When mask mandates lifted in Tarrant County’s alternative school for students with behavior challenges, family therapist Abby Phifer heard an odd concern from staff: Some students weren’t removing their masks at all, even during lunchtime. 

Phifer asked around, and a handful of students provided clarity. They were worried about their looks. “They felt like people got so used to seeing what their face looks like with a mask on. They were kind of self-conscious to take the mask off,” she said.  The mask “has kind of become a safety blanket for them.”

She and her colleagues at Tarrant County’s Juvenile Justice Alternative Education Program didn’t press the issue. They had others to address amid the pandemic: Students falling behind academically and socially, students without access to WiFi, students slipping through the cracks. 

Now, three weeks after the COVID-19 public health emergency formally ended, Phifer and other professionals around Tarrant County are still grappling with the effect of the pandemic on children and teenagers, especially those who struggled with stress and trauma long before it started. 

A risk factor, not fate

The inquiry into a child’s well being often includes an assessment that measures how many adverse childhood experiences — like domestic abuse or rape — that child has lived through. 

At the alternative education program, for example, students complete the questionnaire in a life skills course. The results help Phifer triage: The higher the score, the more likely the student will experience poor health outcomes later in life, and the more quickly she’ll meet with them. 

Two physicians first developed the questionnaire in the mid-1990s. The idea grew from curiosity: One physician couldn’t understand why some people in a weight-loss had program quit, even while successfully losing weight. Perplexed, he interviewed them — and discovered a spate of childhood traumas among those who left.

Over time, the physicians discovered that most of the people in the study had experienced at least one adverse childhood experience and that, as the number increased, so did the likelihood that that person would experience poor health outcomes like heart disease, cancer, sexually transmitted diseases and depression.

Breanna Anderson, program manager at Cook Children’s Center for Community Health, is quick to clarify: The score is a risk factor, not fate. 

“A lot of times, the takeaway can be, ‘I’m doomed to have these really poor outcomes,’” she said, “which isn’t the case.” She and her team work to diminish the effects of adverse childhood experiences by fostering healthy relationships between caregiver and child.

Still, for young people already experiencing traumas, the pandemic became further kindling. In 2021, for example, high school students with at least four adverse childhood experiences were 25 times more likely to attempt suicide than their peers with none, according to the U.S. Centers for Disease Control and Prevention. 

“Everyone experienced the pandemic,” Anderson said. “It just didn’t affect everybody equally. It broadened the disparity gaps for individuals that were already really, really struggling.”

Is the pandemic itself an ‘adverse childhood experience’?

“It’s a complicated question,” said Angelica Noel, Fort Worth clinical supervisor for Alliance For Children. 

That’s partly because adverse childhood experiences are “preventable,” according to the U.S. Centers for Disease Control and Prevention. The agency lists strategies like family-friendly work policies, childcare subsidies and after-school programs to increase economic stability and healthy development. 

“I don’t know that we could have avoided the pandemic,” Noel said. 

Furthermore, the original questions center family-specific traumas, like substance abuse and suicide, not global experiences like war or natural disasters. Later iterations expanded the list to include community-level traumas like neighborhood violence.

The focus on family-specific traumas does partly capture the effects of the pandemic, family therapist Abby Phifer said. Both substance abuse and suicides increased in the pandemic. “The pandemic alone is already going to skew those scores,” she said.

‘They need more support and care’

The Center for Community Health is the “community health outreach and prevention arm” of Cook Children’s Health Care System, Anderson said. 

Within it, teams provide families with education and support about myriad topics: Oral health, mental health, gun safety, drowning prevention, safe sleep, to name a few.

Anderson manages the team that focuses on minimizing the effects of adverse childhood experiences. Before the pandemic, she and her colleagues piloted the Build-a-Bridge program, in which community health workers help connect families with resources, education and health care. 

For example, if a family needs rental assistance, a team member will walk the parents through an application. If a family secures an appointment with a pediatrician, the team member will help them get there through bus passes, gas cards or taxi vouchers. 

Anyone with a child under 5 is eligible. The program focuses on young children to provide interventions as early as possible and to support families long before they enter the school system, Anderson said.

Throughout the pandemic, the team noticed more people needed access to mental health services. As waitlists grew, team members built a library of digital resources to help parents in the meantime. 

They take special care to be trauma-informed and establish long-term relationships in the community, Anderson said. She emphasizes hope amid struggle. 

“I have a lot of families that we work with that have almost all of the (adverse childhood experiences),” she said. “When I hear their stories, I can go and check through (the list) in my mind. And all that tells me is that they need more support and care.” 

Strong relationships lead to flourishing

Angelica Noel, clinical supervisor for Alliance For Children’s Fort Worth office, noticed another increase during the pandemic: the need for caregiver support. 

Alliance For Children provides counseling services and support for children in Tarrant County who’ve been abused. Before the pandemic, Noel and her colleagues also offered group therapy for caregivers. 

But as illness, death and economic struggles compounded, parents already navigating trauma expressed the need for more support. Now, as much as possible, Alliance For Children offers one-on-one counseling to caregivers in addition to group sessions.

The focus trickles down. “When a child comes in and has a lot of that caregiver support, or even a caregiver who may not know how to support but is willing to, that is a big predictor of like, we’re going to be OK,” Noel said.  

Research into positive childhood experiences suggests that strong relationships within the home help children recover from trauma and other stresses. 

Specifically, children are more likely to be resilient when “they and their parents could discuss things that mattered, when parents participated in their child’s activities and knew their friends, and when parents managed their own stress around parenting,” according to a 2017 report.

Noel encourages families to ask their children questions. “I think sometimes we can brush things off and think, ‘Oh, there’s no impact. They’ll adjust, they’re resilient, they’re kids,’” she said. “But I think it’s really important to just check in and see how they’re doing and see how they’re experiencing the world.” 

Phifer, with the alternate education program, coordinated group sessions with students to discuss that very thing. 

“When kids (had) a space to kind of share their own experiences and feel like they’re not the only one going through it, I think that normalized their stress for them and validated their stress,” she said.

Before the school year ended, she took students a few at a time to play basketball and chat. The setting was informal, the questions simple: How was learning by Zoom? What’s it like to play sports again? How does it feel to be back at school?  

“​​I think, yeah, just being around people that they feel supported by, that they know went through (the pandemic), is what is helpful,” she said.

Alexis Allison is the health reporter at the Fort Worth Report. Contact her at alexis.allison@fortworthreport.org or via Twitter

Her position is supported by a grant from Texas Health Resources. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.

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Alexis Allison covers health for the Fort Worth Report. When she can, she'll slip in an illustration or two. Allison is a former high school English teacher and hopes her journalism is likewise educational....