COVID-19 and Immunization: Reflections and Rationale on Why Child and Adolescent Psychiatry Should Help

Abstract

The COVID-19 pandemic has resulted in widespread reflection in medical communities about the role of professional stakeholders in public health interventions. Health professionals, including mental health clinicians, should question how, when, and why they should intervene to address the obstacles and objections to these interventions.

Diversity & Inclusion Statement: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

The COVID-19 pandemic has resulted in widespread reflection in medical communities about the role of professional stakeholders in public health interventions. Health professionals, including mental health clinicians, should question how, when, and why they should intervene to address the obstacles and objections to these interventions.

One public health intervention, immunization, has been shown to be an effective and safe way to reduce the morbidity, the mortality, and the psychosocial consequences of the COVID-19 pandemic.¹ Immunization as a public health policy, however, has faced objections, and providing vaccinations has been hindered by practical, structural, and social barriers. These have contributed to inequitable and inadequate rates of immunization, which remain particularly low in many populations of children and adolescents.¹

In a recently published paper, Rothe et al. ² discuss the role of child and adolescent psychiatrists in dealing with the impact of COVID-19 for already underprivileged Latinx children in the United States. The structural violence, social underprivilege, and inequity observed in US Latinx communities² is similarly, although not identically, present in Latin American youth and those in other low- and middle-income countries (LMICs).^{3 , 4} In LMICs, the COVID-19 outbreak worsened an already existing scenario of mental health risk, resulting in a locally shaped syndemic.^{2 ,} 4, 5, 6 Such a complex scenario, marked by intersectionalities,⁷ required a response from public health officials and advocates, including mental health practitioners.^{4 , 6 , 8}

The Need for Mental Health Providers to Address Immunization

Our local observations suggest that there is a substantial potential for child and adolescent psychiatrists to increase their participation in the promotion of immunization. Despite gaps in the research on the direct impact of immunization on mental health, we join Rothe et al. ² in recommending engagement with these complex social and political issues, even if they are perceived as outside the psychiatrist’s role. We believe that psychiatric caregivers have a clear role to play in supporting public health interventions.

First, the pandemic has had a direct deleterious effect on the psychosocial development of youth. In particular, school closures have had negative consequences for child and adolescent mental health.^{2 , 3 , 8 , 9} The lack of on-site schooling and group activities was shown to be a risk factor for psychological suffering for children and their families.^{3 , 9} In addition, home schooling may not offer adequate resources for children with special needs.³ Now that COVID-19 immunization rates have increased, with children as young as 6 months of age being vaccinated,¹ these public health counter-measures can be lessened, a demonstrable benefit to youth. Similarly, lower transmission and risk of contagion provided by immunization enables safer attendance of mental health facilities, improving treatment adherence and rehabilitation.^{2 , 8 , 10}

Second, access to mental health services and education must not be considered in isolation. They are directly related to many domains of development and childhood life, including social development, nutrition, and inequity. For example, the loss of the social protection offered by schools increased children’s exposure to domestic and neighborhood violence, impaired their leisure opportunities, and worsened other effects of poverty. ³ Food insecurity became a problem as meals were no longer provided in schools, and food costs for these children increased the risk of poverty in many societies.³ In addition, although telepsychiatry has been shown to be feasible, it is dependent on access to electronic devices and Internet availability, which might be less available to minoritized or marginalized communities, especially in socially lower economic classes.² The pandemic has exacerbated inequalities by unequally exposing youth to more psychosocial risks with less access to treatment.⁸

A Space for Engaging With Concerns

Child and adolescent psychiatrists are in a privileged position to advocate based on science, both in terms of a broader advocacy but also in terms of local engagement, including in their practices. We have the opportunity to collaborate with our patients and families respectfully and yet openly on matters of health care, especially around delicate topics. It is an opportunity to bridge medical, psychosocial, and psychiatric perspectives, recognizing the artificiality of some of these distinctions, while safely exploring sources of resistance, confronting social divisiveness, helping our families negotiate government mistrust, and speaking out against conspiracy theories that empower anti-vaccine movements.^{1 , 10 , 11}

Given that immunization coverage has been hindered by behaviors, fantasies, beliefs, and fears, as well as by inequalities and disparities, child and adolescent psychiatrists are uniquely positioned to address these concerns. Furthermore, discussing vaccination as an individual’s contribution to improved public health can be a productive way of supporting an individual’s contribution to the collective as well as therapeutic validation of agency when faced with ambient trauma that is isolating and disempowering.

Community Cohesion Is Part of Child Psychosocial Development

The pandemic has demonstrated the extent to which the networks that are needed to support healthy childhood development are interconnected, but also the frailty of these networks. Voices that connect advocacy for childhood psychosocial development with public health policies such as immunization are an opportunity to advocate for the strengthening of these networks and their necessity in the lives of children.

As discussed above, psychosocial development entails multiple, interconnected networks. In Bronfenbrenner’s Ecological Framework for Human Development, a child’s development is situated within multiple systems, nested within one another.¹² Bronfenbrenner’s model explicitly recognizes interactions that may not appear to directly involve the child but that can nevertheless impact the child’s development, including adult−adult relations, an interconnectedness that was made more visible during the pandemic (where, for example, parents struggled to maintain their own outside peer relationships). A second striking feature is that the framework includes values, beliefs, politics, and societal organization, recognizing that these cannot be excluded from an understanding of child development and must be addressed if we are to promote child well-being.¹²

The promotion of public health interventions can stimulate social cohesion, encourage dialogue with underrepresented and marginalized communities, and teach the importance of collective responsibility. For example, despite the low immunization coverage in some Brazilian areas, we have observed lively demonstrations of creativity in how vaccination programs have been rolled out. Children wearing costumes, carrying photos of deceased family members and friends, and expressing gratitude for immunization and the national health system became a ritual of care. This was frequently shared on social media, demonstrating digital activism in favor of immunization in which agency, resilience, and empowerment are given back to children and their families. Vaccination became a rite of passage, but also a turning point for social and psychological reorganization in a society that was deeply fragmented by the pandemic. Vaccination became a social contract in which individuals, including youth, can demonstrate their commitment to and engagement with the collective. This process is essential to the psychosocial and emotional development of youth.¹²

Medical providers likewise engaged with vaccination as a cultural practice for youth, for example by providing empathetic and entertaining spaces for vaccination in which health professionals were dressed as superheroes and awarding “being courageous” certificates to those who were vaccinated. This does more than make the children comfortable, it enables the inclusion and participation of children in the process as important and valued actors in society. Beyond potential medical benefits, these kinds of engaging practices and warm, community support could have a positive outcome on mental health.

Conclusion

The COVID-19 pandemic showed how new and emergent health challenges have adversely affected the mental health of all children, with worse effects on underprivileged and minoritized youth. Just as health workers in primary care fields have been encouraged to apply early psychological care as a preventive strategy, child and adolescent psychiatrists can broaden their clinical interventions to protect child development and to promote mental health by engaging directly with the public health policies and strategies that affect child development.^{1 , 7 , 13}

Promoting mental health in children and adolescents must take into account differences in ethnicity, culture, and individual freedoms,² but should not be misinterpreted as a reason for psychiatrists to turn a blind eye to their duties to the community as health professionals. The pandemic has widened our vision of what mental health encompasses in both clinical practice and professional training. Checking immunization status, promoting immunization, and publicizing vaccination campaigns, in addition to other scientifically validated behaviors aimed at community health improvement, can be a standard practice for psychiatrists. We have the opportunity to encourage and participate in community practices that transform adversity into empowering experiences, strengthen social cohesion, and help youth and their families negotiate social responsibility.