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Recently, CNN wrote about an alarming drop in the number of reports of child abuse and neglect during the coronavirus shutdown.
To find out more about the long-term effects of the pandemic on children, I talked to Dr. Nadine Burke Harris, who is the surgeon general of California and in that position is deeply involved in that state’s aggressive response to the coronavirus. I wanted to talk to Harris in particular because she is in a cross-pressured spot. Her career achievement is bringing attention to the effects trauma in kids has on their lifetime health. (If you want to learn more about that, watch her TED Talk, “How childhood trauma affects health across a lifetime.” It’s been viewed many millions of times.)
But her current job involves a shutdown policy that creates a perfect environment for that very trauma, which raises the question of whether state officials are weighing child welfare with stopping the spread of the disease.
One thing you need to know before reading further: The professional shorthand for childhood trauma is ACEs, or “Adverse Childhood Experiences.” Kids get a score depending on how many adverse experiences they encounter and there is a correlation between a higher score and worse health later in life. The touchstone for this work is a study conducted by the Centers for Disease Control and Prevention and the Kaiser Family Foundation.
An edited version of our Q-and-A, conducted via telephone, is below:
ZW: I was going to write about how this coronavirus shutdown will mark a whole generation of kids. But your specific area of interest is how childhood traumas affect long-term health. Is that going to happen because of this as well?
NBH: I understand your question, but there are two parts to it that I want to clarify. When we look at the adverse childhood experiences identified in the CDC Kaiser study, they include 10 criteria including physical, emotional, sexual abuse; physical and emotional neglect; or growing up in a household where a parent was mentally ill, substance dependent, incarcerated; where there was parental separation or divorce; or domestic violence. So those are the 10 ACE criteria.
And what we see is that the more of those a person has experienced, the greater their risk for lifelong health, mental health and behavioral problems. The reason for that is because the repeated activation of the stress response can lead to disruption of the stress response which disrupts brain development, the immune system and hormonal system.
Now, what we’re seeing in the Covid pandemic is that intimate partner violence is increasing, substance use is increasing, mental health disorders are increasing. And because of that on the one hand, we are seeing an increase in the traditional ACEs and that’s of really significant concern.
But to the other point that you’re making – everyone’s stress-response system is activated right now. Right? And that’s for kids and adults.
What we understand about the way in which activation of the stress response system leads to long-term health risks, there’s one piece of that that’s really, really important – which is that if kids get adequate buffering caregiving, that can biologically buffer that stress response and prevent those harms.
And so one of the most important things that we see right now is the importance of that stable and nurturing relationship and environment for kids.
ZW: But they’re not in school. They can’t go to community centers. Is there a universe of kids that’s essentially being swept under the rug during during this pandemic?
NBH: So, to your point, that is of great concern. What we’ve seen in the state of California has been – actually while we’ve seen reports of all of these other ACE indicators increasing – the reports of child maltreatment have fallen from 40% to 50% state-wide since the shelter-in-place order was implemented.
Now what we think that reflects is that children are not coming into contact with the safe adults who would be making those reports. So we don’t think child maltreatment is going down. We think that it’s likely following the trends of these other indicators and probably going up.
But the concern there is that it’s going unreported. So, yes there is real concern about kids being at increased risk.
ZW: You’re the surgeon general for California and you must have some input into or at least be privy to some of the decision-making that goes on with shelter-in-place orders. To what extent are these unintended consequences being taken into account by the decision-makers right now?
NBH: Well, you know, certainly when we’re thinking about the remain-at-home order we are thinking about all of these things. We’re thinking about the economic impact, right. We’re thinking about these stress-related secondary impacts. We’re thinking about safety and well-being and looking at the death toll related to the the virus. So all of this is being considered.
ZW: What should states be doing to reach kids that are not being encountered by the normal mandatory reporters?
NBH: So some of the things that we have been encouraging folks to do have been, for example, if you’re a trusted adult in a child’s life, continue to reach out, even if it’s sending a text or by FaceTime. If it’s grandparents connecting in the lives of children, coaches, faith leaders – we’re trying to encourage everyone who has a role to be reaching out to others and not just to the kids themselves. But also to their caregivers who may be struggling.
We’ve also made available on the state’s COVID19.ca.gov website a whole series of hotlines and warm lines including the teen crisis line, including the National Domestic Violence hotline, and the suicide prevention hotline – all of these different resources so that folks can readily reach out and access help if they need it.
ZW: You are perfectly formed as a doctor and a public advocate for this moment because you were talking about this specific issue long before this pandemic hit, and now you’re in a position to do something about it, at a moment when it would seem to be the worst nightmare for you that we can’t reach these children right now. How have you processed that?
NBH: Well, I think I try to be a solutions-oriented person.
And I’m definitely focused on how we utilize the resources that we have. And so one example is, and I have to say it is actually incredibly timely that the state of California just launched an initiative called ACEs Aware.
It’s a state-wide program to train primary care clinicians to screen for adverse childhood experiences in both children and adults and respond with trauma-informed care support and solutions.
It’s one of the pieces that are really powerful. And not only are we offering training and support for clinicians to do this work, but we’re also providing reimbursements. So we’re paying providers to do this and it could not be more timely. Because right now as kids are out of school, they’re not being seen by their teachers or their coaches.
The American Academy of Pediatrics actually last Friday announced their recommendation that pediatricians resume in-person visits for well-child exams. So we recognize that doctors and other frontline healthcare clinicians can be an important bridge between kids and getting the services and resources that they need. And our doctors in California are now screening for adverse childhood experiences. So that’s really important. And in fact, as a state, we issued guidance to both adult- and child-serving health practitioners to say there is going to be an increase in stress-related chronic disease all the way from high blood pressure to diabetes to substance use and depression.
ZW: How important are schools specifically in trying to identify and mitigate these? Is it overstating to say that schools are the single most important identifier?
NBH: One of the things that I want to clarify is that while we are training doctors and other health providers to screen, we recognize the role of schools and the educational environment.
Everyone has a position to play. And so we recommend that doctors and health providers screen, but educators are in the position of providing the daily doses of nurturing, buffering interaction that are actually healing for kids.
And from that standpoint, our educational community has among the most vital roles to play.
And that requires our educational institutions to be trauma sensitive and trauma informed to know how to recognize that when a child is demonstrating, for example, poor impulse control or angry outbursts, that those may actually be symptoms of a child who has an overactive stress response because of the adversity that they’ve experienced.
I think that educators have this really important role to play of recognizing that and then connecting that child with family services that are healing as opposed to further punitive or stigmatizing responses.
ZW: We’re doing this interview and I’m home. My kids are outside. This shutdown is going to be harder on communities that don’t have those luxuries. Is this just going to compound the nature of being at-risk, if that’s the right term?
NBH: One of the things that we’re seeing right now with the Covid pandemic is that black and brown communities are being disproportionately impacted by Covid-19 in terms of infection rates and death rates.
And part of that has to do with the fact that we recognize that there’s an increased risk of exposure. So black and brown folks are overrepresented among frontline workers that are really essential workers like, for example, grocery store clerks or bus drivers, folks who are in the service sector.
In addition, when I talk about the overactivity of the stress response as a result of ACEs that lead to changes in brain, immune and hormonal function, that biological process is known as the toxic stress response.
And what we know about that is that the higher the total dose of adversity someone has experienced in their life, the greater the risk of someone having a toxic stress response.
One of the things my office is trying to understand is whether or not the cumulative dose of adversity – so we recognize that the cumulative dose of adversity for black and brown individuals on average as a population tends to be higher in part because of the historical discrimination that has limited access to certain neighborhoods educational opportunities, job opportunities, but also because the experience of discrimination is in and of itself an adversity that is also a risk factor for toxic stress.
It’s not one of the traditional ACEs because it wasn’t one of the criteria that they looked at in the study, but we do recognize that it is an adversity that increases the risk of this topic stress response.
And one of the concerns is that this may be playing a role in the increased vulnerability of black and brown communities to Covid and the increased mortality rate.
So when you ask the question around – which communities are going to be more impacted? – we believe that communities that experience high doses of adversity have greater vulnerability during this time.
ZW: Is there anything else you’d like to tell our readers?
NBH: I think the thing that just comes to mind for me is that when most people think about the impact of stress, they think about anxiety or depression or substance abuse, of the mental and behavioral health consequences.
The research and literature that my team has worked on has shown that after natural disasters, some of the things that we see are increased risk of heart attack and stroke, increased risk of diabetes and poor diabetes management, increased risk of high blood pressure.
As our health care system is responding to the Covid pandemic, I think it’s just as important for us from a health care standpoint to be looking at the secondary impacts of the Covid pandemic – stress and the increases in stress related chronic disease – as it is for us to be looking at Covid infection itself.