by Swapnajeet Sahoo, MD; Diksha Sachdeva, MPhil; Sana Yumnam, MD; Ruchita Shah, MD; Aseem Mehra, MD; and Sandeep Grover, MD

All authors are with the Department of Psychiatry, Post Graduate Institute of Medical Education and Research in Chandigarh, India.

Funding: No funding was provided for this study.

Disclosures: The authors have no conflicts of interest relevant to the contents of this article.

Innov Clin Neurosci. 2022;19(10–12):40–42.

Abstract

The mental health of children and adolescents has been significantly affected by the COVID-19 pandemic, and recent data suggests there had been an upsurge of psychiatric morbidity in this subgroup of population. Nonpharmacological behavioral intervention in the form of play therapy has been regarded as one of the best treatment strategies in children with emotional disorders. During lockdown, we attempted a play therapy via telemedicine. In this case report, we describe the case of a four-year-old girl who had sudden-onset behavioral problems following an unplanned hair cut during the lockdown, which was managed with teleplay therapy.

Keywords: Teleplay therapy, emotional disorder, children, COVID-19, lockdown

Recent data indicate an upsurge in psychiatric morbidity among children and adolescents, which has been associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, more commonly referred to as COVID-19 (coronavirus disease-2019).1 The causes of this increase in psychiatric illness, in relation to COVID-19, are multifactorial and may include lack of outdoor activities, closure of schools, staying homebound/experiencing isolation, and facing/witnessing domestic conflicts of relatives/parents, all of which may be especially traumatic during the developmental years of childhood and adolescence.1 

Teletherapy, or psychotherapy provided remotely by a licensed professional via telecommunication technologies, has been utilized as a mode of delivering nonpharmacological psychotherapy to adult and child/adolescent patients with mental illness for several years; however, its use has become more prominent as a result of the pandemic due to the mandatory lockdown that was in effect globally.2–4 

 Play therapy is regarded as one of the most effective nonpharmacological treatment strategies for helping children with emotional dysfunction/disorders,5 and play therapy via telemedicine has been explored as a means to effectively treat, in a remote setting, children with emotional/behavioral problems.6 We describe a case of a four-year-old girl who exhibited sudden-onset regressive behavior, following a traumatic event, that was managed with play therapy via telemedicine during the mandatory COVID-19 lockdown.

Case Description

A four-year-old girl was referred to the child telepsychiatric services of our clinic for acute-onset regressive behavior. History revealed the patient was an only child living with both parents, who were married and of middle socioeconomic status. The mother reported having a normal pregnancy and birth and that the girl had been meeting all developmental milestones appropriate for a child her age. The mother described the patient as having an easy temperament, with no abnormal emotional or behavioral manifestations, prior to presentation. The patient’s mother and father both worked outside of the home as physicians, and when they were both at work, the child was cared for by her grandparents, who lived in the same house with the child and her parents. The child was reportedly well-accustomed to this routine and was described as having a loving relationship with both her parents and her grandparents. Prior to presentation, the patient performed biofunctions (e.g., using the toilet) in a manner appropriate for a child her age.

About two weeks prior to presentation, the child’s cousin, a nine-year-old boy from her father’s side who was also being cared for by the grandparents while his parents were at work, forcibly shaved a portion of the patient’s hair to the scalp with an electric hair trimmer. The cousin had been routinely cared for by the grandparents before the pandemic as well.  The patient tried to resist the attack, but the older, larger male child reportedly slapped her on the back and then verbally ridiculed her over the appearance of her shaved head. According to the grandparents, the patient then started crying inconsolably, despite the cousin being reprimanded for his actions by the grandparents. On the evening of the same day, upon the parents’ return home from work, the patient witnessed a verbal quarrel between her parents and her cousin’s parents over the incident; the mother said the argument was resolved in an appropriate manner without further quarrel within an hour. After the incident, the cousin and his parents separated from the joint family set up due to interpersonal problems resulting out of the index incident. This decision was made by the child’s parents, and the therapy team was not involved in these issues; hence, this was not addressed in therapy.

Immediately following the hair shaving incident, the patient exhibited a sudden change in behavior. The mother said the patient began acting fearful and clingy, especially at night, and refused to be left alone. The patient stopped talking and began only using hand gestures to communicate what she wanted, which was atypical behavior for her. The patient stopped playing and interacting with others and began urinating/defecating in her clothes, without showing any concern over this behavior and for no apparent reason to the family members. The patient would cry inconsolably when the mother tried to leave for work. Therefore, the mother stopped going to work due to the patient’s crying behavior, which would occur more frequently if the mother tried to go to work. The patient began to frequently and randomly say the word “bhaag” (the Hindi word for “run”) two or three times in an angry voice while curling one of her hands into a fist. This behavior would occur while she was clearly conscious, in any position, anywhere in the house, with or without family members close by, and with no other abnormal body movements during such episodes. 

Over the next 2 to 3 days following the incident, the patient interacted less and less with her parents and grandparents, and, after three or four days, became completely mute and stopped communicating her basic needs with hand gestures. These symptoms persisted for an additional 3 to 4 days (i.e., 7 days after the incident) without any signs of fever, loss of consciousness, other family stressors, or other physical disturbances to the child. Her sleep and appetite remained normal. 

Using a cross-platform, centralized, instant messaging and voice-and-video-over-IP service provider (WhatsApp Messenger, WhatsApp LLC; Menlo Park, California, US), a video consultation session was initiated between our clinic and the patient and her mother. During the consultation, the patient remained mute and did not respond to various attempts by the therapist to interact with her, including repeatedly calling the child’s name. The patient was observed playing with her mother’s face and hair, as if she wanted her mother to attend to her instead of interacting with the therapist. Based on the provided history and observation via teleconsultation, the patient was diagnosed with emotional disorder with specific onset to childhood, unspecified, as per the International Classification of Diseases 10th Revision (ICD-10). Because of the ongoing COVID-19 pandemic, therapy was provided remotely using the voice and video conferencing features of WhatsApp. 

The therapeutic team and parents decided to initiate teleplay therapy sessions on a twice weekly basis. However, despite attempts by the therapist to engage the child, via video conference, in drawing, story-telling, and participating in stories, the child remained unresponsive to the therapist; thus, psychological assessment and play therapy via the teletherapy platform between the therapist and the child were unsuccessful. In an effort to facilitate therapy and reinforce interventions between sessions, it was then decided that the mother would attend the teletherapy sessions to learn the vital techniques of play therapy in the hopes that she could engage the child in treatment and achieve successful outcomes.

 Both parents were educated about the nature of the child’s diagnosis and course of therapy, and the mother agreed to take a 15-day leave of absence from work so that she would be available to work with the child. Activity scheduling and change of home environment in the form of not forcing the child to behave as she had before the incident were advised. Teleplay therapy sessions based on client-centered theory principles were initiated with the mother, during which she was educated on the proper techniques of play therapy. She was told that when playing with the child, she should follow the child’s wishes to engage in different types of play. An important factor of play therapy is to avoid instructing, suggesting, or criticizing the child during any play session. In the initial sessions, the child was made to wear her previous clothes (e.g., Radha dress) in which she used to be happy and playful. She started to engage in these play sessions, and over two weeks, the mother was able to engage the child in make-believe scenarios, such as pretending to be a doctor treating a patient or playing with the toy kitchen set. The main theme that was incorporated into these play sessions was the removal of hair and its regrowth over time. Within a month of play therapy initiation, the child’s behavior improved—the frequency of soiling her clothes decreased and she began to participate in a few outdoor activities. However, lack of initiation, loss of interest, and withdrawal persisted. 

The mother was motivated and consistent in her endeavors to engage the child in different play activities. For example, she used storytelling to introduce neutral plots at first that eventually would involve the theme of natural hair regrowth over time. After three months of play therapy, the child was fully recovered. The mother attended monthly online booster sessions for another three months, during which the child maintained her improved behaviors. In the follow-up sessions, the child would interact with the therapist in a positive manner. Throughout the treatment period, no medication was utilized.

With regard to preventing similar situations in the future, the parents were advised to discuss the possibility of repetitive trauma from the nine-year-old cousin with the grandparents. After a joint family meeting, the boy’s parents and grandparents counseled the boy not to repeat similar incidents in the future, to which the boy agreed; the boy also apologized to the parents for his behavior. The grandparents assured the girl’s parents that they would keep strict vigilance over the boy when both he and the girl were under their care.

Discussion

The unplanned, unwanted, and sudden action of shaving the patient’s hair with an electric hair trimmer by an older, larger child could be regarded as a traumatic event for the patient that resulted in regressive behavior. The child displayed an “angry voice,” “fisting of one hand,” and verbalizing “bhaag” (meaning “run”), which suggests that there were underlying feelings of protest, resentment, and anger in the child, which possibly led to the regression. Teleplay therapy with the mother’s help led to a quick recovery from the traumatic event. The mother provided affection, acceptance, love, and quality time with the child. She became sensitive toward the child’s physical and emotional needs. She was able to teach the patient appropriate physical and psychological verbalizations and behaviors to positively modify the child’s thoughts, emotions, and behaviors. Play time was used as a primary tool toward the resolution of trauma faced by the child. Playing provides children with the opportunity to make contact with others and integrate fragmented parts of themselves through emotional expression.7 Our case report highlights the efficacy of teleplay therapy, which can be used in children with emotional disorders, and further suggests the creation and exploration of new, technology-based therapies to help children and adolescents who are unable to participate in in-person clinic visits.

References

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