Mental health services and other support can help — if they reach children and their caregivers quickly
From The Hechinger Report
By Jackie Mader
October 25, 2021
At the beginning of 2020, Brisandi Ruiz was hopeful about the year ahead. Her two-year-old was enrolled in a high-quality preschool program near their home in Greenbelt, Maryland. The office manager of a medical technician company, Ruiz was working to validate her medical degree from her home country of the Dominican Republic, so she could practice medicine in the United States. Her husband, Francisco Villar, had steady work in the construction field, and they were planning to have a second child. But then reports of cases of the novel coronavirus hit the news. By March, most of the nation was under lockdown.
Her son’s preschool closed, and Villar saw a steady decline in his work hours. It didn’t take long for Ruiz to feel overwhelmed. “Trying to do all these things, keeping the house, working from home, calling customers—it was driving me crazy,” she said. The couple tabled their plans to get pregnant. Soon, Ruiz had to quit her job. Short on savings, the family saw their financial situation quickly worsen. Unemployment benefits temporarily helped, but Ruiz began to fear that if they couldn’t get a stable income soon, her family might struggle to afford food and end up homeless.
When she found a new job as an allergy technician in September 2020, it didn’t pay enough for the couple to send their son to a licensed childcare center, so a neighbor watched him at her house for a more affordable fee. But as her son tried to adjust to yet another disruption in his routine, Ruiz noticed a change in his behavior. Being home with his family for several months had made him more attached; in the mornings, he was nervous and didn’t want to enter the neighbor’s house. He was frequently scared, had more tantrums, and began to regress in potty training. He stopped writing his name, too. Even at home with his parents, he was often in a bad mood and had little interest in playing outside.
“The biggest feeling I had was guilt,” Ruiz said. “Because I was putting my son’s well-being behind the economic well-being of the family.”
Over the course of the pandemic, it’s been apparent to anyone who works with or parents small children how deeply the nation’s difficulties have been felt by its youngest citizens. Outside of Helena, Montana, childcare center owner Rachel Supalla has seen an unmistakable uptick in behavioral issues resembling those experienced by Ruiz’s son. Last year, when kids started to trickle back to her three childcare centers after several months at home during the lockdown, she could tell that they’d been affected by the sudden changes in their lives. Supalla, who opened the first of her Discovery Kidzone Learning Centers in 2009, noticed that children were having more emotional challenges and that their social skills were declining. They seemed lost, she said, confused by the disruptions to their routines. When transitioning between classroom activities, they often threw tantrums, pushed and hit their peers, or resisted teachers’ guidance.
Across the country, parents and educators are struggling to assess and alleviate the pandemic’s toll on young children. Covid-19 exacerbated inequality, plunging families on the brink into poverty and leaving millions of kids without enough food or in housing they couldn’t expect to stay in, not to mention subject to emotional distress from family members’ illness or death. Childcare arrangements unraveled as many centers closed or childcare was deemed too risky, especially if it involved older friends, neighbors, or relatives more at risk of complications from the coronavirus.
Social support programs such as food and housing assistance and unemployment aid struggled to meet the extreme demand. Ultimately, the pandemic accentuated the weaknesses of a childcare system that was already deeply flawed. In the United States, high-quality options have long been unaffordable for many, and families are often left to choose providers from a patchwork landscape that varies markedly in quality and level of oversight. For adults in low-wage jobs, especially those who work unpredictable or atypical hours, reliable, high-quality care can be especially elusive.
What is the effect of all this on young kids’ bodies and minds? Ordinarily, we think of trauma as stemming from a defined event—the emotional shock waves you might experience from a single act of violence, for example. During the pandemic, many children have experienced singular traumas, such as the death of a parent or loved one. But decades of research on child development have also made clear that trauma is not caused by isolated events alone. Significant levels of ongoing stress—“toxic stress,” as it is known—can dramatically affect young people’s brains. What’s more, in very young children, nearly any major change or disruption can be traumatic, especially for kids who lack an attentive adult who is responsive to their needs.
When children are exposed to repeated, ongoing stressors during the first few years of life, a pivotal time of brain development, those experiences can have a lasting impact, even leading to changes in the brain’s structure and the body’s ability to regulate stress. Kids experiencing ongoing neglect or contending with a parent’s mental illness, for example, may be flooded by high levels of the stress hormone cortisol. Without supportive caregivers who can address their needs and help them regulate their emotions, their cortisol levels will remain elevated. This can result in difficulties with executive functioning and decision-making, academic challenges, and behavioral issues, and even manifest in higher rates of health problems such as heart disease and depression during adulthood.
Already, evidence is piling up to suggest that the pandemic has undermined children’s emotional well-being: One recent survey from the National Institute for Early Education Research at Rutgers University found the percentage of young children reported to have a “high” level of social and emotional difficulties—such as hyperactivity and conflict with peers—increased during the pandemic when compared to previous national data on child behavior norms. A report released in May by RAPID-EC, a biweekly survey of caregivers of young children administered by researchers at the University of Oregon, found that during the pandemic, parents’ stress has trickled down to kids, and kids’ behavioral problems have worsened, especially among those whose parents reported high levels of emotional distress. And a recent survey of parents in Massachusetts found that more than half of those polled reported a decline in the social and emotional skills of their young children during the pandemic.
The difficulties kids experience now may affect their ability as adults to hold down jobs; they may get sick more easily and die younger. “We will see the short-term impacts,” said Cynthia Osborne, director of the Prenatal-to-3 Policy Impact Center at the University of Texas at Austin. “We will see kids show up to kindergarten feeling less secure, needing more assistance and more services. But we will also see this for decades to come. We will see teenagers who have not been able to kind of reach that level of executive functioning they need to make better choices.”
“I’m not trying to be an alarmist,” she added. “This is science.”
Of course, not all young children will be noticeably affected long-term by the difficulties of the pandemic. Research suggests that, among kids who have lived through natural disasters such as Hurricane Katrina, at least half emerge relatively unscathed. Kids who were exposed to multiple stressors during and after the hurricane, and those who experienced chronic hunger or homelessness or a serious event such as the death of a family member, were most likely to endure long-lasting effects. Whether or not children and their caregivers got help to stabilize their lives and address trauma and stress also made a difference.
Those lessons are critical to shaping society’s response to the pandemic. The worst impacts on young children and their caregivers, researchers say, can be mitigated by improving the level of care offered and providing access to mental health services—if the services reach those in need quickly. And on this front, there’s at least some reason for optimism: An infusion of childcare funding in the American Rescue Plan Act, passed in March, could not only stabilize the industry but also pay for mental health services for children and help providers afford more staff and more training in trauma. And an additional $10.7 million allocated in August from the American Rescue Plan to the Pediatric Mental Health Care Access Program, which is aimed at expanding pediatric mental health care through telehealth, could make it easier for some families to access services. We know how to stave off the worst consequences, Osborne said. “But if we neglect to do that, we do it at a huge cost”—to kids and to society.
There are several major avenues for mitigating childhood trauma—including mental health interventions, such as therapy, and trauma-informed care, which emphasizes sensitive, responsive caregiving and uses practices that help children understand and better regulate their emotions. Childcare centers like those Rachel Supalla runs outside Helena are crucial: They provide safe, stable settings with the sort of clear, predictable routines that children need to feel secure.
After the pandemic began, Supalla, a longtime early childhood educator who coaches directors of other centers in addition to running her own, threw herself into finding ways to help her students cope. She added yoga and mindfulness lessons and increased the amount of time outdoors at her centers, which feature colorful, well-stocked classrooms with outdoor areas from which you can see the Montana countryside. Her teachers followed a social-emotional curriculum that included lessons, activities, and classroom routines meant to help children verbalize their feelings and problem-solve, a program they’d adopted earlier but now found even more useful. To help with transitions between activities, teachers invited children to bring a comfort item, such as their favorite stuffed animal, with them, and encouraged kids to visit their classroom’s designated “safe place” if they needed a break. Supalla also treated her staff to lunches and hosted seminars on mental health and financial planning to address their personal concerns. “If an adult isn’t healthy and in the right mindset, then they’re not going to be help for the children,” she said.
Before long, with these changes in place, and as children readjusted to structured group care, Supalla began to see a difference in their behavior. “The weight had been lifted from them,” she said one recent afternoon. “That gave me clarification that this is the direction that we need to keep heading.” She is currently waiting for the next round of grants to open up in Montana, and plans to use those funds to hire mental health professionals.
Experts in child trauma encourage childcare centers to embrace a trauma-informed approach in order to help kids process painful experiences and develop coping skills. In large part, such an approach is about training adults, because while the teachings may sound straightforward, they can be difficult to master, and can go against an adult’s instincts in how to respond to a child, said Colleen Maher Turner, family services director at Mainspring Schools, a childcare center and preschool in Austin, Texas, that enrolls a diverse student population, including a high percentage of low-income kids. “It’s 100 percent, I think, against what our culture tends to think for kids,” Turner said. “It takes a big shift, and I think it takes a lot of education around what is trauma.”
If a child knocks items off a table or throws a chair, for example, many adults may assume the act is spiteful and react with irritation or anger, Turner said. An adult might tell the child to immediately pick up what they tossed or might say, “You just need to sit down and follow the rules.” But with a trauma-informed lens, you would consider why the child threw the chair. Perhaps a stress response has been activated; perhaps they were triggered by or are thinking about something upsetting; perhaps they are overwhelmed. “It’s acknowledging that this behavior is not malicious,” Turner explained, and that the child is rather “trying to meet some need.” The idea is to help kids determine what they need to process their feelings before working on “restitution or accountability,” she added. A teacher might ask, “‘Does your body need a break? Do you need to be held?’ In that moment, that child is not capable of picking [items] up, and we’re not going to demand that.”
Also key is mindfulness of situations that could retraumatize children, even if they’re the sort an adult may not think twice about. While many kids like to hug, Turner said, others may be triggered by a seemingly small physical touch. “Some kids are like, ‘You hugged me, but I perceived that as you were trying to hurt me.’” And some kids just don’t like to be touched at all. At Mainspring, staff members teach students how to ask permission before touching someone and model this by asking children if they need or want physical affection. Students practice with each other to make sure each child knows what to say in that situation.
While trauma-informed care can be time-consuming at a moment when many providers are stretched, it can reap long-term benefits for children and their teachers. And even in the short-term, “it will pay off in less disruptive classrooms, better learning, less turnover and burnout for teachers,” said Jessica Dym Bartlett, a research scholar at the nonprofit organization Child Trends who focuses on trauma-informed practices in early childhood settings. “Even the most severely traumatized young children can heal and thrive if they have the right relationships.”
At Mainspring Schools, trauma-informed teaching is already woven into the fabric of the school. Situated in a homey, single-story gray building nestled between a public housing development and a small, city-run park, Mainspring has a long history of attending to children who have experienced poverty and trauma. The school opened in 1941 as a “war nursery” for children whose mothers took wartime jobs. Teachers are trained in Trust-Based Relational Intervention, which is meant to support children’s needs for responsive, dependable caregivers and address problematic behaviors that grow out of trauma and fear, as well as in Conscious Discipline, a trauma-informed and social-emotional approach to behavior management. The staff focuses on serving parents, too, by providing them with counseling and groups designed to support their ability to nurture their children.
On a recent morning outside Mainspring’s “Songbirds” classroom of mostly three-year-olds, lead teacher Hope Bell was hard at work helping her young charges manage an array of emotions. Children were spread out on one of the school’s playgrounds, an outdoor oasis carved from the natural landscape. Piles of tires were scattered around for children to jump and balance on; a yellow slide was embedded in the rocky side of a small hill, and well-loved plastic toy trucks waited on a wooden bookshelf. Calm and self-assured, Bell hurried over to three young girls who were standing on a small wooden bridge. One girl wailed after being inadvertently kneed in the face by her friend, who was now jumping up and down, oblivious. Unable to get off, the little girl clung to the side of the bridge as it bounced. “Whoa, whoa, freeze!” Bell said. “When you hear that your friend may be scared, you stop and check in.” She turned to the girl whose wails had simmered down into whimpers. “And you can say, ‘Please stop!’” “Please stop,” the little girl repeated.
This work continued for the rest of the morning. As the children played in various parts of the playground, Bell mediated, choosing her words meticulously and speaking in a firm yet friendly tone. “We’re taking turns!” she reminded one child. “It’s hard to wait your turn,” she acknowledged to another. “You’re proud of yourself!” she said to a little girl who had carefully balanced in the V of a tree trunk. “Let’s try that again,” she told a child who had just pushed by a friend. “You can say, ‘Excuse me,’” Bell encouraged the child. “Excuse me,” the girl responded. “And you can say, ‘Please don’t push me!’” she suggested to the aggrieved party. Bell has learned, through training and experience, that kids thrive when they feel safe, when their feelings are validated and they are not made to feel ashamed of them. During these interactions, she reminds herself to regulate her own emotions first and not take kids’ behavior personally.
Bell has seen the benefits. She recalled that at a school where she worked previously, a child was eventually suspended for frequent biting, trying to escape from the school building, and hitting other children—behaviors that are often related to trauma. But teachers were focused on the actions alone, rather than what the child might have been trying to communicate. “We kicked him out of school just because we didn’t know what to do,” she said. “Here I see the same [behaviors], but there’s actually an effective way” to address them, she added. Looking back, Bell said she now sees what that child likely needed: “They needed a safe place to go when they wanted to escape and ways to bring their body out of that fight-or-flight response. In those moments when they were triggered and unable to think logically, they needed to be held, reassured that they were safe with me, reminded to take slow, deep breaths, and given the right words to use to get what they needed when they were calm.”
In her classroom now, decorated with student artwork and strings of tiny white lights draped across the walls, Bell devotes entire lessons to helping children verbalize their feelings and regulate their emotions when they’re calm, so they can rely on those techniques when triggered.
Despite the evidence behind trauma-informed approaches, Dym Bartlett said, they are rarely taught in any depth in teacher preparation or credentialing programs for early childhood educators. But mental health consultations by trained professionals can help bridge that gap, a strategy used by some childcare centers and preschools, including federally funded Head Start centers. During these consultations, a mental health professional visits an early childhood classroom and meets with teachers to discuss challenging behaviors and other concerns. The consultations are meant mostly to support the mental health of the teachers, who often use them to discuss personal concerns or frustrations and work through those feelings so that they are better equipped to respond to students’ needs in the classroom.
“We have teachers that have their own families, that have people who got sick, people who died. They have their own health fears and concerns,” said Tena Sloan, vice president of early childhood mental health consultation and training at Kidango, which runs a large network of childcare centers and preschools across the San Francisco Bay Area, including Head Start programs. All of the children in Kidango’s centers qualify for free or reduced-price care, subsidized by the state, and spend their days in warm, inviting classrooms where teachers emphasize social and emotional skills and relationships with peers and adults. Even Kidango’s literacy approach involves strengthening the teacher-student relationship, with a focus on supporting a child’s positive self-image and using intentional affirmations, among other things, to drive reading growth. This focus on relationship is present in other areas, including meals, which are free and served family-style.
Officials from Kidango have seen so much promise in the mental health consultation model that they successfully advocated for the practice to become commonplace in the state’s early childhood settings. In 2018, former California Governor Jerry Brown signed legislation backed by Kidango that increases state reimbursement amounts for children in centers that use mental health consultation services.
The benefits of consultations with early childhood teachers can trickle down to students and can lead to improved social skills and fewer challenging behaviors among kids, according to several studies, as well as improved interactions between teachers and their students. Consultations have also been linked to a reduction in problematic, systemic trends, like preschool expulsion rates. (While centers often have to raise or find funds for the visits, they can use money from the American Rescue Plan Act to help expand that work.) Mental health consultants can also work with families enrolled in centers to provide help in dealing with challenging behavior or tips for healthy development. “At the end of the day, we always believe that the strongest and most powerful intervention is [with] the adult,” Sloan said. “How do we help our teachers, who are having their own personal and professional stressors, to be able to create emotionally safe, regulating, soothing environments for children?”
But if organizations are going to address childhood trauma, they first have to get better at identifying it. Just before the pandemic, in late 2019, California launched a program to train pediatricians and other health care providers to screen children for traumatic events known as adverse childhood experiences, or ACEs, such as neglect, abuse, or exposure to mental illness or divorce, so that these medical personnel can connect families to counseling and other programs that can help. Because it’s a place that children and families visit frequently, the pediatric primary care office can be a powerful setting to address early childhood mental health and well-being.
The initiative appears to be having an impact: Some 80 percent of the health providers surveyed who were not previously screening for ACEs said that after participating in the training, they planned to start routine screenings for kids or adults. The number of ACE screenings administered by providers participating in California’s Medicaid health care program increased significantly between January and September 2020, from 14,390 screenings to 55,740. More than a third of the total screenings during that period were for children under the age of five. With the pandemic, the need for an intervention like this could be near-universal. “I think of the pandemic as an ‘ACE’ for every kid in America,” said Dr. Shannon Thyne, director of pediatrics at the Los Angeles County Department of Health Services.
Some organizations are finding ways to provide mental health support to kids and their caregivers simultaneously. In Los Angeles, the mental health nonprofit Westside Infant-Family Network (WIN), which operates out of an office building on the edge of Baldwin Hills, has long provided free weekly in-home therapy sessions jointly to parents and children, as well as therapy for adults and help connecting them to services such as childcare, health care, and basic supplies like food and diapers. Parents are often referred to WIN from a local community health center, a nearby prenatal clinic, or from federally funded Early Head Start centers, which serve infants and toddlers up to age three.
During the pandemic, WIN continued those services online for families stuck at home. The program launched “parent cafés” on Zoom, where caregivers could casually chat with one another, and program officials read books over Facebook to children, to ease families’ isolation and help them connect with people outside their homes. The overall goal of WIN is to allay parental stress and recognize and alleviate any mental health problems adults may be facing. It’s easier for caregivers to respond to their children in nurturing ways when they aren’t depressed, anxious, or stressed, and children in turn experience less stress when they feel safe and comforted by their caregivers. “That secure attachment is the best buffer to help children and parents cope with any stressful events that they might experience,” said Wendy Sun, former co-executive director of the organization. “Our idea here is prevention is always better than intervention.”
WIN’s approach—at once addressing families’ basic needs, parents’ mental health, and parents’ relationships with their kids—seems to be working. Data from the organization shows that six months after families started receiving services, more than 90 percent of parents or primary caregivers originally identified as having clinically significant levels of stress showed a significant reduction in that stress. Nearly 90 percent of children demonstrated an increase in behaviors that reflect a secure attachment with their parent or primary caregiver, such as sustaining eye contact with their caregivers, smiling back at them, or turning to them for comfort, and 90 percent of children who demonstrated development concerns showed significant improvement within six months. These efforts have been limited by funding and the availability of therapists. WIN provided virtual therapy to 56 caregiver-child pairs in the first half of fiscal year 2021, but has been exploring ways to expand further, and recently received a grant from the California state program on ACEs.
Parents like Ruiz who have seen their mental health and childcare arrangements fray during the pandemic say the kind of help WIN provides would be invaluable. Late last year, Ruiz took on a second job as a Covid-19 contact tracer for the state of Maryland so she could earn enough money to pay for a licensed childcare center for her son. Now three, he was thrilled to be in a structured setting again, and, with the help of his teachers, he started to make progress in the areas in which he had regressed. Then, in the spring of 2021, Ruiz was offered a job as an internal medicine resident physician at a hospital in Missouri.
In early June, she nervously uprooted her family once again for a chance at greater stability. She still worries about how the past nearly two years have affected her son, especially after yet another transition to a new state, a new home, and a new school. She hopes that families will receive more ongoing help.
“This changed everything,” Ruiz said of the pandemic. “We need psychological support, we need help with our kids. Everybody is traumatized.”
Without diminishing the importance of psychological support or trauma-informed care, it’s crucial to acknowledge that the mental health and well-being of children and their parents may not truly stabilize without stronger federal and state policies to reduce the sources of the stress in families’ lives, including after the pandemic subsides. The United States is far behind most other developed nations when it comes to providing family-friendly policies that support parents and provide stability, such as parental leave, adequate childcare assistance, and access to home visiting programs from nurses or other child development professionals. Many Western European countries, including Belgium and Germany, provide some version of a universal basic income to families with children, which in certain cases has helped drive down overall poverty.
The Biden administration’s efforts to expand the Child Tax Credit and disburse funds to parents on a predictable basis could greatly reduce child poverty here in the United States, but even more is needed. A sweeping social policy bill that Democrats have drafted would go further, by potentially funding paid family and medical leave and helping to make childcare more affordable. “There isn’t just one silver bullet that will solve everything,” said Philip Fisher, director of the University of Oregon’s RAPID-EC project. “Ongoing financial support is critical,” as are “things like paid leave, maternity and paternity leave, and paid vacation time.”
Researchers know what works: more money to families and policies that support them; programs that consolidate help and assist caregivers; reliable, high-quality childcare; and access to mental health services. When systems and programs approach families and children with a trauma-informed lens, the results can be even more profound. “The brain has a lot of plasticity early in life,” Fisher said. “So it’s possible things may still get back on track.” But efforts to provide such services to a sizable number of families, let alone universally, would require considerable financial investment, as well as communities’ acknowledgment that a comprehensive approach is necessary. Will the pandemic finally prompt us to provide our children—to provide all of our children—with the kind of care we know they need?
Photo: Children line up to go inside their classroom at Mainspring Schools in Austin, Texas. Mainspring provides extensive support to families, including counseling services, support groups and help meeting basic needs. Credit: Jackie Mader/The Hechinger Report
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