A Child Psychiatrist on the Unprecedented Risks Our Pandemic Response Poses to the Very Young

Allan M. Josephson, M.D., discusses the psychological consequences of keeping children out of schools and other aspects of coping with the virus.

Allan M. Josephson is a distinguished, board-certified child and adolescent psychiatrist based in Louisville, Ky. Over the course of his four-decade career in academic medicine, Dr. Josephson was clinically active treating patients and families, led two academic divisions of child and adolescent psychiatry, held senior teaching positions at three institutions, and published widely. He is a Distinguished Life Fellow in the American Academy of Child and Adolescent Psychiatry and the recipient of the Oskar Pfister Award from the American Psychiatric Association.

Dr. Josephson has previously offered commentary on child and adolescent mental health for National Review. Here, he talks to Madeleine Kearns about some of the more vexing psychological consequences of keeping children out of schools and other family aspects of coping with the pandemic.

MK: Dr. Josephson, am I right in saying the behavioral response to the pandemic, for children and the developing brain, constitutes an unprecedented social experiment? What’s the thinking behind it? What are the risks?

AJ: To be honest, precisely because this is unprecedented, there is little systematic thinking behind it. We are taking what we know of the behavioral and medical sciences and trying to craft a plan. We’re just going step by step. And one of the things that’s become increasingly clear to me is that taking children out of schools, disrupting the normal rhythm to their life, has huge implications. And we’re just beginning to see some of the implications and its effects.

The socioeconomic experiences of children vary widely. Those who are economically deprived, as is always the case with any health condition, are at much higher risk of harm. With lower-income kids, you take kids out of school and you right away affect their diet because, for many kids, that’s where they get nutrition. To take children out of the normal socialization process and the social experiences that healthy development requires, and expect overwhelmed parents to provide all their developmental needs, magnifies the stress on parent and child.

MK: Right. I actually briefly trained as a schoolteacher in a very rough part of Glasgow. It was astonishing to me how chaotic the pupils’ family lives were: children staying with one parent one day, shipped off to a grandparent the next, in and out of foster care, etc. So I think you raise a critical point about the importance of family structure — or just structure, period.

AJ: Yes, and pandemic-induced school absence takes away the security of structure in the child’s daily routine. The enormous security of that pattern gets taken away, and can be quite destabilizing. Schools are the primary way that child abuse is reported. Teachers recognize that children are in trouble. They may see a bruise or detect something amiss with the child. And so, we’ve taken that protective layer away from the kids. It’s also a place where mental-health services are delivered for a great number of children, so that is also taken away.

Another aspect that is very important, and one of the damaging things about the pandemic, is that special-needs children, kids with autism and similar chronic conditions, need specialized services. They need structure — they need these services every day. Regular, structured programs can be expensive but are critical for the kids’ safety and educational advancement. And of course, this has been taken away from them.

MK: Yes, from the numbers, it does seem that there’s been a big surge in domestic violence and child abuse since the beginning of the pandemic, with more children being admitted to hospital with inflicted head injuries and so on. I know these are extreme examples, but is this related to what you were saying about an increase in parental stress? Could you say more on that?

AJ: Yes. There’s a principle that I’ve always found useful regarding the interactive nature of child psychiatry and child development. And it is this: The stressfulness of an event depends upon the capabilities of the child experiencing it. Okay, so you can have something difficult happen to a child, but the child is loved, secure, self-confident, does not find it as stressful. But for a neglected child, with low self-confidence, unavailable parents, that same event can be enormously stressful. Let’s look at the family unit. The stressfulness of the pandemic for most families depends on how healthy they were to start with. And many families are, I won’t say sailing through, but they’re solidly coping because year after year they have built various strengths into who they are as a family.

Whereas these kids’ families in Glasgow that you just mentioned, they had nothing to fall back on. You sneeze and the family blows away. The focus of much of my career has been on family, family processes and so forth; kids don’t come to the clinic alone. They really come with a family constellation that’s either helping them or it isn’t.

MK: Even for relatively stable families, the pandemic has brought about quite dramatic shifts in environment. In the context of a quarantine, at least, there was typically no peer contact, no in-person educational support, no grandparents or babysitters permitted. You raised something just there about the relationship of stress and how it’s a family issue. How does the mental health of the parents affect the children, exactly?

AJ: Well, at a general level, the mental health of the parents and the parents’ behavior structures the way children think about the world. That’s how they learn about life, particularly when they’re very young. And so, when parents communicate acceptance and security, the child picks that up, thinking “I’m a child of worth. I’m a good person.” If a parent is anxious, withdrawn, or short with his/her temper, the child approaches the world thinking, “I must be doing something wrong.” The mental health of parents has an enormous impact on the development of the child’s cognitive set.

Another way to put it is that children have a kind of antenna for any emotional tension in the home, they pick up on a parent’s change in behavior. So, when a parent worries about money, food, job — basic life necessities — children pick up on it and know that something’s wrong. It takes an incredibly healthy parent to protect a child from that, because it’s just so obvious that there’s something very different. And so now, parents really are under the gun because they have to provide so much for children that normally is provided by school or other adults.

We all know that children are creatures of habit. They need things the same every day, and change makes them anxious. And it’s not that they can’t survive change, but routine and habit and structure are soothing for them. And that’s taken away by the pandemic and the parents have to continue to try and provide that. We’ve known for some time that an increase in unemployment is correlated with an increase in children’s mental-health problems. This pandemic may again be illustrating this sober fact.

MK: Technology has been both a blessing and a curse during this time. I’ve heard a lot of exasperated parents say that they’re resorting more and more to the iPad. Is sustained use of iPads and other electronic devices bad for attention span?

AJ: Yes, probably. But it’s even worse for relationship development. Kids need to go outside and play, go outside with their friends, go to school and have all the different social interactions that kids usually have. The electronic device emphasizes the cognitive more than the relational, the thinking more than the feeling part of a child’s development. And these devices over time could stunt relationship development. So in the short run, and we’re still probably well within that window, we can get away with it during this crisis. But even effective parents, who spend time with their child, need to spend time away from their child for adult tasks.

I think one of the stressful things for parents is that kids seem to more easily have “meltdowns.” Limiting the iPad, for example, can be a toxic combination. You’ve got to depend on the iPad but once you get them off the iPad, there’s a meltdown. These are very stressful experiences for parents who are trying to live their own adult lives as well as take care of children. So, it is a unique situation that we’ve never faced before.

Just a few years ago we expected that children could be creative in occupying their free time. And guess what? Kids were creative. Playing in isolation had an adaptive part to it — they made things, they did things by themselves. This free time eventually became filled with electronic device “play,” and the pandemic has exacerbated this cultural change. I know parents feel helpless because they know it’s not necessarily good to use the device as a “babysitter,” but what else do you do? Parents need all the help they can get. So that’s the parenting challenge of the pandemic.

MK: Some schools are doing a kind of rotating capacity or they’re doing partly online, that sort of stuff. I think everybody recognizes that this is not really ideal, but on a short-term basis, it’s better than the alternative, which is nothing. I wonder about another alternative, though. Do you think it is realistic to hope for pretty much what we had before COVID-19, which is everyone going to school at the same time, out playing in the classroom, except with some more hand-washing and social distancing, etc., without a vaccine?

AJ: That’s a key phrase — “without a vaccine.” Because an effective vaccine would change everything. But I still think it’s realistic, with the precautions that we’ve learned: social distancing, masks, and washing hands. The thing is we are social beings. We need interaction with others, and the basis of your question is really profound yet simple. You can’t take other people out of your life and get away with it. It’s just not going to work, especially in the lives of children. And so, back to your earlier question: Take the virus and its physical effects and the emotional-psychological effects — which is worse? Well, there’s no doubt in my mind what the answer is, based on what we know. For children, the emotional and psychological effects are worse.

MK: I want to read you a short excerpt from an interview I did with a five-year-old girl. And I wonder what you make of it. So first, she had a COVID test, because some kids in her class got sick at the same time. I asked how this made her feel, and she just did a thumbs down. So, I think that about answered that part.

What is most strange about the virus?

Not being able to get close to people.

Do you get to hug your friends?

No.

What would happen if you tried to hug your friends at school, what would the teacher say?

They’d say: “No, don’t do that.”

And do you understand why?

Because the virus.

And do you understand what it is about the virus that means you can’t hug people?

No.

When grownups say things about the virus, do you feel you understand or that you just have to trust them?

Just have to trust them.

 

Is this kind of processing characteristic of a child of that age?

AJ: Yes, absolutely. What you’re seeing there is a dependence on the adult to structure the child’s mental world. That’s all that they have to depend on. They think, “I just have to depend on these big people who seem to know everything.” And if you think about the complexities of virology: What is a virus? How do they replicate? How do they transmit disease? I mean, adults barely understand that. The virus can’t be seen or touched, so the child just has to go by the faith of the parent whom they’re relying upon. Children are exposed to these new rules, no touching, no hugging, masks. And really, I think the best we can say is it’s probably all a blur to them. Which comes back to the thing we started with. The only thing they can rely on is the veracity and the smarts and the caring of adult people, usually their parent or parents.

MK: The other thing that I thought was interesting was we played this game. And the game was that I was to cover the lower half of my face, and then make facial expressions and she was to tell me what the emotion was —

AJ: Madeleine, you are a closet child psychiatrist! Your natural sense of behavior is impressive.

MK: [Laughing] Well, thank you, I will of course have to include this flattery in the transcript! What was particularly interesting was that she was pretty accurate; whether I was doing a sad, angry, happy face, she almost always got it right. And then she wanted to play the game in reverse, so we did. But I was hopeless! Now, I know that’s just one anecdote — it could just be her, it could just be me — but it did get me thinking about what influence all this mask-wearing will have on children’s emotional processing and development, given how important facial expressions are in determining those.

AJ: Yes, it’s very important. When you can’t see someone’s mouth and you don’t know if they’re smiling, you’re just relying on their eyes. It’s a totally different way of assessing emotion and dealing with it. Usually you can guess with some certainty if they’re smiling or they’re angry, but when you remove part of the data that we normally use in social interaction, we then have to refine our ways of interacting.

MK: So, let’s assume the mask-wearing continues for the next few years. I don’t know that it will, but is this likely to have some kind of cognitive impact on children growing up in this period?

AJ: Well, I would think that it would. They would have to figure out a new way of how do I know whether my father is upset or angry or my mother is happy or sad — or my teacher, for that matter. It removes part of the data, and then they’ll have to make those judgments based on new parts of what they’re able to see and physical characteristics. And so, I think over several years, yeah, it would likely make a difference. But several big qualifiers are needed. The duration of mask-wearing is crucial. Now, masks aren’t worn all the time, they’re on and off. Only persistent use over years would be likely to have impact. And the subject would benefit from empirical study.

MK: Here’s a quote from an eight-year-old boy. I asked him what the differences were that he noticed at school. He said: “The teachers are way more strict. Don’t know why. And then it’s just, like, annoying because you can’t sing songs in music class. It’s just listening to music. You can’t sing songs, ’cause I guess, like, singing and yelling is spreading germs.” He also said that masks are “horrible,” “not fun,” and can make it difficult to decipher emotions.

AJ: So, he makes the same point.

MK: He does. I thought it was interesting that he was more irritated than the little girl.

AJ: Yes, but he’s a few years older. And see, that illustrates something very important about child development, the integration of new information then gets differentiated into more complex ways of understanding. So, a real-life example I’ve used in my teaching for years is illustrative. A three-year-old boy asks his seemingly all-knowing six-year-old sister, “Are octopuses good or bad?” And his sister quickly and somewhat condescendingly asks, “What do you mean? Good to eat? Good to look at? Good to play with?” And then I think she introduced some aspect of good versus evil, as if to really confuse him. And the kid likely just wanted to know are they are safe or not. He had one limited definition, she added about five definitions to the word “good.” And that’s what happens with development. And so, in assessing whether somebody is happy or sad, and you can’t see their entire face, it is a more complex task for the younger child.

And that gets to another aspect of how the pandemic affects kids and one of the things which is so profound and so hurtful, really. We have talked about younger children, but adolescents, what’s important to them? Their peers, their social relationships, their dating relationships, whatever. And then they move toward graduation from high school or a prom or a certain special social event, or a major athletic competition at the end of the season. And it gets canceled! And it was all taken away from these kids by the pandemic. The parents or schools might have patched something together, but the enormous sense of loss makes this totally unique. This experience has never happened before, where those kinds of special things were abruptly taken away from young people. We do not know yet how enduring these hurts might be.

MK: So, here’s a good opportunity to return to what I think has been on a lot of parents’ minds. In your professional opinion, weighing up the physical risks of COVID-19 with the psychological risks of our handling of it, which is the greater threat to children and young people?

AJ: Oh, clearly the psychological risks of the handling of the virus are greater than the physical risks. This is because kids essentially don’t die from this. They appear to get sicker from a normal influenza. So these psychological issues we’ve talked about are subtle, we don’t know how enduring they are, how much effect they’ll have in the long-term, but they are much more problematic. Psychological risks are also increasingly seen in late adolescence: increased depression, suicidal behavior, loneliness — whereas the effects of the virus itself seem minimal. We must be cautious as we just don’t have much data for that yet. And that’s what’s so amazing. The only rationale I can determine for schools to not open is that we do know kids can carry the virus and possibly transmit it to teachers and other adults in schools. This possibility must be countered by the clear negative effects on countless children, and families, of having their futures seriously compromised.

MK: Right. I want to situate this conversation by taking the 10,000-foot view. There were a number of trends already afoot within child psychiatry and psychology before this pandemic happened, observed primarily by people other than psychiatrists. I have two books in front of me. One of them is The Coddling of the American Mind: How Good Intentions and Bad Ideas Are Setting Up a Generation for Failure, by Greg Lukianoff and Jonathan Haidt. The other is iGen: Why Today’s Super-Connected Kids Are Growing Up Less Rebellious, More Tolerant, Less Happy — and Completely Unprepared for Adulthood, by Jean Twenge.

What Lukianoff and Haidt are saying, basically, and I’m quoting some excerpts here, is that “when we overprotect children, we harm them,” that “children today have far more restricted childhoods, on average, than those enjoyed by their parents” and as a result of this obsession with “safetyism” haven’t been able to develop psychological “antifragility.” Twenge, likewise, says, “never having known another parenting style, iGen doesn’t rebel against their parents overprotection — instead, they embrace it.”

First, do you agree with their assessment of where we’re at?

AJ: Yes. I very much agree, and the notions are consistent with those that have guided my treatment efforts with narcissistic youth and their families and my teaching about them. And I think one way to think of it is if parents do things for you, you end up not learning how to do them for yourself, depending on others to think for you. So, it’s directly related to a lack of development of interpersonal skills and inner resources needed as the child moves toward independence. In some of my clinical family-therapy situations, when I see this pattern emerging, I’ll stand up and lean against a wall. I will ask parents: “So, what’s going on here?” “Well, you’re leaning against the wall.” “What would happen if someone abruptly took the wall away?” “Well, doctor, you, you’d fall over.” And then I develop that theme for the family and say, “Well, yeah, I’d fall over or at the least lose my balance.” And that’s what’s going on with your child right now emotionally. They have no moorings, they’re anxious, they’re unsteady. And the reason they’re unsteady or feeling out of balance is because you’ve always been there, perhaps out of love or caring. But your being there has prevented their own development of balancing mechanisms. And that is not how best to parent and indeed it is harming them.

I remember a New Yorker cartoon I’ve used in my lectures. It was great. A child comes to his father with his homework, but the father is busy reading the newspaper. In the caption the father says, “Daddy’s way of helping you with your homework is not to help you.” There comes a point during a child’s development in which self-sufficiency needs to click in. And so, if the coddling of the mind prevents children for learning themselves, then they become kind of dependent, helpless, anxious, and here I’ll use the word — I know Twenge has written that in her work — “narcissistic.” They are self-absorbed.

Now, the mind is shaped by interactional experience. That’s how you begin to think things. And so, if someone is always there for you, you begin to assume that you’re special. You’re always going to be taken care of. There will always be someone there. That’s how the mind works. It takes information from the environment and it becomes part of your mind as a schema or template.

If you worship a child, if you coddle them, they think, “Well, I must be pretty special.” And then what happens is that they have a great deal of difficulty in social relationships. Their friends, their acquaintances, their companions don’t worship them quite the same way. Other people don’t think the child is that special. Others expect reciprocity, the essence of a relationship. So, it’s a very important feature in that the kids who have been coddled can’t handle stress, can’t deal with their problems.

MK: So let’s say for argument’s sake that, as far as their own physical safety is concerned (as opposed to the safety of the elderly and vulnerable), we are overprotecting children from the coronavirus. Do you think it plausible that the psychological harms of “coddling,” of the sort that Lukianoff and Haidt and Twenge already described in their respective works, could become exacerbated? Might the emerging generation be at greater risk of the kind of pathological self-absorption and fragility to which they are overly inclined?

AJ: Yes, it is entirely plausible. As we discussed earlier, the stressfulness of an event is determined by the psychological capabilities of the individual experiencing it. If you have been coddled, protected from the adversities of life, pandemic-related stresses may be beyond your coping capacities. You may need more support and protection, but your parents are away trying to protect their jobs and family income. The healthy child then draws on inner resources developed through growth-promoting, independence-inducing experiences. The overprotected child goes to the emotional bank account to draw on such resources but has none. They are fragile. They have not developed the inner strength to succeed.

MK: Finally, for parents reading this, we don’t want to tempt them to despair! So let’s end on some of the ways in which to foster resilient and well-adjusted children in the face of this very unusual social experiment.

AJ: Well, I think that we start, as best we can, asking the kids what they know or don’t know. Because there are certain misconceptions and fantasies which need to be explained. And then explain the reason for the precautions. As best, one can try to educate them on what a virus is. And they likely would have had some experience of a flu-like illness before and be optimistic that most people who get this are fine. Older people are more at risk. Then we should do what we can to get kids back into school. Now, parents can’t do that alone, but they can put pressure on school districts and leaders to open schools. I think that’s important.

This is not going to last forever. It’s going to end, so if there’s one message I could leave it’s that the more the parents have control of their own emotions, their own lives, and communicate that we will get through this, the better off we are, because the kids will trust that. Mom and Dad seem okay, so we’ll be fine. But if you’re at all panicky, or children see Mom and Dad quarreling, or in the worst cases they are exposed to violence, that’s just terrifying to the children. The more you can be healthy, the more your kids can be assured that they will be healthy and safe.