Americans have been debating pandemic restrictions for two years, a debate that has become particularly controversial among parents of young children. While measures like masking and isolation represent a temporary inconvenience or inconvenience for most people, the consequences for children who are still growing are more mysterious and perhaps more serious and permanent.
Children with language impairment provide perhaps the clearest example of this unclear trade-off. Pandemic restrictions vary by state, county and school district, but we spoke with parents in California, New York, Massachusetts, Washington, New Jersey, Iowa and Maryland. They said their child's speech therapy had been discontinued. -Do your personal treatment and then mask your needs where they are.
For example, Megan's son has Joubert syndrome, a rare genetic disorder that causes severe language delays. At the start of the pandemic, the then 4-year-old could roughly say a few simple words: mom and house, each a hard-won victory in the intensive speech therapy he has received since he was two years old. But he regressed a lot during remote therapy, and is still struggling now with in-person therapy because the therapist wears a face mask. (Megan, who lives in California, asked that we identify her by her first name only to protect her son's privacy.)
Diane Paul, director of clinical affairs in speech-language pathology at the American Speech-Language-Hearing Association, said speech and language disorders can have serious consequences if left untreated. Children who have difficulty expressing themselves may feel frustrated, which can lead to behavioral problems and may have difficulty making friends. Many children with language disorders have difficulty learning to read. But “language becomes the medium through which we learn everything later in school,” said Alex Levine, a speech-language pathologist at the Child Mind Institute's Center for Learning and Development. And the longer you wait to resolve a speech or language problem, the more difficult it becomes to do so.
Many parents I interviewed felt frustrated at being asked to jeopardize their children's social and academic lives in the name of public safety. The early years of a child's life are important. Anything that risks disrupting development, whether it’s COVID-19 or the mitigation measures put in place to prevent it, can feel like rolling the dice on a child’s future. One way or another, every parent with young children has had no choice but to gamble during the pandemic. Many parents of children with language delays do not like this possibility.
When the world shut down in the spring of 2020, many speech-language pathologists said they adapted quickly. Many practices immediately transitioned to teletherapy, often successfully. But remote therapy can be challenging for young children. “He completely broke out, laid on the floor and started playing with his toys and literally turned his back on the computer and tried to close it,” said parent Julia Toof of Somerville, Massachusetts. – My three-year-old son. “It just didn’t work.” Teletherapy typically required significant involvement from parents, many of whom were already overwhelmed with work and homeschooling during the pandemic.
And when in-person care resumed, masking requirements made it difficult. Of the more than a dozen speech therapists I interviewed, some said children find masks distracting. More importantly, the mask hides your mouth from view. Therapists say this interferes with some forms of therapy, especially those targeting motor speech and motor planning. “It’s all about the actual language coming out of your mouth,” Alexandria said. Zachos, a pathologist residing in Illinois. “For that type of therapy, you definitely need to see the speech therapist’s mouth and they need to see your mouth,” Zachos said.
When possible, therapists have used masks with transparent panels, but results have been mixed. “It’s a bit uncomfortable to wear. They got really hot,” Zachos said. She's tried many different methods to prevent fogging, but it inevitably happens. Fogging aside, even a clear mask prevents the therapist from using tactile cues, such as straws or tongue depressors, to push the patient's tongue into place, or using bite plates to keep the jaw in alignment. Therapists found creative solutions. For example, some use video to demonstrate tongue position, but people I consulted agreed that masks are not ideal. “I think there are definitely children who have had their treatment negatively impacted and their progress slowed because there is so much interference on so many levels,” Levine said.
Problems with speech therapy were made worse by problems outside of therapy. Parents said it was harder for them to feel secure in their communication skills because their children were more reluctant to talk with masks on. “He barely understands. without “A mask.” The mother of a 3-year-old boy from Iowa spoke on condition of anonymity. “If he doesn’t understand, he won’t have the confidence to keep speaking.” And as school closures extend, children seem to be becoming more socially anxious. It can take even longer to warm up to a therapist, says Craig Selinger, who owns a company that provides speech therapy and tutoring services in New York City. “Their verbal expressions are more limited because they feel more uncomfortable,” Selinger said. This is of particular concern for children with autism. Their treatment often focuses more on building engagement than on building vocabulary, says Danielle Lindgren, a speech-language pathologist in Los Angeles.
Many parents and speech therapists have tried to find any kind of accommodation. “She thinks there is no solution. She doesn’t have the opportunity to go outside or use a clear face shield,” Megan said of her son’s therapist. “We would do a quick test every day before seeking speech therapy if necessary.” Several therapists and parents said their school or institution did not provide clear masks.
Because the CDC does not list speech or language impairments among the reasons for exemptions allowed in its school mask-wearing guidelines, many schools do not approve them during in-school therapy sessions or when children are in class. Even though exemptions are available for children with disabilities who qualify, some parents said they were afraid to ask for them for fear their children would be ostracized by classmates due to the risk of the virus.
In these situations, some speech therapists simply ignored the rules. One Iowa mother I interviewed said that even though the public school where her son receives treatment requires masks, she allows his speech-language pathologist to take off his mask during her treatment, she said. “She was like, ‘This is our little secret,’” she said. (The district has now switched to a mask option). Two therapists who work in public schools admitted to occasionally lowering their masks to provide a visual cue. And if they can, some parents are going to great lengths to compensate for the shortcomings of parenting, paying $100 per session to private therapists willing to practice while wearing only transparent face coverings. Megan has been looking for such a therapist in her area, but she can't seem to find one. So in January she cut her hours by 20% to help her son learn to speak.
While the situation for children with language delays is not universal, here are some tricky characteristics of COVID-19 calculations for parents of young children: Many very important developments occur during the first few years of a child's life, and they are a key window for identifying and addressing developmental delays. That's why many parents think carefully about seemingly small issues, such as screen time, the number of words their children hear each day, and whether it's okay to give their children timeouts. Pandemic restrictions feel scary and experimental for parents of the youngest children. Asking us to trust that we won't hinder our children's development is asking a lot.
With appropriate treatment at a young age, some children with Joubert syndrome can learn to speak. In early 2020, Megan felt like her own son was on the verge of doing just that. Now she's not sure he will. “The window is closing.” Megan said. It is impossible to know how things would have turned out had his care not been interrupted. She says Megan wishes she had never been in a situation where she found herself wondering.