COVID-19: Q&A for Parents with Michael Jellinek, MD

Sapir: Hello, everybody. My name is Joan Sapir, and I am formerly a senior vice president at Mass General Hospital, now SVP emeritus, and we scheduled this time to have a conversation with Mike Jellinek.

Mike is formerly a senior VP at Mass General as well and formerly the chief clinical officer at Mass General. Most important to this conversation is that he is a child psychiatrist an adult psychiatrist and a pediatrician. He was the chief of our child psychiatry department at Mass General for 32 years. He pretty much founded the department so he is well equipped to answer your questions about parenting in the time of COVID-19.

With that I will start by asking Mike the question that we heard from some of the moms and dads at the hospital. How do you talk about the pandemic with a preschooler and with an elementary school child in a way that doesn't scare them but lets them know what's up?

Dr. Jellinek: So there are some resources for this and if you go to the website with all the resources from MGH, there is a resource on talking to preschool children and elementary school children. It's a one-pager that has a cartoon quality to it and uses the right language and it was developed by a group of Harvard medical students who want to do something to help parents during the COVID epidemic. What you'll see there, and what you can do using your own words, is first to remember the age of the child and maybe I would start by asking my 4-year-old or 3-year-old, have they heard of this and what do they think it is? See where they're at, what their thoughts or even magical ideas are about what COVID is. They may have heard the word a hundred times and had to develop their own theory about how to understand it since until now nobody has told them.

Once I understood where they were at—and that would be true for the elementary school child, too—I would then start using very concrete language. Adults and adolescents can use abstractions and, for example, we can use the word virus and we all probably can remember a picture of a virus and they can make up a story about what a virus does. Young school age children and preschoolers can’t. They’re concrete so you'd have to call it something like a germ and maybe draw it and then explain to them that sometimes germs are around our environment, our area and germs can get into our body and that's why it's so important to follow the rules that everybody's been following because the germ could get on your finger and then get into your body and then the germ could cause you to get sick like when they've gotten a cold before.

Luckily for most, almost all young children, COVID doesn't cause serious symptoms so in fact calling it a cold would make sense. Of course you'd also have to tell them that the reason it's so important to wash your hands and be careful around parents and grandparents is because they don't just get a cold, they could get a lot sicker. They probably understand, even 4-year-olds, what it means to have a bad cold or a bad headache or a fever because most 4-year-olds have had that.

Elementary school children, you can get a little bit more complicated. I think you can begin talking about what happens when a germ enters the body and you can talk to a 7-, 8-year-old about how the body fights germs. A lot of people use military analogy: The little white cells become soldiers and those soldiers look for the germs and when they see one they capture them and that stops the germ from doing more harm to the person. I think that's harder to do at age 3 or 4. It's pretty easy to do at 7, 8. As a matter of fact a lot of 7-, 8-year-olds play like they're soldiers or cowboys or so forth so the notion of good and evil and being a soldier and capturing—those are all terms that a 7-, 8-year-old routinely do in their play so that's the way I would approach it for those two ages.

Sapir: Many of our listeners, many people in the hospital obviously, are working—and we'll talk about how you handle it when you're working from home—but for those who are working at the hospitals and out in the community and really are the first line, so they're seeing patients or may see patients with COVID, how do you help your child not be scared for you, for the parent? You're going out there, what if you get sick? How do you handle that?

Dr. Jellinek: I think again by age it's different. You know, 3-,4-year-olds, they're not going to be as worried about that and parental reassurance to a 3- or 4-year-old is often enough. If you tell a 3-, 4-year-old, don't worry, you can pick this up or don't worry, you can touch this or don't worry, let's go into the room together, they're going to do it because they trust you and their world is defined by what you call safe or not safe.

When you get to 7,8,9, they may have listened to the news, they may have heard much more about it and the same is true for adolescents. I think once they get to that age, you can actually teach them about personal protective equipment. You can teach them how careful you are, what you wear and what you do and how you gown. You can give them information that very few, a very small percentage of the people at the hospital, have actually gotten the COVID virus and many of those may have gotten it not from working with patients but from their contacts outside the hospital. So there's a kind of concrete reality that will help an elementary school child.

An adolescent is going to be able to use abstract reasoning so they'll listen to all that and they'll tell you that they understand what the protective equipment does and the viruses and all that but they will also ask you, well, has anybody gotten sick taking care of a patient that didn't get it from the outside? And you’d probably have to say yes and could it still happen to you? Well, you'd say yeah, it's a very small percentage ... but yes it could happen and then you've got to really go into abstract reasoning, which is how an adult makes a decision. What are your values? What are your pros and cons? How do you assess taking risk? What are the risks that you take in everyday life? Where in the past have you set a limit? You drive a car, you take a plane, maybe you don't do skydiving ... and you talk about your values, your professional values and the importance of your relationships to others.

Adolescents will be able to understand that in terms of their own life and you might even apply it to some of the decisions they make in terms of whether they learn to drive or whether they play football or whether they drink or whether they vape—all of those things are risk-benefit analyses that are based on data, personal wishes and values. So I think you can have a very good discussion with an adolescent about it with all the complexity that goes into making a decision about being a doctor, a nurse, a unit secretary, environmental service worker and facing the danger, being as safe as you can but feeling a professional obligation to help others. And that could be a very good conversation so I wouldn't shy away from it nor from the complexity of it.

Sapir: Thank you. I'm going to switch now to the trials and perils of trying to work at home with kids. One mom said: My kids are on screens virtually all day. I know the American Academy of Pediatrics says they shouldn’t be on screens and all when they're little but they are. So should we limit screen time or just types of screen time? What's reasonable in our new reality and is there really any harm associated with a few episodes of Sesame Street?

Dr. Jellinek: I'm going to be the last person to limit access to a few episodes of Sesame Street. We don't actually know the impact of screen time. There have been consensus committees for the Academy, there's been anxiety about it from professional organizations, we just don't know.

I would say that if a child has a balance of screen time, school time, friendships, family relationships, nobody knows whether one hour ... four hours makes a difference in that balance. Going to extremes, we know that kids who have depression or who are fearful of social situations may become over dependent so I do think there are a number of factors to take into account.

One is ... this is not going to be the way the world is in a year. Hopefully this will ease in a matter of weeks, we’ll gradually get back to a more normal life. Hopefully a vaccine will be developed or medications and schools will open probably in the fall and you'll be able to assess if your child is going back to a normal balance. I think the amount of screen time that they had during the COVID pandemic will be indistinguishable. Maybe we will do studies to try to figure out, gee, if they did six hours versus eight hours, was there any difference in their return to school? I would be very surprised if that little thing made that big a difference. Let me just say I would also differentiate screen time that's academic, with homework, screen time that's games, screen time that's interpersonal, either with family or friends, and I would try to figure out some time in my daily schedule that included play, non-screen time, reading, social interaction with the family. Family meals to me would be very important. Family discussions around those meals would be very important, and in that blend I guess I wouldn't make the amount of screen time a high priority in my mind.

Sapir: Mike, I know ... this is not totally related to COVID but just for those who haven't heard you say this before about violence and violent games, which means the people may have that in the back of their mind as well, and you say?

Dr. Jellinek: There’s virtually no evidence that watching violent or playing games where you shoot people on a video screen impacts your future in terms of behavior or violence. Now, again, if you're very socially isolated, have no other relationships, have serious other problems, maybe even pre-schizophrenic or schizophrenia, and have difficulty separating fantasy from reality, sure, that would be a concern but that's not what applies to 99-percent-plus of all children.

Another thing that's quite reassuring is that as the violence on television and the violence in video games have increased, the overall violent crime rate in the United States is going down so if you look at a 20-year curve of violent behavior and crime in the United States, it has decreased at the same time as screen time and video games have increased.

Again, I don't think that's necessarily perfect proof but you’d think if the whole of society were more involved in violence and millions of children were doing millions of video games and it had any effect—you just wouldn't think that the national crime rate would go down dramatically, murders and violent crime.

The other thing which is important to remember is most kids learn to be violent if they are physically abused. And if you look at the history of people who are actually in jail, the kinds of factors that matter are poverty, serious learning disabilities, head injuries and being abused as a child. Child abuse and neglect, sexual abuse, that cluster are much more of a contribution, plus genetics, having life of crime in the family history, all those factors lead to violence and incarceration. Video screens in the mix of those things I think are trivial and unproven. So I guess that's the way, that's the framework I would approach it, except in extremes. Somebody's in the room alone for 14 hours a day, that's a different calculation. Not that they'll be violent but there are other problems there.

Sapir: So as parents, what should we be looking for in our kids to make sure they aren't getting depressed; they aren't really disturbed by this? Some kids I imagine will be much more affected by worry or by isolation whatever it would be. And some young kids through teenagers ... what should we all be able to look out for and get help (for)?

Dr. Jellinek: Let's first talk about after the epidemic and then we can talk about during the epidemic.

Sapir: Okay.

Dr. Jellinek: After the epidemic, most kids function in five areas of life: family, friends, school, activities and their mood. If you look at those five areas, if they're interacting recently with their family, if they have friendships, if they're doing well in school, the teacher doesn't note any major problem, if they have activities and they enjoy participating in them, and if their mood is the way it was generally—hopefully at least positive—and willing to try things. That cluster is sort of mental health in children. And you can have expectations by age in each one of those areas and if the child is functioning in those areas, I think you can be pretty confident that your child or adolescent is on the right track. Those areas aren't as available during the epidemic because activities are severely limited, friends—although you might observe them on video—it’s still not quite the same and you don't have school.

Remember, a school teacher has seen (many students) ... let's say a fourth-grade school teacher has seen not only this class of fourth-graders and has a nice understanding of what a fourth-grader should be like in a fairly structured performance setting. Many of the school teachers have seen hundreds of fourth-graders like that so they are a very good barometer of a child that's having problems, given a baseline experience of hundreds of kids like this. But you don't have the teacher available right now and in fact the child is under additional stresses because there's no activity outlet like usual. They're not part of the course, or not part of the soccer team. They don't have a teacher in a group setting that is familiar because all of it's virtual as opposed to being in a classroom and they don't have as much friend contact or activity so I think you have to go much more on how the child is interacting with the family. Are they able to meet the demands that are there in terms of school? Do they still maintain interest in friends or activities? And in this situation I think you have to look at their mood state.

Are they sad, are they anxious, are they withdrawn? And you also have to look at your own mood state because what's the atmosphere of the house? I think everybody's household probably varies day to day and week to week under these conditions. We may be under more work stress or we ourselves may feel ... socially isolated. We may be in a down mood, we may be more anxious especially if we've got friends or family at risk. And I think children and adolescents will pick up on that so I think that there has to be more attention paid to the child's mood and ability to function in this new way and then I would get some reassurance by assessing the five areas once there's a return to normal.

I'd also say having a little anxiety right now is— probably more anxiety than usual—I think it’s kind of expected. There's going to be a little more tension, everybody is going to be a little more stressed and it will move some kids into more anxiety or into depression and we just have to keep an eye on their mood and interaction.

I do think family lunch and family dinner, hopefully even family breakfast ... if you can spend 20 or 25 minutes at each one of those meals, checking in, talking about things, informing, finding out about friends, finding out about homework, what's going on in the extended family. I think that would be a very strong kind of resilience factor to both help the family stay together and also assess how everybody's doing.

Sapir: Thanks. I guess I could put a plug in here for our EAP program at Partners because I know they were available to be called if you're worried about yourself or your partner or your kids and could give you some advice or some referrals as well so people can call on that.

So one mom mentioned that she thought her 2-and-a-half-year-old son's world has been totally upended. Their parents are working crazy hours at home and barely have any quality time: How can I get some structure in his life, some normalcy? But I think having just read that out loud I think you just answered that (question), which would be trying to get some structured time during the day—breakfast, lunch, dinner.

Dr. Jellinek: Yeah. Also you have to sort of check your own reactions. If you're working 11 or 12 hours a day on a screen at home and don't have any available time for your child, I think you got to ask yourself whether that's reasonable, whether it's sustainable for you, whether you're doing it out of some inner sense of anxiety or special obligation that may be disproportionate. How are you assessing your values in terms of work responsibility, versus family and child responsibilities? So if you're in that situation I think one of the first things you got to do is step back and say, is it realistic? And if both parents are doing that without alternating or spelling each other in certain ways I would be concerned. It's hard for me to think of a job that would obligate you to work at that intensity level for both people for week after week after week.

A couple of other things I might think about, is there someone, a child care person, who's taking care of that child who is consistent? I mean if this is happening in a household and Grandma's living there it might not be that bad because then grandma can devote the attention, although I think the child will still feel somewhat deprived or not valued if the family parents are apart at that level of intensity. And can there be an expectable routine so that the 2-and-a-half-year-old can count on parental contact at certain times like at meals, helping to wash up in the morning, a bedtime story and so on so that the child doesn't constantly feel like they have to be anxious, hoping the parent will go to the bathroom and get off the computer and then grab the parent and cause a scene at that time. If there's some predictability and you can let the child know when something's going to happen and it's going to happen the same way every day, that would contain a child's anxiety.

Two-and-a-half is especially difficult. That probably works better at 3, 3-and-a-half, 4 and, again, children are different so you have to assess what kind of kid you have. There's some that are much more self-sufficient and there's some that are needier and if you want them to feel valued you're going to have to adjust your behavior a little bit to who they are.

Sapir: We don't know when schools are going to reopen. I guess the jury's out but I think the expectation at this point is schools will not open again this year, likely. I’m not an educator. I don’t know. I'm not making that decision but likely, probably, we open in the fall, we hope. So parents are worried about children regressing, not being up to speed in the fall, especially parents of kids who are on individualized education plans, IEPs, or have some special needs so we got a six-month break. Usually you have maybe two months of break. How can we deal with that?

Dr. Jellinek: So for all kids, I expect that the teachers are going to go back and try to get the essence of the spring term in and the fall term next year into a more intense and selective catch-up period. And all kids probably lose a little bit over the summer and that's why we have summer reading lists which some of us did and some of us didn't (do). ... I think it's a general phenomena and I think it's reasonable for parents to try to encourage kids to read and do something to keep going over the summer.

The child with special needs is a different kind of issue. There are two components to that. One is the areas you have to remediate and the other is the areas of strength.

Let's do the areas you have to remediate. We give a lot of responsibility to the schools to understand the learning disabilities and then target those learning disabilities. If I had a child with learning disabilities at home for three or four months, I would probably have to fill out the psychological testing report or maybe even call the psychologist and really try to understand what those learning disabilities are and then talk to the psychologist about what could I do at home that might support that particular learning disability and how important is it.

If it's not very important, I guess I wouldn't press it too hard. So if a child has a math disability and can't memorize multiplication tables I guess I wouldn't drill them forever because they're probably not [break in audio] ask the psychologists if it's possible that really helps or does not. If it's an organizational ability it may not matter to do that as much because kids are going to have to relearn that organizational behavior at school when they go back.

There may be some tricks you can try, you know, having a computer in the [break in audio] laptop and organizing their day and making lists and all that might be helpful. But I would understand the specific learning disability and then see if I could get some guidance on what I could do at home that might supplement that remediation.

On the other side we often try to remediate weaknesses when long-term building of a strength is more important. Virtually nobody goes into life working every day, emphasizing their weakness. If you're not good with numbers and you're not good concentrating for long periods of time, you end up usually not being an accountant. It's just you don't choose it because it's so much work and all of us have strengths and weaknesses and we tend to pick areas that we’re strong in and that come easily to us and that we enjoy doing.

So if I had a child with learning disabilities, I might try to remediate weakness to a minimum level but I wouldn't do it at the price of not emphasizing a strength. I might, if they are a strong reader but very weak in math, I'd spend at least as much time on making them a stronger reader or a stronger writer if they're in high school because the odds are that what they're going to pick in life is going to be something to do with reading and writing and not something to do with math.

And by the way the reverse is true. If they have severe dyslexia, I need to get them to a minimum reading level and I would push that. On the other hand, if they really liked computer programming and math, I would strengthen that because it's much more likely they're going to do this the rest of their lives than become an English teacher if they have dyslexia. So that's the way I would approach it.

Sapir: Thanks. Now moving on to middle school kids. We heard from one parent: My middle school kids want to laze around all day. It's making me crazy. Any suggestions?

Dr. Jellinek: So one of the jobs of a middle-schooler is to drive you crazy. Developmentally, let's say a 13-year-old ... their developmental task or stage is to separate from their parents and to begin to develop their own identity. They do that in a number of ways. They get much more involved with friends. They begin to have some personal goals like making the soccer team or playing in the orchestra and they often find another adult that's not too different from the parents that they connect to.

So they get very involved with a coach or with a music teacher or in a subject that they're good at. They'll spend extra time in the math club or the English club at school and school is your design, middle school and early high school, to welcome. They're given an advisor that they can connect to. The clubs open up—there there are not that many clubs in first grade—but by early adolescence all of those activities are encouraged, and they're all built around the transition from being your locus of life being the living room, to your locus of life being outside and into the world: traveling for a game, traveling to being in an orchestra performance or so forth. So the entire context of talking to a middle school child is that child asserting their beginning identity.

If you are a hard-driving person who really believes in school and academics and you don't want to lose a step despite the epidemic and they ought to do excellent on their schoolwork or be dedicated to school work during this time and they have a chance to drive you crazy by lying around? If they know that it's important for you to push schoolwork? I'm pretty sure they'll lie around and it might not be because they're not interested in school. In fact they may have been very good students six months ago or three months ago and were doing homework every night but they do have to establish their own identity and separate from you and this might be one way of separating.

So what I would do in that circumstance is I would ask them about what their goals are and then see if I could figure out ways of helping them achieve their goals. Now if they had the goal two months ago of playing varsity soccer, you know, probably gaining 10 pounds and not exercising is not going to get them there. If that's still their goal, they probably need to deal with that. If their goal was to apply to private school or get into honors math ... or be the leader of the chess club, you might be able to motivate them based on their goals. Some teenagers will be pretty clever and say that’s not my goal anymore. But at least it might be a start to meet them on their own ground.

Second, I would take some of the pressure off, especially seventh, eighth grade is a time where if a child fails, there are no long-term consequences but yet it's a great opportunity to learn about taking responsibility and the consequences of not taking responsibility.

So I would let the teacher worry a little bit more about the quality of the homework. I would try to get out of the line of fire and I would see if the natural pressures and wishes of that child would make them the kind of student I want them to be. And if I'm wrong for one term, it's not the end of the world because we're talking about their seventh grade English grade so that can lead to a whole other negotiation but I'd rather find that out in seventh grade and pressure them (rather) than find out in tenth or eleventh grade that they want to separate from me by doing nothing when those grades become more important.

So I would take some of the heat off and I would see this as a kind of a test period and I would try to meet them where they're at and worry more about trust and communication than achieving a goal. If you can maintain trust and communication while they separate, man, that's terrific, even if you have to give up on some goals or they have to test failure themselves and see how it feels.

Sapir: So you're kind of saying that we have to give up some of our goals for them during this time.

Dr. Jellinek: Well said.

Sapir: And let them set their own goals and see if we can support that.

Dr. Jellinek: Right. Even if we don’t completely agree.

Sapir: And if they still wind up lazing around all the time, hey, it's not going to kill them.

Dr. Jellinek: It’s not going to kill them.

Sapir: It might kill us. It’s not going to kill them.

Dr. Jellinek: You may wonder, gee ... just think about this, is this going to lead to where you want to go?

Sapir: Got it. So many folks who are sheltering in place, working from home, are not used to doing it themselves and certainly not used to being around their partner all day, raising the kids. Any thoughts about that?

Dr. Jellinek: Dangerous ground [laughter].

Sapir: But we have no choice [laughter].

Dr. Jellinek: We have no choice. I still see a fair number of patients and this has been an issue with a number of them, not necessarily negative but a re-looking at who they are, who they want to be as individuals. A couple of people have had much more time with their children and are committed to maintaining that so they/we examined how they measure, how they judge themselves. They've looked at what's the nature of their marriage.

If both people are working and very busy some of the “us-ness” of a relationship can decrease. And again, this is a period of time where you can think through how much of an us do we want to be, even if there's separate projects. I was recently talking to a family where they had ... a whole list of projects and I asked them the question, are you doing those projects together? Or are you each taking two or three projects in the house and doing them separately? I asked, what do you want? It might be (that) you want to do them separately, which is just fine. It might be that some of them are overlapping and might be fun to do together.

If you're both running, can you figure out some way that somebody takes care of the kids and run together? I asked one couple, when they take walks together now, which they hadn't done for a long time, are they holding hands? So there's a lot of things that you can reconsider when you're in this situation and some of them may arouse questions or concerns and some of them may actually build a fair amount of closeness.

Sapir: That’s all very helpful and kind of a positive spin on things like, well what can we make good out of this? I was thinking a little bit more practically in my question (however) which was (that it can be) really aggravating to have someone there all the time. We're not used to this, right? Love your husband, love your wife, love your partner but please [laughter].

Dr. Jellinek: So everybody's got a balance of social time, family time and alone time and as you’re reconsidering this, you might recognize that you do have a certain need for alone time and that's not against anybody, it's for yourself.

Sapir: We're used to going to work and interacting with other adults and having that separation, then you come home and you're glad to see the person you live with. Here (during the pandemic), it's all day.

Dr. Jellinek: Yep, but it's also a chance for maybe a little bit more depth. Often when we get married, in the first few years, there's much more intensity and togetherness because neither of us are as accomplished or busier—time demands, (demands from) kids are lower. And then you have a period of time where you're apart by necessity because of the workload and the kids and so forth. In this situation, you're now back together.

I think it's just worth thinking all of that through and then coming up with a new balance that might be the same as you had before. Or it might be different.

Sapir: Yeah but have a discussion in any case about it.

Dr. Jellinek: Well first a discussion with yourself and then a discussion.

Sapir: You certainly have enough time in the house together, right [laughter]?

Jellinek: And again there may be certain rituals you want to maintain. Maybe you have breakfast and dinner together but, you know, lunch is sort of part of your workday and not together or maybe you do take a walk every other day and that is your personal time. So I think most of the people I've spoken to have had more attention and more time for reflection and have come out with a slightly different formulation then they went in with because of being forced into this way of living.

Sapir: Mike, thank you so much for your advice and wisdom today. Is there anything we should be asking that we haven't?

Dr. Jellinek: No, it's been a lot of fun and you're a great interviewer and maybe we'll take the show on the road sometime.

Sapir: All righty, well, I think with that, we'll probably stop this recording if I can figure out how [laughter].