Оцінка ефективності проведенної психологічної реабілітації дітей та батьків, які були пацієнтами НДСЛ «ОХМАТДИТ» МОЗ України у Латвії

Анотація

Актуальність. Повномасштабне вторгнення стало надзвичайно серйозним викликом для кожного жителя України. Одна з найбільших категорій групи високого ризику за віковими особливостми стали "Діти та підлітки", адже вони є однією з найбільш вразливих категорій населення. Бо ще несформована психіка може вражатись в рази більше і нести негативні зміни у майбутньому протягом усього життя.

Постійний тривалий стрес через існуючу небезпеку, необхідність покинути дім, порушення звичного способу життя та розрив соціальних зв’язків, негативно впливають на психічний стан будь-якої особистості. Однією з ключових психологічних проблем, які виникають в наслідок військових дій, є висока тривожність, яка пов'язує у собі складність адаптуватись до різких змін, або повна дезадаптація, апатія та депресія. Більшість стикаються із питанням переходу на дистанційне навчання, необхідністю відвідувати нові школи через переселення або ж інтегруватися в закордонні освітні установи, поєднуючи дві освітні програми паралельно. Усі ці обставини створюють широкий спектр стресових викликів, які діти відчувають під час навчання у школі та у середовищі свого оточення. Саме тому психологічна реабілітація має поєднувати у собі різноманіття способів у комбінації індивідуальної терапії та групових форм роботи.

Матеріали і методи. Для дітей та підлітків застосували для визначення рівня шкільної тривожності методику «Тест шкільної тривожності Філіпса», а також дослідили рівень самооцінки за методикою Дембо-Рубінштейна. Для батьків було проведено психодіагностичне дослідження за допомогою спеціальних методик: «Шкала депресії PHQ-9»; опитувальник для визначення генералізованого тривожного розладу GAD-7»; «Госпітальна шкала тривоги і депресії HADS», також було оцінено якість життя за методикою «Шкала оцінки якості життя».

Результати. У дослідженні прийняло участь 147 дітей (віком від 3 до 14 років): з них - 103 дитини віком 7-14 років та 44 дитини віком 3-6 років; кількість батьків, що прийняли участь у дослідженні 113 осіб.

У батьків було досліджено рівні тривоги та депресії до початку та після проходження реабілітації за методиками «Шкала депресії PHQ-9»; опитувальник для визначення генералізованого тривожного розладу GAD-7»; «Госпітальна шкала тривоги і депресії HADS», також було оцінено якість життя за методикою «Шкала оцінки якості життя».

У дітей визначали рівень шкільної тривожності до початку та після проходження реабілітації за методикою «Тест шкільної тривожності Філіпса», а також дослідили рівень самооцінки за методикою Дембо-Рубінштейн.

Статистичний аналіз проведений у програмному забезпеченні Jamovi v. 2.3. Використані методи описової статистики. Визначення статистичної імовірності проводилося методами хі-квадрат та ANOVA.

В результаті літературного пошуку в огляд літератури було включено 3 публікації. Був здійснений теоретичний аналіз застосованих у програмі реабілітації методів інтервенцій.

Психологічна реабілітація є важливою частиною ведення дітей з будь-якими соматичними захворюваннями, станами та патологіями. Саме під час перебування в таборі найбільше застосовувались такі методи, як когнітивно-поведінкова терапія (КПТ), каніс-терапія та різновиди арт-терапевтичних методів терапії.

За результатами психологічної реабілітації значно покращився емоційний стан дітей. Рівень тривожності знизився на 12.4% після проходження реабілітації. Також значно виросли показники самооцінки, так більшість дітей мали високу (42,7%) та середню (43,7%) самооцінку, що може свідчити про набуття ресурсу стресостійкості у дітей після проходження психологічної реабілітації та набуття навичок подолання стресу.

Також відмічаються значні показники покращення емоційного стану батьків дітей. Саме за шкалою HADS: зниження тривоги на 32,25%, депресії на 24,5%. За шкалою PHQ-9 показники депресії зменшились на 12.46%, показники тривоги за шкалою GAD-7 зменшились на 14.48%. Такі показники свідчать про високу ефективність проходження програми психологічної реабілітації дітей та їхніх батьків у Латвії.

Висновки. Організація та проведення психологічної реабілітації дітей в умовах безпечного середовища з використанням різних психотерапевтичних методів, фізичної терапії, культурних заходів надають позитивного наповнення,  ресурсу психологічної стійкості дітей та їх батьків. В тяжкі воєнні часи важливою складовою є проведення психологічної реабілітації  вразливих категорій дітей, таких як діти з хронічної соматичною або хірургічною патологією.

Introduction

With the beginning of the full-scale invasion of Ukraine by the Russian Federation, the life of every child changed. The feeling of constant danger, sounds, air raid alerts, worry about family and friends, news of emergency events, and deaths of adults and children are unfortunately a reality of wartime.

Socio-psychological rehabilitation is a step-by-step process aimed at mitigating the negative effects of traumatic events by actualizing the rehabilitation potential of the individual. It has been shown that resilience resources, which reflect the mechanisms of neutralising external risks, are manifested in such features of dynamic adaptation, such as risk-taking and patience. It is determined that the main task on the way to gaining resilience is the reconstruction of basic rehabilitation resources. [1] In working with people in difficult life circumstances, there is an organizational aspect and practical work with a specific person or group of people in need of psychosocial rehabilitation. It is important to keep in mind that affected people carry a great potential (accumulation of negative emotions), perceiving the psychologist as the main source of support. They need help to transform these affects: to listen calmly, to sympathize, to protect. The combination of empathetic statements, clarifying questions and affirmative statements is an effective method of providing such support [2].

Among the main measures of psychological rehabilitation of a personality, the methods aimed at self-identification, development of new communicative territories, sense-making, search for a new life path in the dilemma of choice are considered. The vectors of rehabilitation work and the content targets of rehabilitation influences, social and psychological methods of rehabilitation of the individual in conditions of prolonged traumatisation are highlighted, in particular, the possibilities for psychological rehabilitation of logotherapy, bibliotherapy etc [3].

All these events negatively affect the vulnerable psyche of children and the lives of families in general. Children who have had or have chronic illnesses are particularly affected. According to the cooperation between the National Specialized Children's Hospital "OKHMATDYT" of the Ministry of Health of Ukraine and the Children's Hospital Foundation of Latvia, for the patients of a multidisciplinary hospital since 2022, with the beginning of the full-scale invasion, who have been negatively affected by the war (loss of relatives or loved ones, loss of home; who have witnessed active hostilities), psychological rehabilitation camps have been organized in Riga, Latvia.

During 2022-2024, 7 field camps were held in Latvia to complete a psychological rehabilitation program for children and their parents. Two hundred seventy-seven participants received the psychological rehabilitation program, including 147 children and 113 parents. Among the participants in psychological rehabilitation were children with chronic somatic diseases and surgical pathology. Their parents, who accompanied the child, also received a psychological support program. A study was conducted on the emotional state of children and adolescents and their parents before and after rehabilitation to assess the quality of psychological rehabilitation.

Relevancy

The current situation in the context of a full-scale war in Ukraine is undoubtedly a distressing factor that is directly related to the deterioration of the mental state of the population. Children with physical health disorders are most vulnerable to the stress of war, which is exacerbated by fears of health prognosis, limited functioning, and a deterioration in quality of life. Parents who have children with chronic illnesses also experience chronic stress associated with fears for the health and life of their child, which is exacerbated by the high daily rhythm, the flow of negative information, and the stress of wartime [4, 5].

That is why a psychological rehabilitation program was organized for children, adolescents, and their parents in Latvia. The rehabilitation program involved specialists from a multidisciplinary team, which included pediatricians, medical and clinical psychologists, and rehabilitation doctors. The program used various methods of additional psychological correction and relaxation, such as art therapy, sensory therapy, zootherapy, various cognitive behavioral therapy techniques, and individual and group therapy. The psychological rehabilitation program was designed for 10 days.

The main goal of a psychological rehabilitation program is to teach you how to manage symptoms, take responsibility for your own life, and develop a positive self-perception. In addition, rehabilitation programs for children and adolescents focus on teaching coping strategies and forming healthy behavior patterns during their learning and development. [6]

Aim

To conduct a theoretical analysis of the psychological rehabilitation carried out and determine its effectiveness, feasibility, and prospects for application.

Materials and methods

The scientometric search databases Scopus, Web of Science, Pub Med, and Google Scholar were searched using the keywords “psychological rehabilitation,” “psychosocial rehabilitation,” “anxiety,” and “mental health.”

The Phillips School Anxiety Test to determine the level of school anxiety was used for children and teenagers. Also, the level of self-esteem was examined using the Dembo-Rubinstein method. A psychodiagnostic study was conducted for parents using special techniques.: Depression Scale PHQ-9; Generalized Anxiety Disorder Questionnaire GAD-"; Hospital Anxiety and Depression Scale HADS, quality of life was assessed using the Quality of Life Assessment Scale.

147 children (aged 3 to 14 years) participated in the study: 103 children aged 7-14 years and 44 children aged 3-6 years; 113 parents participated in the study.

Parents were examined for levels of anxiety and depression before and after rehabilitation using the methods PHQ-9 Depression Scale, GAD-7 Generalized Anxiety Disorder Questionnaire, and HADS Hospital Anxiety and Depression Scale, and quality of life was also assessed using the Quality of Life Assessment Scale.

The children's level of school anxiety was determined before and after rehabilitation using the Phillips School Anxiety Test, and the level of self-esteem was also examined using the Dembo-Rubinstein method.

Statistical analysis was performed in Jamovi v. 2.3. Descriptive statistics methods were used. Statistical probability was determined using the chi-square and ANOVA methods.

The results

The literature review included three publications resulting from a literature search. It also carried out a theoretical analysis of the intervention methods used in the rehabilitation program.

Psychological rehabilitation is an important part of managing children with somatic diseases, conditions, and pathologies. During their stay in the camp, cognitive behavioral therapy (CBT), canine therapy, and various art therapy methods were most commonly used.

Cognitive behavioral therapy (CBT) is the gold standard in the treatment of anxiety disorders in children, supported by various empirical data, has high acceptability and safety, no side effects, and a lower rate of treatment discontinuation compared to pharmacotherapy or placebo [7].

Canine therapy is a model widely used in animal-assisted therapy. It is a supportive, targeted intervention primarily based on human-animal interaction. The positive connection that arises as a result of this interaction is the basis of the mechanism of action of zootherapy. Pet therapy can be beneficial for rehabilitating quality of life and psychosocial behavior [8, 9].

Art therapy is a non-drug, low-risk, and highly acceptable therapeutic method. It provides children and adolescents with a safe and creative environment to express, understand, and regulate their emotions, helping to increase their self-confidence and adaptability. Research shows that art therapy significantly reduces anxiety levels among children and adolescents, which has important implications for clinical practice [10, 11].

A significant factor in the psychological rehabilitation program was also the fact that parents were involved in all forms of interaction and also had the opportunity to undergo separate individual therapy sessions.

As a result of conducting the techniques before and after psychological rehabilitation, the following results were obtained:

Parents:

By methods: HADS, GAD-7, and PHQ-9 show a decrease in anxiety and depression levels after undergoing rehabilitation.

HADS, anxiety subscale: the average score decreased from 7.35 to 4.98 (32.25%, p < 0.001). The proportion of parents with no significant signs of anxiety increased from 54.6% to 80.0%; the proportion of parents with subclinical anxiety decreased from 30.8% to 15.4%; the proportion of parents with clinical anxiety decreased from 14.6% to 4.6%. (p < 0.001) (fig. 1).

HADS, depression subscale: the average score decreased from 5.38 to 4.06 (by 24.54%) (p < 0.001). The proportion of parents with no significant signs of depression increased from 72.3% to 87.7%; the proportion of parents with subclinical depression decreased from 21.5% to 12.3%; and the proportion of parents with clinical depression decreased from 6.2% to 0.0%. (p < 0.001) (fig. 2).

PHQ-9, the average score decreased from 10.59 to 9.27 (12.46%) (p=0.034).

GAD-7, the average score decreased from 10.15 to 8.68 (by 14.48%) (p=0.009).

Table 1 . Comparison of groups by the results of methods (HADS, PHQ-9, GAD-7) before and after rehabilitation.

Methodic	Before	After	p (Welch`s)
HADS A	7.35±3.55	4.98±2.87	<0.001
HADS D	5.38±3.06	4.06±2.47	<0.001
PHQ-9	10.52±4.83	9.27±4.67	0.034
GAD-7	10.15±4.63	8.68±4.38	0.009

According to the results of statistical analysis using the Welch's test, the following results were found: HADS, anxiety subscale: the mean score decreased from 7.35 to 4.98 (by 32.25%, p < 0.001); HADS, depression subscale: the mean score decreased from 5.38 to 4. 06 (by 24.54%) (p < 0.001); PHQ-9: mean score decreased from 10.59 to 9.27 (by 12.46%) (p=0.034); GAD-7: mean score decreased from 10.15 to 8.68 (by 14.48%) (p=0.009).

Also, to determine the difference in the levels of anxiety and depression, we used the correlation tables with the χ ² criterion (Table 2).

Table 2 . Comparison of groups by the results by HADS before and after rehabilitation.

Methodic	Before	After	Criterion χ ²
HADS A
No reliable signs of anxiety	71 (54.6%)	104 (80.0%)	<0.001
Subclinical level of anxiety	40 (30.8%)	20 (15.4%)
Clinical level of anxiety	19 (14.6%)	6 (4.6%)
HADS D
No reliable signs of depression	94 (72.3%)	114 (87.7%)	<0.001
Subclinical level of depression	28 (21.5%)	16 (12.3%)
Clinical level of depression	8 (6.2%)	0 (0.0%)

According to the results of statistical analysis using the Welch's test, the following results were found: HADS, anxiety subscale: the mean score decreased from 7.35 to 4.98 (by 32.25%, p < 0.001); HADS, depression subscale: the mean score decreased from 5.38 to 4. 06 (by 24.54%) (p < 0.001); PHQ-9: mean score decreased from 10.59 to 9.27 (by 12.46%) (p=0.034); GAD-7: mean score decreased from 10.15 to 8.68 (by 14.48%) (p=0.009).

Also, to determine the difference in the levels of anxiety and depression, we used the correlation tables with the χ ² criterion (Table 2).

Figure 1. Comparison of parents' anxiety levels before and after rehabilitation using the HADS methodology (anxiety subscale).

Welch's t-test was used to determine the indicators of school anxiety in children before and after rehabilitation (Table 3).

Table 3. Comparison of groups according to the results of the school anxiety methodology (according to the Phillips method) before and after rehabilitation.

Methodic	Before	After	p (Welch’s)
Phillips School Anxiety Test	20.18±9.00	17.68±6.64	0.024

It was found that according to the results of the Phillips School Anxiety Test, there was a decrease in school anxiety after rehabilitation: the average score decreased by 2.5 (12.4%) (p=0.024).

In addition, to determine the difference in school anxiety levels, we used contingency tables with the χ ² criterion (Table 4).

Table 4 . Levels of school anxiety (using the Phillips School Anxiety Test) before and after rehabilitation.

Methodic	Before	After	p (Criterion χ ²)
Phillips School Anxiety Test
Very low level	28 (27.2%)	30 (29.1%)	0.015
Normal level	57 (55.3%)	69 (67.0%)
Increased level	16 (15.5%)	4 (3.9%)
High level	2 (1.9%)	0 (0.0%)

It was found that the proportion of children with a very low level of school anxiety increased from 27.2% to 29.1%; the proportion of children with a normal level of school anxiety increased from 55.3% to 67.0%; the proportion of children with high school anxiety decreased: from 15.5% to 3.9%; the proportion of children with high school anxiety decreased: from 1.9% to 0.0% (χ² criterion = 10.4, degrees of freedom df = 3, p = 0.015) (fig. 3).

Figure 3. Comparison of the level of school anxiety in children before and after rehabilitation using the Phillips School Anxiety Test (anxiety subscale).

Conclusions

As a result of psychological rehabilitation, the emotional state of the children has significantly improved. Anxiety levels decreased by 12.4% after undergoing rehabilitation. Self-esteem indicators also increased significantly, with most children having high (42.7%) and average (43.7%) self-esteem, which may indicate that children have acquired a resource of stress resistance after undergoing psychological rehabilitation and acquiring stress-coping skills.

There are also significant indicators of improvement in the emotional state of the children's parents. According tothe HADS scale, anxiety decreased by 32.25%, and depression by 24.5%. According to the PHQ-9 scale, depression scores decreased by 12.46%, and anxiety scores, according to the GAD-7 scale, decreased by 14.48%. Such indicators show the high effectiveness of the psychological rehabilitation program for children and their parents in Latvia.

Organizing and conducting psychological rehabilitation of children in a safe environment using various psychotherapeutic methods, physical therapy, and cultural activities provide positive content and a resource for the psychological resilience of children and their parents. In difficult wartime, an essential component is the psychological rehabilitation of vulnerable categories of children, such as children with chronic somatic or surgical pathologies.