Understanding and addressing adverse childhood experiences in the face of the COVID-19 pandemic.

Introduction

Exposure to adverse childhood experiences (ACEs), which are experienced by more than half of children worldwide, is considered to be one of the top threats to children's healthy development [4]. ACEs include abuse, neglect, and/or family dysfunction, such as caregiver mental illness, substance use issues, parental loss, or exposure to intimate partner violence [4]. More broadly, ACEs can also include other social risks such as poverty, peer victimization, and community violence. When ACEs are experienced, particularly the accumulation of ACEs, children are at heightened risk of poor lifelong outcomes related to physical and mental health [4]. In addition to the individual consequences of ACEs, the social and economic burden is also substantial, with pre-pandemic annual cost estimates of $129 billion US dollars annually, equivalent to 6% of a European country’s gross domestic product [5].

A pressing question since the start of the COVID-19 pandemic has been whether or not the prevalence of ACEs has increased as a result of elevated family stress, reductions in household family income, and the disruption of social supports and community services. The answer is highly dependent on the type of adversity and the nature of the available evidence. For example, longitudinal data suggests parent mental health difficulties have increased during the pandemic [11]. Cross-sectional data has shown that parents report increased alcohol consumption compared to non-parents during the pandemic as well as increased stress related to threats of violence in the home [2]. Additionally, more than 50% of parents have reported a job loss or income disruption during the pandemic, leading to significant impacts to their ability to meet financial obligations [11], which may be more marked among racially and ethnically minoritized children [10]. Globally, approximately 10.5 million children have already been orphaned or lost a caregiver due to caregiver COVID-19 death [3] and as the pandemic continues, families will continue to experience loss and stressors associated with illness within the family.

However, evidence for increases in other ACEs during the COVID-19 pandemic, such as child maltreatment, remain less clear. Despite early evidence that child and youth calls to distress help lines saw a significant increase, some examinations of acute care visits and hospitalizations associated with severe instances of child maltreatment have not shown increases [12]. Understanding changes in child maltreatment during the pandemic is also complicated by reduced child maltreatment reports to child welfare agencies due to school closures and the suspension of in-person support services [1]. Although there is ongoing evaluation of possible changes in ACEs internationally during the COVID-19 pandemic, what is clear is that risk factors for ACEs, such as increased family stress, financial stress, and parent mental illness, have increased. Accordingly, it is important to consider mitigating long-term effects associated with these exposures as well as promoting adaptive outcomes to help overcome these adversities.

Promoting resilience in child and adolescents

As one of the most frequent touch points for children and adolescents, healthcare and social service providers are uniquely positioned to identify opportunities for risk prevention and promoting resilience in children and adolescents facing ACEs. Resilience refers to the process by which adaptive outcomes (e.g., optimal developmental health) occur despite risk factors (e.g., parental loss). Decades of research have shown that resilience is enhanced when children can draw on the supports around them, which include their caregivers, teachers, practitioners, and providers. This body of research suggests that resilience factors exist at different levels of the child's social ecology (individual level, family level, or community level) and mitigate poor outcomes in the presence of risk.

Resiliency factors at the individual level include problem-solving abilities, self-regulation, and social connectedness [8]. Resiliency factors at the family level include supportive and close relationships with competent and caring adults. Indeed, the presence of supportive and close relationships is one of the strongest and most robust predictors of child resilience. Providing parents and caregivers with resources and skills to support their children in the face of adversities is, therefore, essential. For example, one study during the COVID-19 pandemic showed that parental self-efficacy, including feeling competent in facing parenting challenges, was a protective factor for children’s emotional well-being, despite elevated family stress [9]. At the community-level, schools play an important role in the healthy development of children and youth. Research suggests that schools provide an opportunity to build and develop coping and problem-solving skills that can be applied to promote adaptive outcomes in future [8]. Taken together, bolstering these key areas of resilience can offset the risk of ACEs and lead to more positive outcomes.

Practice implications

Although exposure to adversity, especially in the context of the COVID-19 pandemic, necessitates a multi-systemic response, healthcare providers, particularly those providing mental health services, are often one of the first and longstanding points of contact for families and are well positioned to take steps to address ACEs and social determinants of health. As such, based on practical applications of resilience science [8] and research on education for healthcare providers responding to child maltreatment during COVID-19 [6], we provide some suggestions for bringing conversations about resilience to the forefront of visits with children, youth, and their families accessing services related to mental health in primary care and appointments related to children’s mental health.

First and foremost, conversations with children and families about resilience in the face of the COVID-19 pandemic should be trauma-informed, which includes the acknowledgement of the widespread impact of trauma and an approach that is empathic, validating, transparent, and trustworthy. Although many of the suggestions provided below are universal, there may be more time to address such discussions in the context of a longer visit to address mental health challenges. Starting the conversation with the child or adolescent by asking them how this time has been for them may help to open up the conversation in an empathic and non-judgemental way. The child or adolescent should have the opportunity to have conversations about sensitive topics and family relationships on their own in order to maximize comfort and safety.

Acknowledging the potential hardship associated with exposure to ACEs during the pandemic, while also recognizing that many children demonstrate positive adaptation or resilience despite experiences of significant risk is important [8]. Guidance and educational resources for healthcare and social service providers on how to discuss difficult topics, like child maltreatment and family violence, are publicly available in order to support safe and effective assessment and responses to these discussions during practice encounters [6]. For example, before asking children about relationships in the family, it is important to outline the limits of confidentiality, due to mandatory reporting obligations.

Second, it is important to ask children what helped them be resilient in the face of adversity in the past, to bring their effective coping and problem-solving strategies to conscious awareness, so they can draw on those strategies in the future. Engaging children in conversations about what they can do helps to promote a sense of self-efficacy, which is associated with better-than-expected outcomes in challenging situations. These conversations can also model for families on how to engage in these discussions together.

Third, it is important to discuss the mental and physical well-being of the parent or caregiver. Checking in on how they are doing and asking about what supports the parent or caregiver has available for themselves and how these can be bolstered in times of stress is essential. The COVID-19 pandemic has had a deleterious impact on the stress and mental health of parents [11]. Understanding what the experience has been for the parents and subsequently ensuring that they are connected with adequate supports and resources is essential. Having a list of available mental health supports, both in person and online, that parents can access would be a useful resource. Supporting parents can prevent further or ongoing exposure to child ACEs, which is critical as an accumulation of ACEs over time is associated with the most deleterious child mental health outcomes [7].

Lastly, asking questions about and identifying ways to strengthen positive relationships with the child’s school can be a critical way to increase positive outcomes. The social–emotional learning and relationships that are developed at school are important components for recovery in the aftermath of the COVID-19 pandemic. Healthcare and social service providers are also in a unique position to support parents and caregivers in advocating for their child’s needs within the school system (i.e., via summary reports, diagnoses), particularly for families where a child has mental health or learning needs.

Conclusions

Many children and families continue to face adversity during the COVID-19 pandemic. Although these experiences convey risk for poor developmental outcomes for children, these outcomes are far from inevitable. The multiple systems in children’s lives, including their families and schools, can provide opportunities for support that can lead to better-than-expected outcomes. In line with resilience science, healthcare and social service providers can play an important role in advocating for parent wellbeing and supportive school environments in order to shift the tides to increase adaptive outcomes for this generation of children and adolescents. From a research perspective, there remain important data gaps with regard to some ACEs for children and youth during the pandemic. Surveys of the prevalence and nature of child maltreatment and intimate partner violence will be important to inform prevention, policy, and practice. Prioritizing epidemiological studies with strong methods will help us to better understand which ACEs have increased, for whom, and under what circumstances. Taken together, strong responses from both a practice and research perspective will be critical for promoting healthy children and families.