Repercussions of COVID-19 on the care and behavior of users of a Child and Adolescent Psychosocial Care Center

Objective: to analyze, in the light of Callista Roy’s model, the pandemic implications of COVID-19 on the behavior and care of users assisted at a Child and Adolescent Psychosocial Care Center. Methods: a qualitative study, in which 13 family caregivers of users assisted at a Child and Adolescent Psychosocial Care Center participated. Data collection oc-curred through semi-structured interviews. Data analysis was performed through content analysis. Results : three categories emerged: The impact of social distancing on the behavior of children/adolescents assisted at the Child and Adolescent Psychosocial Care Center; Difficulties experien - ced by family caregivers with children/adolescents during the COVID 19 pandemic; Welcoming and support for children/adolescents and family members linked to the Child and Adolescent Psychosocial Care Center during the CO-VID-19 pandemic. Conclusion: children’s and adolescents’ care and behavior have undergone changes resulting from changes in social interaction and care at the Child and Ado-lescent Psychosocial Care Center. This scenario required adaptation and, through Callista Roy’s model, it was possible to better understand this adaptive process. Contributions to practice: this study allows us to better understand the problem and, consequently, improve the care offered by the team considering the reality presented.


Introduction
The pandemic caused by the new coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has devastated the world, becoming an important public health emergency that has not been faced for decades. The disease caused by the virus was named Coronavirus Disease, popularized as COVID-19 1) . To minimize its spread, prophylactic measures such as isolation and social distancing were advocated. Consequently, these measures brought restrictions on the functioning of health services and negative influences on the mental health of people of all age groups (2)(3) .
Like adults, adolescents and children also had their routines disorganized by the need to maintain social distancing. In this regard, daily activities such as going to school, social interaction with peers, games and outdoor walks were restricted. For changes like these, adaptation needs are required, as they can negatively impact children's mental health, with possible impairment in other stages of life (4) .
Faced with this new reality, family adaptation related to caregivers' functions is seen as one of the main concerns due to available resources, which are no longer the same. Also, it should be noted that, for individuals whose mental health is affected, the negative effects can last longer and have a higher prevalence than the epidemic itself (5) .
Institutions and health professionals must be qualified to support this population in facing the obstacles imposed by the pandemic so that there are new alternatives of care in the face of the epidemiological and health challenges encountered (4) . The mental health care network has specialized devices for the care of children and adolescents in psychological distress, such as the Child and Adolescent Psychosocial Care Center (CAPSi -Centros de Atenção Psicossocial Infantojuvenil), which is an "open door" service, linked to the Unified Health System (SUS -Sistema Único de Saúde), seen as a strategic device for care in the territory (6) .
With regard to children and adolescents, the concept of care has great importance due to its influence on their growth and development (7) . Therefore, reflection on care in the context of the COVID-19 pandemic was the subject of this investigation, due to the influence of stimuli generated by the changes imposed in the period. According to Callista Roy's adaptation model, individuals are a being that adapts in response to environmental stimuli; however, the level of adaptability varies according to stimuli, and may trigger positive or negative responses according to their degree of coping. Thus, it becomes important to analyze the mechanisms that allow adjusting the dynamic care process to establish individuals balance and better quality of life for adolescents and children (8) .
This care offered to this public cannot be carried out in isolation; in this context, the important role of caregivers. Caregivers are people willing to take care of patients or dependents and help them in their daily lives, whether they are family members or not (9) . Therefore, when we consider the context of the CO-VID-19 pandemic as an atypical period, and because researchers have not found similar publications in the Brazilian reality, this study is relevant, also because it is based on a nursing theory.
Thus, it was intended to answer the following research question: In the light of Callista Roy's model, what are the pandemic repercussions of COVID-19 on the behavior and care of users assisted at a CAP-Si? To answer this question, the study was conducted with the following objective: to analyze, in the light of Callista Roy's model, the pandemic implications of CO-VID-19 on the behavior and care of users assisted at a Child and Adolescent Psychosocial Care Center.

Methods
This is qualitative study, written according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) recommendations. As a theoretical framework, Callista Roy's Adaptation Model of 3 Nursing was used, in which it is argued that the person has the ability to adapt positively or negatively to environmental changes. From this perspective, the person is seen as a system that interacts with stimuli, receiving and responding to them (8) .
The study took place at a CAPSi in a municipality in the metropolitan region of Recife, state of Pernambuco. This service provides care for persistent and severe mental disorders and problems related to the use of psychoactive substances. About 50 children and adolescents from all over the territory are assisted monthly.
The service operates from Monday to Friday, from 8 a.m. to 5 p.m., and has a multidisciplinary team consisting of two social workers, a nurse, two psychologists, a speech therapist, an occupational therapist, a psychopedagogue, a pediatrician and a psychiatrist.
Family caregivers aged 18 years or older, whose children and/or adolescents assisted by CAPSi, were being treated at the service for more than a year with regular attendance at the service were included in the survey. Caregivers who did not attend the service for more than 60 days were excluded. Moreover, the main family caregiver was considered eligible, i.e., the one who spends the most time caring for children and/or adolescents, regardless of the degree of kinship.
It should also be noted that none of the participants withdrew and that the recommended measures for COVID-19 prevention were respected. For this purpose, personal protective equipment was used by the researcher and participants as well as alcohol gel for hand hygiene.
Data were collected between December 2021 and January 2022, using the semi-structured interview technique containing sociodemographic information and three guiding questions about the impact of the pandemic on the care of CAPSi users, according to participants' perception: How do you perceive the care of your child/adolescent by child CAPS during the pandemic period? How did you deal with your child/adolescent during the pandemic period? How do you perceive the behavior of your child/adolescent in the face of social isolation caused by the pandemic context?
The interviews were conducted by a researcher specializing in mental health, who received training to conduct them. They were carried out in a reserved place on days when medications were delivered to caregivers, during the day and lasted approximately 25 minutes. The first three interviews were applied in a preliminary version to assess question suitability and understanding by participants, with no need for repeated interviews or instrument adjustments.
The responses were recorded on a digital media device and later transcribed into an analysis grid for data interpretation in accordance with content analysis precepts (10) . The interviews were closed when, after discussion between the authors, data theoretical saturation was observed. Analysis was carried out without the use of software, and the themes presented in results are derived from the data collected in the research, in line with Bardin's precepts. So, the proposed steps were followed: pre-analysis; material exploration; and data treatment and interpretation. In the pre-analysis, text skimming of the transcribed material was carried out, which allowed familiarization with content. In the second stage, there was material exploration, and this supported the construction of thematic categories. Finally, analysis was completed with data processing and interpretation.
Data went through a process of fragmenting the text into units, extracting the audio from the interviews and, subsequently, categorization of the unit by differentiation and regrouping, based on predefined criteria that were coded. To preserve the interviewees' anonymity in the quotes, they were identified with the letter "I", followed by a number corresponding to the order of participation in the collection.
A second contact was scheduled remotely with participants for transcription validity and subsequent presentation of results; however, there were access difficulties for most participants, since only four of them provided feedback validating the transcription.
The study met the precepts of Resolution 466/2012 of the Brazilian National Health Council, which governs research with human beings. The project was approved by the Research Ethics Committee of the hospital complex that involves the Pronto-Socorro Cardiológico Universitário de Pernambuco and the Hospital Universitário Oswaldo Cruz, under Opinion 5,079,361/2021.

Results
A total of 13 caregivers participated in the research, of which only 2 were male. Regarding the degree of kinship, there were ten mothers, two fathers and a first-degree aunt. Participants' age range varied between 26 and 46 years. As for the level of education, more than half of participants completed high school and declared themselves housewives, and the same proportion was found among those who said they had a support network in child and/or adolescent care.
As for the profile of users assisted at a CAPSi, the age range ranged from 3 to 14 years old. Regarding the diagnosis, more than half of children had an autism spectrum disorder, about a third had no definite diagnosis, and some had neurodevelopmental disorders. When asked about follow-up time of children and adolescents in the service, according to the responses, most respondents reported between two and five years.
From content analysis, three thematic categories emerged: The impact of social distancing on the behavior of children/adolescents assisted at the Child and Adolescent Psychosocial Care Center; Difficulties experienced by family caregivers with children/adolescents during the COVID 19 pandemic; Welcoming and support for children/adolescents and family members linked to the Child and Adolescent Psychosocial Care Center during the COVID-19 pandemic.

Category 1: The impact of social distancing on the behavior of children/adolescents assisted at the Child and Adolescent Psychosocial Care Center
This category presents the effects caused by social distancing with the interruption of children's and adolescents' routine, which caused disorganized behavior, expressed as agitation, increased anxiety, irritability and changes in eating patterns: He felt this isola- In the speeches, it is observed that caregivers increased their attributions and began to have more responsibilities regarding school and therapeutic activities, ending up having a greater burden. The internet was used as an alternative means to carry out didactic activities, as highlighted in the speeches: We tried to be a teacher, a psychologist, a mother, everything! It was very difficult, but we sought help from the internet, doing didactic things with her at home so she could have fun (I8). I was looking at things on Instagram, on YouTube and I was doing some activities at home (I13).

Category 3: Welcoming and support for children/ adolescents and family members linked to the Child and Adolescent Psychosocial Care Center during the COVID-19 pandemic
In the following speeches of interviewees, it is clear that, even in the face of the restrictions imposed by the pandemic, there was help from the teams, which were organized to provide guidance and support to users through telephone calls: There was support because the reference technician asked him to call during the pandemic (I1).
CAPS support to find out how he was doing and some guidelines to be followed for us to do at home (I5).
However, some caregivers' opinion differed regarding the support received, and reported difficulties regarding the support offered by CAPSi to children: The care was good, wasn't it!? Because they suspended the services, and I thought that was very important. Which is also for the child not to contract the virus, but there was no support. There wasn't (I11). We had no such contact. CAPS has not been in touch regarding anything (I12).

Discussion
In this study, as the repercussions of the pandemic caused by the new coronavirus on the care offered by family caregivers to children and adolescents linked to CAPSi, adaptive models emerged that were configured as responses to the stimuli received. With regard to children and adolescents, they experienced a way of physiological adaptation and ineffective interdependence, which was influenced by the contextual stimulus, generating behavioral changes.
Family caregivers were influenced by the focal stimulus and showed an ineffective way of adapting their role function, which was represented by tiredness, irritability and family overload. With regard to the support offered by CAPSi to caregivers and users, this situation was influenced by the contextual stimulus, and this led to an effective interdependence adaptation mode for some caregivers and ineffective for others.
Regarding the impact of social distancing on the behavior of children and adolescents assisted at CAPSi, there are negative impacts caused by isolation and social distancing, as there has been a change in routine and a decrease in the number of visits to health services. According to Roy's precepts, the stimulus received by participants was contextual -an environmental stimulus directed at the persons themselves (11) . This reality corroborates a recent study carried out in Latin America by the Pan American Health Organization, which pointed out that the interruption of health services, including mental health services that assist children and adolescents with mental disorders, contributed to the worsening of symptoms and developmental regression (12) .
The social deprivation caused by the COVID-19 pandemic resulted, for these children and adolescents, in an ineffective coping process in the adaptation mode of interdependence presented by Roy, and this is related to social harm caused by social distancing. Receiving social support is fundamental for a good adaptation in living and coping with a disease (13) . This social condition ended up having a negative impact on the physiological conditions of many children and adolescents assisted at CAPSi, leading to poor physical and physiological adaptation.
The frequency of agitation and anxiety behaviors in children and adolescents increased according to the reports of caregivers in this research. Child behavior in the COVID-19 pandemic revealed that anxiety was present in children's and adolescents' lives and was associated with changes in sleep and appetite (14) . During the pandemic, levels of anxiety and depressive symptoms increased sharply (15) . This reinforces the impact of this situation on the health of these users, since, regardless of whether they have a disorder and are followed up at CAPSi, the mental health of this public was affected during the social isolation phase.
Considering as fundamental the period of development that occurs in childhood and adolescence and the experience of this population in the pandemic, the process of cognitive, mental and bodily maturation of these groups is a target of concern. In view of this, the importance of psychological monitoring of these children and adolescents is emphasized in order to alleviate the damage resulting from social isolation during the pandemic period (16) .
The conditions imposed by this event affected children's development, and the changing situation encouraged adaptation responses (17) . The symptoms presented by children and adolescents indicate the existence of emotional situations of behavior that need to be examined, in order to verify the respective causes and mitigate the losses. It is important that, based on the assessment of this experienced adaptive process, these children and adolescents are encouraged to present good adaptive responses (18) . The persons is the target of care, and this should be optimized considering the research that professionals do about them (19) .
It should also be considered that an ineffective children and youth adaptive process may have been influenced by the response of their relatives. From this perspective, the relevance of nursing care being based on Roy's assumptions is highlighted, which encompasses the individual, the family and nursing. Nursing care from this perspective is a valuable instrument for achieving a good adaptive response (20) .
Regarding the impasses presented by parents whose children and adolescents have a mental di-sorder, a study revealed that family members whose children have an autism spectrum disorder have a higher prevalence of psychological distress than family members who do not experience this condition (21) . In view of this, greater attention is needed from the mental health team, especially nurses, in relation to caregivers of children with mental disorders so that they also become targets of care.
Individuals will always come into contact with unpredictable situations, which will require adaptation, and this process will need to occur in the best possible way. After all, health is influenced by the interaction between the individual and the environment; and the adaptation that exists between them (22) . Parents whose children have neurodevelopmental delay reported challenges encountered in dealing with them during the pandemic. This same research attested to the negative repercussions on children's mental health such as increased stress, anxiety and sadness as well as insecurity about the future (23) .
In the present study, it was observed that, considering the condition presented by children and adolescents under their responsibility, in the pandemic period, many family caregivers adapted to various expectations and changing needs. The pandemic appears to have intensified their responsibilities, while fewer possibilities for support were made available. Family members report difficulties in carrying out care tasks with children due to the lack of time in the performance of multitasking, a fact that contributes to increasing the difficulty of maintaining the attention of the child with autism, due to limited support and lack of adequate environment (24) .
With regard to caregivers and parents of children and adolescents with mental disorders, it is clear that there is difficulty in adapting to uncertainties; however, after the pandemic's initial period, they sought strategies to adapt. Some difficulties were evidenced by tiredness, overload and irritability. These sensations and emotional states are also considered based on how persons see themselves in the face of certain circumstances (25) .
For caregivers of children and adolescents with mental disorders, social isolation meant the need to act, even without specific training, not only as parents, but also as teachers, social skills coaches, speech therapists and behavioral therapists, sometimes with little or no professional support and often using only the internet as an auxiliary means (26) . In this regard, it is worth noting that not all caregivers have access to internet resources, which probably makes the possibilities of support even more scarce.
For the adaptation process, nursing plays an important role, based on the identification of the difficulties presented to achieve a positive adaptation. To this end, these professionals use means related to the science of nursing that are used in clinical practice. In this way, it is expected that people will be able to adapt positively to the conditions that make them vulnerable (27) .
With the advance of COVID-19, an alternative that could be used to maintain care in community mental health services was telehealth. This resource was important because, with regard to patients undergoing mental health treatment, the reduced number of visits to the service may favor the situation destabilization, whereas the more visits, the greater the probability of contact with COVID-19 (28) . Call centers were viable alternatives, carried out by video calls or phone calls. In this study, caregivers' adaptive responses to the assistance offered by CAPSi in telehealth care was divergent, being satisfactory for some and unsatisfactory for others, thus revealing a form of adaptation of discordant interdependence.
It was observed that this strategy has also been used in other health units, being a viable option during the pandemic. Occupational therapy professionals used teleassistance to emphasize the importance of a routine within the limitations imposed by the pandemic and to recommend some training related to activities of daily living, as some children were experiencing significant setbacks (13) . For nursing, the use of telehealth also proved to be a way of adapting to ensure health care during the COVID-19 pandemic (29) .
In general, as well as other professionals' health care, that of nursing had to undergo adaptations in the pandemic context. In the process of family adaptation, knowledge and application of Roy's model allow nurses to contribute to the adaptive process. Thus, these professionals can act in favor of family caregivers' health as well as favoring the care provided by them (27) . In order to maintain the health of children assisted at CAPSi, basic knowledge consists of understanding people's adaptation to contemplate adaptable processes and modes.
Individuals' adaptive process in the four types of adaptation (physical-physiological, self-concept identity, interdependence and role performance) contributes to health and quality of life. In the context of caregivers, we see how these adaptive modes have developed differently in caregivers and in children and adolescents treated at CAPSi, due to both stressors and the absence of face-to-face activities.
People respond to a control process that makes each one an adaptive system. Caregivers and children assisted by CAPSi had their system put to the test, given the changes during the COVID-19 period. Still, in Roy's model, we see that, according to the stimuli obtained, the people involved in the change can develop new adaptation characteristics, and this depends on the coping mechanisms of each one, which, when ineffective, may not achieve adaptation qualified. Each caregiver and each child had a unique experience while facing the pandemic. This unique experience reinforces one of the advocated adaptive modes, self-concept, which is related to a person's psychological and spiritual aspect, and this refers in part to human needs such as affection, love, affirmation and human worth.
The current moment of the pandemic allows a plan for a gradual return to service activities; however, it is necessary to consider the effects of caregivers' and users' adaptation, which may last and should be included in the singular therapeutic project.
The "look" of the problem studied according to Callista Roy's model precepts allowed a better unders-tanding of the process of adaptation to different living conditions, as was the case of the pandemic scenario. The results presented here can support care strategies for users assisted at CAPSi, considering their specificities and needs, especially in the situation of the COVID-19 pandemic.

Study limitations
The pandemic context made it difficult to have a second face-to-face contact with participants to validate the transcript and later present the results. Certification was combined remotely, however there was difficulty in accessing it for some participants. Despite this, the researchers took the necessary care during data collection and subsequent transcription, aiming to value its quality and originality.

Contributions to practice
By revealing the repercussions experienced in the face of COVID-19 regarding the behavior and care of children and adolescents who receive care at a Child and Adolescent Psychosocial Care Center, this study allows a better understanding of the problem and, consequently, to improve the care offered by the team, considering the reality presented.

Conclusion
The study revealed that, during the COVID-19 pandemic, there were several behavioral changes in children and adolescents assisted at a Child and Adolescent Psychosocial Care Center; however, both the multidisciplinary team and the caregivers sought strategies to deal with such adversities. Still, the pandemic exposed weaknesses in the care of some family caregivers, evidenced by insufficient support, but the legacy of this pandemic experience reinforces the need for better restructuring of mental health services to care for this specific population. Understanding the problem through Callista Roy's model allows nurses to better plan the care offered by verifying the impasses encountered and, consequently, achieving a good adaptation.