Long Covid is a physical condition which can affect any part of the body, and can cause different symptoms at different times with varying degrees of severity for each individual child and young person. We don't know yet how many children will develop long COVID but we do know that the number of children with long COVID is currently increasing. Prevalence figures vary depending on the study and the research methods employed, but according to the Office of National Statistics (ONS) there are currently 119 000 children and young people living with long COVID; 21 000 of whom are still experiencing symptoms 12 months after their initial infection (ONS, 2022).
The ONS COVID-19 Schools Infection Survey (February 2022) found that since March 2020, 1.0% of primary school-aged pupils and 2.7% of secondary school-aged pupils met the criteria for having experienced long COVID affecting daily life for 12 weeks or more.
There is not a one-size-fits-all approach to supporting children and young people in the classroom, but the following needs and strategies may help guide teachers.
Initially after a Covid-19 infection, some children may be too unwell to attend school. The strategies below are for when a child is well enough to be able to begin attending school again.
As they return, please also refer to ‘A Cautious Tortoise’ and ‘The Pacing Penguins’ guidelines (see Further information).
Communication and interaction
School staff might see a reduced ability to find words or express themselves when feeling fatigued or anxious, or if they do not understand a task, as well as a reduced ability to understand and remember verbal information or instructions.
The following strategies can help:
- Using a ‘secret signal’ which only the children and young people and their teacher(s) are aware of, that can be used to communicate when they feel anxious, fatigued or need help or a break
- Breaking instructions down into smaller chunks, repeating instructions, checking with the children and young people that they have understood. Asking them to repeat or run through what they have to do and providing a visual breakdown/reminder of steps to complete.
- Using simplified language, shorter sentences and visual supports and prompts to reinforce verbally presented information.
‘We don't know yet how many children will develop long COVID but we do know that the number of children with long COVID is currently increasing.’
Cognition and learning
Fatigue
Fatigue and tiredness can be debilitating. Just attending school can use up a huge amount of energy. Add in the energy required to get to school in the first place, then moving around school, then add in the cognitive effort needed for thinking, remembering, learning, talking and socialising.
- Rest breaks during tasks, lessons or exams
- Providing a quiet place to rest during breaks or lunchtimes
- Using an exit card to leave the classroom without question when needed
- A card or signal that they can use to ask for help or to show that they do not understand or need a break
- Extra time for tasks or exams
- Flexibility regarding homework or exams
- Reduced attendance or reduced timetables
- Opportunities to learn from home or online when being physically ‘in school’ is too difficult
- Increased differentiation or non-attendance during PE lessons. Liaising with school nurses or other health professionals as needed.
Concentration and memory
Long COVID can cause brain fog, headaches and daily fevers leading to difficulties with concentration, thinking and memory. The following strategies can help:
- Short tasks broken down into small steps and chunked up into sections that can be worked through in a logical order and can be ticked off
- Simplified task prompt sheets that are reinforced with visual prompts
- Clear instructions and support to start a task
- Clear task expectations
- A clear end point for each task (with clarity on what the finished task will look like or a specified end time)
- Visual prompts, structures, checklists, timetables or reminders
- Practical activities, physical objects and opportunities for experiential learning to make tasks as concrete as possible
- Mind maps or flow diagrams to record ideas visually
- Increased differentiation of tasks
- Rest or brain breaks
- Reducing distractions in the environment to facilitate concentration, (e.g. sitting nearer to the teacher or away from windows or doors)
- Opportunities for pre-teaching, repetition, reinforcement and overlearning to support retention of knowledge and generalisation of skills
- Banks of keywords, especially for topic work or specific subject vocabulary
- Reducing the amount of reading required to obtain information. Using alternatives such as pictures, cartoons and video, paired reading with a work ‘buddy’, taping recordings of source material, simplified texts, diagrams, flow charts, etc.
- Reducing the required amount of writing or copying from the whiteboard. Using alternatives such as a laptop, note taking, mind mapping, etc.
Gaps in learning
Children and young people with long COVID may also experience gaps in learning due to reduced attendance or regression in skills. Careful monitoring of progress, highlighting gaps in learning and planning individualised support to fill these can help. Continued contact with parents/carers to keep them up to date is also important.
Social, emotional and mental health
Anxiety
The duration and severity of difficulties, a lack of understanding, unknown timescales for recovery, missed school or missed opportunities to socialise can cause anxiety. Schools can help by:
- Ensuring access to a key worker to build a relationship with, to talk to and who will listen, such as an emotional literacy support assistant (ELSA), learning mentor, thrive practitioner, education mental health practitioner (EMHP) or equivalent
- Offering support to work on recognising, naming and expressing feelings and support to cope with strong feelings and to communicate how they are feeling about their situation
- Providing emotional literacy resources such as use of role play/mirror games, videos, songs, emotion cards, games, stories and puppets
- Offering wellbeing check-ins
- Social stories or therapeutic stories
- Putting in place evidence-based anxiety interventions
- The use of cognitive behaviour therapy (CBT) informed approaches to understand the link between thoughts, feelings and actions. Diaries, feelings diaries or rating scales can help the children and young people to express their feelings and to link thoughts and feelings to behaviours.
- Opportunities to express themselves and their feelings through art, drama, dance, sport, etc.
- Relaxation, mindfulness, calming activities and breathing exercises.
- Providing a nurturing learning environment with staff members who understand the children and young people's needs will enable them to feel safe and secure and well cared for so that they can focus on getting better (and later to access their learning)
- Understanding that non-attendance due to long COVID is likely to have different underlying causes to emotionally based school non-attendance.
Social isolation
Chidlren and young people may experience social isolation as a result of not being able to attend school full-time, not being well enough to socialise with peers out of school, attending more medical appointments or taking part in less out-of-school activities or sports clubs.
A lack of school ‘belonging’ (due to being absent from school for a period of time or not being able to attend full-time) can be mitigated by:
- Providing check-ins from a key member of school staff such as a form tutor, teaching assistant, ELSA or key adult with whom the children and young people can establish/maintain supportive trusting relationships
- Keeping the children and young people in mind (even when they are not in school) and including them in all school activities to ensure a sense of school belonging (include the children and young people and their parents in planning if needed). This will also ensure that the children and young people have equal opportunities and equal access to education
- Putting in place additional opportunities for making connections, social interaction and developing or maintaining relationships (e.g. social skills groups, friendship groups, circle of friends approaches or peer mentoring/buddy systems)
- Using online platforms so that they can keep in touch with friends and classmates when physically unable to attend school
- Being alert to the possibility of stigma and a lack of understanding in other children and young people leading to unkind words (e.g. that the children and young people with long COVID is ‘faking it’ or doesn't look ill). Working with classmates and peers to understand differences in others and to promote understanding, acceptance and kindness
- Providing close and supportive home/school liaison to enable the children and young people to see that both home and school are working closely together to support them.
Identity and self-esteem
Children and young people with long COVID may experience loss of identity and changes to sense of self (due to reduced school attendance and not being able to take part in social activities, hobbies and sports that previously defined them) and has an impact on self-esteem.
Self-esteem might also be affected due to changes in their sense of self or awareness of increased difficulties with learning.
The following strategies can help:
- Using principles from acceptance and commitment therapy (ACT) to work on acceptance (accepting a change in self/identity and accepting what is outside of the children and young people's control), being present, recognising strengths and values and setting goals.
- Opportunities to develop and share strengths and achievements with others. Use of diaries, records of achievements, etc.
- Resilience building activities. Explicitly teach problem-solving skills and self-regulation strategies in response to adversity (e.g. asking questions such as ‘what would x do?’, ‘what has worked before?’, ‘how can we break this big problem into little pieces?’)
- Self-esteem building activities so that the children and young people experience success and feel a sense of pride in their achievements. For example, using specific praise which emphasises the effort and the approaches the children and young people used as well as the end result; using pre-teaching to increase confidence with learning, designing errorless learning tasks or tasks with a reduced level of challenge that the children and young people can attempt independently and experience success with. Challenge can then be gradually increased with success; using self-monitoring charts, record progress visually or keep a diary of achievements which the children and young people can look back at or share with key adults/parents.
Sensory and physical needs
Chidlren and young people with long COVID may develop sensitivities to noise and light.
It is important to be aware that busy, noisy spaces such as the lunch hall may feel overwhelming and provide alternatives; as well as access to quiet spaces.
Physical symptoms
Physical symptoms can be varied; for example they can involve gastrointestinal issues, chest pain, heart palpitations, joint or muscle pain, dizziness, nausea, headaches, fevers, nerve pain etc. An exit card can therefore ensure that the children and young people can leave the classroom if needed.
School nurses can play a key role in putting together an individual healthcare plan, liaising with families, schools and other relevant health professionals (e.g. paediatrician, GP, occupational therapist and physio). It is key that children, young people and their families are listened to. Seek the views of children and young people; ask them what would help them and how they would like to be supported.
Schools should be made aware of the need for flexibility as the needs of individual children and young people will vary and their support plan will need to be updated accordingly. The focus may need to be on getting better and wellbeing and this may need to take priority over attendance and learning for a while.
Schools should liaise with any involved health professionals and discuss the impact of long COVID on the child's learning and wellbeing with the school educational psychologist (as appropriate and negotiated).
The impact upon families, including siblings, should also be taken into account.
A guide to recognition, support and recovery
Long Covid Kids (LCK) is a UK-based, international registered charity advocating for and supporting families whose children and young people are living with long COVID. The charity aims to achieve recognition, support and recovery for long COVID and related illnesses. It has already received recognition from the NHS and the US Centers for Disease Control (CDC), as well as being a recommended resource in the new National Institute for Health and Care Excellence (NICE, 2021) long COVID guidelines.
The charity has launched a new guide: ‘Shining a light on Long Covid in Children. A Guide to Recognition. Support. Recovery.’
Created by parents and professionals (including educational psychology and occupational therapy input). The support guide is a comprehensive pack containing evidence-based resources and information for parents, families, children, young people, school staff, education, health and social care professionals. It is free to download, print and save as a valuable digital and paper resource for all those supporting children and young people living with long COVID.
Alongside the support guide, a dashboard will provide further links to articles, resources and information for:
- Children (up to approximately age 11)
- Young people (from approximately age 11)
- Families
- School staff and education professionals
- Health and social care professionals.
The charity hopes that this support pack will help raise awareness of the symptoms of long COVID and related illnesses in children and young people and in doing so increase understanding, aid early diagnosis and improve response and intervention.
FURTHER INFORMATION
Long Covid Kids
Pacing Penguins
Supporting Children Living With Long Covid to Manage Their Energy: www.longcovidkids.org/post/pacing-penguins-supporting-kids-living-with-long-covid-to-manage-their-energy
Cautious Tortoise
Long Covid Recovery for Children: www.longcovidkids.org/post/long-covid-recovery-for-children-cautious-tortoise
Shining a light on long COVID in children: A Guide to Recognition. Support. Recovery.
To access the guidance, visit: www.longcovidkids.org
NICE
COVID-19 rapid guideline: managing the long-term effects of COVID-19. NG 188
www.nice.org.uk/guidance/ng188