In the most basic sense, COVID-19 is a disruption that has upended life as we know it. This is all bad. I pray for the ability to adopt cautious optimism, yet I temper this with a natural, healthy skepticism as we move onward and begin to define a collective, new normal, one that simultaneously teaches us how to both grapple with and properly mourn the lost opportunities that never even had the chance to present themselves.

Child abuse issues have been exacerbated in the COVID-19 era. I often find myself thinking about this problem, mostly because of the stark contrast between this reality for someone else– somewhere else, maybe in a home down the street, across town, across the country, and my own situation. Each morning, I wake up early and stretch, meditate. I either go for a run or sit down and read this mammoth book I’ve been able to power through the last month in all of my newfound, quiet solitude. Relatively speaking, this is easy, and all I am left with is the anxiety of what's to come, contemplating and sometimes catastrophizing the million-and-one possibilities for a future that’s beginning to look stranger and stranger by the day. For now, I can weather those possibilities. Today and for the foreseeable future, there is no immediate threat, physical or otherwise. My husband and I spend most evenings talking late or watching movies, cuddled up on the couch. I worry about how I’m going to make money, but this is hardly a unique circumstance for me.

Over the last five and a half months, I have been researching child abuse and the public health implications of child abuse interventions, specifically home-visitation programs. I can’t help but wonder how these programs are being impacted by the virus, and I anxiously await the day where our social services can resume their normal operations. There are thousands of children stuck in violent and abusive home environments, living with parents who may be drinking too much or abusing drugs again. COVID-19 is driving the sale of alcohol, already up by 55% in late March.

In elementary school, I could not wait for the bell to ring on Friday afternoon so I could hop on the bus and go home. My parents would buy my sister and me whatever kind of pizza we wanted for dinner and then they would take us to BlockBuster to rent video games. They would dutifully wait in line to pay the $20 for a couple of VHS tapes and a box of Milk Duds. They were good parents, and I had a childhood so “normal” that I am routinely guilty of taking it for granted. I spent weekends and long summer nights watching Disney Princess movies and playing Spyro the Dragon on a Play-Station One.

I also remember other students, for whatever reason my nine-year-old brain could not comprehend, dreading the weekend and looking forward to returning to school on Monday morning. On Friday afternoon, they were shaking like a leaf, turning inward on themselves. As a young child, the weekend was an escape for me, one from multiplication tables and bad cafeteria food. For some children in my class, returning home for three whole days was the prison where the fridge was empty at home and their parents forgot to pay the water bill again.

COVID-19 continues to threaten the vision of a world where violence against children does not exist. Schools closing means that children are stuck at home with parents who may also be stuck at home. Some of these parents are facing an impending crisis where the responsibility of taking care of their family seems impossible, even before the pandemic, and now their already stretched perseverance wanes dangerously thin. Eventually, there might be a snap. Thousands of children across the country are stuck at home by themselves while their essential-worker parents are gone, with little-to-no supervision and nothing to keep them out of trouble. I don’t need to stress the implications of these disruptions, nor do I need to clarify how traumatic the toll of this viral pandemic will be for some working-class and poor families.

The State of Georgia is ranked 38th in the nation for child wellbeing. COVID-19 will surely exacerbate the existing issue of child maltreatment, considerably more so in the rural south where access to social services might be in the next county over. Before the pandemic, there were 11,445 active cases of child abuse in the state of Georgia for the year 2020, which includes sex trafficking, physical abuse, and neglect. Child neglect is the most pervasive form of child maltreatment and has experienced a sharp incline relative to increases in opioid abuse. The total direct cost for one victim’s lifetime is $226,822. Extrapolate this number to the rest of the country, now throwing in COVID-19, and we have an extraordinary problem on our hands, one whose implications are far-reaching, devastating, and whose violence is perpetrated against the most vulnerable among us.

Some mornings I’ll scroll through my Facebook feed and I’ll see distant acquaintances, and sometimes friends, complain about hair cuts and canceled vacations. They complain about lines at Home Depot and people wearing masks in their cars. I have close friends who complain about those who are not social distancing, they’re wondering how they can report those who aren’t. We’re all complaining about the behavior of other people, not taking the time to slow down enough and take an honest stock of our own.

It is important for me to remember that self-centeredness hinders my ability to think about how COVID-19 might be impacting other communities and populations besides those in my immediate network. For me and for those I am closest to, we are doing okay. We are mildly inconvenienced. I say all this not to say that my problems and other people’s problems aren’t real, and aren’t worth lamenting because others have it worse, but I do ask, both of myself and of my friends, to remain cognizant and vigilant about how the pandemic is affecting the lives of children who live in abusive households across the U.S. What does an indefinite stay-at-home order mean for these at-risk families, and how do we contend with this reality and the decision to open back up?

We need to brainstorm ideas and ways to effectively reach these already hard-to-reach populations [families at-risk for child abuse] in an unprecedented time where many of us are experiencing insurmountable emotional and financial burdens. These burdens are the major risk factors for child abuse, and unfortunately, I don’t see them letting up anytime soon.

As a student at the University of Georgia, I studied public health, focusing on health policy and chronic disease prevention. I took a course at UGA aptly named “Chronic Disease Prevention”, and yep, you guessed it — the course taught us how to research causes and risk factors for things like COPD, cancer, and diabetes, and how to prevent them. 90% of what we learned was that proper diet and adequate exercise were the most important preventative measures one could take to ward off chronic disease risks. I still agree with this reasoning somewhat, as would most Americans — but there’s a combination of lifestyle chances at the intersection of lifestyle choices that go on to affect our biology at the level of epigenetics and molecular sequencing. Being healthy isn’t just about making healthy choices.

In our chronic disease class, we were sorted into group projects where we picked a disease from a predetermined list and spent the semester learning about the etiology and prevention methods of some of the most common conditions of our now post-pestilence era. Smallpox has been eradicated, but suicide is now a leading cause of death in children. Our group picked PTSD.

I wanted to pick PTSD for obvious reasons. PTSD can’t be willed away through a robust exercise regimen or following the Mediterranean diet, although I’m sure both of those things certainly help alleviate some overt symptoms of PTSD. I spent that semester learning about the neurobiological mechanisms of PTSD, the epidemiology (vastly underreported prevalence, I’m sure of it), and prevention methods. There’s a lot of wonderful trauma-focused and intensive therapy that’s recognized as being profoundly effective for treatment, but there’s still an issue of accessibility, both in terms of cost and stigma associated with receiving trauma-informed care. Moreover, there’s a paucity of clinical providers who are trained in trauma-informed patient care (but I’ll save that for another entry.)

What my preliminary research on PTSD led me to discover was the sub-category of C-PTSD, or Complex Post Traumatic Stress Disorder. Rather than a single event being the catalyst for a stress-disorder, C-PTSD is characterized by chronic and repeated trauma that lasts indefinitely. Symptoms of C-PTSD include a lack of ability to regulate emotion, negative self-perception, difficulty with relationships, and loss of systems of meanings, which I like to refer to as the ability to tether yourself to an idea or concept that provides meaning or value to your life. The loss of systems of meanings manifests itself as despair and hopelessness in those affected, which has incredible consequences, a few of which I’m sure you can imagine if you’ve ever loved someone with depression or lost a friend to suicide.

Therefore, you can easily understand why some people suffering from C-PTSD might not seek help for their symptoms or even understand that they have a serious medical condition. Many people will inevitably turn to self-medication, whether that’s by alcohol, relationships, money, work, or any combination of things that provide some sense of relief to the sufferer. To be sure, relief is necessary — living with PTSD symptoms without the ability to manage those symptoms, even only somewhat, is an incredibly arduous task that is unfair to ask anyone to suffer through.

In my senior year of undergraduate studies, I took over the task of researching child maltreatment interventions. Any good steward of public health will tell you that prevention is key. Prevention is also a mostly thankless endeavor. My Public Health hero, Dr. William Foege, once remarked, “nobody will thank you for the disease they didn’t get.” And this is in part why public health is so underfunded. However, I digress, and that’s an entirely different topic for another day. I was looking at home-visitation programs as effective interventions to help at-risk young parents develop the skills to be safe, stable, nurturing caregivers. After all, children don’t exist in a vacuum — we need to focus on empowering parents and giving them the tools to succeed.

While focusing on child maltreatment prevention, I became immersed in the language of Adverse Childhood Experiences. The original ACE Study was conducted by Dr. Felitti and Dr. Anda, from Kaiser and the CDC, respectively. This was back in the ’90s. You can read more about the study here.

About the CDC-Kaiser ACE Study

I urge you to do so. It’s fascinating, and not enough people know about it. The researchers comprised a list of 10 ACE indicators and surveyed over 17,000 participants. It’s important to note that those who were surveyed were largely middle-class individuals in adulthood who had health insurance at the time of the survey, and around 63% of them had 1 or more ACEs. 36.1% had none. ACEs are characterized by abuse, household challenges, and neglect. For example, if your parents separated or divorced while you were 17 or younger, bam — that’s an ACE score of at least 1.

In the circles I associate with, I don’t think I personally know anyone who has an ACE score of 0 — and if I do, they’re an anomaly. However, what’s important to note about this is not the obvious thing you’re thinking of. Yes, Adverse Childhood Experiences increase your risk of engaging in risky behaviors, such as unprotected sex, illicit substance abuse, and truancy — which can set you up for a whole host of negative health outcomes later on. What the ACE Study did was show a correlation between ACE indicators and other chronic conditions, such as cancer and heart disease. Moreover, if you controlled for lifestyle factors such as tobacco use, and exercise (meaning those variables are not dependent on the outcome being measured), people who had ACEs were still at an increased risk of negative health outcomes — and the more ACEs they have, the more at risk they become. In short, that means I can eat a plant-based diet, exercise 7x a week, never drink alcohol, and still be at an increased risk for developing a chronic health condition that will take years off my life.

ACEs are about chronic stress experienced in childhood, and if we didn’t have nurturing, safe, and stable relationships that fostered resiliency, that chronic stress will go on to disrupt neurobiological mechanisms that control our susceptibility to disease.

There’s a lot to unpack here, and I think most of it starts with just beginning to have a conversation about ACEs. Fortunately, there are dedicated and passionate people working in the ACE-field who are determined to mitigate child maltreatment and abuse on a large scale. I have the wonderful opportunity to work with some of them, and that’s never lost on me.

Treatment options will have to be innovative, they’ll have to be cross-sector, and they have to have buy-in. To accomplish that, we have to create a dialogue. We have to start talking about how ACEs have impacted our own lives, and this conversation can’t begin and end in medical and public health circles — we all need to begin the work of unpacking what ACEs mean for our lives and the lives of our children. The COVID-19 pandemic will surely create lasting and deep consequences for the health and wellbeing of our children. Can we please start talking about this?

I hope to use this Medium platform to regularly post ACE-related content that will serve as a resource and guide for those who are interested. It’s my hope that people outside of my own small academic circles will develop a deeper appreciation for the work that ACE-researchers, physicians, and policymakers are trying to do. A recent study claims that total annual costs attributable to ACEs were estimated to be $748 billion in the U.S. Think about the implications for the healthcare industry, criminal justice, social work, education, and worker productivity and absenteeism. This is no doubt a silent epidemic that is hemorrhaging our nation’s ability to find and keep itself healthy and happy.

If you are interested in learning more about this important subject, I suggest these books:

“The Deepest Well” by Dr. Nadine Burke Harris

“The Body Keeps the Score” by Bessel Van der Kolk

I also suggest taking the ACEs QUIZ here to find out your own score.