Introduction
In Portugal, as in many other European countries, the COVID-19 crisis and the nationwide state of emergency, forced families into social confinement. During this period, families were asked to stay home. Gathering in public areas was forbidden. Schools were closed and telework was generally implemented. Commercial establishments were closed except those providing basic needs. Leaving home was authorized for acquiring goods, imperative services, and medical assistance as well as other reasons of extreme need. Short trips for adults and children were allowed for physical activity or walking pets.
These measures had an obvious impact on Portuguese families as well as families all over the world. “Stay home” made a change in daily routines and family ties, for families. “Stay home” meant “adapt and be resilient to get through” but, sometimes, it also meant, “stay safely together, enjoy your children!” Although Portuguese social security provided support for parents to stay home with children under 13 years of age during this period, many families experienced a financial negative impact with a crisis in the labour market, leading to temporary layoffs and unemployment.
The Portuguese National Health Service had no rupture in intensive care units and inpatient services, but ambulatory care changed, and telemedicine was the preferred way of providing non-urgent consultations. During this period there was a significant decrease in Emergency Room visits, most probably due to the fear of contagion in the health services. There was also an excess of mortality per month due to non-covid diseases compared to the monthly average of the past 5 years (2015-2019) (source: Ministry of Health of Portugal).
Our Unit is affiliated with the main Portuguese pediatric hospital in the capital city, Lisboa, which was the center for the COVID crisis. The implementation of the contingency plan to face the crisis resulted in structural changes in the hospital. Consequently, our facilities were needed to install Emergency Room Services. We had to adapt our practice to deal with distance, the fear of families to bring their child to the hospital, and the new dynamics of teamwork that reflected individual responses to stress and fear. Also, we needed to rapidly adapt to using telemedicine and social networks. We kept on providing mental health and developmental services for babies and young children, and their families in a new way. The aim of this article is to describe this experience and show how we dealt with it.
During the first 3 weeks of this period, two infants were admitted to the Emergency Room of the main pediatric hospital in Lisboa, with developmental regression.
Case 1
- A 9-month-old male infant, with no relevant personal or family medical history, showed drowsiness, decreased motor activity, and loss of skills. Namely, absence of response to name, social smile, coos and gurgles or anticipatory gestures, and had not been maintaining circles of communication for the last three days.
- The physical exam was normal. Hematological, biochemical, metabolic, and immunological laboratory studies were normal. RT-PCR SARS-CoV-2 was undetected. Cranial CT scan and MRI were unremarkable.
- During hospitalization, the baby showed persistent avoidance of eye contact. They also showed fluctuating abnormal engagement and communication behaviors. No treatment was provided.
Case 2
- A 4-month-old female infant, with no relevant personal medical history, showed for the last 2 weeks, periods of irritability and drowsiness, and sporadic chills. There was a maternal family history of epilepsy.
- This was the first child of a healthy and young couple; the mother suffered from two previous abortions (1 fetus diagnosed with trisomy 18).
- The physical exam was normal. Hematological, biochemical, metabolic, and immunological laboratory studies were normal. CSF culture was negative. Blood culture was contaminated. Blood and CSF were negative for neurotropic vírus. RT-PCR SARS-CoV-2 was undetected.
- This infant was treated with antibiotics and antivirals, in the hospital. She clinically improved and was discharged after 7 days. The next day she was readmitted due to drowsiness, restricted response to social interaction, loss of social smile, and lack of interest in toys. Sparse ocular flutter of unknown etiology was observed.
- Laboratory studies were expanded and included tests for toxic substances and metanephrines in urine, serum and urinary catecholamines, and CSF; all were normal. Blood and CSF cultures were negative. Cranial CT scan and MRI were unremarkable. EEG was normal. Chest X-ray and abdominal ultrasound were normal. Ophthalmologic evaluation revealed pseudo-strabismus.
- During the 8 days of hospitalization, without targeted therapy, she gradually improved returning to her previous state.
Post-discharge video-based interventions
After hospital discharge, both babies were followed-up in an Infant and Early Childhood Development and Mental Health Center – Centro de Estudos do Bebé da Criança. Facing strong restrictions due to obligatory social confinement and health services restructuring already mentioned, we set up a video-based methodology for follow-up and treatment.
Methods
- We set up a video-call-based developmental and mental health approach.
- The therapeutic target was on the regulation of the interaction between parents and babies and on the promotion of developmental competencies.
- We approached individual characteristics of the dyad and the triad and follow-up clinical evolution, namely signs of an arrest in the acquisition of developmental competencies or regression, or more subtle fluctuating signs and symptoms.
- Legal and regulatory procedures were followed.
The team included a child and adolescent psychiatrist, a neuro-pediatrician, residents, and a mental health nurse. Each member was introduced to the family. They could see the team during the whole session and the setting was the same for all sessions giving a sense of continuity. The team was in the same room, using face masks. For each family case, there was a referral doctor that headed the approach sitting nearer to the camera, with contributions from the others when needed. Residents were observers.
- The first two weekly sessions consisted of an interview with the parents and naturalistic observation of the baby, for 45 minutes.
- Both parents and the baby were always present during observations. In case 2, the family dog was also around.
- The parents were free to choose where they wanted to be seen: one of the families (case 1) set the camera up in a wide and comfortable living room and the other (case 2) set it up in the bedroom, namely on the bed.
The second set of sessions focused on parent-infant interaction regulation and included instructions concerning the setting (toys, camera, the distance between family members to facilitate baby and parents interaction and communication circles) as well as counseling on developmental and behavioral issues.
The evolution of both cases allowed us to make some diagnostic considerations using the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood – Zero to Three (DC:0-5), which is a five-axis classification system.
Results
Case 1
The video-based observation was consistent with subtle signs of limited social-emotional responsivity or sustained social attention, namely reduced ability to engage in reciprocal games and to initiate joint attention. A deficit in non-verbal social-communication behavior, by an atypical use of eye contact, was also a concern. However, compared to the hospital stay, the clinical evolution was favorable.
In the first video session, language acquisition was already a strength. He was vocalizing again and understanding mother ́s speech: when mother said the word “plane”, he looked through the window. Some pragmatic competencies, meaning the ability to use and understand some gestures appropriately, were also present. For example, the baby responded to the parents’ outstretched arms to change laps. Later, he also followed his parent’s pointing gesture and accepted the proposal to move around the room. His favorite toy was a car that he orally explored and repeatedly dropped to the floor. Movement and physical competencies were otherwise fully present.
During the first sessions, the mother was anxiously talking about the whole week’s progress. She was also sharing her doubts and concerns about regression using pressured and perseverated speech. As our presence became frequent, she calmed down and took some quiet pauses in her speech. The father was mainly around the child. When needed, to clarify some facts, he interjected with his partner’s talk.
During the observations and analyzing the material from the way the parents talked about their worries, we could appreciate no other signs of concern in respect to the quality of caregiver/infant interaction and relationship (except the anxious and overstimulating response already mentioned).
The parents were able to play in a joint format, to propose turn-taking sequences, to show contingent talk, with the presence of motherese. They were pointing to present the external world; they were emotionally attuned and showed affect.
The DC: 0-5
This infant was classified (axis I) as Early Atypical Autism Spectrum Disorder, mild (a Depressive Disorder was dismissed); (axis II) caregiver and infant contributions to the relationship quality was in level 1, well adapt relationships, concern – anxious response and overstimulating; (axis III) despite extensive investigation, no physical health conditions were identified; (axis IV) no psychosocial stressors; (axis V) social-relational and language-social communication developmental competencies are inconsistently present or emerging.
The parents were guided to regulate the interaction:
- They were asked to look for the best physical distance between their son and themselves that would facilitate eye contact.
- To adapt the tone of voice and speech rate and style of commenting.
- To always respond to communicative gestures; and
- Practical suggestions were made to tune-in to the infant’s needs and rhythms, and to follow his lead, not overstimulating.
Case 2
Video-based baby observation was indicative of global developmental delay.
When the camera was turned on, the baby was on her mother’s lap in front of the camera, on the bed. The baby had a blank expression, sparsely looking at her mother’s face. Motor competence of holding head up without support was inconsistently present. Her hands were often open and in her mouth. She was vocalizing poorly. After a small period of time, she began to protest and the mother laid her on the bed, distracting her with a rattle, but she showed no interest.
In another session, the baby was crying, and the father unsuccessfully tried to comfort her by proximity and by touching her face, especially her lips.
In a third session, we were surprised by the interest in the family dog, as the baby was focused on the pet for a couple of minutes.
Although both parents were present during all the sessions, only in the third session did the father let himself be seen on camera. This was important for us as a sign of therapeutic adherence.
The mother was focused on infant symptomatic behavior namely periods of excessive sleepiness that alternated with periods of irritability. Both parents had difficulties in providing comfort for their baby’s distress.
Social services were another topic that was present in the mother’s speech and the possibility to receive support to move to a bigger house. They lived in a shared house with the father’s family.
The DC: 0-5
This baby was classified (axis I) as Global Developmental Delay; (axis II) caregiver and infant contributions to the relationship quality was in level 2, strained relationship; (axis III) extensive genetical investigation is in progress; (axis IV) economical and employment challenges were considered as psychosocial stressors; (axis V) global developmental competencies are not meeting expectations.
Our approach was to:
- Guide the parents to recognize and respond to the infant’s emotional needs and signals.
- We also suggested some exercises that could help to improve motor patterns and motor milestones acquisitions.
- Afterward, an approach that focused on the mother-infant relationship was initiated, especially when the mother felt secure to verbalize her suffering with previous pregnancies.
- Further investigations on the genetic etiology of global developmental delay are being performed.
Discussion
We think that this video-based approach provides comprehensive management, allowing early intervention, and taking advantage, even in times of pandemic crisis, of the earliest window of opportunity for brain development and plasticity during the first year of life.
Additionally, this experience raises several questions.
- To start with, the mandatory confinement and permanent cohabitation, along with the consequent change in family routines, may allow parents to closely observe their babies. Is this an opportunity for families to detect earlier subtle warning signs of abnormal neurodevelopment?
- The challenge of re-thinking the intervention setting. It was now split into two scenarios (the patients’ own home and the hospital) and limited by the camera angles that were dependent on the will of both sides, and not under our control. Taking these differences into account, we respected the family choices, and we made a naturalistic home video observation, during the first sessions.
- We were able to offer guided interactions, between the parents and their baby. For example, to regulate the distance between the dyad, and follow the lead of the baby, to help the family with joint attention, responsivity to sensory inputs, and the regulation of themselves and their baby.
From the parent’s point of view
The setting design was also completely new: doctors were seen on a screen, using face masks that hid facial expressions and altered the tone of voice, thus hindering powerful instruments to signal empathic listening.
Despite these circumstances, parents engaged in a therapeutic relationship. This was evidenced by the way that the families became more comfortable, by letting themselves be seen on the screen, to express their feelings, to show us family dyadic and triadic interactions and living style, in a very rich, zoomed-out effect.
From the hospital team’s view
This multidimensional approach and the required sustained attention to the parents words to the baby and to the relationship between the parents and the baby, made us consider that it was advantageous to have more than one observer per session so that all the important elements could be collected, and distractions reduced.
Concluding reflections
- Finally, we realized that access to technology was not a limitation. Families easily accepted this approach and recognized the importance of our regular presence.
- The good acceptance of this video-based methodology was probably empowered by the massive use of video calls since lockdown started.
- We found this video-based approach useful and not widely disseminated for infant and early childhood mental health services.
- After 45 days of mandatory confinement, we restarted in-person medical appointments for these most critical cases.
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Authors
Martins Halpern, Cristina,
Neuropediatrician,
Centro de Estudos do Bebé da Criança, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
Alves, Mariana,
Child and Adolescent Psychiatry resident,
Centro de Estudos do Bebé da Criança, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
Pires, Sandra,
Child and Adolescent Psychiatry resident,
Centro de Estudos do Bebé da Criança, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
Caldeira da Silva, Pedro,
Assistant Senior Graduate of Child and Adolescent Psychiatry, Chief of Child and adolescent psychiatry,
Centro de Estudos do Bebé da Criança, Hospital Dona Estefânia, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
All the authors contributed equally to the manuscript
