Pediatric experts discuss topics ranging from virus transmission risks and a possible vaccine for kids to spotting signs of depression in teens, screen time and supporting children during transitions.
After months in a virtual classroom, many children are starting to return to in-person ones as federal and state leaders encourage K-12 schools to reopen buildings.
While many parents may be looking forward to this milestone during the COVID-19 pandemic, they may also have questions about safety, including protecting their families from exposure to the virus and how children and schools may contribute to transmission in communities.
Families may also face behavioral, social and emotional challenges, as children and teens readjust (again) to a new normal in their learning environments. Others may still be managing the challenges of virtual school.
Experts from Michigan Medicine C.S. Mott Children's Hospital recently answered parents' top questions during a live Q&A. The panel was moderated by Mott developmental behavioral pediatrician Jenny Radesky, M.D. The panel also included Mott pediatric infectious disease specialist Alison Tribble, M.D., and Terrill Bravender, M.D., M.P.H., chief of adolescent medicine at Mott.
See summaries of experts' responses to audience questions below, with extra inputs on additional topics not covered during the event, or watch the full Q&A discussion on returning to in-person school during COVID above.
What does the data tell us so far about how reopening schools may fuel COVID-19 spread in communities?
Tribble: We've learned a lot from complete closures and gradual re-openings of schools since the beginning of the pandemic and have really encouraging data that it's a safe move for K-12 schools to return to in-person education. Studies have shown that the rate of transmission in schools that implement aggressive mitigation measures is low and often much lower than in the regular community.
One study from Duke University and the University of North Carolina at Chapel Hill found 32 cases of in-school transmission of COVID-19 among nearly 100,000 students and staff over a nine-week period – a significantly lower ratio than community-acquired infections. They had zero student-to-staff transmissions. Schools utilized face coverings, distancing and hand-washing. We've seen similar findings from studies in other countries.
One large study in India did suggest that children played a role in spread among other children, but most often through household environments and community settings as school closures were implemented during the study period.
These studies are a constant reminder that we have to maintain strong mitigation measures in schools – not just one – but layers of safety practices to reduce the spread.
Should we be more worried about reopening schools now that the more contagious strain of the virus is here?
Tribble: These new COVID-19 variants do tend to be more transmissible, and we're all going to be watching this very closely. But at this point, experts don't see this as a reason for schools to drastically change reopening plans.
We think the increase in transmissibility might be related to how SARS-CoV-2 binds to receptors in our bodies. This suggests that the mitigation measures we're currently using should be effective, but we continue to learn more. It's reassuring that states are collecting real time data of cases in schools and we can track any changes in trends.
What is the guidance on reopening schools with plans calling for 3-feet distancing instead of 6 feet?
Tribble: There are various mitigation strategies to keep school environments as safe as possible. We think of this as the Swiss cheese approach. Every mitigation measure alone has some holes, but the more strategies we layer on top of one another, the better we can contain the spread. We have flexibility with what measures we use, but we don't want to just do one.
Social distancing is of course one of these measures. The Centers for Disease Control still says six feet is ideal, but we know that droplets spread within a range of distance. The American Academy of Pediatrics has said that if six feet of social distancing isn't feasible, it shouldn't be the only barrier in reopening schools.
Three feet social distancing in the school setting – combined with other measures such as wearing masks, hand hygiene, improving ventilation, and policies preventing kids or staff with symptoms from attending school – will also have a significant impact on transmission.
Schools will need to choose the mitigation strategies that are going to work the best in their environment and optimize the stopping of transmission.
Are there concerns about high schools where students will be in very close contact during the day and it will be difficult to distance in hallways and other common areas?
Tribble: The risk of transmission from transient contact is very low so it's unlikely that COVID would spread from teens passing each other in the hallway. However, schools should enforce policies to prevent teens from congregating by lockers or talking to each other closely during these passing times to reduce the risk of transmission.
Do you think the risk of spread seems lower in schools because kids might get COVID but not show symptoms? I know a family where all kids tested positive but only one had symptoms?
Tribble: We don't have data where we've systematically surveyed asymptomatic kids in schools. There are unknowns, but what we know is the rate of symptomatic disease in kids is lower in kids in schools than other community settings. It's much more likely they're exposed from attending social gatherings like birthday parties than being in a school setting with staff wearing masks.
It's important to note that all of the mitigation measures at schools are to prevent the spread of asymptomatic spread. Kids with symptoms or who are sick should be staying home. That's what makes this work is everyone doing their part.
Tribble: Severe diseases in kids are of course very worrisome and get a lot of media attention. But it's important to know that severe COVID-19 disease in kids is still very rare. About 1% of children with a known case of COVID-19 have been hospitalized and 0.01% have died.
Tribble: In the spring and summer, some U.S. cities and parts of Europe reported cases of a rare COVID-associated inflammatory disease called multi-system inflammatory syndrome, or MIS-C, affecting children. This syndrome appears to most commonly follow SARS-CoV-2 infection by about 4 weeks. As rates in other locales have risen, other cities are starting to see some of these cases now, but we aren't seeing any overall increase in incidence.
Overall the evidence is very reassuring that the vast amount of children won't have severe disease from the virus.
Tribble: We are not seeing signals that children with asthma, allergies, diabetes mellitus, or chronic kidney disease are at higher risk of severe disease from COVID-19.
There is limited data to suggest that those at highest risk of hospitalization and severe disease are children who are severely immunocompromised, such as those who have recently had an organ transplant, are undergoing chemotherapy, or have hypogammaglobulinemia, as well as children with chronic cardiac disease, neurodevelopmental disorders, sickle cell disease and obesity. However, even if such children may be at higher risk for complications, severe disease is still very uncommon.
SEE ALSO: More on making back-to-school decisions for children with underlying conditions.
How has the isolation from peer groups, schools, sports/activities and jobs especially affected teens' mental health and when do you know if you should be worried about signs of anxiety or depression?
Bravender: It's complicated to figure out if increases in cases and severity of teen depression and anxiety are related to pandemic precautions or if it's a continuation of a very unfortunate trend we've seen over the last 10 years. We don't have 2020 data yet, but it is clear that adolescent and young adult suicide rates have worsened over the past decade.
Social isolation and limiting daily activities clearly have an impact on us. One of the important ways of warding off depression is getting out and doing things - being physically active, interacting with friends, seeing friends – these are things that have been much more difficult to do this past year.
It can be difficult for parents to differentiate between normal sadness and red flags of depression. Being sad about missing prom or basketball season – that's normal. But overwhelming feelings of sadness, difficulty with academics, worsened isolation or thoughts of death or suicide are all concerning. If this persists for more than two weeks, it's important to seek out professional help.
Bravender: The number one recommendation: It's important to get outside every day. Even in winter weather, there are ways to enjoy the season and we know that outdoor activities have lower COVID risks and are really good for children and adolescents. We tell our patients you should see daylight at some point in the day.
It's also important to maintain a normal daily structure, even with virtual school. Especially teens who may have asynchronous classes they can attend any time, they should wake up at the same time in the morning and keep their sleep-wake cycles on track so they're not sleeping all day and up all night. These are all ways to help prevent the occurrence of depression.
Check local organizations for resources and ideas for spending time outside. For younger children, The Matthaei Botanical Gardens in Ann Arbor, for example, has started a series called Nature Play Pop-Ups that suggests some great activities.
My teen's sleep habits are completely off as they adjust from virtual to in-person learning – how can I help?
Bravender: The one pandemic positive for adolescents and teens is that they are getting more sleep. Teens normally have a later sleep phase than younger children and adults do. It's perfectly normal for them to feel like going to bed at midnight and wake up at 8 or 9. Many states require high schools start after 8:30 for this reason
When school times don't match their normal sleep wake physiology that can be tough on them. Parents should observe and know what's good for their kids and engage with their community and school district to set up a system that works best.
What should families consider as their kids return to sports?
Bravender: Sports (and other extracurricular activities) are incredibly important for engaging kids with their school. It's the enjoyment of movement and physical activity, and certainly in high school, it's a connection with your school, which we know helps with academic achievement. When kids are pulled out of sports, all of those things suffer. Families need to balance the risk of contracting coronavirus with all of those positive benefits.
These studies are a constant reminder that we have to maintain strong mitigation measures in schools – not just one – but layers of safety practices to reduce the spread.Alison Tribble, M.D.
Some sports are extraordinary low risk, like track and field. Other indoor sports, such as basketball and volleyball, may need more precautions. As we move into spring sports season, there are some really great opportunities to help kids get back some normalcy in their lives.
There have been so many readjustments for young children – in and out of in-person school - how might this impact them emotionally?
Radesky: Kids actually learn and grow through adapting to change. Although the initial few days of adjustment to a new school, camp or learning plan can make children (and parents) anxious, most children start to pick up the routine quickly: they watch others, follow the lead of the teacher, and in all cases of patients I've followed through re-entering school, they actually are happy for the opportunities for hands-on and social learning.
There are some children with slow-to-warm-up temperaments or more rigid thinkers who may take a week or 2 to adapt to changes – but that doesn't mean we shouldn't challenge them to go through changes, we just need to provide more advance planning, emotional support and accommodations to help them adjust.
My child's screen time has been way more than normal – how do I manage this during virtual learning?
Radesky: First, don't worry about virtual learning as "screen time" in the sense that you need to limit the number of hours – instead, focus on making it efficient, quality time learning from teachers and assignments (without digital multitasking such as watching YouTube videos or sending instant messages to friends), and then turning it off to stretch, eat, and get outside.
The second issue is that, once school hours are done, kids don't have as many opportunities to play outside, take part in teams and clubs, or hang out with their parents, who may be working. This is a time when TV, videos, or video games are used to occupy kids so we can finish our workdays and cook dinner.
This 'screen time' will be easier to peel back as our kids get more opportunities to take part in their usual activities, see friends, etc. My guidance for this "keep them occupied" screen use is to set consistent times of day, keep the content super positive (e.g., PBS KIDS, nature shows, shows with good role models – not just channel surfing or following YouTube feeds.)
If your kids can be occupied with podcasts, drawing, reading, or other non-screen activities, that's great. I have my boys complete a list of chores (make bed, straighten desk, feed pets, empty dishwasher, finish all Schoology tasks) before they can play video games on asynchronous days.
How can I handle pushback from my kids on reducing screen time as we transition from virtual learning?
Radesky: We need to think about whether screens have started to be a calming tool or mental escape for kids.
Is screen time high because the tablet comes with them everywhere, to take away any moment of boredom? Do the kids grab it out of habit? Do they fall asleep watching YouTube? This type of relationship with media – which I call for "regulatory" purposes (regulating emotions and mental states) – is what I don't want kids to get used to.
I hope that during this stressful year they will learn strategies for calming their minds and bodies, talking about feelings, and falling asleep. One stepping stone for kids who use their tablets to calm down is an app called "Stop Breathe & Think Kids" – which has guided meditation activities and emotional awareness exercises.
If you think your kids are going to resist peeling back on technology use, then have a family meeting. Talk about what you miss doing, and make plans for, if you peel back on screen time, what you would do with that time instead. What feels good about technology? What doesn't? What sucks you in and makes you ignore other people around you? What makes you laugh and feel more connected with people around you?
Make a plan to keep only the media/technology that's supporting your family, and try out a few weeks of stopping the media that is a time-waster or makes you feel more toxic afterwards.
My child has special needs and has fallen way behind peers during virtual schools. Tips to help them without overwhelming them?
Radesky: I've been recommending more outpatient therapies (speech-language therapy, occupational therapy, reading tutoring, meeting with a psychologist) to fill in the gaps that have appeared during this difficult school year.
Some parents are worried about attending therapies in person; virtual therapy works well for some kids, but if it doesn't for yours, then talk to the therapy center to see how they keep kids safe during face-to-face sessions.
However, it's also the school's responsibility to help your child make more progress. Ask the child's special education teachers for data about academic progress, such as reading scores (e.g., DIBELS scores), math knowledge, or the child's communication or social engagement. Even if school is virtual, they should still be trying to collect this data as part of the child's individualized education plane, or IEP. You can call a meeting with the special education team, or advocate for more face-to-face sessions this year.
If you're concerned your child will become too overwhelmed with lots of new therapies and challenges at once, space them out by a few weeks, try to get therapists your child knows and trusts already, and ask for what "homework" you can practice with the child after therapies. Finally, be proactive about having an IEP progress meeting this spring, so you can plan with the school how they will help address this year's learning gaps in the summer and fall.
My child did better during remote school because it eliminated some anxieties and stresses and issues with peers. What should I be prepared for as they re-enter in-person school and how can I help them have a smoother transition?
Radesky: I've had a few patients feel this way, especially those who are "home bodies" or more socially anxious. Before in-person school resumes, you can:
Talk as a family about the happy surprises of remote learning, but also reflect on what's missing. This can help increase your child's motivation or sense that there are positives to look forward to.
Find out who will be in your child's hybrid class and plan an outdoor get-together or walk in the woods. Having a buddy who the child feels comfortable around can ease the transition.
Give the teacher a head's up that your child may need some extra breaks, a little help solving social difficulties, or self-regulation strategies to help feel more in control during school.
Finally, know that your child may need to blow off steam when they get home. Let the first hour or so be a time of low demands, very open-ended, and positive.
Any tips for continuing to manage remote learning – especially if your child hasn't been engaged, isn't motivated or seems distracted by home surroundings?
Radesky: The lack of engagement and motivation is something I've heard from lots of parents, even whose kids tended to like school in the past.
First, talk to the teacher about it. Sometimes, a change-up in morning meeting activities or discussion topics can get kids a little more mentally engaged.
Distraction is a big problem too – kids wanting to get up and move around the home, get snacks, play with toys or open other browser windows. This is really developmentally normal - for younger children especially. Other than setting up the environment to be less distracting, finding some tools to help with focus (fidgets, weighted lap pads, other sensory input), and blocking non-school websites – it's really hard to harness your child's brain from the outside.
Some kids respond to behavioral reinforcement programs (e.g., if you don't multi-task during Zooms, you can earn X) or natural rewards (e.g., once you are done with SeeSaw, we can go out and play.)
Tribble: The Pfizer vaccine is approved for people ages 16 years and older and Moderna's is approved for use in those 18 and older. Both Pfizer and Moderna have started clinical trials to test the vaccine in kids as young as 12.
These studies will help determine vaccine safety and efficacy and potential side effects in this age group. We're hopeful we'll have some data by the end of the summer. But since most 12-16 year olds are pretty healthy, they'll probably fall into the last tier of vaccinations.
Trials haven't started yet for kids younger than 12. Because of changes in dosing, there's more that goes into researching the vaccine for younger age groups. We've seen estimates that late 2021 would be the earliest we'd see vaccines available to younger children.
What kind of teacher/school staff vaccination rates do we need to help keep schools successfully stay open?
Tribble: There is understandable concern about teachers getting sick in schools, and we need to prioritize teachers being vaccinated. However, research so far tells us that the biggest risks to teachers are other adults at school and their exposures in the community – not students at the school. It's important that schools maintain mitigation measures and that staff maintain these measures around each other.
We know that schools that implement aggressive mitigation measures can open safely without staff vaccination; therefore, vaccination rates should not factor into reopening decisions.
Other resources for families:
Trail to Wellness: Resources to help student wellness for school age and teen children
Zero to Thrive: Guides for parents of young children, perinatal women, and professionals during COVID-19.
Parent Resource: Tips for creating a healthy learning environment and managing multi-tasking during virtual work and school.
AAP: Guidance on reopening schools safely as the pandemic continues.
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