When COVID shut down life as usual in the spring of 2020, most physicians in the U.S. focused on the immediate physical dangers from the novel coronavirus. But soon pediatrician Nadine Burke Harris began thinking of COVID’s longer-term emotional damage and those who would be especially vulnerable: children. “The pandemic is a massive stressor,” explains Burke Harris, who is California’s surgeon general. “Then you have kids at home from school, economic hardship, and folks not being able to socialize.” These stresses could be particularly toxic for children, she and another state health official wrote to health providers in April 2020. Last week U.S. Surgeon General Vivek Murthy issued a similar warning about children for the entire country.

The toxicity has become all too real after 20 months, driven by not just disarray but death as well. As of this past June, more than 140,000 children lost a close caregiver—such as a parent—to COVID, according to research published in the journal Pediatrics. Since 2019 there has been a rise in suicide attempts among people younger than age 18, researchers at the Centers for Disease Control and Prevention found when they examined mental-health-related emergency room visits during the past three years. And a study of pediatric insurance claims filed between January and November 2020, conducted by the nonprofit FAIR Health, found a sharp increase in mental-health-related problems, especially generalized anxiety disorder, major depressive disorder and intentional self-harm. These and other distressing trends recently led the American Academy of Pediatrics and two other health organizations to declare that children’s mental health is currently a national emergency.

Burke Harris says those patterns arise from what pediatric health specialists term adverse childhood experiences (ACEs). These events include 10 types of specific traumas that range from direct abuse and neglect to overall household dysfunction. The adverse experiences activate the brain’s fight-or-flight system—a normal response to an immediate physical danger such as a bear rushing at you. But “what happens when the bear comes every night?” Burke Harris asks. Because adverse events put children in prolonged and repeated danger, it extends their stress response and creates damage. 

When COVID disrupted the routine and resources that school and after-school care ordinarily provide, many children were left to face ongoing hazards at home, including parental issues such as intimate partner violence and substance misuse. Both of these problems significantly rose during the pandemic, according to researchers.

As the pandemic wore on, California, guided by Burke Harris’s warnings, took some action to protect its children. This October the state legislature passed the ACEs Equity Act, a first-in-the-nation law requiring insurance that covers preventive care and pediatric services to also cover in-depth screenings for adverse events. And, since January 2020, California’s ACES Aware initiative has been educating clinicians about nonmedical interventions available to patients facing adverse events, and the state’s Medicaid program has paid eligible providers $29 per screening. Such regular screenings—which involve asking intimate questions in a nonthreatening and supportive manner—are linked to a variety of positive health outcomes. A recent literature review found patients associate these screenings with greater trust in their doctors. And clinicians say the screenings help them identify social factors that influence health, which allows them to offer more effective care.

Lisa Gantz, a pediatrician at the Los Angeles County Department of Health Services, is one of more than 20,000 health providers in California who have received free two-hour online training offered in the state. By teaching her how to screen for and respond to adverse events, Gantz says the training has changed the way she approaches clinical care. She remembers one recent appointment with an underweight four-month-old and his mother. “We had gone through all of the feeding [methods], and I really wasn’t able to come up with a reason why this child wasn’t growing,” Gantz says. But when she talked to the mother gently about possible changes at home, Gantz learned the child’s parents had recently separated. And the family faced newfound financial hardship—a circumstance true of nearly half of U.S. households by August 2020, according to a national survey.

“As soon as the mom felt safe, we learned that the husband was deported, finances were tighter, and the mom needed to water down her son’s formula to make ends meet,” Gantz says. “She was too embarrassed to tell me that before, plus a mom’s not going to walk in for a checkup and say, ‘By the way, dad’s not here anymore.’ But the screenings create a space to have these larger conversations about what’s going on at home.” With that information, Gantz was able to connect the mother and her baby with a social worker and to public services that could help them pay for more formula.

Gantz describes the work of treating adverse experiences as creating a “medical neighborhood”—a cohesive unit that responds to the multifaceted nature of children’s mental health with equally multifaceted resources.

Efforts in other states are trying to reduce children’s adversity by helping parents tackle their pandemic-related problems. In North Carolina, for example, the Raleigh-based nonprofit SAFEchild offers a Circle of Security Parenting (COSP) program. Small groups of parents in the program meet weekly to reflect on their behavior and improve their relationships with their children. Before teaching parents how to listen, the program first helps them feel heard.

That step is crucial if interventions are going to go beyond “telling people what to do” and actually create lasting change, says Ginger Espino, a COSP facilitator at SAFEchild. She notes that many parents in the groups are victims of adverse events in their own childhood. “It’s about breaking that cycle of abuse and empowering parents to have confidence that they can meet any of their child’s needs, even if those needs were not met during their own childhoods,” Espino explains. By inviting participants to affirm their own strengths, talk about concerns, and construct what security looks and feels like within the safe support group, the program aims to help parents create that same loving, nurturing environment for children at home. “They realize, ‘Oh, my child’s not trying to drive me crazy. My child has a need, and I need to figure out how to meet that need,” she says.

A few other states have recently introduced efforts to address the surge of pandemic-provoked adverse events. In May Maryland issued an executive order to create an ACE awareness day and announced a $25-million fund to expand the state’s youth development programs to every county. And Wyoming is using California’s approach to reimburse health providers for their ACE screenings of eligible Medicaid patients, says Elaine Chhean, who assists the executive director of the National Academy for State Health Policy, which co-published a paper on various ways that states try to prevent or mitigate adverse experiences.

Nationally, there have been a few moves to help deal with adverse events. In May bipartisan congressional representatives from Georgia and Utah introduced a bill to expand ACE research and data collection. And that month the nonprofit ACE Resource Network launched an awareness campaign called Number Story. The program, so named because a clinical questionnaire about adverse events gives a person a score based on the number of such experiences, uses conversations with celebrities such as John Legend and Camila Cabello to educate the public about adverse events and how to recognize when they are going through one or more.

Sarah Marikos, executive director of the ACE Resource Network, says such recognition can help change behavior and motivate people to seek help. “In my grandparents’ day, it was the norm to smoke, but now it’s not. And that’s the same thing we want to do around ACEs,” she says.

If you or someone you know is struggling or having thoughts of suicide, help is available. Call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK), use the online Lifeline Chat or contact the Crisis Text Line by texting TALK to 741741.