Children are vulnerable to a range of experiences that can affect their physical health, mental health, and productivity in adult life (Clark et al, 2020). Adverse childhood experiences (ACEs) is a term that refers to traumatic events, including various forms of abuse, neglect, and household dysfunction, that occur before the age of 18 years, (Bryant et al, 2020; McLennan et al, 2020). ACEs were first identified by Felitti et al (1998), when researching the relationships between experiences of trauma in childhood and detrimental effects on health outcomes later in life.
Felitti et al (1998) originally defined ACEs as ‘childhood abuse and household dysfunction’. The original experiences identified included sexual and other forms of abuse, and a ‘dysfunctional family life’, which included drug use and criminal activity by parents, and domestic violence (Felitti et al, 1998). Karatekin and Hill (2019) suggest expanding the original definition of ACEs from maltreatment and household dysfunction. There are now 10 main categories of ACEs (Public Health Scotland, 2020):
- Physical
- Emotional abuse
- Sexual abuse
- Physical neglect
- Emotional neglect
- Parental abandonment
- Parental imprisonment
- Mental illness
- Domestic violence
- Substance misuse.
Prior to the COVID-19 pandemic, 14 ACE assessment methods were identified that can be used across a variety of settings (Bethell et al, 2017). The common issues in these tools are parental incarceration, domestic violence, household mental illness/suicide, household alcohol or substance abuse (Bethell et al, 2017). When considering COVID-19 and ACEs, the question should be by what method and against what criteria can we judge whether COVID-19 is an ACE in itself? If it is an ACE, then the assessment tools used need to include it. This has an impact on future care, because if ACEs are defined more broadly to include COVID-19 then the proposed treatment options should be broader to address the long term implications of it.
What are ACEs?
Although it is now widely held that there are 10 main categories of ACEs (Public Health Scotland, 2020), this list has changed through the years. The types of ACEs have changed from the impact of parental death or parental illness, sibling death, and poverty, to divorce, physical abuse, sexual abuse, physical and emotional bullying and exposure to community violence, with the latter types increasing in prevalence (Finkelhor, 2020). Parental alcohol and drug abuse, oft en resulting in parental incarceration, have been identified as more prevalent ACEs (Finkelhor, 2020). Crouch et al (2019) conducted a study of 45 287 children and identified the most prevalent types of ACE exposure experienced by children. These were economic hardship and parent or guardian divorce or separation; these were particularly prevalent in children who were older, were non-Hispanic African American, who had special healthcare needs, or who were living in poverty and rural areas (Crouch et al, 2019). Prior to the pandemic, UK child poverty levels were predicted to increase markedly and there was a call to ensure a policy approach that considered the socioeconomic context to ACEs (Walsh et al, 2019). Childhood poverty appears to be rising on a global scale during the pandemic (Fry-Bowers, 2020; Van Lancker and Parolin, 2020).
‘When considering COVID-19 and [adverse childhood experiences], the question shouls be by what method and against what criteria can we judge whether COVID-19 is an [adverse childhood experience] in itself?’
The COVID-19 pandemic may have led to increased prevalence of adverse childhood experiences, for example, domestic abuse as families spend more time together during lockdown, and children who have pre-existing adverse childhood experiences may be more vulnerable to the effects of the pandemic.
‘… the COVID-19 pandemic may be amplifying some ACEs in individuals by increasing social isolation, financial pressures and job loss, school closures, and exposure to the morbidity and mortality of the disease. It has also been shown that children are being exposed to an increase in intrafamilial adversity, because of increased levels of parental anxieties’
Bryce (2020) suggests that the accumulation of adversity needs to be considered when seeking to understand risk and ACEs in the context of the COVID-19 pandemic. Children may overcome single episodes of trauma but as risk factors accumulate, an individual's ability to endure them diminishes, (Bryce, 2020; Newman and Blackburn, 2002). Edwards et al (2003) suggest that the more adversity a child experiences, the poorer their health and behavioural outcomes will be as they develop. It is certain that the risk of adverse health consequences increases as a function of the number of categories of adversities adults are exposed to in childhood (Felitti et al, 1998). In essence, when children experience multiple categories of ACEs, they are more likely to have multiple health risk factors later in life. ACEs are recognised as predictors of future poor health outcomes, including increased risk of mental illness and chronic diseases, and reduced life expectancy (Anda et al, 2009; McLennan et al, 2020).
Implications for adverse childhood experiences
ACEs have historically been linked to increased health problems and risk behaviours in adulthood (Murphy et al, 2014). These experiences have been consistently linked to psychiatric difficulties in children and adults (Schilling et al, 2007). The different types of ACEs are also considered risk factors for a spectrum of violence-related outcomes during adolescence (Duke et al, 2010). Early life exposure to trauma has the potential to alter an individual's appraisal of threat and increase their anxiety levels (Kalia and Knauft, 2020).
In the United States, ACEs are considered to be a major public health problem and there is a suggestion that this problem has the potential to worsen in the current COVID-19 pandemic (Bryant et al, 2020). Research has shown that there is a cumulative effect of ACEs, both in the case of repeated exposure to experiences of the same type and exposure to different types of trauma and adversity (Nurius et al, 2015). The current pandemic and consequential lockdowns have been identified as potential ACEs (Verger et al, 2020).
The impact of COVID-19
In March 2020, the World Health Organization (2020) declared that COVID-19 had become a worldwide pandemic. The pandemic forced local and national authorities to implement strict social distancing strategies to reduce the morbidity and mortality from acute infection, but these measures carry a significant risk for mental health (Lau et al, 2010; Moser et al, 2020). Population-wide restrictions resulting from disease epidemics, such as the SARS epidemic, have been shown to increase violence, including domestic violence and child abuse (Fitz-Gibbon and Meyer, 2020; Taylor et al, 2008; Wu et al, 2009). Seddighi et al (2021) conducted a systematic review of child abuse during natural disasters and conflicts, and highlighted that the increase in social and economic pressure exposed children to a higher rate of violence.
There is evidence that several forms of ACEs have increased during the current pandemic, such as domestic violence, as people are trapped with abusive family members during lockdown (Bryant et al, 2020; Campbell, 2020). Sanders (2020) suggests that the COVID-19 pandemic may be amplifying some ACEs in individuals by increasing social isolation, financial pressures and job loss, school closures, and exposure to the morbidity and mortality of the disease. It has also been shown that children are being exposed to an increase in intrafamilial adversity, because of increased levels of parental anxieties (Sanders, 2020).
Guo et al (2020) suggest that pre-pandemic ACEs or scars from the past appear to make people more vulnerable because of the societal upheaval caused by the pandemic. In their large online survey, Guo et al (2020) noted this was a particular concern for adolescents from rural areas who experienced family abuse and neglect in childhood. Shreffler et al (2021) conducted a study that highlighted that individuals who had experienced childhood adversity also reported increased stress and poorer mental health as a result of the pandemic. The authors suggest ACEs influence COVID-19-related distress because of greater social isolation, as participants were less likely to have the social connectedness needed to reduce distress from COVID-19 (Shreffler et al, 2021).
The impact of the COVID-19 pandemic has the potential to cause many far-reaching effects across all strata of society and there needs to be further research to investigate the longer-term psychological impacts of the pandemic (Shreffler et al, 2021). Many schools have closed during lockdown and for many students, schools are their only source of trauma-informed care and support (Phelps and Sperry, 2020). Children and their families are more disconnected from direct support systems, such as their extended family, schools, religious groups, and other community organisations (Buheji et al, 2020). School closure itself has been shown to have a detrimental impact on children's mental health (Golberstein et al, 2020).
Douglas et al (2009) published an article on preparing for a pandemic of influenza and suggested that mental health professionals, communities, businesses, and organisations need to create an infrastructure to help mitigate mental health consequences. They suggested that teachers should be trained in empathetic listening skills and need to provide a safe, reassuring environment for children to discuss their experiences (Douglas et al, 2009). In the current situation, schools should have planned how they can address the potential mental health needs of their students, especially now that they have reopened (Phelps and Sperry, 2020). There is a concern that COVID-19 can lead to individuals fostering comorbidities that compound effects. There is evidence that the pandemic has impacted individuals previously exposed to high-stress events, such as death, or those who have been survivors of trauma or ACEs, and the pandemic has the potential to re-traumatise people (Fowler and Wholeben, 2020).
Children and adolescents who have experienced adverse events before the pandemic are especially vulnerable to consequences of the COVID-19 crisis (Fegert et al, 2020). They are at higher risk of developing anxiety and may adopt dysfunctional strategies to manage COVID-19-associated challenges (Fegert et al, 2020). Children with special needs are also vulnerable and need to maintain open communication with their therapists and school workers (Lee, 2020). Children with pre-existing mental illness, such as depression and anxiety disorders, may feel overwhelmed with current events and may experience an exacerbation of their condition (Imran et al, 2020).
‘…pre-pandemic ACEs or scars from the past appear to make people more vulnerable because of the societal upheaval caused by the pandemic… individuals who had experienced childhood adversity also reported increased stress and poorer mental health as a result of the pandemic’
Implications for practice
Kalia et al (2020) examined the relationship between ACEs, the perceived threat from COVID-19, and the impact on cognitive flexibility. The authors suggest that individuals who have been exposed to maltreatment may be vulnerable to developing anxiety disorders following a stressful experience, and recommend treatment programmes that promote cognitive flexibility (Kalia et al, 2020). The authors also suggest that there is limited literature on the psychological toll of COVID-19 on individuals who have been exposed to ACEs. As children are vulnerable to environmental risks that can affect their future health and wellbeing, there is a call to pay close attention to address these issues effectively to avoid any long-term consequences in children (Wang et al, 2020).
Across the UK, the NHS is embracing trauma-informed practice and there is a call to consider COVID-19 as a traumatic, individualised experience (McManus and Ball, 2020). There are online strategies based on the principles of evidence-based child trauma treatment that help build resilience and strengthen coping strategies (Jensen et al, 2014). There is also a need for a universal screening for ACEs in primary care that includes the impact of COVID-19 and for further training in trauma-informed care for teachers and medical staff (Sanders, 2020). The long-term implications of an accumulation of risk and harm need to be acknowledged and embedded in practice in order to effectively respond to the needs of vulnerable children. There is currently a dearth of research looking at the question ‘is living through COVID-19 an ACE in itself?’ McManus and Ball (2020) suggest that COVID-19 should be added to the list of adverse experiences, as this will encourage practitioners to consider the impact of lockdowns and the pandemic on people.
Summary
ACEs are defined as traumatic events, including various forms of abuse, neglect, and household dysfunction, that occur before the age of 18 years. There are 10 main categories of ACEs and these experiences are recognised as predictors of future poor health outcomes, increased risk of mental illness and chronic diseases, and reduced life expectancy. There is evidence that the COVID-19 pandemic has led to a rise in the prevalence of a number of ACEs, such as domestic abuse as a result of increased time spent with family during lockdown. Additionally, children who have previously experienced ACEs may be more vulnerable to the effects of lockdown on mental health and stress. There is a call to consider COVID-19 as an individual traumatic experience of itself. There is also a suggestion that universal screening for ACEs in primary care should be implemented, and that this should include a consideration of the impact of COVID-19.
‘… there is limited literature on the psychological toll of COVID-19 on individuals who have been exposed to ACEs. As children are vulnerable to environmental risks that can affect their future health and wellbeing, there is a call to pay close attention to address these issues effectively…’