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<div>Introduction</div>
<p>The novel coronavirus disease COVID-19, which first appeared on November 17, 2019 in the Hubei province of China, was later declared a public health emergency by the World Health Organization (WHO) (<a ref-type="bibr" href="#j_sjcapp-2021-017_ref_001">1</a>). The pandemic has drastically changed the lives and daily routines of millions of people worldwide. Numerous factors influence the nature and extent of the pandemic’s impact on children, including developmental age, educational status, special needs status, pre-existing mental health conditions, economic disadvantage, and quarantine status (of children or their family members) (<a ref-type="bibr" href="#j_sjcapp-2021-017_ref_002">2</a>). The following sections discuss the impact of the pandemic on children and assess the effectiveness of various interventions employed to improve their mental health during pandemics (both previous and current) in Turkey.</p>
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<div>COVID-19 and child mental health in Turkey</div>
<p>The first case of COVID-19 in Turkey was announced on March 11, 2020. Strict measures were subsequently enacted, including the suspension of in-person instruction in elementary, middle, and high schools on March 16, 2020. In addition to the strict measures concerning certain age and risk groups, an “age-specific lockdown” was imposed on 25.5 million children and young people under the age of twenty in April 2020, with full closures continuing until June 2020. This constituted a major disruption in the daily routine of children and adolescents, as attending school provides routine and order in their day-to-day lives. In the pre-pandemic period, adhering to school routines represented an important coping mechanism for young people with mental health problems (<a ref-type="bibr" href="#j_sjcapp-2021-017_ref_003">3</a>).</p>
<p>The Child and Adolescent Psychiatry Association of Turkey has updated its psychosocial and mental health support guidelines for families, children, and adolescents during the pandemic. One of its recommendations for school-age children concerns the importance of maintaining a daily routine, including school, sleep, meals, screen time, and family activities (<a ref-type="bibr" href="#j_sjcapp-2021-017_ref_004">4</a>).</p>
<p>The association has also developed a social responsibility project entitled “Fairy Tale Pandemic” in order to increase children’s resilience during the pandemic and strengthen their social bonds, as well as to encourage cooperation between healthcare professionals and the people they serve. Social media posts highlighting the day’s events were prepared and shared every day for three weeks, along with an average of three videos recounting various “tales” starting at 19:00. Over the course of the project, a total of 76 videos were uploaded to the Child and Adolescent Psychiatry Association’s Instagram account, which included the contributions of 25 renowned artists, 15 writers, and 25 healthcare workers. The healthcare workers, who read fairy tales, were chosen from among those who worked under difficult conditions and were therefore unable to see their own children for some time.</p>
<p>Many child and adolescent psychiatrists have reduced their patient numbers due to more restricted working hours, while their clinical efforts have been rendered less effective as a result of working in different units. In particular, the inability to admit some psychiatric patients to hospitals as well as time constraints on attending to patients in overcrowded emergency rooms have adversely affected individuals presenting with emergency psychiatric conditions. Furthermore, since the beginning of the pandemic, there has been less focus on mental illness and more on COVID-19; emergency services for child psychiatry have decreased compared to the previous year (<a ref-type="bibr" href="#j_sjcapp-2021-017_ref_005">5</a>). As the prevalence of mental diseases has increased during the pandemic, the negative effects of the latter on mental health services merit further discussion.</p>
<p>During the current crisis, while mental health services for children and adolescents have been temporarily postponed, inpatient and outpatient treatments continue, albeit in drastically decreased numbers, according to Turkish pandemic policy. Unlike most inpatient health services, communal areas in psychiatric units are also widely utilized by outpatients, who dine together and attend group therapy sessions. When cases were detected in pediatric and adolescent psychiatry inpatient facilities, the facilities were closed one by one. In addition, patients in need of inpatient treatment were adversely affected by the closures of psychiatric facilities in some regions due to the pandemic. In order to cope with the difficulties brought about by this situation, telepsychiatry was adopted as a treatment modality, while other units continued to implement treatment protocols through consultation-liaison psychiatry units.</p>
<p>Throughout the course of the pandemic, its effects on mental health and society in general have been investigated. In Turkey, the pandemic’s adverse effects on society prompted the development of policies to deal with them. In cities with large populations, psychosocial support referral networks using telepsychiatry-based applications with volunteer psychiatrists, psychologists, and counselors were established. However, in Turkey, the supply of mental health professionals has not kept up with the continual growth in demand; with this in mind, and especially in light of the need to maintain physical distance during the pandemic, a review of the state of telepsychiatry in Turkey is merited. Some researchers have suggested that telemedicine will help overcome the challenges of psychiatric diagnosis, intervention, and monitoring during the pandemic, while clinicians express concerns about keeping patients safe (<a ref-type="bibr" href="#j_sjcapp-2021-017_ref_006">6</a>).</p>
<p>The treatment and follow-up of children with special needs have presented other challenges. In the first days of the pandemic, the Turkish Ministry of Health implemented solutions for the basic health problems of these individuals, such as facilitating direct access to medicine and extending the validity period of special needs reports. In cases of children with special needs, intervention was considered necessary in anticipation of problems resulting from home isolation and the disruption of daily routines, as well as additional behavioral problems expected with the increased emotional and physical burdens on families. A new approach for individuals with special needs, including an application that can be used on mobile devices, has been developed (<a ref-type="bibr" href="#j_sjcapp-2021-017_ref_007">7</a>). With the application “Special Children Support System”, children with special needs whose behavioral problems worsened during the pandemic and their families have been provided with a support system based on applied behavioral analysis staffed by volunteer mental health workers and educators. The system also allows families and children to receive the support of mental health professionals specializing in child and adolescent psychiatry. Access to the system, which enables video calls through an official and secure channel, is free of charge.</p>
<p>Given the effects of lockdown, a key open question is: what could be done to establish and disseminate remote psychosocial interventions for individuals of all ages to protect their mental health and minimize psychiatric problems during the pandemic? To address this need, a self-help psychological crisis intervention guide named “Duru’s Blue Paint Adventure” was developed using EMDR techniques. The application, which takes approximately twenty minutes, incorporates a story to teach children literature-based psychoeducation, the safe place exercise, and other beneficial exercises. Children who used the application three times over a one-week period showed significant improvement in their trauma scores (<a ref-type="bibr" href="#j_sjcapp-2021-017_ref_008">8</a>).</p>
<p>In the fight against COVID-19, health authorities should create action plans at regional and national levels to determine the availability of resources and evaluate approaches and interventions to children’s mental health, with the goal of maximizing the effectiveness of mental health services.</p>
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<div>COVID-19 and child psychiatry training in Turkey</div>
<p>During the pandemic, medical instruction was temporarily discontinued in Turkey and many other countries due to issues of safety. Instruction was resumed at different times in different countries, and through different means. Training programs in child and adolescent psychiatry have also been negatively affected by the pandemic. As a result of disruptions to standard medical educational programs such as international-national rotations, observerships, and residencies, which both expand and deepen students’ knowledge and experience, opportunities for medical students to improve their clinical skills are more limited.</p>
<p>The field of education has been forced to change during the current crisis according to the possibilities afforded by technology. Telemental health and education represent improved alternative methods for psychiatric training during the COVID-19 pandemic. With this in mind, an e-mentorship program was created and implemented by the Turkish Association for Child and Adolescent Psychiatry (<a ref-type="bibr" href="#j_sjcapp-2021-017_ref_009">9</a>). The goal of this program is to assemble research assistants, specialists (“mentees”), and senior members (“mentors”) from different departments of Child and Adolescent Psychiatry in Turkey to strengthen communication between colleagues, develop the knowledge and experience of young physicians, consult on difficult cases, provide equal opportunities in education, and, perhaps most importantly, to help our young colleagues feel less alone at this difficult time. A total of 115 sessions were held by 29 mentors with the participation of 346 mentees, in small groups, at a rate of four sessions per day on weekdays. In addition to the weekday sessions, main training sessions were conducted every Saturday. Despite the geographical distances separating mentors from mentees, the restructuring of our mentoring program using online platforms allowed for the program to continue, thus enabling the participants to keep in contact with their colleagues.</p>
<p>Unique challenges have emerged over the course of the pandemic for child psychiatrists, including adjustments in workflow between clinical settings while maintaining educational momentum and both physical and psychological well-being. These workplace constraints, combined with the mental and physical effects of COVID-19 on trainees, have consequently revealed the extremely weak support structures for healthcare professionals in Turkey. As an example, resident physicians have been unable to obtain sufficient educational support and clinical practice in psychiatry, a specialization in which clinical evaluations and interviews are critical. Although the pandemic has resulted in untold damage and numerous losses, education is clearly among the most negatively affected spheres.</p>
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<div>Future directions</div>
<p>The current crisis presents opportunities for early career psychiatrists and trainees to conduct research, teach, network, and collaborate via online platforms. With respect to the training of child psychiatrists, in the post-pandemic period, it will be necessary to determine whether to return to traditional teaching and learning methods or to adopt new approaches. The new methods may of course be combined with traditional methods, resulting in a new hybrid system with the potential to reduce disparities in education between countries or universities, thus providing more equal opportunities for all mental health trainees, especially in developing countries. Further benefits of such methods may include increased access to mental health treatment, reduced delays in care, fewer emergency department visits, and improvements in continuity of care, while the use of videoconferencing would lessen the stigma associated with seeking treatment for mental health issues (<a ref-type="bibr" href="#j_sjcapp-2021-017_ref_010">10</a>). In Turkey, educators need to strive to develop sound yet flexible solutions to cope with the entrenched problems in education, to strengthen the education system following the pandemic, as well as to alleviate damage incurred during the latter. Considering that Turkey is among the OECD countries that closed its schools longest during the pandemic, the additional time necessary to compensate for learning losses should be determined and the relevant deficiencies addressed. To that end, a valid, reliable and process-oriented evaluation approach should be adopted.</p>
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Impact of the pandemic on the mental health of children and clinical practice in Turkey: a narrative review with recommendations

Scandinavian Journal of Child and Adolescent Psychiatry and Psychology

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Impact of the pandemic on the mental health of children and clinical practice in Turkey: a narrative review with recommendations

Article Category: Letter to the Editor

Published Online: Aug 07, 2021

Page range: 160 - 162

Received: Jul 08, 2021

Accepted: Aug 03, 2021

DOI: https://doi.org/10.21307/sjcapp-2021-017

© 2021 Serkan Turan et al., published by sciendo.

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.