Since January 2020 Elsevier has created a COVID-19 resource centre with

free information in English and Mandarin on the novel coronavirus COVID-

19. The COVID-19 resource centre is hosted on Elsevier Connect, the
company's public news and information website.

Elsevier hereby grants permission to make all its COVID-19-related

research that is available on the COVID-19 resource centre - including this
research content - immediately available in PubMed Central and other
publicly funded repositories, such as the WHO COVID database with rights
for unrestricted research re-use and analyses in any form or by any means
with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre
remains active.
 r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(4):279–288

[Link]/rcp

Review article

Psychiatric disorders in children and adolescents

during the COVID-19 pandemic夽

Juan David Palacio-Ortiz ∗ , Juan Pablo Londoño-Herrera, Alejandro Nanclares-Márquez,

Paula Robledo-Rengifo, Claudia Patricia Quintero-Cadavid
Grupo de Investigación en Psiquiatría (GIPSI), Departamento de Psiquiatría, Facultad de Medicina, Universidad de Antioquia, Medellín,
Colombia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The Covid-19 pandemic has generated an unprecedented multimodal (health,
Received 5 May 2020 occupational, economic, and social) crisis, which will impact developing countries. Con-
Accepted 25 May 2020 finement as a preventive measure is itself a threat that produces a social impact. Pandemic
Available online 28 November 2020 and confinement have become a psychosocial adversity factor that affects families and
their children. During the pandemic, children and adolescents with a psychiatric disorder
Keywords: may experience exacerbation of their symptoms. However, little is known about this, since
Covid-19 studies on this population during the pandemic are scarce.
Child mental disorder Objective: To review the data available in the current literature on the effect of the pandemic
Attention deficit-hyperactivity on children and adolescents with a previous psychiatric disorder.
disorder Methods: A literature search was carried out using PubMed, Scielo and, due to the exceptional
Autism spectrum disorders conditions of the pandemic situation, directly using internet search engines. Both English
Anxiety disorders and Spanish papers were included.
Obsessive compulsive disorder Results: The information found is presented in the following sections: family and children
during the pandemic, evaluation of mental disorders in children and young people during
the pandemic, pre-existing psychiatric disorders during the pandemic, and telepsychiatric
care. Specific information is presented on attention deficit hyperactivity disorder, autism
spectrum disorder, intellectual disability, anxiety disorder, obsessive compulsive disorder,
and post-traumatic stress disorder. The current pandemic due to COVID-19 and confine-
ment are a psychosocial adversity that threatens the stability of the family. Such a stressor
can cause exacerbation of symptoms of a previous mental disorder. Children and adoles-
cents with psychiatric disorders are a vulnerable population and require specialised care.
Telepsychiatry is becoming a modality with multiple advantages.
© 2020 Published by Elsevier España, S.L.U. on behalf of Asociación Colombiana de
Psiquiatrı́a.

DOI of original article: [Link]

夽
Please cite this article as: Palacio-Ortiz JD, Londoño-Herrera JP, Nanclares-Márquez A, Robledo-Rengifo P, Quintero-Cadavid CP.
Trastornos psiquiátricos en los niños y adolescentes en tiempo de la pandemia por COVID-19. Rev Colomb Psiquiatr. 2020;49:279–288.
∗
Corresponding author.
E-mail address: tdahcartagena@[Link] (J.D. Palacio-Ortiz).
[Link]
2530-3120/© 2020 Published by Elsevier España, S.L.U. on behalf of Asociación Colombiana de Psiquiatrı́a.
280 r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(4):279–288

Trastornos psiquiátricos en los niños y adolescentes en tiempo de la

pandemia por COVID-19

r e s u m e n

Palabras clave:
Covid-19 Introducción: La pandemia por Covid-19 ha generado una crisis multimodal inédita: sanitaria,
Trastornos mentales niños laboral, económica, social, que repercutirá especialmente a los países en vía de desarrollo. El
Trastorno por déficit de atención confinamiento como medida preventiva es su vez una amenaza que producen un impacto
e hiperactividad social. Pandemia y confinamiento se han convertido en un factor de adversidad psicoso-
Trastorno del espectro autista cial que afecta las familias y sus hijos. Durante la pandemia, los niños y adolescentes con
Trastornos de ansiedad un trastorno psiquiátrico podrían presentar exacerbación de sus síntomas. Sin embargo,
Trastorno obsesivo compulsivo poco se conoce al respecto, pues los estudios sobre esta población durante la pandemia son
escasos.
Objetivo: Revisar los datos disponibles en la literatura actual acerca del efecto de la pandemia
sobre los niños y adolescentes que presentan un trastorno psiquiátrico previo.
Métodos: Se realizó una búsqueda de la literatura a través de PubMed, Scielo y, por las
condiciones excepcionales de la situación de pandemia, de manera directa en buscadores
de internet. Se incluyeron artículos en ingles y español.
Resultados: La información encontrada se presenta en los siguientes apartados: la familia
y los hijos durante la pandemia, evaluación de los trastornos mentales en niños y jóvenes
durante la pandemia, trastornos psiquiátricos preexistentes durante la pandemia, y aten-
ción en telepsiquiatría. Se presenta información específica sobre el trastorno por déficit de
atención e hiperactividad, trastorno del espectro autista, discapacidad intelectual, trastorno
de ansiedad, trastorno obsesivo compulsivo y el trastorno por estrés postraumático. La pan-
demia actual por COVID-19 y el confinamiento son una adversidad psicosocial que atenta
contra la estabilidad de la familia. Tal estresor pude causar exacerbación de los síntomas
de un trastorno mental previo. Los niños y adolescentes con trastornos psiquiátricos son
una población vulnerable que requiere de una atención especializada. La telepsiquiatría se
convierte en una modalidad con múltiples ventajas.
© 2020 Publicado por Elsevier España, S.L.U. en nombre de Asociación Colombiana de
Psiquiatrı́a.

are illnesses affecting the parents (24%), financial difficulties

Introduction (22%), family discord (18%) and parental alcohol consumption
(17%).5–7 During pandemics, the scale of these adversities may
The world is facing one of the most important global chal-
increase.
lenges since the second world war: the coronavirus disease
Rutter8 was one of the first authors to point to the role
2019 (COVID-19). This epidemic outbreak began in December
of psychosocial adversity in the aetiology of mental disor-
2019, caused by the severe acute respiratory syndrome coron-
ders. He revealed that the development of psychopathology
avirus 2 (SARS-CoV-2).1
was associated with other factors of adversity that a child
We are currently facing a situation with tragic conse-
will have.9 Subsequent studies with his group identified the
quences, the COVID-19 pandemic that was declared a public
adversity indicators,10 and considered six family and envi-
health emergency by the WHO.2 An unprecedented multi-
ronmental characteristics: low social class, serious marital
faceted (health, occupational, economic and social) crisis that
discord, families with more than four children, paternal crim-
will particularly impact developing countries. The preven-
inality, paternal mental disorder and a stay in a care home.
tive measures for avoiding catching the virus include social
The presence of two factors increases the likelihood of men-
distancing and confinement, which also constitute a dif-
tal disorders by up to four times, and four factors by up to ten
ferent type of threat as they produce a major impact on
times.10 Few studies in Latin America have studied this asso-
society.3
ciation between psychosocial adversity and mental disorders,
Resilience is defined as the capacity to cope with envi-
although they do confirm this relationship.11
ronmental circumstances that probably require of children a
Studies in children during this pandemic are scarce. One
significant degree of psychological, social or neurobiological
study reports that factors such as a prolonged quarantine,
adaptation and that constitute a deviation from the expected
fear of infection, frustration and boredom, the lack of contact
environment.4 Adverse childhood experiences are common.
with classmates and teachers, the lack of space at home and
For example, some studies show that up to 66.7% of ado-
the loss of loved ones generate psychological repercussions in
lescents have experienced at least one adversity, and almost
children and adolescents.12
50% more than one. The most frequently reported adversities
 r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(4):279–288 281

The objective of this article is to review the available data ties there will be for abuse.15,16 During this pandemic, China
in the current literature about the effect of the pandemic in presented a greater number of cases of depression and anx-
children and adolescents who already have a psychiatric dis- iety in adults,17 which are potential factors of adversity for
order. cohabiting children and adolescents.
In general, children cope better with such situations if they
Methods have a stable and serene adult by their side. However, besides
the factors related to the family environment, individual fac-
A literature search was performed on PubMed, SCIELO and, on tors must also be considered: characteristics of the child (such
account of the pandemic’s exceptional conditions, directly in as temperament), history of adversity, coping and resilience,
search engines such as Google and Safari. This search yielded which all together will modulate the response to the threat.
information from official specialised organisations and those For some children, the closure of schools entails factors such
dedicated to child and adolescent psychiatry and worldwide as not having access to education and food, a lack of face-to-
public health topics, such as the World Health Organisation face contact with their schoolmates and significant teachers,
(WHO) the American Academy of Child and Adolescent Psychiatry and being unable to carry out their sport and leisure activities,
(AACAP), the United Nations Children’s Fund (UNICEF) and the among other things.18
Instituto Colombiano de Bienestar Familiar (ICBF) [Colombian
Institute of Family Welfare]. No date limitation was placed Evaluation of mental disorders in children and young
on the articles found and only articles published in English people during the pandemic
and Spanish were included. The bibliographic references of
the articles located were also reviewed in order to expand the There are certain common considerations for the evaluation
sources of information. The following keywords were used and treatment of young people with different mental disorders
for the search: pandemic, COVID-19, children, adolescents, fam- in the context of COVID-19.19–23 Those collected in the recent
ily, risk factor, emotional stress, telepsychiatry, mental telehealth, literature are shown in Table 1.
telemedicine, attention deficit-hyperactivity disorder, autism spec-
trum disorder, neurology, bipolar, anxiety, schizophrenia, intellectual
Pre-existing psychiatric disorders
disability, oppositional defiant disorder, psychosis, anxiety, phobia,
The literature in this field is rather scant. The rapid spread
depression and bereavement. Combinations of these keywords
of the pandemic has limited the performance of longer-
in English and Spanish were also used.
lasting and better quality studies. The bulk of the literature
is comprised of editorials, expert opinions and consensus
Results documents issued by organisations. The existing publications
about the most notable groups of mental disorders in child-
The data obtained from the search about pre-existing psy- hood and adolescence are referred to below.
chiatric disorders in children and adolescents during the
COVID-19 pandemic are presented. Attention deficit-hyperactivity disorder (ADHD)

Families and children during COVID-19 The European ADHD Guideline Group published a guide for
the treatment of these patients during the pandemic.20 Fam-
The coronavirus and COVID-19 are a threat with complex char- ilies are advised to use behavioural strategies for parents to
acteristics and an uncertain duration that has led numerous improve their care and to reduce opposing, defiant and disrup-
countries to introduce a mandatory lockdown.13 The reper- tive behaviour.24 They could also try self-help25–27 or online28
cussions in the social context stemming from the dynamic versions of certain evidence-based treatments, being careful
between the threat (the virus) and the preventive measures with the use of untested mobile applications. Those receiving
(lockdown) exert a pressure that ultimately affects the family other non-pharmacological therapies should be encouraged
nucleus. Lockdown, meanwhile, is a measure that has gener- to continue doing exercises that can be transferred to the new
ated high rates of unemployment and a lack of livelihood for activities.
self-employed workers. A long lockdown and the imposition Face-to-face cardiovascular risk screening could be post-
of restrictions on freedom are risk factors for a greater psy- poned until further notice, since the risks outweigh the
chological impact.14 Fig. 1 displays the relationship between benefits. If possible, heart rate and blood pressure should
the different elements. be taken with household devices following the relevant
Families have undergone abrupt and highly impactful guidelines.20 In the event of any cardiovascular symptoms (e.g.
changes in the course of the pandemic. Moreover, prolonged chest pain, prolonged palpitations and breathing difficulty) or
lockdown and unemployment increase the risk among par- any other worrying symptoms, the treating physician should
ents of greater consumption of alcohol and other substances, be contacted.
partner abuse, family discord, child abuse and sexual abuse.12 Few recommendations are made about pharmacological
Lockdown involves continuous cohabitation with other people treatment of ADHD. The use of antipsychotics and sedatives
that necessitates a change in the family dynamics. Families to treat disruptive behaviour should be limited whenever pos-
already exposed to intrafamily violence will continue to have sible. Moreover, since confinement and social distancing can
a latent risk, and the more financial difficulties the abusers exacerbate the risks related to ADHD, there is no compelling
have and the longer the lockdown lasts, the more possibili- reason to introduce “medication holidays” during this crisis.29
282 r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(4):279–288

Threat: Covid-19
Isolation
- Fear of the disease REPERCUSSION
- Economic Crisis
- Death of a relative
- Social Crisis
- Health crisis

Family
Stress
Unemployment Anxiety, depression,
Anxiety and Depression hyperactivity, other
Children mental disorders.
Alcohol Consumption
Young people Abuse – Neglect
Intrafamily Violence
Adversity Factors

Fig. 1 – Relationship between the different elements: threat, isolation and impact on the family and children.

Table 1 – Considerations for the evaluation and treatment of young people with different mental disorders in the context
of COVID-19.19–23
• Apply the strategies and recommendations intended for young people in the general population to maintain physical and mental health
• They are more vulnerable to the negative psychological effects of the pandemic and lockdown
• Behavioural problems may occur that affect compliance with social distancing measures
• They are more likely to have frequent contact with family members, caregivers, professionals and people in the community
• They could have systemic comorbidities that increase the risk of COVID-19-related complications
• They need to continue to have the same intensity of care provided by health professionals as before Telehealth strategies are
recommended57
• Be on the lookout for signs of stress in patients, family members and caregivers
• Ask caregivers to try and maintain a positive or neutral emotional expression as much as possible, since young people can learn to copy
their parents’ coping strategies
• Offer pharmacological treatment if it is indicated If the patient is already on medication, they should continue as before
• Barriers to access or continuation of treatment may increase the risk of COVID-19 infection due to poorer behavioural control
• Patients or caregivers should avoid increasing medication doses on their own initiative
• Requests for additional medication should be analysed carefully, taking into account the context and impact of COVID-19 on the setting
and treatment
• Non-pharmacological behavioural interventions are preferable to dose adjustments or the addition of new medications
• If additional medication is required, ensure regular monitoring by the treating team
• Pay special attention to the application of depot injections and determinations of the serum concentration of the drugs, since these
activities could increase the risk of transmission of the virus
• Draw up a risk-benefit balance of the need for face-to-face care
• Give careful consideration to the need for hospitalisation, duly weighing up the risk to the young person and the impact upon the
department
•If hospitalisation or critical care is required, the person and their family must be provided support to help them understand and manage
the process

Initial insomnia may be an adverse effect of stimulant same face-to-face support from therapists or outside interven-
treatment, although it could also be caused by pandemic- tions.
associated factors (stress, getting up late, disruption of The doctor of psychology Antonio Narzisi, from the Depart-
routines, etc.). Proper sleep hygiene should be ensured before ment of Child Psychiatry and Psychopharmacology of the
considering the initiation or adjustment of hypnotic drugs Stella Maris Foundation of the University of Pisa (Italy), pub-
(such as melatonin up to 5–6 mg/night).30 lished a set of tips to help the caregivers of children with ASD
Headache is a possible adverse effect of psychopharma- during the lockdown period21 (Table 2).
cological treatment, and acetaminophen is recommended for Young people with ASD frequently present anxiety
this or other pains. There is uncertainty as to the possible disorders32 and lockdown can be difficult for them to
unfavourable effects of ibuprofen in COVID-19 patients.31 assimilate. During confinement, they may experience an
increase in stereotypies in the initial phase, which appears
as adaptive behaviour that will gradually disappear. Never-
Autism spectrum disorders (ASD) theless, they may also demonstrate increased movements,
as outings to places they formerly enjoyed going to be post-
Young people with ASD require multimodal treatments and poned. Similarly, their parents experience a greater degree of
usually participate several hours a week in interventions with stress and susceptibility than parents of children with other
specialised therapists at home, in the hospital or in specialised disabilities.33
centres. During lockdown, they may possibly not receive the
 r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(4):279–288 283

Table 2 – Tips to help caregivers of children with ASD during lockdown.

• Explanations should be kept simple and specific58
• Augmentative and alternative communication may be used
• Ask therapists for help in preparing material
• For verbal young people, the explanation can be supported with conceptual maps
• Subdivide daily activities59
• Use a different room for each activity
• The activity can be presented as a family game
• Use a board to write down scheduled activities
• Schedule game activities60
• They can be individual or involve the family61
• Choose the activities that the child prefers
• A good example are activities with pieces to assemble62,63
• Use serious games (ones in which the purpose goes beyond mere entertainment, such as education, learning skills or behavioural
changes)64,65
• Educational alternative for video games or online games. Many of them are free and can be downloaded as mobile apps
• Share video games or internet66
• Do not try to stop children from playing on the computer
• It is useful to establish a rule about sharing video games or internet
• This could reduce the risk of isolation or internet addiction
• Support and share special interests67
• Plan some family activities in order to share these interests
• Contact with classmates and teachers68
• At least one weekly contact with a classmate and a teacher
• The modality will depend on the young person’s preferences
• Options: a letter, telephone call or video call69
• An appropriate amount of free time should be allowed during the day

One follow-up option for therapists is to make videos about Some critical care guidelines34 propose determining frailty
the child’s behaviour during free play or structured sessions at to guide access to treatment. However, people with ID are more
home. This allows them to monitor the patients. likely to obtain higher scores on frailty scales, without this
necessarily meaning that they are less stable, which can also
Intellectual disability (ID) result in a disadvantage.
All patients should have a health action plan and a hos-
The Faculty of Intellectual Disability Psychiatry of the Royal pital passport with details about their health situation that
College of Psychiatrists of the United Kingdom published a increases their vulnerability to the complications of COVID-
guide on COVID-19 and persons with intellectual disability.19 19. Ideally, staff trained in the treatment of patients with ID
Young people with ID or intellectual development disorder should be on hand to accompany them during the hospitalisa-
are at significant risk of infection due to a greater prevalence tion process. Finally, people with ID should be ensured equal
of systemic comorbidities, their personal habits, and the fact access to health interventions.
that some of them live in communal settings with constant
exposure to other people (on account of the degree of support Anxiety disorders
they require). They are also more vulnerable to changes in care.
Although the impact of the pandemic, lockdown and The child psychiatrist Nicola Keyhan published an article on
changes in the mental health care of these young people, the Canadian Paediatric Society website explaining how to
and on their families and caregivers is still uncertain, it provide support to young people with anxiety disorders during
could generate an increase in malaise, disruptive behaviours, this pandemic.23 The strategies are summarised in Table 3.
health-related anxiety and the onset of mental disorders or People with anxiety disorders may encounter great difficul-
the exacerbation of existing ones. ties in adapting to current changes. Particularly those with a
It is proposed to identify families at greater risk or more fear of disease may have a worsening anxiety about becoming
vulnerable, such as those with young people who returned infected and engage in excessive hand washing. This con-
home from institutions or those whose housing is at risk. The cern may continue even after the quarantine period is over.
recommendation is to work in collaboration with the social Some children with separation anxiety may become overly
work team. attached to their caregivers during the pandemic and may
Children and adolescents with ID are among the most find it difficult to return to school. Anticipating changes and
vulnerable due to their need for high-level clinical care in hos- transitioning can be part of the plan for resuming activities.23
pital services. Engaging them in treatment and recovery in Moreover, factors such as intrafamily violence may trigger
the context of social distancing, particularly with those who anxiety crises in these patients.35
contract the infection, is a challenge for staff. Some subjects When they return to their activities at school, patients with
will require physical or pharmacological restraint if they show social phobia may have a new outbreak on account of having
agitation during lockdown, a measure that the treating psychi- spent so much time avoiding exposure due to confinement or
atrist should indicate on an individual basis. having their face partially covered (with a mask).
284 r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(4):279–288

Table 3 – Specific tips for the treatment of young people with anxiety disorders and pre-existing OCD in the COVID-19
context.
Tips for providing support to young people with anxiety disorders during the COVID-19 pandemic23
Minimise exposure to situations that generate great fear
Do not over-focus on prevention behaviours (e.g. hand washing)
Maintain normal routines
Insist on the ability to cope with the situation
Talk about the situation with the young people
Ask them what they know and their doubts about the pandemic
Correct information errors
Give reflexive, honest and reassuring answers, suited to their age
Avoid going into too much detail
Explore and validate thoughts and emotions
Ask about the experience of physical discomfort (it could indicate anxiety)
Limit exposure to information focused on negative aspects
Coping strategies can be used to reduce anxiety
Deep breathing
Muscular relaxation
Imagery
Mindfulness
Specific strategies for improving dysfunctional thinking patterns for young people with a developmental age of at least 8 years:
• Identify anxious thoughts and put them to the test
• Demonstrate how certain thoughts can lead to overestimating the possibilities of fears materialising
• Channel them towards more realistic thoughts
• Ask the children to write down their concerns
• Help them to think about the evidence in favour and against these concerns
• Propose more balanced and optimistic views of the situation
• Remind them that, by respecting social distancing and prevention measures, people are doing a lot to protect themselves
• Explain to them that there are resources for people who get sick to help them overcome the infection
Specific tips for parents of young people with OCD in the context of the COVID-10 pandemic22
For young people obsessed with infection or health-related issues or with cleaning or hygiene compulsions:
• It may help to explain how the general public health guidelines (e.g. hand washing) can be compatible with their treatment plan
• Therapists can be asked for help on how to do it
For young people who ask questions about COVID-19:
• Parents should be ready to answer them
• Not all questions imply a search for reassurance
• They are likely to be seeking reassurance if they ask the same question repeatedly or press for an answer or need one immediately
• If they are seeking reassurance, tell them that it may heighten their anxiety
• If there are doubts as to how to proceed, ask the therapist for help
If the young person begins to seek reassurance about future uncertainty:
• Try activities that connect them to the present (e.g. cooking, puzzles, etc.)
• Limit exposure to the media that talk about COVID-19
• Caregivers should be responsible for providing information

Obsessive-compulsive disorder (OCD) Other disorders and COVID-19

Symptoms such as adaptive reaction may increase in patients Although no specific literature was found about other mental
with obsessive-compulsive disorder, although with support disorders, it is believed that subjects with some type of severe
they can revert to their previous status. The virtual support mental disease, such as schizophrenia, psychotic disorders or
group of the International Obsessive-Compulsive Disorder bipolar affective disorder, will be exposed to factors that can
Foundation designed some specific tips for the parents of trigger crises that will require hospitalisation, with all the risks
young people with OCD in the context of this pandemic22 that this implies during the pandemic.
(Table 3). Moreover, in other mental disorders, symptoms could
increase during the pandemic, which is why they are men-
Post-traumatic stress disorder (PTSD) tioned below.
The expression of symptoms in patients with oppositional
Sprang and Silman compared PTSD symptoms in quarantined defiant disorder (ODD) and conduct disorder (CD) may change
parents and children versus non-quarantined controls. They depending on the family and social setting. Parental manage-
found that post-traumatic stress scores are four times greater ment skills are put to the test during confinement. Homes
in quarantined than non-quarantined children. There were presenting a higher adversity index will witness an increase in
more symptoms in the quarantined group (28% versus 17%).36 ODD behaviour. Genetic and environmental factors behave as
During lockdown, some children will be exposed to family protectors or as factors in the onset of ODD in childhood.37
discord, child or sexual abuse12,15,16 , stressful adverse events Families with a child with ODD will have to cope with the
that could trigger an acute stress disorder or PTSD. child’s reactions to the limits imposed.
 r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(4):279–288 285

Capture the patient's attention Position yourself between 60 Take care of your appearance. Children generally enjoy hand gestures.
and act in a trustworthy, and 120 cm away from the camera.
competent and empathetic way Do not forget non-verbal communication.

Moving towards or away from the Talk slowly, clearly and with pauses. Choose a suitable room, Try to guarantee the best possible connection,
camera simulates the effect of But not like a robot. Smiling always helps. ensuring privacy, and be close to the modem or use a wired connection.
interpersonal space. decent lighting and audio.

Parents can participate at the beginning Place the camera in such a way as to be The mobile device should Children can sit next to their parents,
or the end of the session. able to evaluate motor and play skills. be in a fixed position. between them or on their lap, or
The presence of a coordinator is allowed. Particularly in minors. There is better contact when the opposite them on the floor or on a chair.
device is placed upright.

Fig. 2 – Practical tips for telepsychiatry care of children and adolescents.

Taken and adapted from Roth et al.45

It should be considered that while certain antisocial

behaviours in adolescents during the pandemic (such as steal-
Telepsychiatry with children and adolescents
ing) may be regarded by their parents as adaptive, they are still
part of the path towards a conduct disorder.38 In confinement An alternative during the pandemic
prompted by previous epidemics, adolescents were seen to
present difficulties in observing the measures proposed during The barriers to specialised care in paediatric psychiatry have
isolation. They “break quarantine”, which makes them a group increased exponentially during this coronavirus crisis. Travel
at risk of antisocial behaviours and consumption of alcohol difficulties, the risk of contagion at health facilities, the sus-
and substances.39 pension of numerous consultation services and the already
Sleep disorders such as insomnia may increase on account difficult task of obtaining an appointment all make it more
of several factors: changes in sleep hygiene habits, reduced difficult to see a child and adolescent psychiatrist. In this sce-
physical activity, increased exposure to the light (screens) and nario, the resource of telemedicine comes into play, and more
exposure to video games and television programmes. precisely, psychiatry in the form of interactive consultation.44
Subjects with a history of major depressive disorder (MDD) Telepsychiatry with children and adolescents consists of
are at risk of having a new episode due to possible losses, not using telecommunications and information technology to
just because of the economic crisis, but also the possible death provide access to psychiatry services targeting the paediatric
of family members. Due to the treatment protocols applied to population. This modality must include at least audio and
patients with COVID-19, the isolation of the corpse and barri- video.45 For some specialists this is a novelty, although the
ers to performing a funeral ritual are risk factors for a relapse field is not new and has been in development for several years.
of MDD or a complicated bereavement.40 The use of telemedicine results in lower costs, ease of access,
The neurological diseases were addressed in the review, correct diagnoses and effective treatments. Not only has it
since some of them may constitute differential diagnoses of been used in general medicine, it has also been applied in
behavioural disorders, whereas others may involve comorbid- emergency rooms, paediatric critical care units and in com-
ity with other psychiatric disorders. According to the European munity psychiatry.45–47
Academy of Neurology, as yet there is no evidence of affection Although acceptance of the service is favourable and
of the nervous system by SARS-CoV-2 in children. However, the has been documented in surveys about telepsychiatry with
infection’s characteristics constitute a risk to children affected patients, relatives and healthcare personnel,48 it presents cer-
by chronic neurological diseases.41 Evidence is beginning to tain limitations compared to in-person consultations, such
appear that SARS-CoV-2 may cause neurological complica- as the lack of face-to-face contact, partially-absent body lan-
tions such as cerebral inflammation, encephalitis, delirium guage, absence of physical contact and change in emotional
and cerebrovascular complications, among others.42,43 Finally, expressions.45
there is a risk of infection and of serious respiratory diseases Besides the aforementioned considerations, it must be
for children with neuromuscular disorders, immunosuppres- noted that of all the different telepsychiatry models, the most
sive therapies, rare diseases, and inborn errors of metabolism accepted and effective one is that which involves local mental
and neurodevelopment disabilities.41 health personnel who can facilitate the communication pro-
286 r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(4):279–288

cess and also monitor the patient, either via this modality or references
in person in the future.49

1. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel

The experience of telepsychiatry in the world
coronavirus from patients with pneumonia in China, 2019. N
Engl J Med. 2020;382:727–33.
Several new experiences have been reported with this 2. World Health Organization. Coronavirus disease (COVID-19)
modality in the current pandemic. A greater move towards pandemic. Geneva: WHO; 2020 [Link]
telepsychiatry services has taken place in different parts of emergencies/diseases/novel-coronavirus-2019.
the world. From the beginning of the lockdown in China, both 3. Duan L, Zhu G. Psychological interventions for people
affected by the COVID-19 epidemic. Lancet Psychiatry.
the government and academic organisations implemented
2020;7:300–2, [Link]
support, supervision, training and psychoeducation services
4. McLaughlin KA. Future directions in childhood adversity and
for the general population through digital channels. In Aus- youth psychopathology. J Clin Child Adolesc Psychol.
tralia, specialised consultations in mental health are provided 2016;45:361–82.
virtually to vulnerable groups and the system is currently 5. Benjet C, Borges G, Medina-Mora ME. Chronic childhood
being expanded to the general population. Similarly, in Europe, adversity and onset of psychopathology during three life
mental health services are moving towards telepsychiatry- stages: childhood, adolescence and adulthood. J Psychiatr
Res. 2010;44:732–40.
based care.50–53 In the Latin American setting, in Colombia,
6. Benjet C, Borges G, Medina-Mora ME, Zambrano J, Cruz C,
the telepsychiatry programme of the University of Antioquia,
Méndez E. Descriptive epidemiology of chronic childhood
developed jointly with the Living Lab, which had already adversity in Mexican adolescents. J Adolesc Health.
successfully been providing mental healthcare, has imple- 2009;45:483–9.
mented a care strategy for the general public and health 7. Pirkola S, Isometsä E, Aro H, Kestilä L, Hämäläinen J, Veijola J,
personnel, providing psychological first aid, and psychologi- et al. Childhood adversities as risk factors for adult mental
cal and psychiatric consultations for adults and the paediatric disorders. Soc Psychiatry Psychiatr Epidemiol. 2005;40:769–77.
8. Rutter M, Tizard J, Yule W, Graham P, Whitmore K. Isle of
population.54
Wight Studies, 1964–1974. Psychol Med. 1976;6:313–32,
[Link]
Recommendations for implementing telepsychiatry 9. Bishry Z, Ramy HA, El-Sheikh MM, El-Missiry AA, El-Missiry
MA. Risk factors for attention deficit hyperactivity disorder in
a sample of Egyptian adolescents: a case–control study.
Telepsychiatry consultations will probably be effective, ade- Middle East Curr Psychiatry. 2013;20:131–9.
quate and accepted by parents and children, and will serve as 10. Biederman J, Faraone S, Monuteaux M. Differential effect of
an input to continue the follow-up with the same modality, environmental adversity by gender: Rutter’s index of
considering the duration of the pandemic. adversity in a group of boys and girls with and without ADHD.
The pandemic is forcing us to implement alternatives to Am J Psychiatry. 2002;159:556–62.
11. De La Peña Olvera FR, Castro CG, Martin GH, Palacios-Cruz L.
face-to-face consultation, and it is the right time to apply
Adversidad social y trastornos psiquiátricos: Estudio
telepsychiatry, but certain considerations should be taken into
comparativo entre estudiantes de secundarias públicas y
account in order to successfully adapt to this new consultation privadas. Salud Ment. 2014;37:483–9.
context. Fig. 2 describes some tips conducting a telepsychiatry 12. Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects
consultation. of home confinement on children during the COVID-19
Readers are recommended to consult the current telepsy- outbreak. Lancet. 2020;395:945–8.
chiatry guidelines for children and adolescents to expand on 13. Huremović D. Psychiatry of pandemics: a mental health
response to infection outbreak. 1a ed. Cham: Springer; 2019.
the topic.55,56
14. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S,
Greenberg N, et al. The psychological impact of quarantine
and how to reduce it: rapid review of the evidence. Lancet.
Conclusions 2020;95:P912–20,
[Link]
The current COVID-19 pandemic and lockdown threaten to 15. Ferrer-Perez V. Afrontando la pandemia COVID-19 y sus
exacerbate symptoms in children and young people with a consecuencias desde la Psicología Social Feminista. Int J Soc
Psychol. 2020;32:53–60.
prior psychiatric disorder. This occurs within a family dynamic
16. Peterman A, Potts A, O’donnell M, et al. Pandemics and
affected by an economic and social crisis. Although there violence against women and children. CGD Working Paper
is no exact evidence about the effects of the current pan- 528. Washington, DC: Center for Global Development; 2020
demic, children and adolescents with psychiatric disorders are [Link]
a vulnerable population that requires monitoring and inter- against-women-and-children.
ventions by specialised personnel. The current barriers and 17. Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S, et al. Mental
health problems and social media exposure during COVID-19
risks lead to care during the pandemic ideally being provided
outbreak. PLoS ONE. 2020;15:e0231924,
through telepsychiatry.
[Link]
18. Saxena R, Saxena S. Preparing children for pandemics. In:
Saxena S, editor. Coronavirus disease 2019 (COVID-19)
Conflicts of interest epidemiology, pathogenesis, diagnosis, and therapeutics. 1st
ed. Singapore: Springer Nature Singapore; 2020. p. 187–97.
The authors have no conflicts of interest to declare.
 r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(4):279–288 287

19. Royal College of Psychiatrists. Faculty of psychiatry of 35. Mas M, Acebo G, Gaibor M, Chávez P, Núñez F, González L,
intellectual disability: resources for professionals. Roy Coll et al. Violencia intrafamiliar y su repercusión en menores de
Psychiatr. 2020:1–14. la provincia de Bolívar, Ecuador. Rev Colomb Psiquiatr.
20. Cortese S, Asherson P, Sonuga-Barke E, Banaschewski T, 2020;49:23–8, [Link]
Brandeis D, Buitelaar J, et al. ADHD management during the 36. Sprang G, Silman M. Posttraumatic stress disorder in parents
COVID-19 pandemic: guidance from the European ADHD and youth after health-related disasters. Disaster Med Public
Guidelines Group. Lancet Child Adolesc Heal. Health Prep. 2013;7:105–10,
2020;2019:2019–20. [Link]
21. Narzisi A. Handle the autism spectrum condition during 37. Ortiz-Giraldo B, Giraldo-Giraldo C, Palacio-Ortiz J. Trastorno
coronavirus (COVID-19) stay at home period: ten tips for oposicional desafiante: Enfoques diagnóstico y terapéutico y
helping parents and caregivers of young children. Brain Sci. trastornos asociados. Iatreia. 2008;21:54–62.
2020;10:207. 38. Frick PJ. Developmental pathways to conduct disorder:
22. International OCD Foundation Virtual Support Group. implications for future directions in research, assessment,
OCD/COVID-19: resources for kids, teens and families. and treatment. J Clin Child Adolesc Psychol. 2012;41:378–89.
International OCD Foundation; 2020. p. 1. 39. DiGiovanni C, Conley J, Chiu D, Zaborski J. Factors influencing
23. Keyhan N. Supporting youth with anxiety disorders during compliance with quarantine in Toronto during the 2003 SARS
the COVID-19 pandemic. Canadian Paediatric Society; 2020. p. outbreak. Biosecur Bioterror. 2004;2:265–72.
1–3. 40. Melhem NM, Porta G, Shamseddeen W, Walker-Payne M,
24. Daley D, Van Der Oord S, Ferrin M, Cortese S, Danckaerts M, Brent DA. Grief in children and adolescents bereaved by
Doepfner M, et al. Practitioner review: current best practice in sudden parental death. Arch Gen Psychiatry. 2011;68:911–9.
the use of parent training and other behavioural 41. Simonati A, Buerki SE. Child neurology provision during the
interventions in the treatment of children and adolescents COVID-19 pandemic, Vienna; 2020.
with attention deficit hyperactivity disorder. J Child Psychol 42. Carod Artal FJ. Complicaciones neurológicas por coronavirus
Psychiatry Allied Discip. 2017;59:932–47. y COVID-19. Rev Neurol. 2020;70:1.
25. Daley D, O’Brien M. A small-scale randomized controlled trial 43. De Felice FG, Tovar-moll F, Moll J, Munoz DP, Ferreira ST. Severe
of the self-help version of the New Forest Parent Training acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and
Programme for children with ADHD symptoms. Eur Child the central nervous system. Trends Neurosci. 2019:1–3.
Adolesc Psychiatry. 2013;22:543–52. 44. Werlen L, Gjukaj D, Mohler-Kuo M, Puhan MA. Interventions
26. Katzmann J, Hautmann C, Greimel L, Cortese S, Danckaerts to improve children’s access to mental health care: a
M, Doepfner M, et al. Behavioral and nondirective guided systematic review and meta-analysis. Epidemiol Psychiatr
self-help for parents of children with externalizing behavior: Sci. 2019:1–27.
mediating mechanisms in a head-to-head comparison. J 45. Roth DE, Ramtekkar U, Zeković-Roth S. Telepsychiatry: a new
Abnorm Child Psychol. 2017;45:719–30. treatment venue for pediatric depression. Child Adolesc
27. Dose C, Hautmann C, Buerger M, Schuermann S, Woitecki K, Psychiatr Clin N Am. 2019;28:377–95.
Doepfner M. Telephone-assisted self-help for parents of 46. Mathew SR, Elia J, Penfil S, Slamon NB. Application of
children with attention-deficit/hyperactivity disorder who telemedicine technology to facilitate diagnosis of pediatric
have residual functional impairment despite postintensive care syndrome. Telemed J e-Health.
methylphenidate treatment: a randomized controlled trial. J 2020;26:1043–50.
Child Psychol Psychiatry Allied Discip. 2017;58:682–90. 47. Mroczkowski MM, Havens J. The state of emergency child and
28. DuPaul GJ, Kern L, Belk G, Custer B, Daffner M, Hatfield A, adolescent psychiatry: raising the bar. Child Adolesc
et al. Face-to-face versus online behavioral parent training for Psychiatr Clin N Am. 2018;27:357–65.
young children at risk for ADHD: treatment engagement and 48. Greenberg N, Boydell KM, Volpe T. Pediatric telepsychiatry in
outcomes. J Clin Child Adolesc Psychol. 2018;47 Suppl Ontario: caregiver and service provider perspectives. J Behav
1:S369–83. Health Serv Res. 2006;33:105–11.
29. Cortese S, Holtmann M, Banaschewski T, Buitelaar J, Coghill D, 49. Pignatiello A, Stasiulis E, Solimine C, Ayad O, Boydell KM.
Danckaerts M, et al. Practitioner review: current best practice Lessons learned in a physician referral to pediatric telemental
in the management of adverse events during treatment with health services program. J Can Acad Child Adolesc Psychiatry.
ADHD medications in children and adolescents. J Child 2019;28:99–104.
Psychol Psychiatry Allied Discip. 2013;54:227–46. 50. Zhou X, Snoswell CL, Harding LE, Bambling M, Edirippulige S,
30. Bruni O, Alonso-Alconada D, Besag F, Biran V, Braam W, Bai X, et al. The role of telehealth in reducing the mental
Cortese S, et al. Current role of melatonin in pediatric health burden from COVID-19. Telemed J e-Health.
neurology: clinical recommendations. Eur J Paediatr Neurol. 2020;26:26–8.
2015;19:122–33. 51. Kavoor AR, Chakravarthy K, John T. Remote consultations in
31. Evidence review: acute use of non-steroidal anti- the era of COVID-19 pandemic: preliminary experience in a
inflammatory drugs (NSAIDs) for people with or at risk of regional Australian public acute mental health care setting.
COVID-19. London: National Institute for Health and Care Asian J Psychiatr. 2020;51:1–2.
Excellence; 2020. 52. Corruble E. A viewpoint from Paris on the COVID-19
32. Lai MC, Kassee C, Besney R, Bonato S, Hull L, Mandy W, et al. pandemic: a necessary turn to telepsychiatry. J Clin
Prevalence of co-occurring mental health diagnoses in the Psychiatry. 2020:1.
autism population: a systematic review and meta-analysis. 53. Ćosić K, Popović S, Šarlija M, Kesedžić I. Impact of human
Lancet Psychiatry. 2019;6:819–29. disasters and COVID-19 pandemic on mental health:
33. Drogomyretska K, Fox R, Colbert D. Brief report: stress and potential of digital psychiatry. Psychiatr Danub. 2020;32:25–31.
perceived social support in parents of children with ASD. J 54. Martínez-Péreza D, Agudelo-García A, Andrade-Carrillob R,
Autism Dev Disord. 2020 (0123456789). García-Canoay J, Porras-Cataño S. Telepsiquiatría: una
34. COVID-19 rapid guideline: critical care in adults. NICE experiencia exitosa en Antioquia, Colombia. Rev Colomb
guideline. London: National Institute for Health and Care Psiquiatr. 2019;48:1–7,
Excellence; 2020. [Link]
288 r e v c o l o m b p s i q u i a t . 2 0 2 0;4 9(4):279–288

55. American Academy of Child and Adolescent Psychiatry 63. LeGoff DB. Use of LEGO© as a therapeutic medium for
(AACAP) Committee on Telepsychiatry and AACAP improving social competence. J Autism Dev Disord.
Committee on Quality Issues. Clinical update: telepsychiatry 2004;34:557–71.
with children and adolescents. J Am Acad Child Adolesc 64. Carlier S, Van der Paelt S, Ongenae F, De Backere F, De Turck F.
Psychiatry. 2017;56:875–93. Empowering children with ASD and their parents: design of a
56. Myers K, Nelson EL, Rabinowitz T, Hilty D, Baker D, Barnwell serious game for anxiety and stress reduction. Sensors
SS, et al. American Telemedicine Association practice (Switzerland). 2020:20.
guidelines for telemental health with children and 65. Boucenna S, Narzisi A, Tilmont E, Muratori F, Pioggia G, Cohen
adolescents. Telemed J e-Health. 2017;23:779–804. D, et al. Interactive technologies for autistic children: a
57. Turvey C, Coleman M, Dennison O, Drude K, Goldenson M, review. Cognit Comput. 2014;6:722–40.
Hirsch P, et al. ATA practice guidelines for video-based online 66. Fineberg NA, Demetrovics Z, Stein DJ, Ioannidis K, Potenza
mental health services. Telemed J e-Health. 2013;19:722–30. MN, Grünblatt E, et al. Manifesto for a European research
58. Pellicano E, Burr D. When the world becomes “too real”: A network into problematic usage of the internet. Eur
Bayesian explanation of autistic perception. Trends Cogn Sci. Neuropsychopharmacol. 2018;28:1232–46.
2012;16:504–10. 67. Lee EAL, Black MH, Falkmer M, Tan T, Sheehy L, Bölte S, et al.
59. Narzisi A, Muratori F, Calderoni S, Fabbro F, Urgesi C. “We can see a bright future”: parents’ perceptions of the
Neuropsychological profile in high functioning autism outcomes of participating in a strengths-based program for
spectrum disorders. J Autism Dev Disord. 2013;43:1895–909. adolescents with autism spectrum disorder. J Autism Dev
60. Kojovic N, Ben Hadid L, Franchini M, Schaer M. Sensory Disord. 2020, [Link]
processing issues and their association with social difficulties 68. Roorda DL, Koomen HMY, Spilt JL, Thijs JT, Oort FJ.
in children with autism spectrum disorders. J Clin Med. Interpersonal behaviors and complementarity in interactions
2019;8:1508. between teachers and kindergartners with a variety of
61. Peckett H, Maccallum F, Knibbs J. Maternal experience of Lego externalizing and internalizing behaviors. J Sch Psychol.
Therapy in families with children with autism spectrum 2013;51:143–58.
conditions: what is the impact on family relationships? 69. Kumazaki H, Muramatsu T, Kobayashi K, Watanabe T, Terada
Autism. 2016;20:879–87. K, Higashida H, et al. Feasibility of autism-focused public
62. Lai MC, Anagnostou E, Wiznitzer M, Allison C, Baron-Cohen S. speech training using a simple virtual audience for autism
Evidence-based support for autistic people across the spectrum disorder. Psychiatry Clin Neurosci. 2020;74:
lifespan: maximising potential, minimising barriers, and 124–31.
optimising the person-environment fit. Lancet Neurol.
2020;4422:1–18.