (3) psycho‐therapeutic, psycho‐pharmacologist and psycho‐social.

Since February 23, when the first positive cases of Covid‐19 appeared in the city of Turin, the Regina Margherita Children's Hospital implemented security procedures to prevent any possible contamination by following government directives. ⁹ Visitors' access to the Hospital was interrupted and even educational and recreational activities were stopped, forcing patients to endure new trauma and the inevitable suffering that psycho‐oncologists have been left to cope with.

Key Points.

• Pediatric oncology patients and families have been more vulnerable during the Covid‐19 pandemic due to their general health and psychosocial conditions during active and off‐treatment.

• Psycho‐oncologists should specifically support the parent (usually the father) who is forced to stay at home to reduce their sense of impotence due to the distance regulations imposed by the Covid‐19 welfare hospital rules.

• Cancer survivors, especially adolescents are more fearful and hypervigilant to physical sensations and could experience post‐traumatic stress symptoms because of the conditions Covid‐19 has precipitated.

• Professionals have experienced an emotional tension between the need to provide the best care to their patients and the fear of exposing themselves to risk of contagion.

• Psychosocial support and interventions, guaranteed for every patient and family, should be adapted and extend to stressful events that may occur externally over the cancer trajectory.

This is a historical moment in which psycho‐oncology can make even more of a difference. In fact, psycho‐oncologists have recognized the need for new strategies to cope with this unexpected event. A wide spectrum of services has been modified or created from scratch by psycho‐oncologists who, together with doctors and nurses, are available around the clock.

The major challenge observed due to Covid‐19 was visiting restrictions which resulted in causing an additional burden for parents. Currently, patient assistance is limited to a single parent: the mother and father of the child or adolescent cannot take turns anymore as a result of the restrictions imposed by the Covid‐19 welfare hospital rules which have led to an inevitable increase in physical and psychological stress and fatigue. These conditions are particularly critical for newly diagnosed cases in which the principal caregiver, usually the mother, is forced to experience traumatic events completely alone (eg, diagnosis communication, CVC, lumbar puncture, bone marrow aspiration, first chemotherapy treatment). As one mother stated, “It is a sufferance on a sufferance”. To overcome that, psycho‐oncologists have adapted their work based on the needs of the patients First, face‐to‐face psychological support for parents who are hospitalized and alone has been intensified in order to provide relief. Psycho‐oncologists not only proposed verbal support to parents but also practical aid. For example, in the case of hospitalized infants, the psychologists took temporary care of the children, allowing the mothers to take a shower or have a rest for an hour. Practical assistance has also extended to several phone calls to those parents who are forced to stay at home, scheduled by the oncologists and psycho‐oncologists involved to offer the parent emotional support and regular updates about the clinical condition of their children. This strategy permits the parent to be part of the care process by reducing their sense of impotence and allowing them to be at least emotionally close to their families even if geographically they must keep their distance. In this sense, psycho‐oncologists become a “therapeutic bridge” who guarantees an emotional connectivity between father and mother, because they encourage the distant parent to provide support and they reassure him/her about his/her crucial role in the care path.

Several difficulties during the pandemic have also been faced by cancer survivors. Adolescents in the off‐therapy phase are suffering the most because they are conscious of their fragile condition and the potential risks: anxiety and panic are not rare; indeed, they are increasing significantly. Adolescents have shown themselves to be more fearful, hypervigilant to physical sensations and at risk of experiencing symptoms of post‐traumatic stress because of Covid‐19s particular set of circumstances. For this reason, active listening engagements have been proposed; verbal psychological support and anxiety containment in one‐to‐one phone calls reinforced by training in relaxation and breathing techniques. These 40‐minute phone calls are scheduled with the adolescent twice weekly. In addition to stress management, the adolescent is given practical guidance on where to find reliable information about the pandemic by limiting internet browsing on unreliable sites.

It is also commonly believed that professionals themselves have faced several challenges from a physical and psychological point of view. Professionals, such as oncologists, nurses and psycho‐oncologists are currently living with an internal conflict: the need to provide the best care to every patient, but the fear of infecting or be infected. To support those who fight the Covid‐19 battle on the front lines, an on‐demand support service was immediately activated for professionals throughout the entire hospital while in the Department of Oncology, due to the particular conditions of patients and professionals, the service is more structured. A psychologist is available 24 hours a day and an interdisciplinary meeting group, in which the cases are discussed from a clinical and psychological point of view, has been created through digital devices.

In summary, the above‐mentioned strategies, that are nonetheless limited and could be further enriched, are guaranteeing a high‐level of psychological service to a clinical ecosystem of child and adolescent patients with oncological diseases and their parents and the professionals who are severely affected by the Covid‐19 epidemic.

The unprecedented nature of the Covid‐19 pandemic is teaching us that the presence of psycho‐oncologists is fundamental in healthcare settings and support must be offered to every patient and their family. This is because, regardless of how the patient reacts to and faces a cancer diagnosis, unforeseen events, even of a far‐reaching nature, can occur during their care path that have the power to interfere with the cancer trajectory. Therefore, the psycho‐oncologist acquires an even more powerful therapeutic value in being able to support patients and parents with a possible dual trauma.

This pandemic poses a huge challenge and, at the same time, a crucial opportunity for paediatric psycho‐oncologists.

It is certain that some support instruments, such as digital devices, are extremely valuable because they decrease the sense of isolation and allow patients and parents to feel included in the psycho‐oncological process over time.

The pandemic requires the psycho‐oncologist to adapt in terms of professionalism and personal aptitude and furthermore represents the chance for them to learn and discover the potential for new working methods that could also be applied in the future.

In this particular moment, in which social distance is mandatory, psycho‐oncologists have learnt that closeness and emotional presence can be created and shared even if through a screen or a phone. As psycho‐oncologist stated: “We have learnt that we can smile and be empathic with parents and children even through a face mask, using our eyes to generate an emotional connection: this is our biggest victory”.

CONFLICTS OF INTEREST

No potential conflicts of interest were reported.

Zucchetti G, Bertolotti M, Fagioli F. How paediatric psycho‐oncology is changing during the COVID‐19 epidemic in Italy: New approaches. Psycho‐Oncology. 2020;29:1384–1386. 10.1002/pon.5444

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.