Tag Archives: Children & Adolescents

Children & Adolescents

Seeing the whole gifted child

By Lindsey Phillips November 30, 2020

Assessing symptoms and determining a treatment plan for clients is never a simple or straightforward task. That can be especially true when it comes to working with gifted and twice-exceptional clients.

Imagine that a second-grader who is highly intelligent comes to your counseling office. The child has some intense interests, which is not uncommon with individuals who are gifted, and they struggle with emotion regulation, which appears to be related to the child’s perfectionism and low frustration tolerance. You might assume that this client’s struggles are just a natural consequence of being gifted.

Emily Kircher-Morris, a licensed professional counselor (LPC) at Unlimited Potential Counseling & Education Center in O’Fallon, Missouri, made this assumption. It wasn’t until her client entered the fourth grade that Kircher-Morris learned that giftedness alone couldn’t “explain away” the student’s emotional struggles. After experiencing a major event, the client’s problems increased to the point that Kircher-Morris referred him to a psychologist for a full differential diagnosis. Upon receiving the results, she was shocked to find out that her client was not only gifted but also autistic.

“I had fallen into the [common] beliefs about giftedness: That the [emotional struggles] were just sensory intensity or perfectionism,” says Kircher-Morris, an American Counseling Association member who specializes in gifted and high-ability individuals. “I missed how intense his meltdowns were and that his intense interests were related to autism, not giftedness.”

It’s true that individuals who are gifted may possess an intense interest, but they can communicate about other topics in addition to that passion, whereas someone with autism spectrum disorder can’t easily talk about other topics, Kircher-Morris explains.

To make an accurate assessment of a gifted client, professional clinical counselors must first know what “giftedness” even means. The problem is that the exact determinants and measurements for giftedness vary from state to state and even school to school. But according to the National Association for Gifted Children (NAGC), individuals deemed to be gifted or talented have the capability to perform at higher levels than their peers, and they require modifications to their educational experience to learn and to realize their potential.

Neither Kircher-Morris nor James Bishop, an LPC at Blank Slate Therapy in Frisco, Texas, distinguish between “gifted” and “high achieving” because they say some individuals need to be cognitively challenged regardless of whether they meet the formal definition of being gifted. And sometimes gifted individuals have learning disabilities or mental health issues that require them to get help — a concept that can be difficult for individuals who are used to having things come easily to them, Kircher-Morris points out.

(Mis)Identifying giftedness

There is also a substantial amount of anecdotal information, as well as misconceptions, about giftedness, and Bishop, executive director of the Passionate Mind Institute, warns that even mental health professionals can fall prey to pseudoscience on the topic. For example, some counselors too easily embrace overexcitability as a common characteristic of gifted individuals even though there isn’t much current research to support the belief, he says.

People may incorrectly assume that someone cannot be gifted if they are not doing well in school or that gifted individuals never need help, Bishop continues. Some also believe that individuals who are gifted are more prone to depression, but research shows they are as well-adjusted, if not more so, than their peers in the general population, he adds.

Such misconceptions, as well as concern about clinical misdiagnoses, led Bishop, a member of ACA, to conduct a study to test the ability of mental health professionals to recognize gifted characteristics in presenting clients using vignettes that illustrated common issues and characteristics related to giftedness. Half of the 330 participants were prompted that giftedness could be a factor, but regardless of that prompting, Bishop found the majority of participants still clung to the diagnosis of a disorder over an assessment of giftedness. (See “The potential of misdiagnosis of high IQ youth by practicing mental health professionals: A mixed methods study” in the journal High Ability Studies.)

Bishop’s study suggests that even mental health professionals, not just educators, have trouble factoring giftedness into their clinical assessments. “Being mindful and educating yourself on the real struggles that gifted [individuals] face can make you a better clinician in terms of assessing a gifted [client] and being able to determine whether their problems are the result of a disorder or are simply part of their gifted nature,” says Bishop, who chairs the NAGC Social and Emotional Development Network.

But finding training in this area can be challenging for counselors. Bishop says he had to get a doctorate in educational psychology to become formally educated in the subject. He isn’t aware of any counseling program that offers a concentration in giftedness.

The lack of adequate training is a problem because, according to Michelle Tolison, a licensed clinical mental health counselor in Charlotte, North Carolina, giftedness should be a specialty just like trauma. In fact, she believes that without being adequately trained, counselors can do extensive damage if they work with clients who are gifted.

Bishop, author of a forthcoming book on anxiety and giftedness for parents, recommends that counselors attend national and state gifted and talented conferences for opportunities “to dive into the subject, meet people in the field and get a sense of how they [as counselors] can play a role.” In addition to the resources provided by Supporting Emotional Needs of the Gifted (sengifted.org) and NAGC (nagc.org), Bishop and Tolison, owner and lead therapist at Dandelion Family Counseling, recommend reading Giftedness 101 (by Linda Kreger Silverman) and Misdiagnosis and Dual Diagnosis of Gifted Children and Adults (by James T. Webb et al.).

The gifted gap

Most gifted children are identified through testing or teacher referrals in elementary schools. The problem is that there is no one standard test used in schools to determine giftedness. On top of that, many school districts don’t test every student. Instead, they rely on teacher referrals, which, as Renae Mayes, an associate professor in the counseling program in the Department of Disability and Psychoeducational Studies at the University of Arizona, points out, introduces bias.

To highlight this potential bias, Mayes, an ACA member whose research focuses on gifted education and special education for students of color in urban environments, poses several insightful questions: How are teachers trained to recognize giftedness? How are they trained to recognize that giftedness exists in many different kinds of bodies? Will teachers see a Black student who can’t sit still in their seat and has lots of energy as someone who is gifted and excited about learning, or will they perceive the child negatively — as someone who has a behavioral problem or wants to disrupt the learning environment?

The sad reality is that the current method of identifying giftedness has led to an underrepresentation of individuals from marginalized backgrounds in gifted programs. Researchers at the Thomas B. Fordham Institute recently found that in schools that feature gifted programs, only three states enroll more than 10% of their Black and Hispanic students in such programs; in 22 states, that figure stands at less than 5%.

Black and Hispanic students are also overrepresented in special education, Mayes points out. When children are put in special education, it often becomes the only lens through which they are perceived, she says, and the likelihood of them also being identified as gifted dramatically decreases. As Mayes notes, these children tend to be viewed through a deficit perspective, which often incorporates stereotypical understandings of culture and disability rather than allowing children to be seen for their gifts and talents.

According to the article “Myths and research regarding the socio-emotional needs of the gifted,” published in the September issue of The Gifted Education Review (of which Bishop serves as co-editor), individuals from different cultures may not be as readily identified as gifted. Among the reasons highlighted in the article are because these individuals’ cultural norms differ from those of the prevalent culture (e.g., what might be viewed as positive assertiveness in one culture might be perceived as too aggressive in another) or because they are gifted in their first language, which differs from the English language programs in their schools.

“There’s a big push in gifted education to modify how we identify students and make it tied to what kids need academically,” says Kircher-Morris, the president and founder of the Gifted Support Network, a nonprofit dedicated to helping the families of gifted and high-ability learners. “And schools are getting better about identifying kids younger, and they’re doing more universal screening,” which helps remove issues of bias that can arise with teacher and parent referrals.

Twice-exceptionality

Gifted individuals may also have a special need or disability. According to NAGC, the term twice-exceptional (also known as “2e”) describes gifted children who have the potential for high achievement but also have one or more disabilities, including learning disabilities, speech and language disorders, emotional/behavioral disorders, physical disabilities, autism spectrum disorder or other impairments such as attention-deficit/hyperactivity disorder (ADHD).

“People don’t often think that individuals who are gifted can also have [a] disability,” Kircher-Morris says. “It’s kind of counterintuitive, so you end up with kids who are exceptionally cognitively able but perhaps they have ADHD or are autistic and they need a 504 plan or perhaps even an individualized education program.”

Kircher-Morris, chair-elect of the NAGC Social and Emotional Development Network, has noticed that sometimes teachers don’t feel as though they have to make accommodations in environments such as advanced placement classes. These teachers just expect that if a student is in such a class, they should be able to do the work. She often reminds educators that not taking a challenging course is not an accommodation. Twice-exceptional students still need to be challenged; they just need some help along the way.

It can be easy for counselors and other mental health professionals to miss a diagnosis of twice-exceptionality, says Kircher-Morris, who hosts the Mind Matters podcast, which focuses on the development of high-ability and twice-exceptional people across the life span. She is also the author of the forthcoming book Teaching Twice-Exceptional Learners in Today’s Classroom.

Kircher-Morris has had several clients get psychological evaluations and come back with a misdiagnosis. She recalls an example in which one of her elementary-age gifted clients was having meltdowns at school, becoming emotionally dysregulated and having trouble understanding nonverbal cues. Kircher-Morris knew the client was gifted, and she strongly suspected he was also autistic. The boy’s parents were reluctant to accept that label because of the stigma surrounding autism. It was easier for them to just say, “He’s quirky because he’s gifted.”

When Kircher-Morris finally convinced the parents to get a psychological assessment for their son, she wrote a letter to the person doing the assessment and told them the child was gifted to ensure that would be factored in. But the person doing the assessment did not specialize in giftedness and ended up diagnosing the child as depressed because sometimes when he had meltdowns, he would say, “I hate myself. I wish I could die.”

Kircher-Morris knew the client wasn’t clinically depressed. Instead, he was having big emotions and wasn’t sure how to talk about them, she says. She adds that one day of testing and questionnaires is not enough to fully understand and diagnosis a person.

Kircher-Morris still works with this student, and now that he is in high school, his autism is more pronounced. When his schedule shifted and he had to start showering in the mornings instead of the evenings, he didn’t handle it well at first. Kircher-Morris worked with him on regulating his emotions around this change. The student also has some issues with friends at school, but other people in his life often view him solely through a lens of giftedness and assume that he shouldn’t have any trouble communicating, Kircher-Morris says. They don’t realize that as a twice-exceptional adolescent, he sometimes does have certain challenges.

Trying to identify a client as twice-exceptional is even more difficult because of the concept of masking. As Tolison notes, gifted individuals with a learning disability can fall into one of three categories:

1) The individual’s advanced intellect compensates for their learning disability.

2) The learning disability or special need overshadows the person’s giftedness.

3) The giftedness and learning disability mask each other to the point that the individual appears to have average intelligence.

Research shows that twice-exceptional children are often diagnosed later than their peers because their struggles aren’t as noticeable initially, Kircher-Morris says. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders states that individuals with autism, for example, may be able to compensate for their comparative lack of social skills until social expectations exceed their abilities, she notes. A gifted child who is also autistic may not have a language delay when they are little, but by the time they get to middle school or high school, their emotional and social struggles and rigid thinking become more problematic.

“And we’ve now lost all of that time to be proactive and to support them and to help them build the skills they need to be successful, confident and happy,” Kircher-Morris adds.

To avoid mislabeling clients, Tolison, a registered play therapist who works with children who are twice-exceptional (particularly those with ADHD), advises counselors to always consider what the client’s behavior is communicating. Are they fidgeting in the classroom because they are understimulated, or is it a symptom of ADHD?

Therapists need to recognize “the blend of symptomology between gifted and diagnosis,” Tolison continues. For example, mental health professionals shouldn’t presume a client is autistic just because the client is smart and struggles to socialize with peers, she says. Instead, she advises digging deeper and considering whether the symptoms decrease or dissipate when the client is in an ideal setting, such as being around others who have interests similar to theirs.

Giftedness and special education are often seen as being opposite ends of the continuum, Mayes says, but she asserts they are separate continuums and can exist simultaneously. “The disability is the how you do something,” she explains. Even though an individual may need to do a task or skill differently or may need help, they can still possess a higher cognitive ability, notes Mayes, who has published several articles on this topic, including “College and career readiness groups for gifted Black high school students with disabilities” in The Journal for Specialists in Group Work.

Mayes recounts a real case example of how these continuums can overlap in a client: A Black student who was in a gifted program in middle school had an accident and suffered a traumatic brain injury. The injury caused the boy to get bad headaches if he sat for long periods of time, and his vision became blurry. But his cognitive ability was unchanged. He just needed some accommodations to help him at school. His teachers didn’t believe he was actually having headaches, however. They assumed he was just trying to get out of doing the work. The boy internalized their disbelief and told his mother the teachers were looking at him as if he were a “lazy Black kid,” a stereotype he knew was prevalent at the school. Soon thereafter, the boy’s grades started to suffer.

His mother became a big advocate for her son and pushed for a special education and gifted label for him. Even so, the school refused. It wasn’t until the boy entered high school and the school counselor joined the mother’s fight that they finally got some accommodations for the student. When the boy translated his talent for STEM (science, technology, engineering and math) into a passion for band, the band director also advocated for him.

This student had to reconfigure his identity as not just a gifted student but as a gifted student with a traumatic brain injury, and he had to learn to self-advocate, Mayes says.

Asynchronous development

Gifted children’s cognitive, emotional and physical development are often asynchronous, meaning that their intellectual development outpaces their maturity or emotional development. Even though their intellectual skills are advanced, their social and emotional skills may lag behind.

“Cognitive giftedness is not necessarily the same as emotional maturity,” Kircher-Morris says. Because gifted children are often highly verbal and speak as if they are mini-adults, people incorrectly assume that their behavioral and emotional regulation skills will also be advanced, she explains. So, counselors should consider clients’ emotional development along with their cognitive development.

According to Tolison, “There can be upward of a 12-year spread between a child’s intellectual age … [and] their social/emotional age.” For example, a twice-exceptional child with ADHD could be 8 biologically, but with the intellectual capabilities of a 12-year-old and the social and emotional development of a 6-year-old. And at times, the child might have emotional outbursts that are on par with a 4-year-old, Tolison adds.

Tolison often helps her clients first understand emotional language. She finds the “anger iceberg” exercise helpful for teaching emotion identification and awareness. Because some clients might be gifted in empathy, this process is less about identifying emotions and more about learning how to express them, she adds. Tolison then helps clients focus on executive functioning skills such as planning ahead, organizing one’s thoughts, flexible thinking and demonstrating self-control — all of which can be challenging for individuals who are twice-exceptional. She may play chess or Othello with clients to help them work on impulse control, for example.

Kircher-Morris engages clients’ higher-level cognitive skills by adjusting her counseling approach. This can be as simple as using a more advanced technique with a younger client (similar to grade skipping in school), or it may involve tailoring a technique to make it more analytical and creative.

The emotion wheel, which describes eight basic emotions and their varying degrees, is a great tool for helping clients identify and name their emotions, Kircher-Morris says. But this tool may not stimulate gifted clients enough to keep them engaged, so she alters it to make it more cognitively challenging. Her emotion wheel is mostly blank. She leaves a few emotion words in different places around the wheel and works with clients to fill in the blank spaces. Sometimes they look up words in the thesaurus or online to find the “just right” word, and then clients evaluate and determine which words should go on the wheel. This activity builds on the higher-level vocabulary that gifted clients often possess, and it provides them with some autonomy in session, she says.

Letting gifted clients direct (but not dictate) sessions

Kircher-Morris finds that gifted children are often unaware that anything is “wrong.” They can be skeptical of counseling at first, especially if their parents are the ones who initiated it. And because these children are gifted, she says, they often want to know the “why” before they completely trust and participate in different counseling approaches.

For that reason, Kircher-Morris encourages these clients to ask questions and takes time to explain the psychology behind the interventions. She also allows clients to explore what works best for them and to develop their own ideas about what would be helpful.

When Kircher-Morris introduces the cognitive triangle exercise (which emphasizes the relationship between one’s thoughts, feelings and behaviors), she moves beyond just drawing the diagram on a dry-erase board. She also poses a hypothetical example to help clients better understand the underlying principle behind the activity.

An example she often uses is a student who has an upcoming math test. She asks, “What uncomfortable emotions might they be experiencing?” After she and the client brainstorm some possible feelings, she asks, “If they’re experiencing those uncomfortable emotions, then what thoughts might they be having?” She draws speech bubbles on the board, and she and the client fill them in together.

Then they discuss how these thoughts might influence the hypothetical student’s behavior, where the student could intervene and how this would change the outcome. Running through this hypothetical allows clients to better understand the way the exercise works before they apply it to their own situations, Kircher-Morris says.

The fact that gifted individuals have higher-level thinking skills also means they are more likely to find fault in others’ logic, Kircher-Morris says. In fact, because these individuals are often brighter than their parents, teachers and others with whom they interact, counselors might find themselves trapped in a logical corner when a gifted client pokes holes in their reasoning. Should this happen, Kircher-Morris advises counselors not to engage in a power struggle.

“Don’t try to assert your intelligence or the information that you have because that’s going to damage the rapport,” Kircher-Morris says. Instead, her approach is to acknowledge the valid point the client has made. For example, she may say, “I hadn’t thought about it that way. I’ve seen this counseling technique work with other clients, but maybe it won’t work with you. Let’s figure out what will work. Do you think any part of that activity might be relevant for you?”

Tolison agrees that gifted clients benefit from being able to have some control over their therapy, but she cautions counselors not to let them dictate the direction of treatment. She says she often has parents who come to her because they previously worked with another therapist who allowed their gifted child to take control to the point that they weren’t making progress. 

Often, gifted clients are excited to engage in a topic they are passionate about, but that can dominate the session. However, as Tolison points out, counselors can turn that passion into a therapeutic intervention. She once had a client who wanted to talk about the dwarf planet Pluto for most of their sessions. She seized on that as an opportunity to teach the client about mindfulness and social awareness.

She used the phrase “I noticed” to stop him from discussing Pluto: “I noticed you’ve talked 20 minutes now on Pluto. I love that you are sharing your passion with me, but can we take a break because I’m a little exhausted from learning that information right now. Let’s talk about something new.” This statement set a limit for the client while also helping them become more mindful of the passage of time and of other people’s feelings, Tolison says.

Tolison also encourages clinicians to be humble when working with gifted clients. “Sometimes the most therapeutic thing you can do for a profoundly gifted kid is be excited about what they can teach you because in that [process], they are also learning,” she says.

Embracing neurodiversity

Kircher-Morris’ goal is to help normalize the fact that different types of brain wiring exist. People with this brain wiring might be divergent from the norm, but that doesn’t mean something is “wrong” with them. Being gifted or twice-exceptional is simply part of the human condition. Normalizing neurodiversity will encourage people to realize that they need help and give them the courage to ask for it, she says.

Counselors are great at understanding the individual needs of clients, she continues, but unless they consider all the factors, including a person’s cognitive ability, then they may misread the situation and the client’s true needs. For example, if a cognitively gifted child is having a hard time making friends, a counselor might focus simply on helping the child build social skills and self-confidence. But then the counselor would be missing the opportunity to consider other possible factors such as bullying, the child’s high stress levels, their feelings of isolation or others’ upward expectations of them — all of which could inhibit the child’s ability to form authentic relationships, Kircher-Morris explains.

So, she advises counselors working with this population to make sure they view their clients’ struggles through a lens of giftedness. How does giftedness or twice-exceptionality influence these clients’ experiences and reality? Clinicians must also figure out how to leverage clients’ strengths with their cognitive abilities to work through any issues they are having, Kircher-Morris says.

Mayes says counselors must be more holistic in understanding clients and see them as more than their struggles or even their giftedness. “We need to take a broader approach in our professional development,” she says, “so we can start understanding more fully individuals’ identities beyond giftedness to include culture, class, gender identity, affectional identities and so much more.”

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Techniques for helping children navigate anxiety related to COVID-19

By Celine Cluff and Victoria Kress September 29, 2020

Counselors are working hard to help children and families navigate the uncharted territories the COVID-19 pandemic has introduced. Many children, especially those who are already managing stressful situations, have experienced an uptick in anxiety this year due to the pandemic, the spotlight on racial injustices and ensuing conflicts, and the various related challenges 2020 has presented.

In this article, we discuss several strategies that counselors can use during these difficult times to help children manage their anxiety.

Clear communication

Children have many questions about the challenges we are currently facing. Adults should explain things to children in clear, concrete terms. For example, in trying to educate a 5-year-old on safety and the pandemic, it would be best to say something along these lines: “There is a virus that can make people sick, and we can catch it. It is important to wash your hands and to keep space between you and other people that is as long as your bed.”

Clear, open communication is key. Children are inquisitive by nature, and it is important to show them that an adult or caretaker is available for exchanges of information. Keeping that exchange simple and age appropriate will help set the child’s mind at ease without causing them unnecessary stress.

On the other hand, shutting down a child’s request for information (out of fear of upsetting them, for example) is not helpful to children. Having a dialogue with a child is always a good idea because it can alleviate some of the tension and turn it into an opportunity for connection and care.

Taming worry dragons

Jane Garland and Sandra Clark — creators of the Taming Worry Dragons: A Manual for Children, Parents and Other Coaches — provide one approach that can help children manage anxiety. A “worry dragon” is characterized by negative or unpleasant thoughts, scared feelings and worries that will not go away.

For some people, worry dragons show up only occasionally. For others, these creatures are constant companions. The dragons might even present themselves in a herd with some frequency.

It can be very tiring to spend so much energy worrying. Having worry dragons means that a person (or child) has a special talent, which is worrying all the time. These individuals are likely able to imagine the worst possible scenario for any situation and to see it in vivid color, with all the gory details.

Children can be taught that tame worry dragons do not scare people and, in fact, can even be useful. What follows are some tips and tricks on how to hone dragon-taming skills.

Scheduling

Children can learn to better manage anxiety through thought-stopping tools — such as dedicating time to worry. When children start worrying actively about topics such as death or the possibility of losing a caretaker or other loved one to COVID-19, this skill can prove useful. Note that this type of worrying typically starts around the ages of 4 or 5; this is when children become aware of mortality (nobody lives forever) and other realities. Mixing this realization with the active and vivid imagination of a child can lead to the creation of worry dragons.

Using an egg timer for “worry time” works well. If a child is repeatedly asking if they are going to be OK because they have been directly or indirectly exposed to news about the coronavirus, a parent or caretaker would get the timer and tell the child they can dedicate five minutes to worrying about the virus. Afterward, they are to leave worries about the virus behind and start doing something else. Because children like to know what happens next and respond well to routines, this technique can help them feel in better control of some of their unpleasant or unwanted emotions.

By using scheduling to integrate worrying into daily activities, the anxious child can take a proactive approach in taming their worries instead of the worries taking hold of the child’s mind at random times throughout the day (or night). 

Creative imagination

Another interactive way of helping children manage anxiety is to have them write or draw their worries on a piece of paper and toss them into a worry jar. By shrinking, harnessing, locking up or trapping worries in a small space such as a jar, the child can make the worries more approachable.

Another option is to buy some colorful miniature pompoms for the child, which they can then place into the jar. When the time comes to work with the jar (e.g., the child is worried about something in particular and cannot relax), the parent or caretaker would extend an invitation to the child to pick a color (or multiple colors) and talk about it as if it represented the worry they cannot let go. This approach helps distract the child (through the texture and visualization of the soft, fluffy, colorful pompoms) while still allowing them to process whatever is bothering them.

Creating a routine

Children thrive on routine, and they require scheduled downtime. Scheduling time to relax and recharge is vital to harmonious home life. A good place to start would be using some of the tools covered in this article in combination with giving the family time to connect, restore and feel love (preferably without the use of a tablet or other device).

The deepening of a connection to a loved one can be a reassuring experience when a child’s sense of safety has been compromised due to the unforeseen circumstances families find themselves in currently. The suggestions in this article were curated to help families navigate these challenging times together while equipping children with helpful tools to combat anxiety. These methods can be applied regardless of the source of anxiety because they are designed to increase the level of control in children who experience anxiety. Helping children hone these skills from an early age can equip them with valuable coping mechanisms to last a lifetime.

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Related reading, from Counseling Today columnist Cheryl Fisher: “The Counseling Connoisseur: How to talk to children about the coronavirus

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Celine Cluff is a registered clinical counselor practicing in Kelowna, British Columbia, Canada. She holds a master’s degree in psychoanalytic studies from Middlesex University in London and is currently completing her doctorate in occupational psychology. Her private practice focuses on family therapy, couples therapy and parenting challenges. Contact her at celine.cluff@yahoo.com.

Victoria Kress is a professor at Youngstown State University in Ohio. She is a licensed professional clinical counselor and supervisor, national certified counselor and certified clinical mental health counselor. She has published extensively on many topics related to counselor practice. Contact her at victoriaEkress@gmail.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Utilizing evidence-based practices in telehealth

By Krystal Vaughn, Kellie Giorgio Camelford and George W. Hebert August 23, 2020

The field of mental health is undergoing unprecedented challenges during the COVID-19 pandemic. Professional counselors who worked with children and adolescents before the pandemic have found that some traditional in-person techniques are not appropriate via virtual platforms.

These circumstances are requiring counselors to consider the selection of treatment approaches and interventions that are adaptable to or created for the provision of telemental health. Today, counselors must determine how to select and implement evidence-based practices (EBPs) when working with child and adolescent clients via telemental health during times of crisis.

History of EBPs

In 1996, David L. Sackett and colleagues stated that evidence-based medicine was “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Additionally, Leslie Greenberg and Frederick Newman recognized in 1996 that there were different types of study designs that lead to the evidence base, each suited to answer specific types of research questions. For example, according to a 2005 American Psychological Association task force, one may use any of the following to build evidence: clinical observation, qualitative, systematic case studies, single case design, ethnographic, process-outcome, random control trails or meta-analysis.

EBPs and the terminology associated with them have gained popularity over the past few decades in all health care fields. However, their exact origins are mixed. Parts of the nursing profession, for example, posit that EBP originated with Florence Nightingale, whereas the mental health field argues that Lightner Witmer used a similar approach with his creation of the first psychological clinic in 1896.

Regardless, the concept of EBP marked a paradigm shift among health care professionals to consider data-based research rather than relying on the opinions of authorities to guide clinical practice.

Evidence levels

The rigor, or degree, of scientific evidence is often presented in the form of an evidence pyramid analogous to Benjamin Bloom’s taxonomy of educational objectives.

This evidence pyramid traditionally moves from expert opinions at the base to case series/case reports to case control studies to randomized control trials to systematic reviews and, finally, to meta-analyses at the pinnacle.

 

Expert opinions

These sources of evidence range in forms from editorials to book chapters. They are good resources for an early understanding of clinical areas because they discuss definition, assessments and treatments. However, these sources lack statistical inferences to reach scientific conclusions.

An expert opinion might come in the form of a textbook chapter in which a person who is generally very knowledgeable in the field opines on the subject matter without referencing a specific compilations of facts. While expert opinions can be very informative and insightful, they should be regarded only as a minimal form of scientific evidence. Few of these expert opinions speak to our current predominant practice of telemental health.

Case series/case reports

These are descriptive studies that may be from a single clinical case or from a series of clients with similar presentations. While traditionally missing inferential statistics, single-case experimental designs will often be implemented. However, control groups or conditions are clearly lacking. Despite these limitations, case series/case reports are often heralded for illuminating novel concerns that generate additional research.

Classic examples of case studies in the mental health field seemed to begin with Anna O., who received psychoanalysis for what was termed “hysteria.” Sigmund Freud wrote about her case and how the “talking cure” led her symptoms to fade. Biopsychologists often cite the case of Phineas Gage, who demonstrated personality changes after a large iron rod was driven through his head in a railroad accident. Then there is the behaviorist report on Little Albert (by John Watson), in which fear was actually instilled into a baby through conditioning.

Case control studies

Case control studies are generally retrospective in nature and investigate the risk of exposure to an event with an eventual negative outcome — usually a disease or disorder. Comparison or control groups are then utilized with people who did not have the initial experience or the disease/disorder. However, these studies are able to declare only relationships, not cause-and-effect relationships. Despite this limitation, evidence for a cause and an effect begin with a correlation.

A typical case control study in the field of mental health might investigate the relationship between physical activity and depressive traits. To that end, the investigators would harvest information from a previously administered questionnaire to patients receiving services at a mental health facility. Additionally, these investigators would use a matched control group of participants without mental health concerns who also completed the questionnaire. Although a control group or comparison group is part of the study, it lacks the characteristic that makes it a true experiment: randomization.

Randomized controlled trials 

It has often been stated that randomization is what brings an investigation from quasi-experimental to truly experimental. Randomized controlled trials assign patients with similar presentations to either the treatment group or the control group based on chance alone. This allows for other mitigating factors to balance themselves between the groups and for the “treatment” itself to cause the scale to tilt. This strategy allows a treatment to be compared with no treatment, an alternative treatment or a waitlist controlled treatment.

A typical randomized controlled trial investigation for a new treatment for depression would involve randomly assigning half of the participants to the new treatment, while the remaining half would be assigned to an existing treatment. Then pretests and post-tests for each group would be compared to evaluate the efficacy of the new protocol.

Although regarded as the gold standard for clinical research trials, randomly assigning patients to treatments may not reflect the best ethical practice without consideration of other mitigating factors.

Systematic reviews 

Systematic reviews evaluate and synthesize the results of similar studies to reach a higher-order conclusion than could be achieved by any one study by itself. Usually, the authors will select a priori factors or themes for which the studies are to be rated. Then, all of the factors or themes are considered and tabulated to reach this conclusion.

Frequently, systematic reviews will limit themselves to only studies that used randomized controlled trials. This way, the results from the group of similar randomized controlled trials can be integrated for a truly convergent conclusion.

In building upon our previous examples of possible depression studies, a systematic review might be used to identify the best treatment protocol for adolescent depression that involves psychopharmacology, individual therapy or both. Additionally, the investigators might restrict the investigation to include only those studies that utilized random assignment. Then, rubrics might be created to gauge the treatments along themes such as symptom reduction, satisfaction of the approach and time commitments. Generally missing from typical systematic reviews is an objective measure that uniformly assesses the results from the different studies. 

Meta-analyses

Meta-analyses are often referenced as a type of systematic review meriting the gold standard of clinical knowledge. Meta-analyses, like all systematic reviews, evaluate similar studies along factors or themes that are selected a priori. However, these forms of evidence utilize a statistical procedure — effect size — to reduce sources of bias in the conclusions. This is the objective uniform measure that is lacking in systematic reviews.

Basically, effect sizes report the magnitude of progress from a treatment. It has often been stated that effect size actually indicates the importance of the results rather than the likelihood that the results are not due to chance, as is the case with statistical significance.

Increasing the rigor from our previous example of a systematic review to that of a meta-analysis would therefore involve utilizing effect sizes. Rather than building upon the a priori themes for comparison, this meta-analysis would compute the effect sizes from measures reported in each study. Then, from the selected studies, average effect sizes would be computed for each treatment protocol so that meaningful comparisons could be made and so that each protocol could be graded on its efficacy.

Beyond the evidence

While the concept of EBP originally relied on the practitioner to consider only data-based research rather than the opinions of authorities to guide clinical practice, the field of medicine built upon this to include other parameters. Specifically, this newer definition defines EBP as the integration of the best research evidence with clinical expertise and patient values. The expansion of this definition clearly illuminates the additional paradigm shifts that account for cultural sensitivity and patient involvement for treatment decisions, while acknowledging that there are advantages and disadvantages.

Advantages

EBP has advantages and disadvantages. The 2005 American Psychological Association Presidential Task Force on Evidenced Based Practice described EBP as the integration of science and practice. It acknowledged that much research is needed to determine that a treatment is effective. However, the research demonstrating a treatment protocol effective then needs to become a practice offered by clinicians who are treating patients in the field. So, one must consider both the efficacy and the clinical utility of the treatment.

The APA task force defined efficacy as the way in which we evaluate the protocol and examine how strong the evidence is within that evaluation. The clinical utility of the protocol must then explore if the treatment is generalizable and feasible and the cost benefit of the treatment. The marriage of research and practice leads to better clinical outcomes for clients.

EBPs offer clinicians and their clients information on the efficacy of a treatment. This research can inform the expected time frame and outcomes of a given treatment. It clearly demonstrates what the EBP will treat and the age groups for which evidence is provided. It is then up to the counselor to determine if the EBP is a good fit for the child and family. After all, most children do not present with the exact parameters as the control group in a research study. Nor does the current COVID-19 pandemic offer counselors traditional clinical sittings or historic data mirroring the current situation. 

Disadvantages

Not all individual differences can be accounted for in each EBP. For example, one should consider how development, gender, gender identity, culture, ethnicity, race, age, family context, religious beliefs and sexual orientation play a role in treatment. Clients should also have input into their treatment protocol and be afforded informed consent. This may lead to their desire or preference for one type of treatment over another.

As counselors, it is our duty to inform clients of the costs and benefits of treatment approaches but, ultimately, clients determine whether they will proceed with the EBP. During our current times, clients may agree with a treatment approach but have difficulty with technology or face other barriers that decrease their comfort with telemental health.

One example of considering fit for EBP is with cognitive behavior therapy (CBT). Pamela Hayes discussed the specific challenges between CBT and multicultural therapy. She acknowledged that CBT is evidence based for many disorders and populations, but it may have limitations when applied to some cultures.

Specifically, she named three major limitations:

1) CBT has strong assertiveness themes, overlooking cultures that favor subtle communication.

2) CBT has present focus, neglecting the past.

3) CBT cognitions are focused on individualism, with less regard for environmental interventions.

The last limitation may be especially problematic for individuals with physical disabilities, for whom the disregard of environmental barriers may be great. In response, Hayes recommended culturally responsive CBT modifications.

However, not all EBPs have recommendations on how to modify them to fit certain clients or populations with which the counselor may be working. Therefore, while a treatment may be proved effective for a particular age or disorder, it may be in contradiction to the client’s values. In addition, there may be other barriers to consider, such as technology, privacy or logistics, as is the case currently for many practitioners.

COVID-19 forced many counselors to examine their “practice as usual.” Many sought to gain certification in telemental health so that they could continue offering services to existing clients. This in many ways followed best practices and guidance from the 2014 ACA Code of Ethics, which prohibits abandonment of clients.

At the same time, this also forced clinicians to consider whether their treatment of choice was still possible via telemental health or whether another practice/protocol made more sense. For example, in the field of child and adolescent counseling, many play therapists examined the feasibility of child-centered play therapy (CCPT), which is an EBP, via telemental health. Dee Ray expressed the opinion that CCPT might not be the best treatment for telemental health but acknowledged that a similar theoretically oriented treatment involving the parents — filial therapy — could be amenable to telemental health.

Case study

Jane is a 7-year-old girl who experienced anxiety, reportedly resulting in behavioral outbursts and refusals to comply. Jane was seen by her counselor for approximately six sessions prior to the clinic’s closure due to COVID-19 and a statewide stay-at-home order. Jane’s counselor met state board requirements to provide telemental health services, but she could not conceptualize how to work with Jane using CCPT as she had prior to the stay-at-home order.

Jane’s counselor researched the EBP literature and identified other options for the treatment of childhood anxiety. However, the counselor found herself limited in her training, which restricted her ability to provide EBP services outside of her current scope of practice.

Jane’s counselor discussed the options, including a referral, with Jane’s parents in a scheduled telemental health parent consult. In the consult, the counselor discussed the benefits of filial therapy and the typical populations with which the modality is used in therapy. The counselor also explained that the parents would be more involved in session because filial therapy utilizes parents as change agents.

Jane’s counselor stated that this type of therapy would translate to telemental health in ways that CCPT would not. For example, CCPT relies on the therapist-child relationship to facilitate change. This may be difficult to achieve via telehealth because the therapist is not in the room. Filial therapy, on the other hand, relies more on the parents as change agents and may work well via telemental health because the parents are in the room with the child. In addition, they meet with the therapist via telemental health to learn the techniques to use with their child. Through the weekly telemental health sessions, parents are able to discuss challenges while receiving guidance and supervision, making this method more amenable to telehealth.

EBP databases and clearinghouses

Mental health practitioners can access several EBP databases and clearinghouses online, allowing them to consider different approaches to meet the individual needs of clients and cases. A wide range of techniques and programs is available, and through these clearinghouses, practitioners can make comparisons and learn about the reliability and evidence for the techniques and programs. We will highlight a few examples of databases and clearinghouses that we use within our practice when working with children and adolescents.

The seventh edition of the Collection of Evidence-Based Practices for Children and Adolescents With Mental Health Treatment Needs is an educational tool that specifically highlights available mental health treatments for nonclinicians. The guide breaks down treatments into what works, what seems to work, what does not work, and what has not been adequately tested. It highlights disorders such as adjustment disorder, autism, anxiety, depression and many more.

The Results First Clearinghouse Database is powerful because it combines available EBPs from nine national clearinghouses encompassing the categories of crime and delinquency, child and family well-being, education, employment and job training, mental health, public health, sexual behavior and teen pregnancy, and substance use. The programs can be broken down by category, setting, clearinghouse or rating. The rating scale breaks down programs based on highest rated, second-highest rated, mixed effects, no effects, negative effects and insufficient evidence. The following clearinghouses highlighted in this article are included in the Results First Clearinghouse.

Blueprints provides information on programs to promote healthy youth development and to decrease antisocial behaviors in children and adolescents. The database is geared toward youth, families and their communities, from prevention to intervention programs. The database breaks programs into three categories of research: model plus, model and promising.

The California Evidence-Based Clearinghouse for Child Welfare provides information and resources used by any professional who may work with children and families in the welfare system. The database breaks down treatments based on a scientific rating scale that includes well supported by research evidence, supported by research evidence, promising research evidence, evidence fails to demonstrate effect, concerning practice, and not able to be rated.

Social Programs That Work provides information on social policy programs. The goal is to enable policy officials and other readers to readily distinguish these programs from other available programs that do not have supportive evidence. The guide breaks down programs into top tier, near top tier and suggestive tier. Of particular interest to practitioners, it highlights some early childhood, parenting, substance abuse and suicide prevention programs.

The National Institute of Justice’s CrimeSolutions provides information on criminal justice, juvenile justice, and crime victim services outcomes to inform practitioners and policymakers about what works and what does not. The database breaks down programs and practice outcomes into effective, promising and no effects.

The Substance Abuse and Mental Health Services Administration Evidence-Based Practices Resource Center provides clinicians, community members and policymakers with resources and information on a variety of topics, including mental health services.

The U.S. Department of Health and Human Services Teen Pregnancy Prevention Evidence Review identifies programs with evidence of effectiveness in reducing teen pregnancy, sexually transmitted infections and associated sexual risk behaviors. The database breaks down studies based on a quality rating of high, moderate, low or not applicable.

 

Additional resources

  • For practitioners hoping to learn more about the EBP process, Evidence-Based Behavioral Practice is a useful online training resource.
  • “Evidence-based practice in social work: A contemporary perspective” by James W. Drisko and Melissa D. Grady, Journal of Clinical Social Work
  • “Evidence-based practice in psychology” by the American Psychological Association Presidential Task Force on Evidence-Based Practice, American Psychologist
  • “Clinical expertise in the era of evidence-based medicine and patient choice” by R. Brian Haynes, P.J. Devereaux and Gordon H. Guyatt, BMJ Evidence-Based Medicine
  • Evidence-based practice for the National Association of Social Workers
  • “Evidence-based practice: A common definition matters” by Danielle E. Parrish, Journal of Social Work Education.

 

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Krystal Vaughn is a licensed professional counselor supervisor specializing in children ages 2-12. As an associate professor at Louisiana State University Health Sciences Center-New Orleans, she enjoys both teaching and providing clinical services. Her research interests include autism, supervision, play therapy and parent consultation. Contact her at kvaugh@lsuhsc.edu.

Kellie Giorgio Camelford is a licensed professional counselor supervisor specializing in parenting, women’s issues, children and adolescents. She has received specialized training in the fields of play therapy, school counseling, parenting and perinatal mood disorders. As an assistant professor at Louisiana State University Health Sciences Center-New Orleans, she enjoys teaching and supervising students, as well as providing clinical and community services. Her research interests include ethical issues in counseling and supervision. Prior to teaching, she was a professional school counselor at a local parochial high school in New Orleans, and a private practitioner.

George W. Hebert is a faculty member in both the Department of Clinical Rehabilitation and Counseling and in the Master of Physician Assistant Studies Program at the Louisiana State University Health Sciences Center-New Orleans. He is a licensed psychologist and holds certificates as a school psychologist and supervisor of school psychological services. He specializes in the assessment and treatment of learning and behavior problems for school-age children and their families, and supervises interns and practicum students in the university-based Child and Family Counseling Clinic.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Supporting families with engagement strategies during COVID-19

By Carson Eckard June 18, 2020

To combat the toxic stress caused by the COVID-19 pandemic, I have created a list of activities to positively engage children during this time. The following list includes a description of what each activity is, what materials are needed (with an understanding that many families are under financial hardship) and the possible psychological benefits of the activity.

These activities are designed for entire families, including adults, to reduce stress and promote healing during the pandemic. Most of these activities can be done either inside or outside and can be tailored to individual interests, ages and ability levels.

 

Obstacle course

This activity will get the whole family moving. Use objects around the house to get the family involved. This could include climbing under or over chairs, throwing a bundle of socks into a laundry basket, spinning, using paper strips in place of lasers, and so on.

Inside, a slower pace can be taken to ensure that nothing gets broken and no one gets hurt. If you have access to an outdoor space or a sidewalk in front of your home, you can create an obstacle course out of chalk. Here’s an example.

This website includes a list of materials to use.

This slideshow has ideas for children in wheelchairs.

Materials: Whatever you have in the house

Ages: Toddlers and early elementary-age children

Psychological benefit: Obstacle courses can target many aspects of a child’s brain, including sensory input, motor planning, coordination, sequencing and problem-solving. They can also reduce psychological stress and anxiety. When more people participate, the teamwork and competition can provide some of the social interaction children have been missing from environments such as school.

 

Broadway play

This activity allows children to engage in imaginary play by creating plots to their own stories. When the story is written, have the child cast the characters in the story, find props (or imagine them) and direct the scene. If there aren’t enough family members to act out the scene, consider playing multiple parts at once or having the child draw the characters instead. Children may need direction and prompting, but allow them to be in control of constructing their own narrative. Activities that could be added include constructing sets and props and making movie posters.

Materials: Whatever you have in the house — paper, markers, drawing materials, prop-making materials and so on

Ages: Toddlers through early middle school age

Psychological benefit: During the pandemic, children may be struggling with an inability to control the situation. When they are able to control a scene and story in a healthy way, it can reduce their stress and promote individuality and resilience. Furthermore, creativity reduces anxiety and depression and can help children process toxic stress.

 

Board games and card games

When everyone is stuck at home, board games and card games are a great option for helping the entire family to connect. For younger kids, games such as Go Fish, Candy Land, and Guess Who? could be hits, whereas older kids may like Monopoly, Clue, and Sorry!

If you don’t have any board games at home, use paper or cardboard to create your own. WikiHow has information on steps to take when you’d like to create your own board game. Make sure your child is part of the creative process of creating the game if you choose to make your own.

For more information on why board games are good for a child’s mental health, as well as a breakdown of age-appropriate games, check this link from Manhattan Psychology Group.

Materials: Cardboard, paper, markers, small toys, etc.

Ages: Any

Psychological benefit: Playing fun games decreases anxiety and can increase confidence in children. Some games include aspects of problem-solving and can access the cortex for children who feel safe. Board games allow for healthy cognitive and social development for children.

Mazes and finger labyrinths

Mazes and finger labyrinths are easily made at home. They are a great brain teaser for kids and can also be extremely relaxing. Finger labyrinths are just like mazes, but instead of drawing a line to the exit, a finger is used to follow the path. When paired with deep breathing exercises, this can have a meditative quality.

For help on constructing labyrinths made out of materials such as rice, play dough, paperclips and more, go to this website.

The Labyrinth Society offers an online resource for downloadable and printable finger labyrinths.

The All Kids Network has many printable mazes for kids.

Materials: Paper, printer, something to write with

Ages: Whereas mazes are most engaging for children ages 3-6, finger labyrinths are a good mindfulness activity for children of all ages

Psychological benefit: Mazes offer many benefits to a child’s development, including problem-solving and motor control. Children will need patience and persistence to complete the puzzle and, once done, may experience a boost of confidence. Finger labyrinths originated in prayer but are also used as a grounding exercise.

 

Dance party

Turn up your favorite songs and get moving. Be sure to build a playlist the entire family can move to. Only upbeat jams! Spotify is a free service you can use to build playlists if you establish an account. Spotify playlists that might make for super fun dance parties can be found here. You may need to look around to find a playlist without explicit lyrics, but Spotify does offer an explicit content filter in its settings. Other free services include Amazon Music, Pandora, iHeartRadio and YouTube, but most have ads and can incorporate explicit lyrics, so be careful.

Materials: A phone, laptop, tablet or any device that plays music

Ages: Any

Psychological benefit: Dancing is both great exercise and a form of creative expression. Dancing keeps your heart healthy and muscles strong, improves coordination and balance, and provides an outlet for emotions. Music activates the cerebellum, stimulates the release of hormones that reduce stress, and improves self-esteem.

 

Karaoke party

On a similar note to a dance party, a karaoke party could be another viable option for the family. Because you want family members to sing, I recommend using YouTube and allowing each person to pick a song of their choice, unless you have a premium subscription for a music streaming service. As a finale, try singing a few songs that everyone knows together. For an added bonus, try creating a song by making your own lyrics and finding objects around the house to use as instruments.

Materials: A phone, laptop, tablet or any device that plays music; maybe a prop to use as a “microphone”

Ages: Any

Psychological benefit: Singing releases hormones that reduce stress and make us feel happy, improves mental alertness and helps us control our breath flow, which can help us regulate. Singing also helps children’s communication skills and self-esteem. Studies show that singing stimulates the vagus nerve responsible for our senses, motor function, digestion, respiration and heart rate. When stimulated, the vagus nerve reduces stress, lowers the heart rate and blood pressure, and reduces inflammation.

 

Play teacher

Let your child become the expert and pretend to be a teacher of whatever they are passionate about. This can take a more “formal” approach by pretending to be in school, or it can be more informal, simply asking them questions about the things they are interested in. This helps children realize that adults don’t know everything and allows them to develop as individuals.

Materials: None

Ages: Elementary school age (Note: It is beneficial and important to ask children of any age what their interests are to strengthen your relationship with them)

Psychological benefit: Taking on a formal “school” scenario involves imaginative play. Imaginative play allows children to experiment with different interests and skills. Furthermore, children who engage in pretend play are understanding social relationships, expressing and understanding emotions, expressing themselves both verbally and nonverbally, and practicing problem-solving skills. If imaginative play isn’t your cup of tea, have conversations with your child about what they are passionate about or interested in. Having these kinds of conversations will help you and your child relate to each other more.

 

Yoga

Although it may be difficult to practice advanced yoga poses with younger kids, it is possible to find something appropriate for their level. One of the most important aspects of yoga is breathing. Try doing the yoga poses with your child. Model a positive attitude and a willingness to try new poses, and compliment the child when poses are attempted. Make sure the poses are not too advanced for children or they may become frustrated.

Here is a free YouTube video of yoga poses that you can do with children. If you do not have access to a video device or the child would not benefit from structured instructions found in a video, you can find printable yoga poses from Kids Yoga Stories. If you and the child are new to yoga, it is vitally important to follow a guide to ensure that you are not hurting yourself or the child.

Materials: A guide to follow (either pictures or a video)

Ages: Any

Psychological benefit: It is no secret that yoga has therapeutic qualities such as offering a sense of calmness and relaxation. Furthermore, yoga enhances children’s flexibility, strength, coordination and body awareness. Doing yoga can reduce muscle tension held in our bodies and is another activity that stimulates the vagus nerve, which reduces stress, lowers the heart rate and blood pressure, and reduces inflammation.

 

Indoor sports

This category can depend on whether there is space to move around and interact with each other, but there are options for small spaces too. Each activity is meant to allow children to have fun and can be created with multiple objects around the house.

The Fatherly website has many ideas, such as balloon tennis, for bigger spaces. Roll up some paper and make a ball or a puck to kick, throw or hit around the house. Use a balloon to play volleyball or keep-up. If you have a smaller space, perhaps finger football might suit your needs.

Materials: Anything you can find around the house

Ages: Early elementary to early middle school age

Psychological benefit: If your family doesn’t have much space to run around and play, even the simplest games such as finger football increase coordination. In addition, these sports need multiple participants, which assists in the social development of the child.

 

Video games

Many video games are not family friendly or age appropriate for children. However, many options are available for younger kids both online and offline. PBS Kids offers many educational games for young children. Older kids may benefit from playing games online with their friends. Among popular options are Fortnite, Roblox, Minecraft, League of Legends and titles usually found on consoles, such as NBA 2K and Call of Duty. Many of these games are not free (some can be very expensive), and many are not appropriate for all kids. Have a conversation with the children in your life about what their friends are playing, and then set healthy boundaries around screen time.

There are also online video games that you can play with your family and friends. Popular options include Kahoot!, Jackbox Party Pack, digital board games through apps, Mario Kart Tour and others. Many of these games require only your phone or another device with internet access.

Materials: Games to play and something to play on

Ages: Any (as long as you monitor what games they are playing)

Psychological benefit: Your child is likely missing their friends from school and other environments. Allowing children to play video games with their friends online can help them stay connected and have fun. With all ages, video games offer an outlet for motor development, the release of stress relief hormones, social interaction, problem-solving, development of leadership skills, and increased alertness.

 

Call-and-response songs

If you’ve ever been to summer camp, call-and-response songs will be familiar to you. These songs are started by one person and imitated by another person or group. For children, particularly children with special needs, transitions between activities may be challenging. Side note: I worked at a summer camp with children with autism spectrum disorder, and mealtimes were one of the most stressful parts of the day for them. Singing a simple song such as “We put our foot up on the tree, we put our foot up on the tree, we put our feet up on the tree so that we can eat” makes these times less stressful for all.

Performing a quick redirect activity such as a call-and-response song can lighten the mood and offers a fun incentive for completing an activity. Although there are already call-and-response songs that you can utilize, you can also make your own (or change the words to an existing song) to suit the child’s needs. This activity could also be paired with dance moves or even a camp-themed day.

Go to Ultimate Camp Resource for a list of call-and-response songs. Design Improvised has a great list of themed summer camp ideas to use if you’d like to host a camp-themed day at home.

Materials: None

Ages: Toddler through elementary school age

Psychological benefit: Singing has profound mental health benefits. Singing forces a person to control their breathing. If someone is anxious and having trouble regulating their breathing, singing can help. Singing also improves mental alertness and confidence.

 

Grounding activities

The purpose of a grounding activity is to refocus on reality. It is particularly effective for children who suffer from anxiety, high levels of stress, trauma, dissociation, self-harm tendencies and suicidal thoughts. When children experience these events, they are more likely to enter a state of fight, flight or freeze because they feel they are in danger. Grounding techniques help move the brain from survival mechanisms to a calm state.

Although grounding activities are used in circumstances of higher emotion, they should be practiced often (and even when children are feeling happy) to ensure that children can perform them while in a dysregulated state of mind. You should take time out of the day for all family members to practice these skills together.

Sound search: Sit calmly in a comfortable position. The person lists the sounds they hear. Focusing on other senses helps bring the child back to safety and stabilization.

Coloring break: Although this is most effective for younger kids, it can be used for any age. Even if you do not have coloring pages, encourage the child to draw or color on a piece of paper. Support whatever they need to create in the moment. Crayola has printable coloring pages both for kids and adults.

Sensory bin: A sensory bin is a container filled with materials to stimulate the senses. You must know what types of sensations the child feels are soothing and what sensations may make the child excited. When used with soothing objects such as water or sand, a child may be able to focus on the container instead of overwhelming thoughts. The good thing about sensory bins is that they are easy to make and easy to store when needed. This technique is used mainly with younger kids, but a child of any age may appreciate a sensory bin if it is filled with the appropriate objects. Go to Your Kids Table for a list of ideas on what to put inside a sensory bin.

Positive affirmations: Building a mantra, based on a child’s strengths, that the child can repeat when they are feeling overwhelmed may be beneficial. The idea of having a child repeat a positive mantra when overwhelmed is to help the brain focus not only on the words they are saying but also on the breath needed to form the words. Whenever a family member or friends see the child becoming overwhelmed, they can support the child by guiding the child through the mantra.

Breathing techniques: You can teach children to utilize many different breathing techniques. Breathing exercises calm the brain’s reactions to threats by getting more oxygen. The adult should make sure the child has no anxiety about breath retention and that the child is slow and intentional instead of hyperventilating. If the child is hyperventilating, try to get them to exhale longer than they inhale. Model the techniques for them. Repeat the technique for as long as it takes the child to calm down. Breathing techniques take many forms, such as:

  • Sniff the Flower, Blow Out the Candle: The child imagines holding a flower in one hand and a candle in the other. The child must focus on breathing in through their nose while bringing the “flower” to their face, as if sniffing it, and then exhaling out the mouth while bringing the “candle” to their face.
  • 4-7-8 breathing: The child should breathe in through the nose for 4 seconds, hold their breath for 7 seconds, and exhale out their mouth for 8 seconds.
  • One-nostril breath: The child should place their finger over one nostril and breathe in deeply. The child should then switch to the other nostril and breathe out.

 

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Carson Eckard is a rising second-year graduate student in the community and trauma counseling program at Thomas Jefferson University. He graduated with his B.S. in psychology from Thomas Jefferson University in December 2019. He is passionate about advocating for clients, particularly LGBTQ+ youth. Contact him at Carson.Eckard@jefferson.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

School vaping cultures: Acknowledging the impact of COVID-19

By Zachary Short and Nicole Baliszewski June 4, 2020

This past January, global tobacco conglomerate Altria saw a major drop in its stock value on the New York Stock Exchange, depreciating at a value of almost 40% versus its record-breaking highs in 2017. What caused this sudden dip in one of the biggest-rebounding industries of the 21st century? It would be fair to suggest that the COVID-19 pandemic has caused some major complications for both the traditional and electronic cigarette corporations located across the United States.

As a respiratory-based infectious disease, COVID-19 poses an unparalleled threat to the health and safety of individuals across the age spectrum with significant histories of vaping or smoking. In fact, a recent study in the New England Journal of Medicine found that Chinese patients with a history of smoking were twice as likely to suffer from severe infections associated with diseases such as COVID-19 in comparison with those without any smoking history.

Having always opposed the youth vaping/smoking culture, counselors and community advocates across the nation are currently working to answer a significant question: What actions can we be taking to protect our communities from the combined threat of COVID-19 and recent vaping trends?

The truth is, now is the prime time for considering how we can influence our communities to create better post-quarantine schools for our students.

The loss and revitalization of the smoking industry

Only five years ago, health specialists with the Truth Initiative anti-smoking campaign speculated that the tobacco industry and most of the nation’s smoking addictions would expire with the Generation Z demographic. But vaping, the process of inhaling prepackaged aerosols (also known as vapor), has led to the resurgence of nicotine products within school systems.

Through a combination of peer pressure and social media campaigns, students from all backgrounds have found themselves under the influence of Altria’s newest partner, Juul Labs, maker of the Juul electronic cigarette. Largely as the result of the popularization of this flavored electronic smoking device, the number of high school students who use nicotine products has increased from 3.6 million to 5.4 million in the span of only one year, according to the Centers for Disease Control and Prevention (CDC).

How significant it would be to know that schools were free of the harmful aftereffects of adolescent smoking, leaving school counselors and clinicians available to attend to the important mental health developments that are so essential in our school systems right now. Instead, we find ourselves dealing with another truly concerning issue: According to the Truth Initiative, 1 in every 4 high school students now uses e-cigarettes.

These concerning statistics represent a call for preventative action in middle schools across the nation. A number of schools and organizations have taken such counteractions to trends in vaping by launching interventions such as confiscation, disciplinary action, and even educational programming. But the culture of vaping continues to persist as a significant concern for parents and educators.

The most terrifying thing about the Juul product so far is that it appears to come off as being innocuous to many people. Most students and parents recognize it as the small USB-shaped device that produces fruit-flavored smoke. Very few seem to grasp the long-term consequences of vaping habits. That being said, those consequences might already be here.

The individuals at risk

Based on data collected by the CDC in early March, evidence suggests that COVID-19 poses a serious threat to all individuals ages 65 and older. Fortunately for students under the age of 18, the percentage of those infected and harmed has been relatively low by comparison.

While most parents find some comfort in hearing that the student demographic is the least impacted by the pandemic, the statistics can change drastically if students are part of the vaping culture that is rampant among youth. According to data provided by the CDC for China’s mainland population facing COVID-19, individuals with respiratory issues predominantly associated with even a small history of smoking or vaping have a 6.3% case fatality rate, in contrast to 2.3% overall. Recognizing how exposure to vaping increases a person’s health concerns, imagine the increased risks that our students could face should their still-developing physiques come in contact with both nicotine products and a respiratory infection.

“What they say is about 80% of people feel the flu, but they will be OK. Where we are getting into trouble is that it can lead to severe pulmonary distress,” says Anna Song, an associate professor of health psychology and leader of the Health Behaviors Research Lab at the University of California Merced. “Smoking is a risk factor for having this disease progress, be incredibly severe, and lead to mortality.”

As we know, COVID-19 has posed widespread challenges to the health and lifestyles of the global population. Societal and educational norms have begun to deteriorate, and everyday tasks and responsibilities now come with an unprecedented health risk to individuals and their families. Of great concern to us is that the unattended trends and cultures of our school systems could be having a negative impact on our students right now. To allow these trends to persist beyond this pandemic is to continue putting our students at risk unnecessarily.

A unique opportunity for change

What makes now such an ideal time to invest in removing the harmful vape cultures that continue to linger in our school systems? Students are largely being required to undertake remote learning during this time, and that may continue for many students even as a new school year begins. The changes and circumstances that come with students’ remote learning actually promote our greatest opportunity for the development of an anti-smoking culture.

Society is recognizing that our plans, policies and preparation were inadequate to succeed in the face of an unanticipated global pandemic. Thus, things are beginning to change. Legislation is developing to create preventative actions around practices deemed unhealthy by medical specialists, and educational policy is constantly being reformed to reflect the needs and issues present in our impromptu teaching conditions. If there was ever a time to acknowledge the statistics that point to the harm that nicotine products pose to our adolescents and to advocate for the safety of our children, it is now.

Large systemic changes are challenging and often are out of our hands, but educators and parents currently have the opportunity to make a notable difference in students’ environments. During this time of partial quarantine, most families are now all in one location — the home. Our students currently find themselves in a setting where they are under the watchful eyes of their families and where smoking purchases and practices are essentially impossible.

In addition to that, they are also in a potential learning atmosphere. Through the joint efforts of educators and parents, our youth can be exposed to real educational and intimate conversations regarding the dangerous practices of smoking. These conversations can mean the world to students who currently feel that their futures and health might be dictated by vaping culture.

COVID-19 has had a harsh and unpredictable influence on our way of life, but it also presents us with a rare opportunity to support our students through one of the greatest health issues of their generation. So, making use of the present, it is time that we as a supportive community of counselors consider what we should be doing to help facilitate and emphasize this process of growth for students’ mental and physical health.

Our responsibility to intervene

As of early April, individuals within Rowan University’s Department of Psychology have been conducting their own research to confront the vaping culture that remains prevalent during the COVID-19 pandemic. Their research takes an interesting approach to behavioral analysis with younger age groups, including the development of interesting activities such as mobile- and video game-based interventions that promote smoking abstinence.

Fortunately, this is just the tip of the iceberg when it comes to the collective efforts of universities to combat vaping trends in student populations. Even educational institutions outside of higher education are recognizing the statistically supported danger that vaping is putting our students in when facing the current health pandemic. As a community, it is our collaborative responsibility to provide education and to take the necessary precautions to protect our students’ health. We are just beginning to understand the proper steps to take when working from a remote distance.

Educating the community: Providing knowledge of the increased risks and hazards of smoking behaviors is the first step to reducing nicotine consumption within our school systems. Given the myriad resources available on the consequences of vaping from the CDC, the National Institute on Drug Abuse and even university websites such as Johns Hopkins Medicine, it is the obligation of school counselors and other school personnel to appropriately share this information with our local communities. It is important to remember that this information needs to be given not only to the students we support, but also to our educational partners and to the families who are acting as our immediate support systems in homes at this time.

Promoting real conversations: With the knowledge and statistics being supplied to our students’ homes, it is more important now than ever that school systems promote real conversations with students regarding the present vaping cultures. Whether it is school counselor-to-student or parent-to-student conversations, we need to understand what the student perspectives are when they see products such as Juul in the media while also witnessing terrifying statistics regarding the spread of a global virus.

With those who are currently smoking, it is vital that we understand their concerns and interests so that we can provide them the appropriate support they need. These conversations are the optimal opportunity to promote and communicate resiliency, empathy and community support to our students. And with those who have never touched a vaping device, communicating this information and the associated risks is the best possible preventative action at this time.

Advocating for policies: To reiterate, now is a turbulent time when leaders are reflecting on educational preparations and policy and how they might be applied for future incidents. In addition to redesigning our school’s remote learning policies, we need to be working as a professional community to advocate for anti-vaping policies within our schools. It is essential that school counselors reflect on school policies regarding smoking tolerance, as well as preventative actions to take, so that they can create real opportunities to support student health.

Fortunately, states and health institutions are rallying to create a number of anti-vaping models that can be implemented or referenced by school counselors looking to better their schools. One such model is the Make Smoking History campaign, conducted by the Massachusetts Department of Public Health, to reduce the percentage of vaping disciplinary actions taken in middle school settings. This is the time to ask for and support the voices of the education community to find out what should be done for the development of our educational systems — not just on a school-by-school basis, but from a legislative perspective.

Forming support groups: Finally, acknowledging that this is a difficult time for individuals who have a dependency on smoking tools to which they no longer have easy access, we need to prepare and create remote counseling groups to support them through potential issues such as withdrawal or rehabilitation. A number of counselors may struggle with the concept of remote group counseling, but these students still need emotional and mental health support to cope with their new distancing from vaping. Counselors should utilize the medical resources and personnel within their school districts to support students in their transition to healthier living. Ultimately, it is groups such as these that we should be planning to implement more frequently in our later return to school.

The truth is that in the midst of a global health crisis, most individuals view the issue of vaping in school systems as relatively small. But the fact is that vaping is a real health issue for our youth, and in combination with the threat of COVID-19, it puts our newest generation of students at exceptional risk for loss. In a moment in history when many counselors are at home and wondering what they should be doing to support their students, imagine what significant change could occur if we all directed a portion of our efforts to acknowledging and countering the present vaping culture.

 

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Related reading, from the Counseling Today archives: “Pushing through the vape cloud

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Zachary Short is a master’s counseling in educational settings student at Rowan University. He currently works as a clinical research intern in a high school setting, where his research in student behavioral outcomes is being supported through the Mental Health Grant Demonstration Program. Contact him through LinkedIn: linkedin.com/in/shortzachary/.

Nicole Baliszewski is a master’s counseling in educational settings student at Rowan University. She currently works as a clinical intern in a middle school setting, where she seeks to provide trauma and mental health support to the special education student population. Contact her through LinkedIn: linkedin.com/in/nbaliszewski/.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.