Schools, safety, SLPs, and the evidence

Written by:
Meredith Harold, PhD, CCC-SLP
Katherine Sanchez, PhD, CPSP
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Meet our Team, here

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Each month, we've been writing age-specific evidence reviews on COVID-19 for our members. The month, we decided to give all SLPs our monthly update for free. We hope it helps.
 
COVID-19 continues, justifiably, to be the hot scientific topic of the year, as the number of publications mounts. In children, the evidence continues to suggest that:

• The disease is milder than in adults (here, here, here, here), although infants under one year of age and children with comorbidities like chronic lung disease are at somewhat higher risk (here, here, here)
• Despite children generally contracting the disease less, and having milder symptoms, the Kawasaki-like complications (a serious multi-inflammatory condition occurring in a tiny number of children with COVID-19) that we discussed last month in our membership site are still keeping us all on our toes (here, here, here, here)
• Children don’t seem to transmit COVID-19 any more than adults, which is surprising, given that children are germ factories who are constantly “sharing”.

 
But now researchers are starting to think more broadly...
 
Increasingly, researchers are asking questions (and here) about the flow-on effects of the pandemic upon children, like:

• Poorer access to ‘non-COVID19-related’ healthcare. We are seeing:
  • Decreased pediatric emergency presentations, with resultant severe illness and death
  • Cancelled or delayed routine child health checks
  • Delayed vaccine administration
  • Delayed access to diagnostic testing
  • Delayed access to appropriate treatment (example here)
• Food insecurity, arising from financial instability and school closures
• Decreased academic opportunities secondary to absence from school
• Decreased opportunities for socialization
• Decreased opportunities for physical activity
• Decreased access to support workers and therapists for children with disabilities
• Increased screen time as families struggle to combine childcare with working from home
• Emotional and behavioral concerns related to lock-down
• Increased rates of child abuse
• Decreased access to welfare services

We still have more questions than answers, but as SLPs, we should be asking ourselves what we can do, not just to prevent the spread of disease, but to ameliorate the impact of the pandemic on the children we serve. Obviously telehealth has a huge role here, but could we also be doing more to link families in with other services? Might some of our goals need to shift to consider changes in behavior, mental health, academic and social opportunities, and parenting demands? Should we be doing more (cue spooky music) telehealth groups? Food for thought.

 
So what about schools?

We know the question on many SLPs’ lips, both as parents and as professionals, is ‘what about schools?’ We spoke last month about how complex a question that is, and how many factors there are to take into account. It’s not just about disease spread between children, but about the flow-on factors above, along with the role of schools in allowing parents to continue to earn a wage, access and equity for underprivileged students, the fact that many teachers fall into a higher risk bracket, the difficulty of maintaining hygiene and social distancing regulations and so on.
 
Want to really delve into this thorny issue? The Pennsylvania Department of Education released this research report which does an amazing job at summarizing the scientific evidence (equivocal), stakeholder concerns (broad), and mathematically modelling some possible plans (fun! If you’re a nerd! Like us!) This paper is long, but really important in helping us understand the nuances of the situation. We highly recommend reading it. It lays out possible return-to-school scenarios, and the differences among all of them in virus spread, highlighting things like:

• Elementaries and high schools don’t model the same.
• Large schools and small schools don’t model the same.
• There’s a huge difference (huge) between full-time school and part-time and rotating schedules.
• The likelihood of infection across different times of the day is also significant— bus time vs. lunch/recess time vs. class time. And this changes by age.
• If you’re trying to skip straight to the Results, start reading on page 21 of the document, where it says ‘Scenarios for reopening schools’, then keep reading down through the end. See all the graphs, too, like page 28? Then read the discussion section on page 32 as well.

 
If you want to know what we can learn from other countries, check out this open-access article which looks at approaches around the world, and considers what we could apply to schools in the U.S. Same with this incredibly thorough document from Washington University. If you want to get as informed as possible, these are must-reads.
 

Just tell us. Should schools be open?

We cannot emphasize enough how irresponsible it is to answer that question at a national or international level without taking local data into consideration. Just like what’s best for one kid isn’t what’s best for another, what’s best for one school isn’t what’s best for another. What’s best at one time point isn’t what’s best at another (hello, Rt). And decisions at the extremes—like fully reopening with minimal precautions in place, or keeping schools fully closed from any in-person instruction—both require pretty specific circumstances to be the best possible (evidence-aligned) option.**


What about the pediatric SLPs who aren’t in schools?
 
There are quite a few papers on what to consider when returning to work, which are particularly helpful for people who have control of their environment (like private practice owners). Like this paper (for dentists; lots of parallels to our work), and this one. And, really, everyone should be considering their own social network:
 
“In workplaces and schools, staggering shifts and lessons with different start, end and break times by discrete organizational units and classrooms will keep contact in small groups and reduce contact between them. When providing private or home care to the elderly or vulnerable, the same person should visit rather than rotating or taking turns, and that person should be the one with fewest bridging ties to other groups… Repeated social meetings of individuals... who live alone carry a comparatively low risk. However, in a household of five, when each person interacts with disparate sets of friends, many shortcuts are being formed that are potentially connected to a very high risk of spreading the disease.”
 
 
I guess we'll need a lot more face masks?
 
Yep. And hopefully it’s not like the U.S. Toilet Paper Fiasco of 2020, where too many people purchase between now and mid-August, making them tough to find.
 
First we could ask—are all masks created equal, or are there good and bad ones? Well, safe masks can actually be made at home. If you go that route, there’s information here, here, and here. See also how to properly wear a mask (which you already know, but may be helpful to display for students/clients).
 
Then—what’s the difference between an ok mask and a good mask? Fit. If a mask isn’t snug, it’s likely leaking more air along the sides and around your nose than it’s actually filtering. Not good. Also, if you can’t easily breathe through your mask, ditch it. To get air, you’ll naturally create leaks on the sides. Then, some sources suggest avoiding exhalation valves, which may not properly filter the air. Instead, filter your air through higher-weave density cotton (some other fabrics have been found to be good, too) and multiple layers. Finally, wear it indoors, all the time when you’re with other people. Six feet of distance helps, but isn’t enough for indoor airborne transmission.
 
Finally—as SLPs, people need to see our mouths. So most of us will need at least some masks with clear windows.
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Feeling frustrated and uncertain?

I know. We are too. And ultimately, nobody has perfect answers to the questions a lot of us are asking right now. Not even the experts. But we’ll keep digging and reading and summarizing as long as we need to to make sure we’re keeping you in the loop.
 
 
**Editors’ Note: Keep in mind that we write for an international English-speaking audience. U.S. schools are unique in how everything is playing out, with only a month or two before our schools reopen. For us, the ‘pretty specific circumstances’ to warrant extreme actions can be something as simple as leadership being unwilling, unprepared, and/or underfunded to put required changes in place. For example, some U.S. schools are having difficulties with supplies and staffing, which could end up making the best-laid plans really difficult to implement. And none of the research takes those unfortunate circumstances into account. Finally, nearly half of our staff are current or former school-based SLPs. We are you. And please know that no matter what the international research shows, we trust in your ability to advocate for what’s best at your school. Please take care of yourself and the clients you serve.

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