Children's online care during COVID-19

Atendimento on-line infantil em tempos de COVID-19

Abstract

Objective:

This study aims at shedding light on online child psychotherapy using cognitive-behavioral therapy as well as suggesting forms of psychological interventions during a pandemic.

Method:

Since the beginning of the recent coronavirus (SARS-CoV-2) outbreak, which causes COVID-19, there has been a great concern about a disease that has rapidly spread over the world, bringing about several different socio-economic issues. The fear of contracting the disease has led to safety measures and uncertainties with regard to the future, and it is believed that social isolation has had a direct and psychological impact on both adults and children. This way, we conducted a systematic search for literature review articles.

Results:

The clinical practice has led to observe that children had their routine interrupted and, consequently, prevented from basic activities such as going to school, being separated from friends, being apart from grandparents, spending the day with their parents, and not to mention, depending on their age, attending online classes in the most varied ways.

Conclusion:

It is clear that through the use of cognitive-behavioral therapy, forms of psychological interventions can be suggested in the face of the COVID-19 pandemic. Thus, it is clear that effective results are possible with online intervention.

Keywords:
Child psychotherapy; Cognitive-behavioral therapy; COVID-19; Psychological interventions

Resumo

Objetivo:

O objetivo deste estudo é sistematizar conhecimentos sobre o atendimento online infantil através da terapia cognitivo-comportamental e sugerir formas de intervenções psicológicas diante da pandemia de COVID-19.

Método:

Desde o início do surto do coronavírus (SARS-CoV-2), causador da COVID-19, houve preocupação diante de uma doença que se alastrou rapidamente em várias regiões do mundo, com diferentes impactos. Além do medo de contrair a doença, dos cuidados com os familiares e das incertezas frente ao futuro, o isolamento causou impactos psicológicos diretamente relacionados à COVID-19 tanto em adultos como em crianças. Deste modo, foi feita uma busca sistemática por artigos.

Resultados:

A prática clínica levou ao entendimento de que as crianças passaram por mudanças, como a interrupção das idas à escola, o afastamento dos amigos e dos avós e a presença dos pais o dia todo em casa, além de, dependendo da idade, aulas online em diversos estilos, e a percepção de que os pais também não sabiam como lidar com a situação.

Conclusão:

Percebe-se que através do uso da terapia cognitivo-comportamental pode-se sugerir formas de intervenções psicológicas diante da pandemia de COVID-19. Assim, nota-se que resultados efetivos são possíveis com a intervenção on-line.

Palavras-chave:
Psicoterapia infantil; Terapia cognitivo-comportamental; COVID-19; Intervenções psicológicas

The new coronavirus, called SARS-CoV-2, which causes the disease COVID-19, was detected on December 31, 2019 in Wuhan, China. On January 9, 2020, the World Health Organization (WHO) confirmed the circulation of the new coronavirus. The following day, the first SARS-CoV-2 sequence was published by Chinese researchers. On January 16, the first virus importation into the Japanese territory was notified. On January 21, the United States reported their first imported case. On January 30, the WHO declared the epidemic a public health emergency of international concern. By the end of January, several countries had already confirmed imported cases, including the United States, Canada and Australia (World Health Organization, 2020). In Brazil, on February 7, there were 9 cases under investigation, but with no records of confirmed cases. As of the closing date of this article, December 21, 2020, 7,238,600 cases were recorded.

In addition to the fear of contracting the disease, care for family members and uncertainties about the future, social isolation as a form of prevention has caused psychological impacts directly associated with COVID-19, both in adults and children. In a literature review on quarantine, Brooks et al. (2020) identified that the negative effects of this measure include symptoms of post-traumatic stress, confusion and anger. Concerns about supply shortages and financial losses also erode psychological well-being. In this connection, social stigma and discriminatory behavior towards some specific groups increases, such as the Chinese, the population first affected by the new coronavirus infection (Shimizu, 2020), as well as the elderly, as it is in this age group that the highest number of deaths due to COVID-19 (occurred) (Ornell et al., 2020). We should add here the existence of risk groups with underlying diseases.

On the other hand, clinical practice generated the understanding that children also go through many changes during the pandemic (Liu et al., 2020), such as discontinuing going to school, separation from friends, staying away from grandparents, presence of parents at home all day long, in addition to, depending on age, attending online classes in the most diverse kinds, and observation about the perception of parents who also do not know how to deal with the situation. Until the conclusion of this article, in December 2020, no scientific research on children's perception was found.

The pandemic has also brought about important changes in the way psychologists and other mental health professionals provide care to their clients and interact with colleagues, requiring, in many cases, a rapid transition from face-to-face to remote mode (Gritti, 2020, Matheson et al., 2020; Wade et al., 2020).

When all those factors are reviewed, the relevance of psychological interventions aligned with the emerging needs in the current pandemic framework, for different audiences, become evident. Considering the above, the objective of the present study is to systematize knowledge about online child care, as well as to suggest forms of psychological interventions in the face of the new coronavirus pandemic.

The Conselho Federal de Psicologia (CFP, Federal Council of Psychology), in view of the COVID-19 pandemic, which affected the professional activities of Psychologists, authorized online psychological care, using distance communication technologies, without the need to wait for the approval of registration at E-Psi (National Registry of Professionals for the Provision of Psychological Services through ICTs).

The measure was valid, in principle, for the months of March and April and aimed to contribute to minimizing the impacts of this pandemic, attending the requests from the category.

Online Psychotherapy

For Finn and Barak (2010), internet psychotherapy must follow the same standards of the professional code of ethics used in face-to-face care, such as confidentiality, availability in case of emergency, intervention in situations where the patient poses a risk to himself or herself or to others and reporting child abuse and compliance with local law regarding operational license. In the US, for example, there are court decisions that understand that the norms that apply are those of the patient's location, and some states prohibit their citizens from contracting services from therapists without a local license.

The Conselho Federal de Psicologia (Federal Council of Psychology), published Resolution nº. 11/2018, which updated Resolution nº. 11/2012 on online psychological care and other services performed by technological means of distance communication. This resolution expanded the possibilities of offering Psychology services mediated by Information and Communication Technologies (ICTs), maintaining the requirements set out in the profession and linking to the individual registration and guidance of the professional with the Regional Council of Psychology for potential investigations in case of incorrect service rendered.

The decision to reformulate the previous resolution was taken at the Assembleia de Políticas, da Administração e das Finanças (Assembly of Policies, Administration and Finance) in December 2017, based on the category's demand. In the 2012 resolution, revoked by the current regulations, the provision of Psychology services mediated by ICTs was linked to the existence of a registered website. With the new resolution, the Psychology professional will be responsible for the adequacy and pertinence of the methods and techniques in the provision of services, with no need to link to a website. The new resolution only entered into force on November 10, 2018, 180 days after its publication.

The psychologist began to offer advices or psychological care of different types through information and communication technologies. Each technology used must be coherent and grounded in science, legislation and professional ethical parameters. It is up to the professional to substantiate, including in the service rendering records, whether the technology used is technically applicable, methodologically relevant and ethically supported.

When it was regulated, the service could be provided through the E-Psi Registry (National Registry of Professionals for the Provision of Psychological Services through ICTs).

During a pandemic, psychologists had to reinvent themselves with regard to their services format in order to be able to deal with current treatments, as well as meeting upcoming demands. With regard to adult care, it was already a common practice for many patients; however, child care was questioned for a long time, due to the need for games and interaction that are present and necessary during this process. The practice of online therapy takes place via videoconference, audioconference or written text (chat, SMS and e-mail), synchronously (simultaneous interaction) and/or asynchronously (non-simultaneous interaction). This therapeutic modality offers advantages such as availability, convenience and stigma reduction (Cartreine et al., 2010), expanding access to psychological treatments (Proudfoot et al., 2011).

In addition, it is up to Psychology, as a science, to look into this field of professional practice and human dimension. The interaction between Psychology and Informatics, although it has been in existence for only a few years, gradually ceases to seem so new and imposes itself, alien to our discussions and desires, still bringing surprises, challenges, difficulties and potentialities. The more research and efforts are implemented to understand and support the practice of internet Psychology, the greater the preparation of Psychology professionals will be, whether for face-to-face clinical visits, at a distance, or even in other areas of psychology. It is necessary that trained psychologists, and those currently in training, have a broader view of the contemporary subject. The internet is already part of our social context with such intensity and power that without a proper understanding of its influence on the psyche, one will be significantly distant from reality and from the new forms of our world subjectivation (Siegmund & Lisboa, 2015).

One of the approaches to carry out online consultations in Psychology is Cognitive-Behavioral Therapy (CBT), due to its practical and structured nature; thus, child care based on this approach can be effective and productive.

Child Cognitive-Behavioral Psychotherapy

We will talk about child cognitive-behavioral therapy, which is the author's approach, based on the development in the 60's by Aaron Beck based on the assumption that the way the patient processes and interprets situations is what generates suffering. The objective of the CBT is to achieve flexibility and re-signification of the pathological ways of processing information, since it is postulated that individuals do not suffer because of the facts and situations per se, but because of the distorted and rigid interpretations they make of such facts and situations. It is already possible to find scientific evidence in the literature that this treatment modality is effective for a large number of psychiatric pathologies and psychological demands, as well as, it is known that the psychological treatment of children and adolescents has been considered not only as a therapeutic measure, but mainly as a way of preventing mental illness as well as promoting health (Pureza et al., 2014).

In 1960, CBT stablished itself as a psychotherapeutic model. From that point in time, the child's behavior began to be assessed functionally in relation to his/her environment (for example, family and school environments). Thus, the child ceased to be a supporting player and became very important in the therapeutic process; his private world started to be assessed and, therefore, considered relevant.

The CBT with children differs from therapy with adults; first, because few children come to therapy out of their own accord. They are brought in by their parents for problems they may not be willing to admit they have. Furthermore, many children are referred for therapy because their psychological difficulties create problems for some system (family or school). According to Friedberg and McClure (2004) children do not choose when to start treatment, nor can they choose when it ends. In some cases, they may enjoy therapy and make significant progress; however, for different reasons, their parents stop the treatment. In other cases, children may avoid the therapeutic process and even fear the therapy, but external circumstances (juvenile courts, school, parents) may force them to continue. In no case do children control the process.

According to the same authors, CBT with children is based on an empirical, here-and-now approach, since they are action-oriented, they learn easily by doing, and their motivation will boost when they are having fun.

With the child's more active participation in the therapeutic process, therapists seek to rely more on playful strategies. It was from the 1960s onwards, with the development of studies in the children's area and with studies carried out on the importance of playing, that games and toys began to be considered important (Gadelha & Menezes, 2004). Silvares (2001) points out that it was only in the mid-1980s that scientific communications on playing with children had a greater impact on the scientific scenario. Even the term child behavioral ludotherapy, imported from psychoanalysis, was used for the first time by Gomes, in 1998, and means “the insertion of ludic activities in behavioral therapeutic procedures with children” (Silvares, 2001, p. 54).

The main difference between adult and child therapy probably lies in the child therapist's constant search for procedures that can replace the verbal statement, in order to obtain information about the variables that control the child's behavior. In adult therapy, clients can describe their behavior and report their feelings; in contrast, in children therapy, the children verbal repertoire to describe their feelings and talk about their memories can be restricted and make it difficult for the therapist to establish contact with the child with the variables that interfere in their behavior and feelings (Kohlenberg & Tsai, 2001). Therefore, children hardly report their feelings and behaviors in the same way as adults. For this reason, observation of the child is critical for the assessment and therapy planning. Without observation, the treatment will depend exclusively on the parents' report (Silvares, 2001).

Children often need non-verbal ways to express their feelings, to allow the gains that the expression of feelings means for the development of therapy. These non-verbal ways of expression include drawing or telling stories, fantasizing, imagining and interpreting situations, using dolls and games, books, paintings, collages, clay, plastic modeling clay, music, among other instruments that characterize a natural situation for the child and a censorship-free environment to display their feelings. The use of these instruments depends on an effort by the child therapist to identify which of them are useful in identifying important control variables over the child's behavior (Regra, 2000).

It is considered that the ludic refers to the use of games, toys, drawings and storybooks, with some specific objective in child therapy. Any activity can be considered playful, since any object can be used as a toy by the child. A piece of wood can become a doll, as well as a leaf can be, a boat, a bottle becomes a microphone, a calculator becomes a cart, a pen becomes a road and so on. The ludic strategy is important, because in addition to being reinforcing for the child, it is an instrument that facilitates the child's emotional, social, intellectual and relational development (Gadelha & Menezes, 2004). The child, in addition to having fun, learns and develops, and his/her process of emotional expressiveness is facilitated.

It is also known that the different CBT techniques are adapted through playful resources in order to apply the same techniques used with adults, only in a creative and playful way. As an example of this, there is the application of relaxation techniques, through exercises of smelling flowers and blowing candles, modeling through books and videos, cognitive restructuring through the feelings clock and the same happens with other techniques, which, depending on the therapist's experience, take shape in the most diverse ways.

The use of resources has several objectives, such as: pairing the therapy and the therapist with pleasant activities, exploring toys and playing as a form of expression for the child, evaluating the therapeutic relationship and the course of the therapeutic process, explaining antecedents and consequences of the children's responses to help them identify outside the session, and study with the child, more adaptive behavior alternatives and train them (Moura & Venturelli, 2004).

All these strategies are known by child therapists and, in a way, applied with certain ease and mastery. However, when all these activities need to be migrated to remote care, many reflections, adaptations and changes in clinical practice become necessary.

Online Child Psychotherapy and a Systematization Poposal

With a total population of 210,147,1254 people, according to the Instituto Brasileiro de Geografia e Estatística projection and in line with data from the Child and Adolescent Observatory for the year 2019, Brazil was a country with 65,600,982 million children, that is, almost 1/3 of the Brazilian population is made up of children and adolescents up to 18 years of age. Of this total, it is estimated that more than 55 million children live in urban areas, while the rest live in rural areas, with most of the proportion of people aged up to 18 years living in the north and northeast regions.

With this datum of extreme relevance, it appears that Brazil is a country with a young population, and therefore, this population deserves attention. Over the years, national and international investigators on childhood have sought to give visibility to children and childhood in a social and cultural context, refuting many of the universalizing views that encompass ways of acting and developing policies for children, based on biologist views and/or developmentalists who have conceived them over the decades, in which the polarizations are found between a “normal” or “atypical” childhood, that is, a unique conception of childhood and children who fit or not within each segment (Pastore, 2020).

That said, it becomes clear the importance to consider resources, strategies and research aiming at child care on line, since this is a phase of life with specific characteristics. Hence, it deserves specific attention as well as to proceed with online consultations and thus committing to children's mental health, because in the face of the many changes already mentioned in this article, it is not an exaggeration to say that it is so much necessary as for adults.

Although telephone psychotherapy is a practice that dates back to the 1950s (Godleski et al., 2008; Scharff, 2012), internet psychotherapy, in its inception that dates back over a decade ago, was met with great opposition. It was believed that the therapeutic relationship would occur through an impoverishment of non-verbal communication, an element considered essential to the interaction between therapist and patient. Ethical concerns about confidentiality, the identity of patients and therapists, the roles played in the network and dealing with emergency situations took on great relevance. Legal issues regarding the jurisdiction and regulation of the practice were also disturbing, as well as considerations about the need to train therapists in the new psychotherapeutic modality (Barak et al., 2008).

Despite offering several advantages such as availability, convenience, accessibility, low cost, anonymity, privacy and stigma reduction (Cartreine et al., 2010), internet psychotherapy requires further studies for a better understanding of its effects. Until now, most of the research in the area has been performed abroad, with little Brazilian production. However, in Brazil, there are already positive results from online psychological interventions for individual treatments. Pieta (2014), using the Working Alliance Inventory (WAI) and the Outcome Questionnaire therapeutic outcome questionnaire, found a high score in the relationship between clients and psychotherapists in psychoanalytic psychotherapy via videoconference during 12 weeks, as well as a significant decrease of the clients' symptoms. Rodrigues (2014), also using the WAI, observed that the therapeutic alliance of clients who received brief focal psychotherapy via videoconference was maintained throughout the psychotherapeutic process and was similar to the face-to-face psychotherapy. Empirical investigations on this therapeutic modality are practically still scarce in our country, despite the ongoing discussions on the subject. Research in countries such as the United States, Australia and the United Kingdom has shown that the practice of psychologists giving advice virtually is already somewhat consolidated and there are positive indicators of this practice, revealing the effectiveness, cost reduction and greater access of the population to psychotherapy (Pieta, 2014).

According to the same author when advocating the potential of online psychotherapy, she lists anonymity, access to treatment by geographically distant people, with difficult access to means of transport, impossibility of locomotion or some other personal limitation, greater consumer empowerment in managing their own health process (in the case of applications and self-application software), in addition to the flexibility to adjust treatment at their own pace and the possibility of reviewing the material whenever they deem it necessary.

With the world situation, and the stoppage of activities, all playful strategies began to be scrutinized with the advent of online child care. Professionals began to carry out tests and discover more diverse ways of bringing playfulness online, without losing effectiveness and without jeopardizing the therapeutic relationship. However, in the framework of the COVID-19 pandemic, there was a wide and rapid transition from face-to-face assistance to remote assistance (Gritti, 2020; Matheson et al., 2020). In general terms, this transition was motivated by social distancing measures; however, even in cases where it is possible to carry out face-to-face consultations in adequate conditions, there are those who prefer the remote modality, due to necessity or convenience (MacMullin et al., 2020). Therefore, the relevance of qualifying online therapy should be emphasized, especially when considering that the duration of the pandemic is still unknown and that there are chances that this modality will become more widespread and will be definitively integrated into the practice of many therapists, even after the pandemic (MacMullin et al., 2020).

The modality of online assistance with children has its peculiarities, and should not consist only of a transposition of face-to-face care to the virtual setting (Duque, 2020). For this reason and for all the structure that CBT offers for services with children, it is known that a first step is to maintain the necessary steps for each child psychotherapeutic service.

In a first phase, the contact and the agreement with the parents is of great value to explain how the care will be given. Furthermore, the issue of therapeutic bonding is a central aspect for a successful psychotherapy and, as the therapist-client bond in a virtual environment is still a little explored aspect in this country, with a reduced number of investigations, it is one of the issues of most concern to Brazilian psychology when addressing this kind of care. In a study carried out by Siegmund and Lisboa (2015), the objective was to investigate the perception of professionals regarding the services they perform over the internet, especially with regard to the bond that is established. Based on the content of the interviews, one may think that it would be possible, in psychological visits in the internet, to develop a positive relationship with the clients, express empathy and achieve goals. However, to do so, it is necessary to adapt to this new field, which has its own language and expression. Furthermore, it is important to consider the positive and negative aspects raised by the participants, as well as the specific characteristics of these professionals' work.

In general, children therapists work by teaching parents ways to identify and conceptualize their children's behavioral problems, also using CBT techniques, such as role-playing, feedback and homework. Therefore, the bond between the professional and the child, as well as between the professional and the parents, is necessary and fundamental. Dalton et al. (2020) already pointed out that when adults inform children, there are benefits for the child and their families.

In the first session, some objectives must be fulfilled, such as establishing the clinical contract, presenting the therapist's way of working, evaluating the indication of psychotherapy, collecting data about the child, formulating and analyzing the complaint about the child's behavior, presenting or not the basic concepts about the approach and guide those responsible on how to prepare the child for the therapy session. In addition, it is important for the therapist to agree on the frequency of parenting sessions (Vermes, 2012).

Another important issue to be discussed is the time and frequency of the sessions, which last an average of 50 minutes and are performed weekly. The sessions may eventually be combined, depending on the need and purpose of the session. With regard to online care, shared sessions are welcomed because for very young children, their parents’ presence is necessary. It is a process in which the child has their reference adult near them, and when carrying out psychoeducation, two people are reached simultaneously. In spite of this, this term refers both to the provision of relevant information to patients about the disorder, treatment and prognosis, and to the search for clarification of doubts and corrections of distorted information. Psychoeducation aims to expand the patient/family member's knowledge about their problem in order to increase understanding of their condition, assist in decision-making based on reliable information and promote greater adherence to treatment (Oliveira & Dias, 2018). In this part of the therapy the family and the child get to understand the step-by-step and how the therapy works and this is a key part of the actual therapy.

Still in this initial phase, after collecting all the information, and after explaining all the therapy rules, limits, structure and process, carrying out the cognitive conceptualization, which is fundamental for the therapeutic process, and the child is invited to participate in a partnership for solving his/her problems (Moura & Venturelli, 2004).

On the other hand, in an intermediate phase, it is known that the need to play and interact is fruitful (Moura & Venturelli, 2004), and therefore, in sessions online, activities must be managed, such as relaxation activities, books placed on the screen according to age, drawings, videos, always with the participation of parents if extra materials are needed. As a way of approaching the topic of COVID-19, several resources have been created to be displayed on the screen or provided to parents, from information books to books to work on emotions, either by providing information about the current time, with the relevant emotional regulation, and with the ease of being able to be used in online therapy making available the material mentioned, or previously sent to the parents, so that it can be printed and later used during the therapy. Emotional regulation can be defined as the ability of human beings to identify their emotions according to different circumstances. That is, it is the response that the subject gives to internal and external events, which is also related to the person's resilience.

The children's book Feeling Masks, by Camilla Volpato Broering and Ana Paula Garcia Della Giustina in a digital version (unpublished), aims to guide children on the importance of wearing masks in combating the transmission of the new coronavirus, as well as, the expression of feelings in this phase of intense adaptations (Della Giustina & Broering, 2020). This was a resource that arose from the concern to develop a digital playful material for psychologists to use in their online consultations and share with other professionals of the area. Thus, as these many other materials emerged in this period to help working on issues associated with COVID-19.

In the final phase of the child psychotherapeutic process, the objective is to make a comparison between the beginning of the therapy and the changes resulting from it, as well as to talk more directly about the difficulties, make playing more relaxed and provide guidance for future demands.

The proposal that will be presented below was formulated by the author of the present work after almost 20 years of clinical experience in CBT and more than 10 years of activities as a supervisor in the training of cognitive-behavioral therapists. It should also be noted that this is not a completely new model, but a sequence of suggestions aimed at helping novice clinicians to develop skills to perform their child care online.

As a first point, it is stated that the sessions with children presuppose a basic structure, which must be maintained throughout the treatment, so that the child has predictability of what will happen, helping the child’s self-monitoring. This framework includes the participation of parents in the therapeutic process, which should occur regularly and at different levels, which may be in the form of collaborators of the children (Petersen & Wainer, 2011), or even their co-therapists, taking responsibility for the necessary activities to be carried out. At this first point in time, the structure of the sessions and of the therapeutic program must be maintained, regardless of the online form, in order to maintain what CBT preaches in terms of structure and organization.

As a second point, one cannot avoid to talk about family relationships, which are very important bases for the development of children and adolescents, and usually parents receive little or no preparation for this tasks; they base themselves on their own experiences as parents, testing their interventions through trial and error, which can generate insecurity and, consequently, a great chance of inadequacy in dealing with the children (Coelho & Murta, 2007). However, parents become the gateway for the child with regard to child care. It is with the parents that the therapeutic contract will be drawn, confidentiality will be addressed, the possibility of joint sessions will be discussed, as well as, research will be carried out on the child's technology skills, and his/her age group. It is with the parents that we will talk about online child care, checking the feasibility of the service according to the child's understanding and age. Some children will be able to participate in their sessions alone and others may require their parents’ help.

As a third point, there is a need to assess how familiar the child is with technology. It is well known that with regard to technology, the growing access that children have to the universe of computers, the internet, cell phones and other digital technologies considerably change their daily lives. Younger and younger, they already make regular and massive use of these resources both for schoolwork and research and for communication and, above all, for fun. This excessive use, both positive and negative, has been associated with direct and indirect effects on children's behavior or even on their development. We are witnessing the proliferation of the use of technology in the daily lives of families, for different purposes, from work to entertainment, communication and personal organization. Children grow up being familiar with technologies such as computers, the internet, video games, tablets and mobile phones, using them to play, learn and communicate. Digital language is part of the lives of these digital natives, and may even change their thinking patterns and the way they learn (Prensky, 2001). Younger children's learning is intuitive and action-oriented. Technology, in particular the computer, can be used to build knowledge, as it offers countless possibilities for learning about the surrounding world (Papert, 1996). With regard to online child care, this easy access that children have to Information Technology (TI), helps facilitating their adaptation to the psychotherapeutic process (Jackson et al., 2011).

The frequent use, for example, of computers, electronic games and the internet by children can facilitate different types of learning, can improve reading skills of children with poor initial reading performance (Jackson et al., 2011); it can develop skills such as accessing, evaluating and using information efficiently; it can stimulate skills for processing and selecting information, decision-making, establishing problem-solving strategies. In this way, with so many facilities that technology can provide, the advent of psychotherapy through the web, in addition to its consolidation as something possible, can also make the whole process rich and productive.

The fourth point is checking the web quality (Pieta & Gomes, 2014) to prevent the signal from dropping during the session; it is worth investing in a quality internet provider, as well as an antivirus. For safety reasons, public places such as cafes, libraries or coworking spaces should be avoided, and this precaution should be passed on to families. It is appropriate to use, if possible, a personal computer or cell phone. In the same way, this information should be passed on to the families, because depending on the children’s age, many children want to have sessions alone, and should have their right to privacy ensured. In addition, although performing the session in the home setting may be considered more comfortable by many clients, there are those who find it difficult to separate a space with privacy, free of interruptions, or even to organize the care of their children during the session. It is suggested that therapists discuss these aspects with the clients in a collaborative and sensitive way. The importance of avoiding distractions in the home environment during consultations should also be considered. This may include agreements to turn off television or other electronic devices, avoiding meals, and keeping pets in a separate room (Matheson et al., 2020).

A fifth point, after all the initial checks, is to think about the techniques to be used, so that they may be adjusted to this new framework, since aspects of non-verbal communication may be impaired. Depending on the age and level of autonomy of the children, there must be an adult nearby to guide them in relation to technological tools and provide resources that may be needed in the session, such as pencils, paper, clay, among others (Villas-Bôas, 2020)

One last point to be addressed, however, no less important, is about the supervision in the training of therapists. In a study by Schmidt et al. (2020) it was found that online supervision has proven to be useful in allowing access to qualified supervision for therapists who work in remote regions or small towns, as well as in regions in which there are few professionals who work in the chosen approach or who are experienced in specific subjects. The COVID-19 pandemic has reinforced the demand for this type of supervision, as therapists who started offering therapy online have also started to seek supervision in this format. In this connection, remote supervision represents an important strategy to ensure that the needs of clients and care for the mental health of therapists are met.

Final Considerations

This article aimed at systematizing the understanding about the practice of online therapy for children during COVID-19 pandemics. We chose to follow the structure of child psychotherapy that follows Cognitive-Behavioral Therapy, as this is the author's approach. With what has been informed so far, it was noticed that child care on line, as well as adult care, can be as effective as face-to-face and, to that effect, some points were established to be considered during this process. Some points are crucial to think about, such as drawing the contract with the family authorizing the child, good internet connection, checking the child's skills in the use of technologies, separating activities consistent with the child's age, organizing if necessary, shared sessions, checking how confidentiality will be ensured, selection of an appropriate platform that addresses children's needs. It is known that the need to play and interact is healthy; therefore, in online sessions, activities must be managed, such as relaxation activities, books displayed on the screen according to age, drawings, always counting on parental involvement if extra materials are needed.

Hence, we sought to bring information from articles and research carried out until the end of the same, a possible adaptation to this new demand for online child care, as well as suggestions of psychological interventions considering the new coronavirus pandemic. We sought to emphasize that the requirements of planning, definition of objectives and continuous and permanent evaluation are a rigorous way of experimentally ensuring the quality of the work, and if this rigor is combined with the flexibility and creativity inherent to children’s therapists, one will have a rich experience and profoundly intellectually stimulating for both therapist and children and their family.

Several obstacles and stumbling blocks were found in this endeavor, and it is clear the lot that is necessary to adapt to the storms of life as professionals and researchers. Research with children is suggested to investigate what perception they have about this type of care, in order to guide and support future psychotherapeutic interventions in the online format, since it is not known how long this situation will last, as well as it is believed that this modality may be even further explored, as well as used by different professionals who work with children.

In general, we conclude that the pandemic brought a great deal of reflection on the psychologist professional’s practice. In the midst of a global crisis, psychologists had to rethink their practice and their way of acting. It was a year of much learning for professionals who, driven by the ethics of giving continuity to their care and commitment to their patients, sought new ways of performing, going beyond their limits, in order to seek supervision, and find ways of being able to ensure technical and ethical quality in their services.

References

• Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 26(2/4), 109-160. https://doi10.1080/15228830802094429
  » https://doi10.1080/15228830802094429
• Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet, 395(102227), 912-920. https://doi.org/10.1016/S0140-6736(20)30460-8
  » https://doi.org/10.1016/S0140-6736(20)30460-8
• Cartreine, J. A., Ahern, D. K., & Locke, S. E. (2010). A roadmap to computer-based psychotherapy in the United States. Harvard Review of Psychiatry, 18(2), 80-95. https://doi.org/10.3109/10673221003707702
  » https://doi.org/10.3109/10673221003707702
• Coelho, M. V., & Murta, S. G. (2007). Treinamento de pais em grupo: um relato de experiência. Estudos de Psicologia, 24(3), 333-341. https://doi.org/10.1590/S0103-166X2007000300005
  » https://doi.org/10.1590/S0103-166X2007000300005
• Dalton, L., Rapa, E., & Stein, A. (2020). Protecting the psychological health of children through effective communication about COVID-19. Lancet , 4(5), 346-347.
• Della Giustina, A. P., & Broering, C. V. (2020). Feeling Masks https://www.canva.com/design/DAD55z0cXm8/hYBDErd-CBwK5vaReVwaYw/view?fbclid=IwAR3zX9s8AhGkbVB24vOzLbLglYwc9el3_m_4TueVkzxUtgkt07uFaeV5Gos
  » https://www.canva.com/design/DAD55z0cXm8/hYBDErd-CBwK5vaReVwaYw/view?fbclid=IwAR3zX9s8AhGkbVB24vOzLbLglYwc9el3_m_4TueVkzxUtgkt07uFaeV5Gos
• Duque, F. M. (2020). Planejamento do atendimento on-line. In A. L., Oliveira, A. C. A., Nascimento, & F. M., Duque (Orgs.), Psicoterapia infantil on-line: técnicas e ferramentas desenvolvidas durante a pandemia do covid-19 (pp. 17-23). EdUnitau.
• Finn, J., & Barak, A. (2010). A descriptive study of e-counsellor attitudes, ethics, and practice. Counselling and Psychotherapy Research: Linking research with Practice, 10(4), 268-277. https://doi.org/10.1080/14733140903380847
  » https://doi.org/10.1080/14733140903380847
• Friedberg, R. D., & McClure, J. M. (2004). A prática clínica da terapia cognitiva com crianças e adolescentes Artmed.
• Gadelha, Y. A., & Menezes, I. N. (2004). Estratégias lúdicas na relação terapêutica com crianças na terapia comportamental. Universitas: Ciências da Saúde, 2(1), 1-151. http://dx.doi.org/10.5102/ucs.v2i1.523
  » http://dx.doi.org/10.5102/ucs.v2i1.523
• Godleski, L., Nieves, E., Darkins, A., & Lehmann, L. (2008). VA telelemental health: Suicide assessment. Behavioral Sciences and the Law, 26, 271-286. https://doi.org/10.1002/bsl.811
  » https://doi.org/10.1002/bsl.811
• Gritti, P. (2020). Family systems in the era of Covid-19: From openness to quarantine. Journal of Psychosocial Systems, 4(1), 1-5.https://doi.org/10.23823/jps.v4i1.64
  » https://doi.org/10.23823/jps.v4i1.64
• Jackson, L. A., Eye, A. von, Witt, E. A., Zhao, Y., & Fitzgerald, H. E. (2011). A longitudinal study of the effects of internet use and video game playing on academic performance and the roles of gender, race and income in these relationships. Computers in Human Behavior, 27, 228-239.
• Kohlenberg, R. J. & Tsai, M. (2001). Psicoterapia Analítica Funcional - Criando relações terapêuticas intensas e curativas ESETEC.
• Liu, J. J., Bao, Y., Huang, X., Shi, J., & Lu, L. (2020). Mental health considerations for children quarantined because of COVID-19. Lancet , 4(5), 345-349. https://doi.org/10.1016/S2352-4642(20)30096-1
  » https://doi.org/10.1016/S2352-4642(20)30096-1
• MacMullin, K., Jerry, P., & Cook, K. (2020). Psychotherapist experiences with telepsychotherapy: Pre Covid-19 lessons for a post Covid-19 world. Journal of Psychotherapy Integration, 30(2), 248-264.http://dx.doi.org/10.1037/int0000213
  » http://dx.doi.org/10.1037/int0000213
• Matheson, B. E., Bohon, C., & Lock, J. (2020). Family-based treatment via videoconference: Clinical recommendations for treatment providers during Covid-19 and beyond. International Journal of Eating Disorders, 53(7), 1142-1154.https://doi.org/10.1002/eat.23326
  » https://doi.org/10.1002/eat.23326
• Moura, C. B., & Venturelli, M. B. (2004). Direcionamentos para a condução do processo terapêutico comportamental com crianças. Revista Brasileira de Terapia Comportamental e Cognitiva, 6(1), 17-30.
• Oliveira, C. T., & Dias, A. C. G. (2018). Psicoeducação do transtorno do déficit de atenção/hiperatividade: o que, como e para quem informar? Trends in Psychology, 26(1), 243-261. https://doi.org/10.9788/tp2018.1-10pt
  » https://doi.org/10.9788/tp2018.1-10pt
• Ornell, F., Schuch, J. B., Sordi, A. O., & Kessler, F. H. P. (2020). “Pandemic fear” and COVID-19: mental health burden and strategies. Brazilian Journal of Psychiatry, 42(3), 232-235. https://doi.org/10.1590/1516-4446-2020-0008
  » https://doi.org/10.1590/1516-4446-2020-0008
• Papert, S. (1996). The connected family: Bridging the digital generation gap Longstreet Press.
• Pastore, M. N. (2020). Brincar-brinquedo, criar-fazendo: pluriversos de infâncias e crianças desde o sul de Moçambique [Tese de doutorado não publicada]. Universidade Federal de São Carlos.
• Petersen, C. S., & Wainer, R. (2011). Princípios básicos da terapia cognitivo-comportamental de crianças eadolescentes. In C. S., Petersen, R., Wainer (Orgs.), Terapias cognitivo-comportamentais para crianças e adolescentes Artmed.
• Pieta, M. A. M. (2014). Psicoterapia pela internet: a relação terapêutica [Tese de doutorado não publicada]. Universidade Federal do Rio Grande do Sul.
• Pieta, M. A., & Gomes, W. B. (2014). Psicoterapia pela internet: viável ou inviável? Psicologia: Ciência e Profissão, 34(1), 18-31. https://doi.org/10.1590/S1414-98932014000100003
  » https://doi.org/10.1590/S1414-98932014000100003
• Prensky, M. (2001). Digital natives, digital immigrants. On the Horizon MCB University Press, 9(5), 1-6.
• Proudfoot, J., Klein, B., Barak, A., Carlbring, P., Cuijpers, P., Lange, A., Ritterband, L., & Andersson, G. (2011). Establishing guidelines for executing and reporting internet intervention research. Cognitive Behaviour Therapy, 40(2), 82-97.https://doi.org/10.1080/16506073.2011.573807
  » https://doi.org/10.1080/16506073.2011.573807
• Pureza, J. R., Agliani, A. O., Pureza, J. R., & Lisboa, C. S. M. (2014). Fundamentos e aplicações da Terapia Cognitivo-Comportamental com crianças e adolescentes. Revista Brasileira de Psicoterapia, 16(1), 85-103.
• Regra, J. A. G. (2000). A agressividade infantil. In E. F. M Silvares (2000). Estudos de caso em psicoterapia comportamental infantil (pp. 157-194). Papirus.
• Rodrigues, C. G. (2014). Aliança terapêutica na psicoterapia breve on-line [Dissertação de mestrado não-publicada]. Universidade de Brasília.
• Scharff, J. F. (2012). Clinical issues in analyses over the telephone and the internet. International Journal of Psychoanalysis, 93, 81-95. https://doi.org/10.1111/j.1745-8315.2011.00548
  » https://doi.org/10.1111/j.1745-8315.2011.00548
• Schmidt, B., Silva, I. M., Pieta, M. A. M., Crepaldi, M. A., & Wagner, A. (2020). Terapia on-line com casais e famílias: prática e formação na pandemia de Covid-19. Psicologia: Ciência e Profissão, 40, e243001. https://doi.org/10.1590/1982-3703003243001
  » https://doi.org/10.1590/1982-3703003243001
• Shimizu, K. (2020). 2019-nCoV, fake news, and racism. Lancet , 395(10225), 685-686. http://dx.doi.org/10.1016/S0140-6736(20)30357-3
  » http://dx.doi.org/10.1016/S0140-6736(20)30357-3
• Siegmund, G., & Lisboa, C. (2015). Orientação psicológica on-line: percepção dos profissionais sobre a relação com os clientes. Psicologia: Ciência e Profissão, 35(1), 168-181. https://doi.org/10.1590/1982-3703001312012
  » https://doi.org/10.1590/1982-3703001312012
• Silvares, E. F. M. (2001). Ludoterapia cognitivo-comportamental com crianças agressivas. In H. J. Guilhardi. Sobre comportamento e cognição. Expondo a variabilidade (pp. 373-385). ESETEC.
• Vermes, J. S. (2012). Clínica analítico comportamental infantil: a estrutura. In N. B. Borges & F. A. Cassas (Orgs.), Clínica analítico-comportamental: aspectos teóricos e práticos (pp. 214-222). Artmed.
• Villas-Bôas, L. E. R. (2020). Psicoterapia infantil on-line. Um novo caminho possível frente à pandemia da covid-19. Revista IGT Na Rede, 17(32), 53-64.
• Wade, S. L., Gies, L. M., Fisher, A. P., Moscato, E. L., Adlam, A. R., Bardoni, A., Corti, C., Limond, J., Modi, A. C., & Williams, T. (2020). Telepsychotherapy with children and families: Lessons gleaned from two decades of translational research. Journal of Psychotherapy Integration , 30(2), 332-347.http://dx.doi.org/10.1037/int0000215
  » http://dx.doi.org/10.1037/int0000215

Publication Dates

• Publication in this collection
  29 Mar 2024
• Date of issue
  2024

History

• Received
  26 Feb 2021
• Reviewed
  28 Nov 2022
• Accepted
  03 Feb 2023