One of the most contentious — indeed, at times, vitriolic — public health debates of the COVID-19 era has revolved around the safety of opening schools for in-person classes. For some politicians, the push to open seemed to be influenced by optics — a signal that states were “open for business.” At the same time, parents have struggled to help children and adolescents with their schoolwork and other aspects of distance learning and have longed for a safe way to get back to a less chaotic educational experience. Some parents were forced to leave their jobs to take care of children and still cannot return to work. Teachers and other school staff have expressed concern for their own safety and the safety of their families and students. 

Everyone agrees that online learning is not ideal for most students — and can be virtually inaccessible for marginalized populations — but in many areas, it seemed like the safest option. However, mental health professionals, educators, parents and community activists remain apprehensive about the negative effect that the lack of in-person instruction and interaction with peers is having on the mental, emotional, social, developmental and academic well-being of children and adolescents.

There has been much confusion about how often children and adolescents get COVID-19 and how likely they are to spread the coronavirus. Recent guidance from the Centers for Disease Control and Prevention (CDC) stated that while fewer children than adults have had COVID-19 in the United States, the number of cases among school-age children was rising. Not only can children and adolescents be infected and get sick, but they can also spread the virus to others. At the same time, the CDC revised its guidance for physical distancing in schools in March, saying that 3 feet of distance (as opposed to 6 feet) is sufficient in elementary, middle and high schools where masks are worn and where community transmission is low.

In many states, teachers and other educational system personnel have received vaccinations. School districts are implementing physical distancing protocols, and the American Rescue Plan Act of 2021 passed by Congress in mid-March includes money to improve building ventilation. With these developments, many schools that weren’t already open were planning a return to in-person education, either full time or on a hybrid basis. 

Amid all the debating and planning, one group has been noticeably silent: the students themselves. Many children and adolescents are struggling with a feeling of powerlessness, says Adam W. Carter, a former school counselor who is currently the coordinator of the trauma-informed counseling graduate certificate at Northern Illinois University’s Department of Counseling and Higher Education. “We’re not asking children if they want to go back to school, if they feel safe,” he says. “We’re making decisions as adults with [the needs of] children almost as an afterthought.”

The lack of agency in decisions regarding in-person schooling is not the only area in which many children and adolescents feel voiceless, say the sources Counseling Today spoke to for this article. Like adults, children and adolescents miss their friends; are frustrated by the inability to get together with others without fear of infection; mourn the loss of celebrations and the marking of milestones; are afraid that they, or a loved one, will get sick; and are tired of spending so much time in front of a computer screen. 

In other words, they have all of the stress but not as much control as adults do, notes Carter, an American Counseling Association member. Children and adolescents often don’t know how to talk about — or, for that matter, recognize — how the pandemic is affecting them. 

For example, “Children may not know how to talk about how they miss getting together at school or with friends,” says ACA member Barbara Mahaffey, a licensed professional clinical counselor and executive director of the Scioto Paint Valley Mental Health Center in Ohio. They might ask often about visiting others but not recognize that they’re having stomachaches and other psychosomatic effects because they’re lonely, she adds. “Children may not ask for help, and parents may not recognize a child’s distress,” Mahaffey says. 

Many parents are experiencing significant worry and stress about their finances or how they can keep their family safe from COVID-19. They may also be grieving the loss of friends or family members who have died from the coronavirus. Parents often believe that it’s best to shield their children from these concerns, but the reality is that kids pick up on the underlying fear without understanding its source, say Mahaffey and Carter. 

The strain on children and adolescents is showing. According to the Nov. 13, 2020, issue of the CDC’s Morbidity and Mortality Weekly Report, child and adolescent emergency room visits related to mental health began increasing in April 2020 and remained elevated through October 2020 (the latest date for which statistics were available). Compared with the same period in 2019, emergency room visits related to mental health rose 24% for children ages 5-11 and 31% for those ages 12-17. 

Missed connections

Children and adolescents want to be with each other, Carter says. Absent in-person classes and social activities, it is difficult for them to figure out how to interact. This generation is used to socializing through social media platforms and chat apps, but after spending six to seven hours online each day for school, interest in electronic gatherings has diminished throughout the pandemic, he says. Being in the company of others all day virtually but rarely if ever getting the opportunity to interact in person has produced a particular kind of loneliness for children and adolescents.

Counselors are also finding it difficult to connect with these clients online. Once the pandemic began and counseling shifted online, Sarah Zalewski, a licensed professional counselor (LPC) who specializes in child and adolescent counseling, knew she needed a new way to engage her clients. At the time, in addition to her private practice, Zalewski was working as a school counselor in a Connecticut middle school. 

“When they come into my office, I always have toys,” she says. “They love to play, [and] I do too.”

The toys functioned as an icebreaker, with students and young clients finding it easier to open up while their hands were busy, explains Zalewski, an ACA member. But with that icebreaker gone thanks to the abrupt end of in-person sessions, she had to start thinking of alternative ways to connect. “I didn’t want to do the traditional grown-up thing, like, ‘How was your day? What was school like?’” Zalewski says.

Zalewski thought about what she had been doing herself to cope with the stresses of the pandemic. One of her favorite coping mechanisms: playing video games. Given the popularity and ubiquity of video games, she decided they might offer a great way to bridge the gap with young clients.

In the beginning, Zalewski mainly discussed the games with her clients, asking them what games they liked and why. Whenever role-playing games entered the discussion, she explored what characters her clients typically chose to inhabit. Did they pick a warrior or a priest? How was the character similar to them? How was it different? In what ways did the character reflect who the client wanted to be in real life? “Why do you want to be a druid?” Zalewski might ask. “What is it about druidism that is really cool?” 

Zalewski emphasizes that counselors who try this approach need to know or learn the language of the games. “Gaming is a culture,” she says. “Use cultural humility. If you don’t know, for example, what a druid is — [because] it’s different in different games — ask. They love to talk about it.”

Eventually, Zalewski began playing the games with her clients. They start in Google Meet, where they do all of their communicating. They then use an online link or gaming platform. Zalewski has multiple screens, and clients often use tablets. 

Sometimes the games are relatively simple. For example, Zalewski recently began playing Connect Four with a young client as an exercise in frustration tolerance (because the client doesn’t always win). When a client expresses frustration during the course of a game, Zalewski probes for the source. Is it truly about the outcome of the game itself or is it frustration at a person in the client’s life that is coming out during the gaming session? Sometimes the frustration is really about the situation that children and adolescents find themselves in with the pandemic, including feeling like they no longer have the ability to do the things they once enjoyed.

Game-based problem-solving helps clients build coping skills as they are playing, Zalewski points out. In addition, she often directs young clients to use relaxation techniques that she has taught them, such as square breathing (breathing in for four counts, holding for four counts and then breathing out for four counts).

Zalewski also likes to use Roblox, an online platform that features various games and also gives users the ability to create their own games (a function that she likens to sandbox therapy). By creating games or even leading Zalewski through a virtual obstacle course, young clients can develop a sense of leadership, she says. 

Children and adolescents are struggling with the lack of social contact during the pandemic, Zalewski says, and this is often manifesting in anxiety, depression, anger and withdrawal. The isolation is particularly difficult on clients who have depression and attention-deficit/hyperactivity disorder, she adds. 

Because physical activity helps with mood levels and basic functioning, Zalewski tries to get her young clients moving through games such as Just Dance, Ring Fit Adventure (a fantasy adventure world that uses physical exercise to navigate in-game movement), and other virtual reality games.  

To keep clients moving, Zalewski will often give clients “homework” (with parents’ permission), asking them to play a game a certain number of times between sessions. Zalewski also encourages clients to engage in social interaction. Just like any other skill, social skills will atrophy if you don’t use them, she says. 

Many role-playing games enable users to communicate with each other in chat boxes. Zalewski says there are also “clans” and “guilds” that gamers can join. Another resource she likes is Discord, a platform that allows users to discuss games and other interests on secure topic-based text channels. 

Zalewski says her clients laugh at her for her enduring love of Pokemon Go. Still, she feels it is an encouraging way for children and adolescents to get outside with parents and interact with others in a safe, physically distanced way as they collect Pokemon.  

School daze

Although some children and adolescents are doing well with virtual learning, in general, it’s not developmentally aligned to child and adolescent needs, says ACA member Jennifer Betters-Bubon, an LPC and former school counselor. “We know young kids need to move,” she says. “They thrive on environments that provide sensory stimulation and movement. Even in traditional high school, kids get to get up and move through hallways and can interact with friends.”

“We have kids who are on Zoom for hours and not necessarily getting up,” continues Betters-Bubon, an assistant professor of counseling at the University of Wisconsin-Whitewater. “It’s fatiguing for their brains and bodies, [and] it doesn’t lend itself to building relationships.”

When adults feel the fatigue of too much screen time, they can usually disconnect, at least for a little while. “When children get tired, adults are still in charge,” Carter points out. And if a child asks to take a break, parents or caregivers may think that the lack of structure will cause them to fall behind. “They may not understand that children have the same need to disconnect,” Carter says.

Betters-Bubon is noticing a lack of motivation in the children and adolescents she sees in her practice. She believes that’s in part because schoolwork isn’t as engaging without the connection to other people and the school itself. “It can feel like ‘What is the point of doing this work?’” she says. Betters-Bubon points out that on top of COVID-19, students are dealing with the impact of racial trauma and other significant stressors, all of which influence their view of whether their current math assignment is really relevant right now.

Betters-Bubon says some of her younger clients are so disengaged that she has shifted the focus of her work to their parents. She has sought to keep middle and high school students engaged by asking them to create things between sessions such as a vision board of how they’re coping with their anxiety and then sharing their creation with her.

Now that many schools are opening up, at least on a hybrid basis, Betters-Bubon and other counselors say they are witnessing excitement among students about reuniting with friends, mixed with a lot of trepidation. Many of Betters-Bubon’s clients are experiencing anxiety — about the possibility of getting COVID-19, about catching up academically or, in some cases, about starting at a new school without the normal transition. Betters-Bubon has been doing a significant amount of exposure therapy work with child and adolescent clients. This involves having them imagine a list of scary things that they might encounter and working up to doing each one in ascending order. In some cases, she has been able to reach out to school officials to ask them to allow her clients to at least see the inside of their new environment before classes start. 

Betters-Bubon acknowledges that it’s a strange new world for students returning to school. Even the nature of recess has changed. Because of the need to maintain physical distance, her son’s elementary school no longer allows balls on the playground. Students just kind of stand around and concentrate on keeping themselves separated, Betters-Bubon says. As a result, they’re not engaging those gross motor movements essential to healthy growth that they used to engage when they could run around, climb on equipment and toss balls. Betters-Bubon wonders what the implications might be if this scenario becomes normalized. 

Some schools have implemented sensory paths in hallways with different obstacles to run and jump over, Betters-Bubon says. She’d like to see more of those, particularly outdoors. Noncontact games that involve actions such as students moving to different parts of a circle can also be an excellent way to keep children moving while still remaining physically distant, she says.

LPC Melissa Brown works with an Atlanta-area community behavioral health center as a mental health counselor in a local school district with a majority Black student body, most of whom live in poverty. The community has been hit hard, both by COVID-19 itself and by the economic devastation of the pandemic-induced recession. 

The school district has been on a hybrid schedule since January. Brown has tried to give students a sense of normalcy by providing that one thing that will be consistent. “When we meet, this is going to be your safe place,” she tells students. “We can talk about anything and do anything you want.”

Many of the children still worry that they or their loved ones will get sick, so Brown holds family sessions to help students and their families develop a plan to stay safe. The children are used to having a plan for what happens if there is a fire in the school, so the idea of coming up with something similar for home seems natural to them, she says.

In sessions, they talk about teaching kids how to wash their hands, come up with examples to demonstrate what 6 feet of physical distance looks like, and discuss why they can’t see their grandmother, uncle or friends today. They also look at alternatives, such as driving by a friend’s or loved one’s house or mailing them a picture.

Brown also tells parents that they have to be honest with their children. They can’t hide information that they think might be harmful because their children are likely to be exposed to it anyway through social media, the news or friends. Instead, parents can be their children’s first source of information, Brown says.

Grief and trauma

Brown has encountered a substantial amount of grief connected to the pandemic, particularly in elementary school settings. After attending a funeral every Friday for a month, one little girl asked Brown if it was wrong that she didn’t cry anymore. 

Brown frequently uses play therapy and art therapy to help younger children explore their feelings. Eventually, the little girl was able to process her feelings and contextualize them, such as, “This person who died was a friend of my mother’s, and I didn’t really know her” and “This was my grandfather, but he was sick with cancer, and I know he’s in a good place now.”

Zalewski has helped young clients process the loss of grandparents and pets. She notes that furry family members have become even more vital companions during the pandemic. 

One child particularly liked the idea of creating a memorial for a beloved dog. So, with Zalewski’s help, the client created a space on his island in Animal Crossing, a social simulation game that gives players the ability to build and create things. Zalewski and the child found a virtual dog and gave him a red bowl to drink from. The child’s real-life dog had enjoyed being outside and sniffing flowers, so they also created a fenced-in area with flowers, the drinking bowl, a sofa (in case the dog wanted to curl up) and a radio for the dog to listen to. Players in Animal Crossing can pick the radio’s music, so the child chose happy songs because they wanted the dog to be happy.

“Creating it was very powerful, and then [the child was] able to visit [the memorial],” Zalewski said. She suggested that the child share the memorial with their mom and dad, which ended up being an emotionally significant experience. They discussed how losing the dog felt to each of them and were able to mourn together, Zalewski says. She believes the process helped to normalize grief for the child. Mom and Dad were sad too, but they were getting through it, and the client could as well. 

“Now Mom and Dad and the kid can talk more comfortably about the dog,” Zalewski says. “It’s OK to be sad. Sadness won’t break you. It’s OK to share the happy stuff too.” 

Zalewski has also helped child and adolescent clients navigate the loss of loved ones such as grandparents. Many kids are hesitant to share some of their feelings about loss because they are afraid it might be painful for the people around them, Zalewski says. She helps young clients express their grief by inviting them to have a conversation with her about the things they remember about their grandparents or other loved ones who have died. “Everyone has loss,” she says. “I help them access the good memories.” 

These memories are often funny, such as how the grandparent always made the client a cup of coffee or tea, and the client always drank it, even though they thought it tasted terrible. Or they might remember a unique sweater that their grandmother made for them. 

“Many times, kids haven’t grieved before, and they don’t know how to do it,” Zalewski says. She provides a safe place to explore the feelings of being really sad and missing a loved one.  

Moving forward

“We are not holding space for children to be scared to return to in-person learning, especially with the increased safety protocols in place,” Carter says. “Masks, no touching, no singing, playground shut down — all of these things can be scary, yet we expect children to be able to turn that off and learn as usual.”

As schools continue to open, Betters-Bubon believes that a trauma-informed approach with a schoolwide focus on relationships is essential. “Integrated within a trauma-informed approach is social-emotional learning, embedding sensory strategies into the classroom and allowing for voice and choice,” she says. “It also would include a focus on staff wellness. School counselors would focus on teaching and assisting all staff in understanding the impact of trauma on the brain and on student learning, including helping schools carve out specific ways to build relationships.”

Betters-Bubon would also like to see more collaboration between schools and outside mental health counselors to focus on building resiliency in children and adolescents. This may involve taking a wider systemic view and working with the critical adults in students’ lives, she says. “I could see an increased need for family counseling in an effort to create systemic change within families that ultimately helps children and adolescents.”

 

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.