Toxic Stress Affecting Families and Children during the COVID-19 Pandemic: A Global Mental Health Crisis and an Emerging International Health Security Threat

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has created numerous risk factors for families and children to experience toxic stress (TS). The widespread implementation of lockdowns and quarantines contributed to the increased incidence of domestic abuse and mental health issues while reducing opportunities for effective action, including social and educational interventions. Exposure to TS negatively affects a child’s development which may result in a lasting impact on the child’s life, as measured by tools, such as Adverse Childhood Experiences (ACE) score. When TS becomes highly prevalent within a society, it may develop into a health security threat, both from short- and long-term perspectives. Specific resources to combat the pandemic have been put in place, such as COVID-19 vaccines, novel therapeutics, and the use of telemedicine. However, the overall implementation has been challenging due to a multitude of factors, and more effort must be devoted to addressing issues that directly or indirectly lead to the emergence of TS. Only then can we begin to reduce the incidence and intensity of pandemic-associated toxic stress.

1. Introduction

Since its emergence more than 2 years ago, the coronavirus disease 2019 (COVID-19) pandemic has resulted in unprecedented stress for families around the world [1], and perhaps even more so for children [2]. Designed to help curtail the spread of the causative coronavirus, various “curve-flattening” measures have disrupted and/or distorted traditional social networks [3]. In this context, the stress in the absence of protective relationships can quickly become toxic, harming one’s mental and physical health [4]. Interpersonal connections enable the conveyance of compassion and empathy. Without the presence of the above, individual development and well-being are likely to be negatively affected. This chapter discusses the topic of toxic stress (TS) among families and children during the current pandemic, focusing on identifying risk factors and deriving pragmatic solutions. These considerations are further superimposed on the relevance of TS to the general area of international health security, both in the short- and long-term timescales.

2. The coronavirus disease 2019 (COVID-19) pandemic

In Wuhan, Hubei Province, China in December 2019, pneumonia of an unknown origin started affecting index cases linked to a local wholesale food market [5]. Respiratory samples collected from these patients were subjected to genomic analysis, and the virus responsible was discovered to be a novel coronavirus related to Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV). It was therefore named SARS-CoV-2, and the disease it causes was named coronavirus disease 2019 (COVID-19) [3, 5]. Due to its high infectivity, the novel coronavirus began spreading rapidly around the globe, leading the World Health Organization (WHO) to declare COVID-19 as a pandemic disease in March 2020 [6]. As of July 3, 2021, the total number of cases of COVID-19 in the United States was 33,530,880, including 15,555 new cases [7]. To date, more than 1,000,000 patients have died from COVID-19 in the United States alone [7].

In comparison, the 1918 Spanish influenza pandemic was caused by the H1N1 influenza A virus and lasted from 1918 to 1920 [8]. It disproportionately affected healthy, 25-40 years old individuals, who accounted for 40% of mortalities. By the end, the H1N1 pandemic was responsible for 50 million deaths worldwide [8]. In contrast, COVID-19 primarily affects people over the age of 65, especially those with comorbidities [8]. Although the overall mortality rate is very similar between the two pandemics - 2.5% for H1N1 and 2.4% for SARS-CoV2 - the mechanisms for mortality differ [8]. Whereas H1N1 tended to cause secondary bacterial pneumonia, SARS-CoV-2 resulted in an overactive immune response resulting in multiple organ failures [8]. The mean time to death for the H1N1 influenza was 2 weeks whereas it is 25 days for SARS-CoV2 [9, 10]. The latter finding is also responsible for the significant resource utilization (including intensive care utilization) related to COVID-19 cases.

Similar to the 1918 H1N1 pandemic, governments across the world implemented lockdown and quarantine strategies to contain the spread of COVID-19 [11]. In early 2020, many countries started implementing stay-at-home orders and sometimes more extensive shutdowns that mandated the closure of all non-essential businesses with concurrent stay-at-home orders to help minimize the spread of COVID-19 and to prevent hospitals from being overrun with COVID-19 patients [6, 12]. Additionally, universal masking mandates were put in place and there were physical distancing rules to maintain interpersonal distance of at least 6 feet between individuals when in public [5]. While these measures helped to contain the spread of COVID-19, they also had negative public health effects related to adverse childhood experiences (ACE, see later section) as well as TS [6].

3. Toxic stress risk factors and downstream sequelae: assessing the impact on health security

The SARS-CoV-2 pandemic has sent unprecedented shockwaves of stress through the global society. Severe stress in the absence of protective relationships may quickly escalate to become toxic, impairing both physical and mental health [13, 14]. Toxic stress is especially harmful to children, whose developing bodies and brains are highly susceptible to its negative effects, with potential long-term consequences [4]. Curve-flattening measures, including widespread school closures and social distancing, have disrupted the relational networks of billions of children around the globe [15]. Such disruptions, in conjunction with the severe economic stress caused by the pandemic, represent a once-in-a-century social crisis in the making [3]. Health security impacts will likely be felt for years if not decades to come, and will likely involve multiple domains that were previously defined in the ACAIM International Health Security Consensus [16].

Pandemics, armed conflict, and various forms of displacement pose a threat to the health and well-being of vulnerable populations and especially children [17]. As the global community begins to recognize the cumulative effects of various social and economic stressors related to the pandemic, the attention of researchers has shifted to TS and its short- and long-term health effects. Toxic stress, regarded as the result of prolonged activation of the stress response, can occur before birth and during childhood and is known to contribute to epigenetic changes, with potential health and neurodevelopmental consequences [18, 19]. Domestic abuse and child witnessed violence, both of which have increased during the pandemic, can further exacerbate the problem [3, 20, 21, 22]. However, various social factors and early and appropriate intervention can help mitigate many of the negative effects. We will now shift our focus to ACEs and their downstream consequences.

4. Adverse childhood experiences: focus on long-term sequelae

There exists a broad, fairly heterogeneous, and increasingly more recognized group of negative modulators of child well-being. Collectively, these events can be grouped under the umbrella of ACEs [23]. ACEs can stem from traumatic occurrences, and not infrequently may result in adverse downstream effects, both in physical and psychological/mental health domains. These traumatic experiences, among many, include poverty, physical/mental abuse, mental illness, and community violence [23, 24, 25]. When multiple ACEs occur together there is a much greater probability of the child experiencing long-term health effects [26]. To investigate the relationship between ACEs and negative health outcomes, a study was conducted, surveying adults in San Diego, California, about their childhood history to determine if there was a correlation between ACEs and future health conditions [27, 28]. The study indicated that early emotional trauma may indeed be associated with future adverse health consequences [27]. This, in turn, suggests that traumatic experiences in childhood may pose a long-term threat to our health systems and therefore broadly understood health security. More specifically, ACEs, especially if repeated/recurring, may be associated with a higher prevalence of cancer, depression, and other chronic diseases [26, 29, 30, 31]. However, a child experiencing ACEs may not necessarily equate to future long-term adverse health effects [26]. This in part, is due to the resiliency of the child, their ability to cope with traumatic experiences, and their overall support structure [26]. In the context of the COVID-19 pandemic, the latter may also be significantly affected, resulting in loss of critical social support for the child experiencing ACEs.

Another 2021 study published in BMC Public Health showed a correlation between ACEs and self-rated health (SRH) in young adults [32]. In this prospective cohort study of ACE exposure, ACEs were tracked at varying age groups and SRH values were also recorded for comparison. There was a proportional increase in ACE and SRH scores [32], suggesting a substantial degree of correlation. A better understanding of ACEs may lead to more accurate approaches for predicting future health effects of ACEs and, therefore, may help in the development of earlier and more effective interventions. As such, this general strategy may be one of the key components of addressing health security concerns related to downstream sequelae of ACEs.

Based on existing evidence, early intervention is critical when approaching ACEs to minimize their long-term, negative effects. The Centers for Disease Control and Prevention (CDC) suggest six strategies to reduce ACEs: strengthening economic support for families; promoting social norms that protect against violence and adversity; ensuring strong starts for children; enhancing skills to help parents and youth handle stress; managing emotions; as well as tackling everyday challenges, connecting youth to caring adults and activities, and intervening to lessen immediate and long-term harms [33]. However, with the COVID-19 pandemic, there has been an increase in occurrences of ACEs due to the lockdowns and quarantines implemented to help stop the spread of SARS-CoV-2 [34]. The lockdowns are forcing some children to stay in homes that are emotionally unhealthy and traumatic [34]. Additionally, the lockdowns have also made it more difficult to implement many of the strategies that the CDC suggests are needed to prevent ACEs [15].

5. Mental health trends in the pandemic: exploring long term impacts on health security

The COVID-19 pandemic has had many negative effects on the mental health of both adults and children [35, 36]. The stress associated with the fear of the unknown, along with the abrupt closure of schools in March 2020, spiraled many children into emotional upheavals they had not experienced previously. The sudden switch from “going to work” every day to “working from home” or being furloughed or laid off led to enormous financial stress for many families. Not feeling financially secure may lead to significant emotional pressure for adults, which is often projected onto children, in various and often unpredictable ways. The closure of schools and businesses resulted in a significant reduction in direct human contact. Casual daily social interactions constitute an important outlet for mental health stress for many people [37, 38].

Prior to the pandemic, approximately 1 in 10 adults reported anxiety or depressive disorder. This increased during the pandemic, with about 4 in 10 adults reporting corresponding symptoms [10]. A survey in June 2020 showed that 13% of adults admitted to increased or new substance use, attributing such response to the stress related to the COVID-19 pandemic [10]. It is well established that mental health stress in adults directly impacts toxic stress in children [39, 40]. When adults are under stress, they have less emotional “reserve” or “bandwidth” to effectively care for their children, which may, in turn, result in physical child abuse, emotional child abuse, neglect, or unhealthy interactions that although not necessarily outright abusive, may still have deleterious effects on our children [41, 42].

Irritability, inattention, and clinginess were seen among children in early pandemic studies along with sleep issues, decreased appetite, and separation anxiety [43]. Adolescents may be prone to hoarding behavior due to the panic-buying seen in the early pandemic. Obsessive–compulsive behavior may be increased because of hoarding, general feelings of fear and uncertainty, a heightened awareness of how viruses are spread, as well as the need for cleanliness to prevent viral spread [43]. Increased reliance on electronic devices for online schooling or as a means for human interaction while in the quarantine may lead to worsening social media/electronic addiction as well as cyberbullying [43, 44].

The mental health needs of our society related to the COVID-19 pandemic, will continue to be apparent for years to come. Many downstream effects will be unpredictable, individualized, and likely highly variable in terms of temporal patterns. Toxic stress from the poor mental health of our adults and children will lead to deleterious emotional and health effects that are yet to be seen. Focusing on the mental health of our entire population is essential to help decrease these effects. Increased mental health support with both inpatient and outpatient resources is needed now, and will certainly be needed for the foreseeable future.

6. Toxic stress as an international health security threat

No one is immune to the effects of COVID-19. In addition to millions of confirmed cases worldwide, COVID-19’s effects on individuals and communities extend far beyond hospitalizations, morbidity, and mortality. Pandemics have deleterious consequences on the well-being of individuals and communities through direct effects of the illness and emotional isolation, economic loss, work and school closures, and maldistribution of resources [45]. Published data describe how various consequences of pandemic mitigation efforts (such as quarantine) affect stress, depression, fear, anger, boredom, stigma, and other negative states. Adults readily report worse psychological well-being now as compared to before the pandemic [46]. Because data suggest that children might less frequently transmit or become severely ill from the virus, the more unique consequences that COVID-19 has on children may easily be overlooked. Although data on child and family well-being during COVID-19 are not as robust, increasing reports of intimate partner and family violence around the globe continue to be of great concern [47, 48, 49]. Long-term impacts on broadly defined health security will likely be both significant and difficult to predict.

Within the international context, conflict-affected populations are particularly vulnerable to COVID-19. Overcrowding and inadequate water and sanitation systems in refugee camps and informal settlements, coupled with previously existing illnesses, may increase the spread of COVID-19 and further exacerbate the emotional trauma upon the most vulnerable segments of the population. Moreover, resource and health system constraints may restrict access to adequate and appropriate care. Control measures such as physical distancing may be difficult and may also increase economic precarity, intimate partner violence, and food insecurity in populations already vulnerable [3]. The incidence of post-traumatic stress will likely increase following the pandemic – another “invisible” aspect of this global event, reported following previous emerging infectious disease outbreaks [50].

Downstream, long-term consequences of toxic stress are more poorly understood, but the associated increase in behavioral health issues, combined with secondary implications inherent to these considerations, are bound to create a truly global urgency and crisis [4, 51]. This is especially true when looking at geographic areas with limited resources and a lack of robust mental health infrastructure. In terms of addressing some of the challenges related to halting any downstream escalations secondary to toxic stress, several truly international strategies can be considered. Among those, the most prominent is telehealth/telemedicine, as discussed in a subsequent section of this chapter [52, 53]. Other important components here include the provision of safe environments, education, as well as ongoing close support and reassurance.

7. Vaccination availability: a gateway to normalcy

On December 14, 2020, the U.S. COVID-19 Vaccination Program began, with vaccines from Pfizer (New York, NY); Moderna (Cambridge, MA); and Johnson & Johnson (New Brunswick, NJ) being deployed [54], first for domestic then for global use. To date, Pfizer and Moderna each require two shots to achieve fully immunized status, whereas Johnson & Johnson requires a single shot [55]. Pfizer vaccines must be given to patients ages 12 and older, while Moderna and Johnson & Johnson vaccines must be given to patients ages 18 and up [55]. An additional booster dose has been recommended by all companies for patients ages 12 and up [55]. Other countries also deployed their own vaccines to meet local needs [56]. As of April 1, 2022, as many as 561,173,692 COVID-19 vaccines have been administered (255,582,575 have received at least one dose and 217,703,007 are fully vaccinated); thus, 77% of the U.S. population has received one dose, and 65.6% are fully vaccinated [54]. Studies have shown that Pfizer and Moderna vaccines are approximately 94-95% effective for patients who have received the second dose and 64% for those who have received just one dose [57]. The Johnson & Johnson vaccine has shown 66.3% effectiveness in clinical trials for patients with no prior COVID-19 infection [58]. Compared to fully vaccinated patients, unvaccinated children are 1.6 to 2 times more likely to be hospitalized, and adults are 5 times more likely to be hospitalized [55]. According to the CDC, the number of new COVID-19 hospital admissions has been generally decreasing from April 19 to June 22, 2021 [55]. Therefore, the global distribution of COVID-19 vaccinations appears to be providing immunity against the virus, shown by the decline in hospitalization and a slower increase in new cases of COVID-19.

Increased vaccination rates in eligible candidates significantly help to curb virus transmission rates within a population. This, in turn, may be able help neighborhoods to lift quarantine and lockdown measures, aid in a quicker return to “normal”, which therefore may help reduce the toxic stressful environment and its harmful consequences on children. Consequently, well-implemented vaccination programs are critical to international health security, the well-being of the global population inclusive of children, as well as our current best attempt at the return to normalcy [59].

8. Role of telemedicine: an important part of a comprehensive mitigation framework

Telemedicine plays an important role in our collective efforts to prevent and mitigate toxic childhood stress in the COVID-19 era [52, 60]. By leveraging technology to deliver patient care remotely, telemedicine enables interpersonal connectivity while overcoming many of the limitations related to either social distancing or lack of resources (e.g., transportation). Health care providers, through virtual visits and other telehealth platforms, may be able to provide effective emotional support and psychosocial buffering for families experiencing acute stress [61].

Through the provision of frequent interpersonal touchpoints, telemedicine can furnish an important platform to support the well-being of children [62]. One of telemedicine’s main strengths resides in the ability to reduce costs associated with access to care, primarily by reducing the time and expense of travel, waiting, and paid time off [63, 64]. Moreover, health systems can leverage the lower associated cost(s) to perform more frequent virtual check-ins (and thus provide more support). More face-to-face time, in turn, helps build trust and creates opportunities for providers to affirm families’ strengths and resiliencies, as well as reinforce strategies that are effective in combating acute stress, including balanced nutrition, physical activity, quality sleep, mindfulness practices, supportive relationships, and mental health care [65, 66, 67].

In the wake of widespread parental fears regarding the potential for exposure of children to COVID-19, telemedicine can help make all stakeholders feel safer, especially in terms of public immunization programs. This is a very important aspect of the overall care provision since visit volume in many outpatient pediatric offices decreased by >50% and vaccine orders have fallen by 2.5 million since March 2020 [68]. The American Academy of Pediatrics has urged the continued provision of routine immunizations for children. In response, some practices have begun offering curbside and drive-through immunization clinics [68]. Utilizing telemedicine for interpersonal connection and relationship building alongside socially distanced medical procedures such as immunizations and biometrics could help optimize the balance between putting patients at ease and bringing them up to date with care.

Telemedicine has its limitations in evaluating the well-being of children and parents. Establishing and maintaining a personal connection with a family is more easily done with an in-person visit. Signs of child abuse may be missed as physical exams are limited during a telemedicine visit. Bruising and intentional skin trauma may not be appreciated through a camera. Intraoral trauma would be difficult to identify [69]. It is more difficult to speak with children alone through a virtual visit and they may be less willing to identify stressors with parents present [69]. Mental health evaluation may be challenging if children do not feel comfortable divulging information while at home or in front of their parents. In contrast with in-person visits, where those present are seen and accounted for, situational awareness during virtual visits is more limited. For example, a violent partner or parent could be present during a virtual visit but out of audio or video range. Traditional social screening questions such as “do you feel safe at home?” may not only have lower utility in a virtual visit, but they could also risk exacerbating household tensions [61].

In light of the above considerations, approaches aimed at specific educational initiatives have been proposed by domestic violence and toxic stress experts during the COVID-19 pandemic. Beyond virtual visits, advances in telemedicine could empower patients through easily (and confidentially) accessible information and resources [61]. Other helpful tools could include confidential two-way messaging platforms and clinical message pools for providers to streamline referrals. Provider education models, such as Safe Environment for Every Kid (i.e., seekwellbeing.org), which incorporate social work collaboration, have been shown to effectively prevent child maltreatment. Trauma-informed screening tools, such as the Pediatric Adverse Childhood Experiences and Related Life-event Screener, have demonstrated strong face validity in pediatric primary care [28]. Adopting such approaches to the telemedicine space could be highly promising. Various sets of specific considerations applicable to health security may also be applicable ‘by proxy’ due to the benefits gained via telemedicine-based behavioral health interventions.

9. Conclusion

The COVID-19 pandemic has ushered dramatic social and economic upheavals, leading to a highly stressful period in our history, especially challenging for families and children. The identification and prevention of toxic childhood stress in the COVID-19 era may be especially difficult during this time. Much remains to be learned about risk factors and ways to remediate this serious health security threat, especially when considering its potential long-term consequences. The initial steps to begin healing our children from a hopefully once-in-a-lifetime pandemic include: 1) widespread recognition and identification of the effects of toxic stress on children, as measured by validated tools, such as Adverse Childhood Event (ACE) scores, and its possible impact on the development of chronic diseases and mental health issues later in life; 2) increase in vaccination rates across all eligible candidate groups; and 3) implementation of telemedicine to support access to health needs, and to build and maintain relationships between healthcare workers and the community. Although the implementation of the above steps may be challenging, continued support and necessary resources must be put forth toward one of our most vulnerable populations to help remediate the long-lasting impact of TS for years to come.