COVID-19 and the need for child and adolescent telepsychiatry services, a case report

A 10-year-old (A) has been brought by his father to the Child and Adolescent Psychiatry (CAP) services of a tertiary care medical center. His abnormal movements have worsened, stuttering increased, and he is now unable to sit for a while even for small academic activities. His parents are scared to give him any studies related tasks lest his abnormal movements would worsen. Unable to bear his sufferings anymore and despite the prevailing lockdown orders, his father, being an essential service provider managed to get his son for consultation.

Another 15-year-old (B) came from Medicine in-patient services to CAP unit because of his repeated attempts of running away. He was admitted for a suicide attempt by partial hanging, and while in the process of medical recovery, he needed specialized CAP care. The ligature marks around his neck and his subconjunctival haemorrhagic patches still visible.

A’s condition has deteriorated with school closure and lockdown restrictions resulting in home confinement with no access to school and no opportunity to play. B’s smartphone use had increased exponentially, and his unfulfilled demands for a 4 G phone precipitated his suicide attempt. Both the children’s parents are distraught and give a harrowing account of their experience of navigating through the lockdown and reaching the tertiary healthcare centre. A’s father is somewhat pacified when after two outpatient visits, he could sense an improvement in his son’s condition and now looks forward to telepsychiatry consultations, which would just be appropriate for him for he has a high-end smartphone with facilities for video-conferencing. However, B’s mother shares her helplessness and a sense of impending doom over the plight of her son upon discharge. She is happy with the care her son is receiving in a controlled environment with small behavioral interventions in place. However, she is worried about the difficulty she is going to face after discharge, knowing how difficult it is to manage the impulsive behaviors of her son.

These two cases highlight the severe problems faced by caregivers of children with psychiatric illnesses in the backdrop of lockdown. The government of India imposed lockdown from 25th march to contain the COVID-19 pandemic (Government of India notification). The routine life of children has been jeopardized since then, which may result in a long-lasting detrimental impact on children’s cognitive development and scars in their tender psyche. Children are now confined to homes with no access to play, friends, teachers, trainers, and counselors. Many of them are subjected to the abusive domestic environment (Green, 2020)

Globally, mental disorders in children and adolescents are often unrecognized and untreated owing to a plethora of problems. Children and adolescents do not seek care out of multiple complex issues like ignorance, logistic barriers in care access, and social problems like stigma and discrimination (Radez et al., 2020). The existing specialized CAP services in India are limited to urban centers, which few can access. The paucity of service provision and the absence of child mental health policy has been well-documented (Malhotra & Padhy 2015). COVID-19 has further highlighted the immense demand-supply gap of CAP services.

In the wake of the COVID-19 lockdown, the Odisha government has made teleconsultation provisions for psychiatry at district levels (H&FW Dept Odisha, 2020). Most of the psychiatrists working at the district level have little experience in child psychiatry and often express their difficulty in assessing and managing children with mental disorders. Adding to the problem is the enormous medical and psychological burden that COVID-19 is causing to the medical practitioners. Most of them are managing routine outpatient and in-patient services, and many are assigned the responsibilities of COVID-19 related patient care only to widen the gap of CAP services further.

Telemedicine facilities have proven feasible and effective solutions for addressing the vast gap of CAP services. Telepsychiatry has been documented to be useful in medical conditions as well as in emergency psychiatric disorders, even in rural settings. Telepsychiatry services in CAP have been functioning with promising outcomes in a tertiary medical center (Malhotra et al., 2015). COVID-19 has further highlighted the need for provisioning and setting up CAP telepsychiatry services (Tandon, 2020a; Tandon, 2020b). While the provision has been initiated in isolated pockets; a lot needs to be done to establish a system of integrated CAP telepsychiatry services across India.

Ethics statement

The authors hereby declare that they have followed the ethical guidelines as prescribed by Indian Council of Medical Research in this manuscript.

Declaration of Competing Interest

The authors declare they have no conflict of interest.