Adapted from: Quotidianosanità.it

by Angelo Fioritti

In the first place, it is clear that it is not all the fault of the lockdown, although this year is weighing on the mental health of Italians and probably to a greater extent on the physical and mental health of children and adolescents. Several indicators of the mental health of the very young have been declining for at least 15 years and at the same time the requests for help from public and private services have been growing exponentially.

29 MAR – In the end it seems that we have noticed. For some weeks the newspapers and magazines have been reporting alarms launched by pedagogists, sociology, psychologists, child neuropsychiatrists on the escalation of malaise and clinical emergencies affecting children and young people. The blame is charged at the lockdown, when schools close, the suspension of sports activities, social and recreational, to forced cohabitation in the family, to the increase in hours spent in front of the PC or smartphone, to cyberbullying and so on. An explosion of access to the emergency room is reported, of self-injurious gestures, of suicides, of hospitalizations in child neuropsychiatry, in pediatrics, in psychiatry, of requests for first visits to local services.

What is true about all this? And if that's true, it is a phenomenon of cities, regional, national, European, global? And how existing services are dealing with the situation? And the company which indication draws from it?

The National College of Mental Health Departments has initiated an internal discussion between its members to seek answers to these questions on the basis of which it is already possible to establish some fixed points and hypothesize lines of research to complete the picture..

In the first place, it is clear that it is not all the fault of the lockdown, although this year is weighing on the mental health of Italians and probably to a greater extent on the physical and mental health of children and adolescents.

Several indicators of the mental health of the very young have been declining for at least 15 years and at the same time the requests for help from public and private services have been growing exponentially. In a metropolitan area like Bologna since 2011 to the 2021 NPIA first visits increased by 50% and in particular those for adolescent psychopathology problems increased by 83%.

The situation is not very different between urban areas, suburban and rural and it doesn't seem to be much different between the North, Center and South, even if there is great difficulty in comparing data collected in a heterogeneous way and between differently organized systems, which also raises a serious question of fairness and guarantee: LEAs must be guaranteed and monitored, they are provided by one or the other macrostructure in which the NPIA centers are hinged. Territorial NPIAs are a long-suffering system, that he had to do more with less, on which other institutions in crisis with young people have relied, such as the school and the social services of local authorities.

Regardless of the social determinants, cultural and economic that led to this situation, it is clear that we are facing a crisis that has structural elements that come from afar and contingent elements due to the pandemic. It is good to say that for the moment we do not have a large amount of data on the latter, but consistent and consistent reports are being collected from various parts of Italy. We know that epidemiology in these fields always comes to explain phenomena that have been highlighted long before and sometimes have already been resolved regardless of its contribution. In the specific case it seems that the first wave did not produce further troubles, compared to the dramatic starting situation.

Some suggest that the closure of the schools was cognitively taken as a kind of early vacation by the children, which then had relative limitations during the summer. The service activity data seem to confirm that on the first round there was no increase or requests for help, nor of emergency activities. The situations of young people with physical or intellectual disabilities and their families who already in the first wave have experienced a significant regression of hard-won skills and important stress levels must obviously be excluded..

Different is what is being observed from October to today, with phenomena that are still difficult to frame in a structured epidemiology, but which occur quite consistently throughout Italy and which must arouse a lot of attention. The emerging aspects concern above all:
1 – the increase in requests for help in all childhood and youth ages,
2 – the transversality to conditions of physical and intellectual disabilities, psychopathology of childhood and adolescence and learning neuropsychology,
3 – the greater use of First Aid and hospitalization interventions for psychopathological or behavioral problems, in particular, this increase appears to be linked to early ages, Come on 10 ai 12 years
4 – greater requests for collaboration from the school system and the social services of local authorities.

The social and cultural changes induced by the pandemic are generating clinical impacts in many different ways. For children and young people with neuromotor and sensory disabilities regression phenomena occur with respect to the skills acquired, despite the efforts of families and health professionals to compensate for the effect of interrupted or reduced social and rehabilitation activities.

For children with learning disabilities there is also a regression with respect to the levels reached and a gap in academic performance levels between digitized pupils with adequate resources and disadvantaged pupils under various profiles, including the linguistic-cultural one. There are clear implications in terms of mental health that this could have if this inequality persists and worsens. Furthermore, from a psychopathological point of view, we find anxious syndromes in children (8-12 years) expressed mainly through the somatic sphere (stomach ache, mal di testa, weight gain or loss, nightmares, enuresi) and complex psychiatric and behavioral syndromes in adolescents ("hikikomori" type home retreat, self-harm, accentuation of obsessive symptoms, aggravation of eating disorders, thought disorders).

From a first non-standardized collection of data from the regional services of Emiia-Romagna it appears that in the November period 2020 - February 2021, compared to the same period 2019-2020 there was an increase in territorial requests of about 30% for all the aforementioned clinical conditions. All in a system that had seen the demand for 50% in 10 previous years, working in practice at isorisorse.

The situation does not appear to be different in other parts of Italy. With regard to emergency services, surges were reported in access to the emergency room and in hospitalizations in wards of various classification. In this regard it must be said that the emergency system in NPIA is of limited size everywhere, with a few dozen cases expected annually in large cities, often based on the construction of ad hoc solutions for individual patients and for all these reasons periodically in crisis. It can be said that emergencies and hospitalizations are the tip of the iceberg and that proposals for solutions based on this aspect can only be unsuccessful,per how the problem exists and needs to be addressed. The current one therefore appears to be a more serious crisis than the previous ones, which, however, had already occurred at various times in the last ten years.

If this is the picture of the situation, what indications can we draw for the immediate future, near and far? Basically indications of three kinds: on communication, on overall institutional strategies, on specific strategies of health services.

The crisis situation in the crisis we are experiencing is an opportunity to put the theme of young people back at the center of the social agenda and contextualize it in a culture of promoting health and responsibility.. The messages that have been sent in recent months are contradictory as few other times.

On the one hand, young people have been blamed for their behavior that is not always attentive to measures to prevent the spread of the infection, on the other hand they are portrayed as victims of the same measures, coming to coin definitions such as "COVID generation", which would implicitly normalize the expectation of a present and a clinical future for many of them.

On the part of health institutions it is necessary to have balanced lines of communication, that do not hide the existing problems, but they convey the courage to face reality with the tools of individual resilience and social systems, if anything to be strengthened. Each generation has its problems and even if those that are now facing society have important ones, it is good that there is an intergenerational awareness that it will be done., with everyone's commitment and responsibility, as the generations that have lived through the war or the years of lead have made it.

Regarding institutional strategies, the time has certainly come to reform the system of relations between schools, social services, health services, judicial institutions and anything else that moves around young people. It is such a complex system, fragmented and contradictory that is difficult to understand even for adults, which disorients and dislikes young people.

And finally, regardless of social determinants, cultural and economic that led to this situation, it is now unavoidable to review an overall policy towards young people and the strengthening of territorial institutions as a whole and of NPIAs in particular.

Some historical issues of the NPIAs themselves need to be addressed, come:
1 – the vastness of the intervention area (from neonatal neurology to adolescent psychiatry),
2 – the heterogeneity of the organizational models that sometimes see it as an articulation of the Maternal and Child Departments at other times of the Departments of Mental Health, at other times, autonomous departments,
3 – the relationship between territorial NPIAs and hospital NPIAs,
4 – the relationship between territorial NPIAs, CSM and social services for the protection of minors.

If the emergency and hospital system needs greater clarity with respect to its neurological or psychiatric vocations and better organization and some strengthening in some areas of the country, it is the territorial system that has been bearing an increasing load of complex needs for ten years and which risks succumbing to this crisis in the crisis.

The College will bring its proposals to any institutional context that can help address and solve the structural and contingent problems of this crucial sector for our civilization., starting from the technical table of the Ministry of Health which will take office on 30 March 2021.

Angelo Fioritti
President of the National College of Mental Health Departments

This document arises from the analysis of some data from various regions and from a discussion held within the Board of the National College of Mental Health Departments on the day 23 March 2021

Adapted from: Quotidianosanità.it