ACEs and Resilience in the Environment of COVID-19

By Richard Murdock and Jennifer Nottingham, Michigan ACE Initiative

Several weeks ago, a request was made to address the issue of COVID-19 and Adverse Childhood Experiences (ACEs). As serious as these issues are, it appeared at first to be an easy assignment. But maybe not. It is not necessary to recite the statistics or forecast on COVID-19, nor is it necessary to reiterate the public health message embedded in much of the public discourse. Many of us have family, friends, and colleagues who have succumbed to COVID- 19—this makes it personal. Nor will we speak to the needless adversarial environment that we have found ourselves without any likely relief for the remainder of the year. However, most persons will now agree that we initially underestimated the harmful impact of COVID-19 and how it has penetrated all segments of society. In doing so it has unmasked a substantive and urgent breach in our society of a disproportionate percentage of cases and deaths in for people of color and underserved populations. More on this below.

Some have proposed that COVID-19 may be another ACE. However, we suggest that COVID- 19 is not another ACE category for the simple reason that while it has the potential to be traumatic, not all children will be traumatized by the experience. Many young children, especially though not exclusively children of families that have access to sufficient resources to navigate the challenges of COVID-19, are tremendously enjoying the opportunity to be with their parents all day as a result of COVID-19, even if the parent is distracted by a Zoom meeting. Some children find online schooling a respite from peer pressure and bullying. Nonetheless, we cannot ignore the impact that COVID-19, as a crisis event, will create and exacerbate trauma for some children while still being mindful that this impact may not affect others.

The way a child experiences COVID-19 depends in part on each unique family situation – how the parents or caregivers are coping with COVID-19, and how the child is interpreting what they are experiencing. Are family members dying? Do they still have enough to eat? Is there a message that COVID-19 will kill them, are family members nonchalant about the impacts of COVID-19, or is it being communicated as the CDC suggests, as a potentially but not necessarily deadly disease that must be navigated with caution? Do children and families still have support from factors that contribute to the social determinants of health and critical supports to offset the impact of the stress of COVID-19?

Many variables will influence how communities and individuals experience COVID-19. Further, the potential for trauma associated with COVID-19 is not exclusively limited to children: the trauma and stress can be experienced by all age groups. Thus, while we believe COVID-19 may worsen ACEs and has the potential to create trauma, we do not believe that COVID-19 is a new ACE.

We do acknowledge, however, that COVID-19 will increase the severity and frequency of ACEs for many families, particularly families that were vulnerable and stressed before the crisis. Significantly, several pediatric hospitals report up to a four-fold increase in the number of children hospitalized for severe child abuse since the onset of COVID-19. Domestic abuse victims have no respite, and many domestic violence hotlines have shifted to providing victims of intimate partner violence with coping strategies as opposed to an escape, as the domestic violence shelters are unable to accept victims. Additionally, the stress and anxiety associated with COVID-19 had the potential to exacerbate existing mental health issues and proclivity to abuse substances.

Further, as the unemployment rate skyrockets, the loss of jobs and wages (critical social determinants of health) due to COVID-19 creates tremendous stress. Statewide Michigan 211 data reveals that the number one request and unmet need since the onset of COVID-19 is financial support for housing and food. Limited access to the social determinants of health, particularly for vulnerable populations struggling with inequities whose access before the pandemic was already precarious at best, will worsen existing stress and create environments that are potentially highly risky for children and adults alike. These stressful environments may create conditions that are more conducive for abuse and neglect, as families navigate the hardships associated with COVID-19.

The supports that one might typically access to offset the impact of these stresses are less available. Stay at home and shelter-in-place orders mean that individuals are increasingly isolated from protective relationships to maintain and build resilience. Services to cope with mental health struggles and substance abuse are, when available, often limited to virtual and telehealth platforms.

We must also acknowledge how COVID-19 has worsened social and health inequities, as COVID-19 is disproportionately affecting communities of color. Though 13% of the population, nationally 25% of deaths due to COVID-19 are black. In Michigan, those disparities are even more significant: 14% of Michigan’s population is black, but 40% of the deaths due to COVID-19 in Michigan are black. Experts observe that a combination of systemic disadvantage and unconscious bias may be contributing to these conditions. Communities of color that often find themselves in neighborhoods with concentrated poverty and work in “essential” low wage jobs may be disproportionately experiencing stress and exposure to COVID-19. These stresses may compromise resilience and worsen underlying conditions that have the potential to increase the intensity and frequency of ACEs. These deaths will not only create trauma as children lose parents and grandparents; whole communities are affected by the loss of respected and valued elders.

Summarized, COVID-19 has the following impacts:

– COVID-19 stress creates conditions conducive for an increase in the frequency and severity of ACEs.

– COVID-19 may limit access to the social determinants of health, particularly for vulnerable populations, thereby perpetuating existing inequities: those with the most precarious access to social determinants of health before the pandemic will be most likely to lose access to social determinants of that help to stabilize a home environment during the pandemic.

– The loss of jobs, income, housing, food, and access to health care due to COVID-19 creates additional stress that creates conditions conducive to an increase in ACEs.

– COVID-19 stay-at-home, social distancing, and shelter-in-place orders limit access to protective factors that build resilience and offset the impact of stress and adversity: examples of these protective factors include caring relationships, support services, and opportunities for respite and joy.

The environment created by COVID-19 is creating more stress, which, as described above, creates conditions conducive to a significant spike in ACEs. The presence or absence of the supports of the social determinants of health and supports before and during COVID-19 influences how individuals are experiencing the pandemic, and the resources to which they have access to cope with the new stresses. Even families with sufficient financial resources are finding the isolation from traditional social networks and the interruption of everyday activities to be stressful and overwhelming. Collectively, we must consider how to address the spike in ACEs that are the by-product of COVID-19.

Usually, when you are developing a blog, you have a belief that your words matter, and in small measure will make a difference. But this feels different. Fundamentally, we must begin to challenge our thinking, our programs, and support systems. Recovering back to the pre-COVID period (status quo) is not the answer that will make a difference. We need to begin a change in our thinking. We have always known that ACEs reflect our failure in society, and we pay a steep price in future expenses. The impact of COVID-19 is more immediate; in some cases, it is a matter of life or death.

As lifelong learners, participants, and observers of our health care systems and payment programs – there is no question that COVID-19 has clarified once and for all that our health care policy is poorly informed, has bias, and imposes a heavy burden for our most vulnerable populations. We must begin a hard conversation on values and what we are willing to support.

Conclusions and Next Steps

– Our efforts and advocacy for resources for interventions to build resilience and provide support for individuals who have experienced adversity as a result of COVID-19 will have to be incorporated into our work.

– Our evolving focus on linking equitable access to the Social Determinants of Health with ACEs is the right course of action, and we need to do so more purposefully and urgently.

– Equity matters—now more than ever and COVID-19 has exposed our failure to meaningfully address health equity and social justice. The data doesn’t lie.

To address this, the Michigan ACE Initiative plans to convene professionals across the state of Michigan to identify both specific and cross-sector strategies to create trauma informed support health and social systems. We anticipate identifying innovative ideas to embed a trauma informed approach across Social Determinants of Health.

Further, the Michigan ACE Initiative will work with its network of Michigan ACE Master Trainers, community champions, and sector leaders that have found success in putting trauma-informed supports in place augmented by local and national best practices. These best practices will be compiled into modules that organizations, communities, and institutions can use to create trauma-informed environments that build resilience to achieve systems change.

If you would like more information on these issues, how they affect ACEs, and the work planned for the Michigan ACE Initiative, please contact Jennifer Nottingham at jnotting@mphi.org.