‘Frontline workers’ children suffering dysregulation need support’

Mental health service providers need to collaborate with paediatric and education services to make use of the limited resources available to support frontline healthcare workers, some of whose children are suffering from significant emotional and behavioural dysregulation, a local study suggested.

This recommendation was made in a brief report titled “Emotional and behavioural dysregulation in children of health care workers in the frontline of the Covid-19 response in Sri Lanka” authored by Rathnayake and Chandradasa, and published recently in the Sri Lanka Journal of Psychiatry, which also cited the survey titled “Collaborative networking between regional child mental health, paediatric, and educational services in Gippsland, Australia” authored by Chandradasa and S. Basu, and published in the Australian Journal of Rural Health in support of these recommendations.

Methods such as using social media platforms to provide psycho-education to parents and teachers on mental wellbeing in children, and training non-expert health staff to provide psychological support, could be used to support the children of frontline health workers for their mental wellbeing. These aforementioned methods were used in the aftermath of the Easter Sunday bombings as noted in the study “Early phase child and adolescent psychiatry response after mass trauma: Lessons learned from the Easter Sunday attack in Sri Lanka” authored by Ragama General Hospital Consultant Child and Adolescent Psychiatrist and University of Kelaniya Faculty of Medicine Department of Psychiatry Senior Lecturer Dr. M. Chandradasa, L.C. Rathnayake (also attached to the same Department), M. Rowel, and L. Fernando, and published in the International Journal of Social Psychiatry.

That Sri Lanka has only a limited number of child mental health experts and services, thus creating the need to employ innovative techniques to maximise service provision during crises, is noted by Chandradasa and K.A.L.A. Kuruppuarachchi in “Child and youth mental health in post-war Sri Lanka” published in the British Journal of Psychiatry International and also in “Sub-specialisation in Postgraduate Psychiatry and Implications for a Resource-Limited Specialised Child and Adolescent Mental Health Service” authored by Chandradasa and L. Champika, and published in Academic Psychiatry.

It has already been reported that insomnia, anxiety, depression, somatisation (physical manifestations of psychological concerns), and obsessive compulsive symptoms were higher in medical than nonmedical categories. Parents’ psychological status is known to affect children’s wellbeing. Frontline healthcare workers in particular are susceptible to significant mental health issues. According to the study “Psychological Problems and Socio-emotional Wellbeing among Children of Mothers with Depression and Their Association with Socio-demographic Factors in a Sri Lankan setting” by Y.M. Rohanachandra, S. Prathapan, and S. Wijetunge, parental psychological ailments such as maternal depressive disorder could lead to hyperactivity and conduct, emotional, and peer-related problems in children and adolescents. Therefore, psychological stress in parents could be considered a risk factor for mental health issues in children.

The authors in this particular study, Rathnayake and Chandradasa, reported the cases of three children of health workers without prior history of mental health services contact, long-term medical disorders, or significant past psychological issues, who are presented with significant emotional and behavioural dysregulation while their parents are working in the frontline of the Covid-19 response.

The first was a 10-year-old boy, a son of a nursing officer working in a teaching hospital. The mother was unable to come home for a week, as she worked in the ward/unit dedicated to patients suspected of having contracted Covid-19. After returning home, she had noticed that her son was experiencing new onset anxiety-related sleep disturbance with frequent nocturnal awakenings, nightmares, and difficulty in falling asleep at initiation. He also had recurrent episodes of chest tightness and breathing difficulty, suggestive of panic attacks. This presentation had lasted a week, where the boy had repeatedly stated his fears that his mother would die of the virus. 

Review of the existing literature shows that there is a reciprocal relationship between sleep and emotional regulation in children, while sleep disturbances are highly prevalent in children with anxiety disorders. His physical examination and electrocardiogram were normal. He was treated successfully with psycho-education, progressive muscle relaxation training (which is a method effective in reducing emotional distress in 10-11-year-old children), and advice on sleep hygiene.

The second was a six-year-old girl, a daughter of a male medical officer working in a specialised infectious disease unit. The child was aware that her father was working at a high-risk station where new Covid-19-positive patients are admitted with the spreading disease, and managed. She presented with new-onset temper tantrums for two weeks where she was screaming and rolling on the floor, demanding that her father stay at home, when he was about to leave for work. 

Short-lasting temper tantrums between the ages of two to six years is a well-recognised presentation, and most follow parental noncompliance to their demands. This girl was treated with deep breathing exercises such as the belly breathing technique for relaxation, and parental training on differential reinforcement (effective in reducing temper tantrums in this age), and her symptoms gradually improved.

The third was a nine-year-old boy, a son of a female specialist medical officer working in a provincial general hospital. He presented with irritability and oppositional defiance in the form of vindictive and argumentative behaviour for a duration of two weeks. He demanded that his mother take leave from work, as he feared that she would contract the virus. 

In a prior study among children and adolescents between the ages of seven to 19 years, it was shown that there is a direct link between anxiety in children and irritability. This boy was treated with guided imagery (effective in reducing pre-operative anxiety in children between six to 12 years of age), including the magic shell meditation technique for relaxation and a collaborative problem-solving approach (effective in treating oppositional behaviour in children as the method focuses on identifying and improving the lack of cognitive skills that interfere with a child’s ability to meet parental expectations), and his irritability and oppositional behaviour reduced with the treatment.

The authors, however, noted that a limitation in the described cases was that these children may have also been affected by staying home for long periods due to the curfew imposed in the country to control the spread of Covid-19.