Speech Therapy Shows the Difficult Trade-Offs of Wearing Masks
All parents of young children have been forced to gamble during the pandemic. Many parents of kids with speech disorders don’t like their odds.
Americans have been arguing about pandemic restrictions for two years, and the debate is particularly fraught among parents of small children, for good reasons. While measures such as masking and isolation mean temporary discomfort or inconvenience for most people, their consequences for still-developing young children are more mysterious, and possibly more significant and lasting.
Children with speech or language disorders offer perhaps the clearest example of these murky trade-offs. Pandemic restrictions vary by state, county, and school district, but I spoke with parents in California, New York, Massachusetts, Washington, New Jersey, Iowa, and Maryland who said their children’s speech therapy has been disrupted—first by the loss of in-person therapy and then by masking requirements, in places that have them.
Megan’s son, for example, has Joubert syndrome, a rare genetic condition that often manifests in severely delayed speech. At the start of the pandemic, the then-4-year-old could approximate a few simple words, like mom and home, each the hard-won victory of intensive speech therapy he’d received since he was 2. But he regressed a lot during remote therapy, and is still struggling now that therapy is in person, because his therapist wears a face mask. (Megan, who lives in California, asked to be identified by her first name only in order to protect her son’s privacy).
The consequences of leaving speech and language disorders untreated can be profound, Diane Paul, the director of clinical issues in speech-language pathology at the American Speech-Language-Hearing Association, told me. Children struggling to express themselves can get frustrated, which can lead to behavioral challenges, and they may have trouble making friends. Many kids with speech disorders struggle to learn to read, but “language becomes a medium through which we learn everything later in school,” Alex Levine, a speech-language pathologist at the Learning and Development Center at the Child Mind Institute, told me. And the longer you wait to address a speech or language issue, the harder it is to do so.
Many of the parents I spoke with are frustrated that they’ve been asked to compromise their children’s social and academic life in the name of public safety. The early years of a child’s life are important. Anything that threatens to interfere with development, whether that’s COVID-19 or the mitigations in place to avoid it, can feel like rolling the dice on a child's future. In one way or another, all parents of young children have been forced to gamble during the pandemic. Many parents of kids with speech delays don’t like their odds.
When the world shut down in the spring of 2020, many speech-language pathologists told me, they were quick to adapt. A lot of practices immediately pivoted to teletherapy, often successfully. But remote therapy is tough for young kids. “He would just completely disengage, lie on the floor, start playing with the toys, literally turn his back to the computer, try to close it,” says Julia Toof, a parent in Somerville, Massachusetts, of her then-almost-3-year-old son. “It just didn’t work.” Teletherapy also typically required significant involvement from parents, many of whom were already overwhelmed by work and homeschooling during the pandemic.
And when in-person therapy resumed, masking requirements made it difficult. Some of the dozen-plus speech and language therapists I spoke with said children found the masks distracting. More important, masks hide the mouth from view, which the therapists said is disruptive to some forms of therapy, especially those that target motor speech and motor planning—“anything having to do with actual speech that comes out of your mouth,” said Alexandria Zachos, an Illinois-based pathologist. For “that type of therapy, you absolutely need to see the speech therapist’s mouth and they need to see yours,” Zachos said.
Where available, therapists used masks with a clear panel, with mixed results. “They are kind of uncomfortable to wear. They really heat up,” Zachos said. And although she’s tried a number of tricks to prevent them from fogging up, they inevitably do. Fogging aside, even clear masks prevent therapists from using tactile cues, such as straws or tongue depressors to push patients’ tongues into place, or bite plates to keep the jaw in alignment. Therapists have found creative work-arounds—some use videos to demonstrate tongue placement, for example— but the ones I consulted agreed that masks are not ideal. “There is just a lot of interference on so many levels that I think there are certainly kids whose care was impacted negatively and whose progress probably was slowed,” Levine said.
Problems in speech therapy were exacerbated by problems outside therapy. Parents told me their children are more hesitant to talk with a mask on, which makes it harder for them to feel secure in their ability to communicate. “He’s hardly understandable without a mask,” said a mother of a 3-year-old boy in Iowa who asked to remain anonymous. “If he’s not understood, he will not have the confidence to continue speaking.” And on the heels of extended school closures, kids seem to be more socially anxious; they can take a lot longer to warm up to therapists, says Craig Selinger, who owns a company that offers speech therapy and tutoring services in New York City. “Their verbal output is more restricted because they feel more uncomfortable,” Selinger told me. This is a particular concern for autistic kids, for whom therapy is often more about nurturing engagement than building vocabulary, says Danielle Lindgren, a Los Angeles–based speech-language pathologist.
Many parents and speech therapists have struggled to obtain any kind of accommodation. “She sees no work-around; there’s no opportunity to go outside or use a clear face shield,” Megan said of her son’s therapist. “We would do a rapid test every day before our speech therapy if we needed to.” Several therapists and parents told me that their schools or agencies did not provide clear masks.
The CDC does not list speech or language impairments among the acceptable reasons for exemption from school masking guidelines, so many schools do not grant one—either during in-school therapy sessions or while kids are in class. Even where exemptions could have been available for children with qualifying disabilities, some parents said they were scared to ask for them, fearing that their child would be ostracized by classmates as a viral risk.
Under the circumstances, some speech therapists simply ignored the rules. The Iowa mother I spoke with told me that even when the public school where her son receives therapy had a mask mandate, his speech-language pathologist would allow him to take it off during therapy. “She would say things like ‘It’s our little secret,’” she told me. (The district has now gone mask-optional). Two therapists I spoke with who work in public schools admitted to pulling their mask down occasionally to give visual cues. And where possible, some parents are going to great lengths to make up for the shortcomings of their children’s care, shelling out $100 a session for private therapists willing to practice with just a clear face shield. Megan looked for such a therapist in her area, but they seem impossible to find. So in January, she cut her hours down to 20 percent in order to help her son learn to talk.
While the circumstances of kids with speech delays aren’t universal, the tricky nature of COVID calculus for parents of young children is. A lot of very important development occurs in the first few years of a child’s life, and it’s a key window for catching and addressing developmental delays. That’s why many parents give careful thought to seemingly small matters such as screen time, how many words their children hear in a day, and whether it’s okay to put a child in timeout. Pandemic restrictions feel scary and experimental for parents of kids in the youngest age group because they are. Asking them to trust that they won’t disrupt their kids’ development is asking a lot.
With proper treatment administered at a young age, some children with Joubert syndrome can learn to speak. Back in early 2020, Megan felt that her son was on the precipice of doing so. Now she isn’t sure he ever will. “The window is closing,” Megan said. It’s impossible to know how things would have turned out if his care had not been disrupted. Megan wishes she had never been put in a position to wonder.