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. Author manuscript; available in PMC: 2024 Dec 1.
Published in final edited form as: Child Abuse Negl. 2023 Nov 1;146:106510. doi: 10.1016/j.chiabu.2023.106510

Associations Between COVID-19-Related Family Hardships/Distress and Children’s Adverse Childhood Experiences During the Pandemic: The Environmental influences on Child Health Outcomes (ECHO) Program

Karen Thierry a, Christine W Hockett b,c, Amy J Elliott c, Adaeze C Wosu d, Aruna Chandran d, Courtney K Blackwell e, Amy E Margolis f, Margaret R Karagas g, Carmen Velez Vega h, Cristiane S Duarte i, Carlos A Camargo Jr j, Barry M Lester k, Elisabeth C McGowan k, Assiamira Ferrara l, Thomas G O’Connor m, Cindy T McEvoy n, Allison E Hipwell o, Leslie D Leve p, Jody M Ganiban q, Sarah S Comstock r, Dana Dabelea s, on behalf of program collaborators for Environmental influences on Child Health Outcomes
PMCID: PMC11338313  NIHMSID: NIHMS1942240  PMID: 37922614

Abstract

Background:

Economic hardships imposed by the pandemic could have implications for children’s experiences of adversity in the home, or adverse childhood experiences (ACEs).

Objective:

This observational cohort study examined associations between COVID-19-related hardships and distress (e.g., job loss, caregiver stress) and the cumulative number of child ACEs reported by caregivers during the pandemic (i.e., March 1, 2020 – February 28, 2022).

Participants and Setting:

The study included children (N = 4345; median age = 6.0 years, interquartile range = 4–9 years) and their parents/caregivers who participated in the NIH-funded Environmental influences in Child Health Outcomes (ECHO) Program.

Methods:

We described socio-demographic characteristics and pandemic-related family hardships/distress and cumulative child ACE scores reported during pre-pandemic and pandemic periods. We used negative binomial regression models to evaluate associations between pandemic-related family hardships and cumulative child ACE scores reported during the pandemic.

Results:

Each caregiver-reported hardship/distress was associated with higher child ACE scores reported during the pandemic. After accounting for pre-pandemic child ACE scores, moderate and severe symptoms of pandemic-related traumatic stress among caregivers were associated with 108% and 141% higher child ACE scores reported during the pandemic, respectively, compared with no or low caregiver symptoms. In addition, finance-related stress during the pandemic was associated with 47% higher child ACE scores. After adjusting for pre-pandemic child experiences of neglect, most sources of stress remained significantly associated with higher child ACE scores reported during the pandemic, particularly severe/very severe symptoms of pandemic-related traumatic stress among caregivers. Findings held for children with no known pre-pandemic ACEs.

Conclusions:

This research suggests that caregivers experiencing financial hardships and those with severe pandemic-related traumatic stress may require additional support systems during stressful events.

Keywords: Adverse childhood experiences, Family stress, Child abuse & neglect, COVID-19 pandemic

1. Introduction

The COVID-19 pandemic has caused numerous hardships for communities and families. During the first three months of the crisis, the United States (U.S.) unemployment rate increased at levels greater than those occurring during the 2 years of the Great Recession (Kochhar, 2020). Job loss during the pandemic resulted in a rapid economic decline. Housing insecurity also increased in 2020, with over 2 million U.S. households falling behind on housing mortgage payments, a 250% increase since the Great Recession, and 8 million rental households falling behind on rent (Consumer Financial Protection Bureau, 2021). The lack of availability of childcare and school closures forced many parents and caregivers to take on multiple roles as caregivers, educators, and employees thus making it difficult for them to maintain or seek employment (Johnson et al., 2021). In a survey conducted with U.S. parents in October 2020, 52% of parents with children younger than 12 years of age reported that it was hard for them to handle childcare responsibilities, compared with 38% who responded in this way prior to the pandemic (Kochhar, 2020).

The economic hardships imposed by the pandemic could have serious implications for children’s experiences of adversity in the home, or adverse childhood experiences (ACEs). ACEs have been variously defined to include childhood maltreatment (verbal/emotional, physical, and sexual abuse) as well as multiple types of household dysfunction, including parental separation/divorce, domestic violence, substance abuse, and mental illness among family members (Felitti et al., 1998). A study of the 2008 recession found that unemployment rates were associated with an increased risk of child abuse (Schenck-Fontaine & Gassman-Pines, 2020; Schneider et al., 2017). In the absence of supportive relationships, the cumulative stress resulting from ACEs is associated with negative mental and physical health outcomes (Gilbert et al., 2015; Harms et al., 2017). The main objective of the current study is to examine associations between COVID-19-pandemic-related hardships and children’s cumulative ACE scores following the onset of the pandemic.

1.1. Family Stress Model: Mechanisms through which Stress Impacts ACEs

According to the family stress model (Conger et al., 2010), the economic strain from job loss and the frustration arising from home isolation can lead to increased parental psychological distress, more inter-parental relationship problems, and disrupted parenting. For instance, studies have shown that economic hardships (e.g., job loss) lead to economic pressures or day-to-day strains and hassles, such as difficulty paying bills or purchasing basic necessities (Landers-Potts et al., 2015; Neppl et al., 2016; Newland et al., 2013). Economic hardships and pressure can in turn lead to increased parental distress, including depressive symptoms and feelings of discouragement and hopelessness (Iruka et al., 2012; Landers-Potts et al., 2015; Neppl et al., 2016; Newland et al., 2013). These experiences of parental distress are prospectively linked to disrupted parenting practices, including insensitive and unsupportive parenting practices (Newland et al., 2013), harsh parenting (Neppl et al., 2016), greater risk for child abuse and neglect (Warren & Font, 2015), and domestic violence (Barnett, 2008). Based on the family stress model, the various hardships (financial, quarantine-related, homeschooling) imposed by the COVID-19 pandemic and the resulting increase in parental distress could be associated with children experiencing adverse events in the home, including inter-parental conflict and violence, harsh parenting, and child neglect (Blackwell et al., 2022; Prime et al., 2020; Wu & Xu, 2020).

1.2. Changes in Parental Stress during the Pandemic

Studies have indicated higher levels of caregiver stress during the pandemic compared with pre-pandemic stress levels (Adams et al., 2021; Brown et al., 2020; Spinelli et al., 2020). For instance, in Adams et al. (2021), parents reported higher levels of both general stress and parenting-related stress in the initial months of the pandemic (May through September 2020) compared with the pre-pandemic period. Similarly, Johnson et al. (2021) reported that mothers, parents living with more than one child, and parents with a psychiatric diagnosis reported greater levels of parental stress, more burnout, and more anger towards their children during the initial months of the COVID-19 pandemic. They also reported having less social support, as the study coincided with the enactment of government-initiated physical distancing measures. In addition, in a nationally representative survey of U.S. parents, 75% of parents reported that they could have used more emotional support than they received since the pandemic started, with fathers (82%) being more likely to report needing additional emotional support than mothers (68%) (American Psychological Association, 2021).

1.3. Changes in ACEs during the Pandemic

Concurrent with increases in caregiver stress, evidence also suggests that some types of ACEs have increased since the pandemic began. Studies examining abuse related cases in the emergency department indicated an increase in child abuse-related conditions (emotional/physical abuse, neglect) and family violence requiring hospital treatment compared with pre-pandemic case counts (Cappa & Jijon, 2021; Kovler et al., 2021; Leslie & Wilson, 2020; Sharma & Borah, 2022). In a study that focused on domestic violence service calls, the COVID-19 pandemic was associated with a 7.5% increase in domestic violence calls during the 12 weeks after social distancing began, with the largest increase (i.e., almost 10%) occurring in the first five weeks of social distancing (Leslie & Wilson, 2020). Similarly, when examining police calls that resulted in charges for child abuse and domestic violence from 2015 to 2020 in Canada, a greater number of calls were placed during the pandemic period compared with pre-pandemic (Bucerius et al., 2021). Specifically, a 54% increase in child abuse calls was evidenced during the third yearly quarter of 2020 compared with the same time frame in 2015 to 2019 (Bucerius et al., 2021).

Studies on the frequency of child abuse and neglect reports to child protective service agencies describe mixed findings. For instance, when examining reports of child abuse in New York City, fewer than expected allegations of child maltreatment were reported during the months of March, April, and May 2020, which coincided with nationwide home isolation and social distancing policies instituted in the city (Rapoport et al., 2021). Similar findings were indicated in a study conducted on child abuse reporting in Oklahoma (Whelan et al., 2021). Because reports to child protective services rely largely on notifications from mandated reporters (e.g., teachers or health service providers), the decrease in reports was likely a result of the school closures and stay-at-home orders enacted during this time frame (Jonson-Ree et al., 2020). Rather than relying on child protective service reporting data, Musser et al. (2021) captured rates of foster care placements in the state of Florida that were specifically due to substantiated cases of child maltreatment, including abuse and neglect, as well as domestic violence and substance misuse by caregivers. Using this measure, they found that the rate of foster care placements due to substantiated cases of maltreatment was higher in April of 2020 compared to April of 2019 (Musser et al., 2021).

1.4. Factors Associated with Increased ACEs during the Pandemic

Although researchers and practitioners hypothesized that increases in caregiver stress and hardship would be associated with higher levels of ACEs during the pandemic (Bryant et al., 2020), few empirical studies have tested this hypothesis. In a small community sample in the U.S., parents of 4- to 10-year-old children (N = 342) were asked to report on job loss and child maltreatment during the pandemic as well as any history of child maltreatment prior to the pandemic (Lawson et al., 2020). Parental job loss emerged as a significant risk factor for child physical abuse during the pandemic (Lawson et al., 2020). As part of a population-based study conducted in Germany, parents of children aged 0 to 17 years old (mean age = 9.41) retrospectively reported on any changes in the frequency of child ACEs since the pandemic began (Calvano et al., 2021). To examine risk factors for increases in the frequency of ACEs, they also reported on pandemic-related stress and parental stress. For the ACEs with the most frequent lifetime occurrence, witnessing domestic violence (n = 332) and verbal emotional abuse against children (n = 332), parental stress was the strongest risk factor for a higher reported frequency of these ACEs occurring during the pandemic. Other significant risk factors included pandemic-related stress, parent anxiety/depression, and younger parent/child age.

More research is needed to identify the pandemic-related factors associated with children’s ACEs. Existing studies involved small sample sizes and utilized cross-sectional designs which relied on retrospective reporting to evaluate increases in particular ACEs occurring during the pandemic. Prospective studies would help to confirm associations between families’ pandemic-related hardships/distress and children’s exposure to ACEs since birth (i.e., cumulative ACE scores), as reported by caregivers during the pandemic. Thus, the primary aim of the current observational cohort study was to investigate the types of caregiver-reported pandemic-related hardships/distress (e.g., job loss, food insecurity, poor access to childcare) and distress (i.e., caregiver traumatic stress) associated with children’s cumulative ACE scores reported during the pandemic. At specific time points prior to the pandemic, caregivers also reported on other pre-pandemic factors that could influence ACE scores, including pre-pandemic child ACE scores and maternal depression, a known risk factor for child maltreatment (Windham et al., 2004). We hypothesized that pandemic-related hardships/distress, in particular job loss, caregiver symptoms of traumatic stress, and child-related stress, would be positively associated with children’s cumulative ACE scores reported during the pandemic. Furthermore, we expected these relationships to hold regardless of children’s pre-pandemic history of ACEs.

2. Methods

2.1. Participants

This study included children and their parents/caregivers who participated in the NIH-funded Environmental influences in Child Health Outcomes (ECHO) Program. ECHO includes 69 existing observational longitudinal pediatric cohort studies and was established to assess the impact of early environmental exposures on five major child health domains: pre-, peri-, and postnatal outcomes; asthma and other respiratory conditions; obesity; neurodevelopment; and positive health (Adams et al., 2021; American Psychological Association, 2021). Participants consented to the ECHO-wide Cohort Data Collection Protocol and provided consent to share extant data with the ECHO program. To be included in the current analysis, participants needed at least one assessment of their child’s cumulative ACEs, reported by parents/caregivers during the pandemic period (defined as March 1, 2020 through February 28, 2022) and at least one measurement of COVID-19-related hardship/distress experienced by the family. To reduce clustering within families that had two or more children with available exposure and outcome data, we selected the oldest child from each family for inclusion in the analysis. Figure 1 illustrates the selection of the final analytic sample.

Fig 1.

Fig 1.

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Flow chart showing selection of the final analytic sample (N = 4345).

ACE = adverse childhood experiences *Of children in the final analytic sample, 293 had harmonized pre-COVID ACE scores, and 968 had information about neglect/hardship during the pre-COVID period.

2.2. Periods of Assessment

The pre-pandemic (or pre-COVID-19) period was defined as any time in the two years (approximately 730 days) before March 1, 2020, while the pandemic (or COVID-19) period was defined as any time from March 1, 2020 through February 28, 2022.

2.3. Outcome assessment: Adverse Childhood Experiences

The outcome of interest was children’s cumulative ACEs as reported by parents/caregivers during the pandemic period. All participants with ACE information during the pandemic used a version of the Centers for Disease Control and Prevention (CDC)-Kaiser ACE measure (Felitti et al., 1998) that was modified for use in ECHO (hereafter referred to as the ECHO ACE questionnaire). The ECHO ACE questionnaire asked parents/caregivers to consider seven adverse experiences (physical, sexual, verbal abuse; household member with mental illness; in prison; caregivers separated or divorced), and state how many, but not which adverse experiences applied to the child (Supplementary Material S1). Such modifications were made due to the sensitive nature of the questions and differences in state and local social services reporting requirements that necessitated a more streamlined approach. Two additional items asked caregivers about child emotional and physical neglect. When a child had more than one caregiver-reported ACE form within a given period, we used the form with the highest ACE score within each period for the analyses. For pre-pandemic ACE assessments, we included information from questionnaires where: (1) the ECHO ACE questionnaire was used during the pre-pandemic and pandemic periods, or (2) the pre-pandemic ACE forms contained similar questions to the ECHO ACE questionnaire, and so could be used to create an equivalent cumulative ACE score.

2.4. Exposure Assessment: Pandemic-related Family Hardships/Distress

Pandemic-related family hardships/distress were assessed using a standard questionnaire developed by the ECHO program which asked about whether families had experienced hardships/distress across several domains (Hamilton et al., 2011; PhenX Toolkit, 2020). A copy of the ECHO COVID-19 questionnaire is provided in Supplementary Material S2. Of note, job loss was defined as any report of permanent or temporary permanent job loss of either the child’s primary caregiver or their spouse/partner, given that both individuals held jobs during the pre-pandemic period. Definitions and scoring of all other pandemic-related family hardships/distress considered in this analysis are provided in Table 1. Where assessments of pandemic-related family hardships/distress were completed at two or more time points for the same family, we used information from all the forms for assessment of job loss, childcare issues, and sources of stress. However, for the set of nine questions about caregiver experiences of pandemic-related traumatic stress, we used the questionnaire with the highest score as the predictor.

Table 1.

Scoring of pandemic-related family hardships/distress.

Section Variable Type Scoring
1 Permanent or temporary unemployment (experienced by the responding caregiver/partner) Binary Excluded caregivers or their partners who were not employed before the COVID-19 pandemic
2 Childcare issues Binary Endorsed any of the following at any point during COVID-19 period:

  • Difficulty arranging for childcare

  • Had to pay more for childcare

  • Caregiver/partner had to change work schedule to care for child themselves
3 Greatest sources of stress (11 items) Count
Binary		 Range: 0 – 11
Endorsed as greatest sources of stress at any point during the COVID-19 period:

  • Health concerns

  • Financial concerns

  • Impact on work

  • Impact on community

  • Impact on family members

  • Impact on child

  • Access to food

  • Access to baby supplies

  • Personal care products or household supplies

  • Access to medical care including mental health care

  • Social distancing or being quarantined
4 Symptoms of pandemic-related traumatic stress (9 items) Count Range: 9–45
(Higher score indicates worse symptoms)
Categorical

  • 9–17: None/Low

  • 18–26: Moderate

  • 27–35: Severe

  • 36–45: Very severe
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For section 4, among those with multiple questionnaires, we used the questionnaire with the highest score.

2.5. Covariates

The following demographic characteristics associated with child ACEs (Giano et al., 2020) were included as covariates in the final multivariable models: sex of the child (male, female), highest educational level reported for parents/caregiver (high school degree or lower; some college or technical school; or Associate’s, Bachelor’s degree, or higher), age of the child on March 1, 2020 (in years), age of the mother on March 1, 2020 (in years), and caregiver marital status (married/currently living with a partner, previously married, single never married). Additional covariates included in the models were an indicator for cohort and the timing of COVID-19 questionnaires. The timing of pandemic-related family hardships/distress was defined as the total number of days between March 1, 2020 and the date the COVID-19 questionnaire was administered. The average of this timing variable was taken for those families that completed two or more COVID-19 questionnaires. In keeping with current best practice recommendations (Kaufman & Cooper, 2001; Krieger, 2000), we did not pre-specify race and ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic self-identified other race) as a covariate, rather, we ran separate models in which we examined the changes in the estimates after the inclusion of race and ethnicity.

2.6. Statistical Analysis

First, we described univariate statistics of background socio-demographic characteristics among participants who had information during the COVID-19 period. In addition, we described these characteristics in three separate samples: (1) those with a pre-pandemic ACE score, (2) those for whom emotional/physical neglect could be assessed in the pre-pandemic period (defined as not being protected/loved, not feeling like family members looked after the child, wearing dirty clothes, or not having adequate food and clothing), and (3) the broader sample of ECHO participants who were eligible to provide information during the pandemic. Next, we described univariate statistics of pandemic-related family hardships/distress and ACE scores. We performed multiple imputation by chained equations to account for missing sociodemographic variables, assuming a missing at random mechanism (25 imputations, 25 iterations) (Royston, 2004). Percentage missing was as follows: sex of child (0.4%), child race and ethnicity (1.6%), mother’s age (2.5%), parent/caregiver highest education level (12.9%), and parent/caregiver marital status (13.7%).

We used negative binomial regression models to evaluate associations between pandemic-related family hardships and ACE scores. We specified separate models for each of the 14 COVID-19 related hardships/greatest sources of stress. The negative binomial model estimates the percentage increase or decrease in the continuous ACE scores with each unit increase in the independent variable (Gardner et al., 1995). Each model was adjusted for child age, maternal age, parent/caregiver highest education level, parent/caregiver marital status, timing of COVID-19 questionnaire administration, and an indicator for cohort. Furthermore, we examined the associations between each hardship/source of stress and ACE score during the pandemic in subsequent models, after accounting for (1) child pre-pandemic continuous ACE score, (2) child’s experience of emotional/physical neglect in the pre-pandemic period, and (3) limiting to the subset of participants who had no known adverse childhood experiences, (i.e., those with a pre-pandemic ACE score of 0). All analyses were conducted using Stata v16 (StataCorp, 2019).

3. Results

Table 2 describes the characteristics of participants included in the final analytic sample. A total of 4345 children who had COVID-19-related family hardship/distress data and ACE information were included in the analysis. Of these children, 47.4% were female, and the distribution of reported race and ethnicity was 55.5% non-Hispanic White, 16.2% Hispanic, and 13.0% non-Hispanic Black. Of the 597 children who were non-Hispanic and of a race other than White or Black, 171 (28.6%) were Asian, and 344 (57.6%) were of multiple races. The median age of the children on March 1, 2020, was 6 years (interquartile range: 4–9), while the median age of their mothers on March 1, 2020, was 36 years (interquartile range: 32–40). Most parents/caregivers had a Bachelor’s or more advanced degree (50.8%).

Table 2.

Basic characteristics of participants.

Variables Pandemic period only
(N = 4345)		 Participants with pre-pandemic ACE score
(n = 293)		 Participants with pre-pandemic emotional/physical neglect information
(n = 968)		 ECHO children at the same consent level
 Total number of participants* 4345 293 968 30,098
 Total number of cohorts 38 9 10
Basic characteristics of child
 Sex of the child
  Male 2269 (52.2%) 140 (47.8%) 485 (50.1%) 13,544 (45.0%)
  Female 2058 (47.4%) 153 (52.2%) 483 (49.9%) 12755 (42.4%)
  Unknown/Missing 18 (0.4%) 0 3799 (12.6%)
 Child’s age in years on March 1, 2020
  Median (25th, 75th percentile) 6 (4, 9) 6 (6, 8) 7 (5, 10) 6 (3, 10)
Range <1, 14 1, 11 1, 12
 Child race and ethnicity
  Non-Hispanic White 2411 (55.5%) 187 (63.8%) 434 (44.8%) 12799 (42.5%)
  Non-Hispanic Black 563 (13.0%) 17 (5.8%) 282 (29.1%) 3376 (11.2%)
  Hispanic 703 (16.2%) 26 (8.9%) 114 (11.8%) 6291 (20.9%)
  Non-Hispanic other race 597 (13.7%) 44 (15.0%) 118 (12.2%) 2839 (9.4%)
  Missing/Unknown 71 (1.6%) 19 (6.5%) 20 (2.1%) 4793 (15.9%)
Socio-demographic characteristics of caregiver/mother
 Mother’s age in years on March 1, 2020
  Median (25th, 75th percentile) 36 (32, 40) 36 (31, 39) 36 (32, 41) 36 (32, 41)
  Range 19, 56 21, 51 21, 56 16, 64
  Missing/Unknown 110 (2.5%) <5 31 (3.2%) 4524 (14.6%)
 Highest education level reported for parent/caregiver (n [%])
  High school degree, or lower 490 (11.3%) 45 (15.4%) 164 (17.0%) 3566 (11.7%)
  Some college or technical school or Associate’s 1087 (25.0%) 68 (23.2%) 314 (32.4%) 4331 (14.2%)
  Bachelor’s degree, or higher 2206 (50.8%) 154 (52.5%) 458 (47.3%) 7851 (25.8%)
  Missing/Unknown 562 (12.9%) 26 (8.9%) 32 (3.3%) 14682 (48.2%)
 Last known marital status of parent/caregiver (n[%])
  Married/currently living with a partner 2935 (67.5%) 212 (72.4%) 602 (62.2%) 9720 (32.9%)
  Previously married 295 (6.8%) 19 (6.5%) 101 (10.4%) 866 (2.9%)
  Single, never married 521 (12.0%) 44 (15.0%) 208 (21.5%) 1825 (6.2%)
  Missing/Unknown 594 (13.7%) 18 (6.1%) 57 (5.9%) 17164 (58.0%)
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ACE = adverse childhood experiences, ECHO = Environmental influences on Child Health Outcomes.

*

Only one child selected per family/household.

In total, there were 7980 COVID-19 questionnaires available across the 4345 children. On 95.6% (n = 7626) of these COVID-19 questionnaires, the respondent was the biological mother of the index child. Likewise, over 90% of the respondents on the standardized ECHO ACE forms were the biological mothers of the children. Of the subset of 293 children whose pre-pandemic ACE scores were obtained from sources other than the ECHO ACE questionnaire, 72.4% of their caregivers were married/currently married compared to 67.5% in the entire pandemic analytic sample, and the children were more likely to be identified as non-Hispanic White (63.8% vs. 55.5%). Compared to the larger ECHO sample, our analytic sample was more likely to be non-Hispanic White, and less likely to identify as Hispanic. A total of 330 (7.6%) of children in the final analytic sample experienced three or more ACEs during the pandemic (Figure 2). The median of the average number of days of the COVID-19 questionnaire administration since March 1, 2020 (i.e., timing), was 384 days with interquartile range of 296–476, and range of 37–732. Table 3 shows the distribution of responses on the ACE questionnaires and pandemic-related family hardships/distress.

Fig 2.

Fig 2.

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Distribution of maximum adverse childhood experience (ACE) scores reported by mothers/other caregivers during the COVID-19 period (N = 4345 children).

Table 3.

Distribution of responses on the ACE questionnaires and pandemic-related family hardships/distress.

Variables n
 Total number of participants during pandemic period 4345
 Total number of cohorts during pandemic period 38
 Total number of participants included in sub-analysis accounting for pre-pandemic ACE scores 293
 Total number of cohorts included in sub-analysis accounting for pre-pandemic ACE scores period 9
 Total number of participants included in sub-analysis accounting for emotional/physical neglect in the pre-pandemic period 968
 Total number of cohorts included in sub-analysis accounting for emotional/physical neglect in the pre-pandemic period 10
Information on ACE questionnaires Pandemic period only
 Maximum score on parent/caregiver reported ACE (pre-pandemic)
  Median (25th, 75th percentile) 0 (0, 1)
 Maximum score on parent/caregiver reported ACE (during pandemic)
  Median (25th, 75th percentile) 0 (0, 1)
Distribution of pandemic-related hardships/distress n with information n (%) endorsing out of 4345 participants*
 Job loss 3898 945 (24.2%)
 Childcare issues 4265 1818 (42.6%)
 Greatest sources of stress
  Health concerns 4313 2235 (51.8%)
  Financial concerns 4313 1681 (39.0%)
  Impact on work 4313 1725 (40.0%)
  Impact on community 4313 1681 (39.0%)
  Impact on family 4313 2514 (58.3%)
  Impact on child 4313 3079 (71.4%)
  Access to food 4313 551 (12.8%)
  Access to baby supplies (e.g., formula, diapers, wipes) 4311 303 (7.0%)
  Access to personal care products or household supplies 4313 912 (21.2%)
  Access to medical care, including mental health care 4313 752 (17.4%)
  Social distancing or being quarantined 4313 2620 (60.8%)
  Greatest sources of stress (continuous), median, IQR 4313 4 (2,6)
Symptoms of pandemic-related traumatic stress (range: 9 – 45) n (%)
 9 to 17 (None/(Low) 1673 (38.5%)
 18 to 26 (Moderate) 1888 (43.4%)
 27 to 35 (Severe) 501 (11.5%)
 36 to 45 (Very severe) 59 (1.4%)
 Missing 224 (5.2%)
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ACE = adverse childhood experiences, IQR = interquartile range.

3.1. Overall Associations between Pandemic-related Hardships and ACE Scores

Each assessed hardship was associated with statistically significantly higher ACE scores reported during the pandemic within the entire sample (Table 4). Of note, job loss was associated with 60% higher ACE scores (incidence rate ratio (IRR) 1.60; 95% CI 1.43–1.78, P < 0.001), and finance-related stress was associated with 64% higher ACE scores (IRR 1.64; 95% CI 1.48–1.81, P < 0.001). Stress related to medical care was associated with 77% higher ACE scores (IRR 1.77; 95% CI 1.59–1.97, P < 0.001). Childcare issues were associated with 13% higher ACE scores (IRR 1.13; 95% CI 1.02–1.25, P = 0.013), while stress related to the impact of the pandemic on the child was associated with 52% higher ACE scores (IRR 1.52; 95% CI 1.34–1.72, P < 0.001). Caregiver report of severe symptoms of pandemic-related traumatic stress was associated with an ACE score over two-fold higher compared with the caregiver experience of no/low symptoms (IRR 2.15; 95% CI 1.86–2.49, P < 0.001). The inclusion of race and ethnicity as covariates did not qualitatively change these results (Supplementary Material S3).

Table 4.

Results of negative binomial regression showing associations between pandemic-related family hardships/distress and ACE scores.

Family hardship/distress Only during the pandemic period Those with ACE score during the pre-pandemic period
n IRR (95% CI) P-value n IRR (95% CI) P-value
 Job loss 3898 1.60 (1.43, 1.78) <0.001 270 1.15 (0.81, 1.64) 0.418
 Childcare issues 4265 1.13 (1.02, 1.25) 0.013 288 0.87 (0.62, 1.23) 0.437
 Greatest sources of stress (continuous) 4313 1.10 (1.08, 1.12) <0.001 289 1.04 (0.97, 1.10) 0.260
 Health concerns 4313 1.28 (1.15, 1.41) < 0.001 289 1.00 (0.72, 1.38) 0.979
 Financial concerns 4313 1.64 (1.48, 1.81) <0.001 289 1.47 (1.05, 2.06) 0.025
 Impact on work 4313 1.29 (1.17, 1.43) <0.001 289 1.08 (0.77, 1.50) 0.664
 Impact on community 4313 1.17 (1.06, 1.29) 0.002 289 1.02 (0.74, 1.41) 0.902
 Impact on family 4313 1.35 (1.22, 1.50) <0.001 289 1.01 (0.69, 1.46) 0.976
 Impact on child 4313 1.52 (1.34, 1.72) <0.001 289 1.43 (0.92, 2.22) 0.109
 Access to food 4313 1.38 (1.22, 1.56) <0.001 289 1.17 (0.77, 1.76) 0.462
 Access to baby supplies (e.g., formula, diapers, wipes) 4311 1.26 (1.05, 1.51) 0.012 289 1.19 (0.69, 2.04) 0.528
 Access to personal care products or household supplies 4313 1.42 (1.27, 1.58) <0.001 289 1.12 (0.78, 1.60) 0.539
 Access to medical care, including mental health care 4313 1.77 (1.59, 1.97) <0.001 289 0.79 (0.53, 1.18) 0.252
 Social distancing or being quarantined 4313 1.25 (1.12, 1.38) <0.001 289 1.21 (0.85, 1.72) 0.281
Symptoms of pandemic-related traumatic stress
 None/Low 1673 Ref 108 Ref
 Moderate 1888 1.45 (1.30, 1.63) <0.001 133 2.08 (1.35, 3.21) 0.001
 Severe 501 2.15 (1.86, 2.49) <0.001 31 2.41 (1.48, 3.91) <0.001
 Very severe 59 1.83 (1.31, 2.57) <0.001 6 2.24 (0.68, 8.14) 0.179
Open in a new tab

ACE = adverse childhood experiences, IRR = incidence rate ratio. Covariates adjusted: sex of the child (male/female), highest educational level reported for mother/other caregiver (high school degree or lower/some college or technical school or Associate’s/ Bachelor’s degree or higher), age of the mother on March 1, 2020 (integer), age of the child on March 1, 2020 (integer), caregiver marital status (married or currently living with a partner/ previously married/ singer or never married), timing of COVID-19 questionnaire administration (in days, continuous), and indicator for cohort. Analysis for the pre-COVID sample also includes pre-COVID ACE score.

3.1.1. Inclusion of pre-pandemic total ACE scores.

After accounting for children’s pre-pandemic total ACE scores (continuous variable), stress related to financial concerns was associated with 47% higher ACE scores reported during the pandemic (IRR 1.47; 95% CI 1.05–2.06, P = 0.025)(Table 4). Moderate and severe symptoms of pandemic-related traumatic stress among parents/caregivers were respectively associated with 108% and 141% higher ACE score compared with no or low symptoms. The inclusion of race and ethnicity as covariates did not qualitatively change these results (Supplementary Material S3).

3.1.2. Inclusion of pre-pandemic child neglect.

In Table 5, which shows the model results after adjusting for the presence of emotional/physical neglect in the pre-pandemic period (binary variable), most sources of pandemic-related hardships/distress were associated with statistically significant higher ACE scores reported during the pandemic. Of note, severe symptoms of pandemic-related traumatic stress were associated with over two-fold higher ACE scores compared with no or low symptoms (IRR 2.40; 95% CI 1.78–3.24, P < 0.001). The inclusion of race and ethnicity as covariates did not qualitatively change these results (Supplementary Material S4).

Table 5.

Results of negative binomial regression showing associations between pandemic-related family hardships/distress and ACE scores, after adjusting for emotional/physical neglect during the pre-pandemic period.

Family hardship/distress Those with information on emotional/physical neglect during the pre-pandemic period
n IRR (95% CI) P-value
 Job loss 877 1.61 (1.29, 2.00) < 0.001
 Childcare issues 949 0.99 (0.80, 1.21) 0.901
 Greatest sources of stress (continuous) 959 1.10 (1.06, 1.14) <0.001
 Health concerns 959 1.32 (1.09, 1.60) 0.005
 Financial concerns 959 1.45 (1.19, 1.77) <0.001
 Impact on work 959 1.22 (1.01, 1.48) 0.043
 Impact on community 959 1.19 (0.97, 1.45) 0.090
 Impact on family 959 1.39 (1.14, 1.69) 0.001
 Impact on child 959 1.40 (1.11, 1.77) 0.005
 Access to food 959 1.48 (1.15, 1.90) 0.002
 Access to baby supplies (e.g., formula, diapers, wipes) 959 1.23 (0.86, 1.77) 0.260
 Access to personal care products or household supplies 959 1.32 (1.07, 1.64) 0.011
 Access to medical care, including mental health care 959 1.77 (1.42, 2.21) <0.001
 Social distancing or being quarantined 959 1.61 (1.33, 1.97) <0.001
Symptoms of pandemic-related traumatic stress
 None/Low 437 Ref Ref
 Moderate 393 1.66 (1.34, 2.06) <0.001
 Severe 80 2.40 (1.78, 3.24) <0.001
 Very severe 12 1.19 (0.67, 2.12) 0.553
Open in a new tab

ACE = adverse childhood experiences. Covariates adjusted: sex of the child (male/female), highest educational level reported for mother/other caregiver (high school degree or lower/some college or technical school or Associate’s/ Bachelor’s degree or higher), age of the mother on March 1, 2020 (integer), age of the child on March 1, 2020 (integer), caregiver marital status (married or currently living with a partner/ previously married/ singer or never married), timing of COVID-19 questionnaire administration (in days, continuous), emotional/physical neglect during the pre-COVID period (no/yes), and indicator for cohort.

3.2. Children with No Known Pre-Pandemic ACEs

When we limited analysis to the subset of children who had no known ACEs in the pre-pandemic period (i.e., had a pre-pandemic ACE score of 0), we found that child ACE score during the pandemic was positively associated with caregiver report of stress related to impact of the pandemic on the child (IRR 2.36; 95% CI 1.07–5.20, P = 0.032), financial concerns (IRR 2.13; 95% CI 0.98–4.62, P = 0.056), concerns about access to personal care products and household supplies (IRR 2.29; 95% CI 0.97–5.40, P = 0.059), and caregiver experience of severe/very severe symptoms of pandemic-related traumatic stress (IRR 8.64; 95% CI 2.92–25.56, P < 0.001) (Supplementary Material S5).

4. Discussion

In this large national multi-cohort study, we found that caregiver symptoms of pandemic-related traumatic stress was the strongest factor associated with higher child ACE scores reported during the pandemic, both when controlling for pre-pandemic ACE scores and pre-pandemic experiences of emotional/physical neglect. Hardships/distress that were also positively associated with ACE scores reported during the pandemic included job loss, ability to access medical supplies, and various other sources of stress (i.e., quarantine-related, finance-related, food-related, and child-related). Previous studies also identified parental job loss and stress as predictors of ACEs reported during the pandemic (Calvano et al., 2021; Lawson et al., 2020). However, the current study identified additional stressors, in particular the stress associated with having access to medical supplies and being quarantined, as positively associated with ACE scores reported during the pandemic. Perhaps caregivers who selected accessing medical supplies as a source of stress were worried about family members, especially children, with physical health conditions. Consistent with this idea, a pre-pandemic study that utilized the National Survey of Children’s Health found that children with special healthcare needs were almost two times more likely to experience four or more ACEs than children without special healthcare needs (Crouch et al., 2019).

Notably, we found that for children with no known history of pre-pandemic neglect, pandemic-related hardships/distress was associated with higher ACE scores reported during the pandemic. For these children, severe or very severe symptoms of pandemic-related traumatic stress and finance-related stress among caregivers were the strongest factors associated with ACE scores. Thus, even children with no previous history of ACEs were put at risk for experiencing these events for the first time when their caregivers reported severe levels of distress from the pandemic. No previous study has examined associations between pandemic-related factors and ACE scores, when ACEs were absent prior to the pandemic. Given the severe economic impact of the pandemic on families, this type of hardship may have been experienced by many families for the first time, especially those families who were living paycheck to paycheck prior to the pandemic. This finding underscores the importance of providing financial relief to parents. The federal government’s COVID-19 relief package included monthly child tax credits provided to eligible parents over a six-month period in 2021. According to the Census Bureau’s Household Pulse Survey, which analyzed spending patterns of recipients of the child tax credit during September and October 2021, 40% of parents indicated relying on the money to pay off debt, almost a third of parents used the credit to pay for school expenses, and 25% of families with young children spent it on child care (US Census Bureau, 2022). This type of financial support for families could help to relieve the traumatic stress, identified by this study as the largest risk factor for pandemic related ACEs, that many families experienced during the COVID-19 pandemic.

4.1. Limitations of Study

The current findings must be interpreted in the context of the study limitations. The demographic characteristics of the sample were not as diverse as the larger cohorts from which the sample was drawn. In particular, families of color and from lower socioeconomic backgrounds were underrepresented. These families were disproportionately affected by the pandemic, with persons of color being more susceptible to COVID-19 infections, hospitalizations, and death (Webb Hooper et al., 2020). If these groups were better represented in the study, we suspect that stronger associations between pandemic-related hardships and ACEs may have been found.

Given the way in which ACE information was collected, individual ACEs could not be isolated, except for experiences of neglect. It is therefore not clear which specific ACEs were more highly associated with pandemic-related hardships. Additionally, children’s exposure to domestic violence was not captured in the ACE questionnaire used in the current study. according to the family stress model, the psychological distress resulting from financial hardships and economic pressure can reduce the quality of inter-parental relationships, in particular domestic violence (Landers-Potts et al., 2015; Neppl et al., 2016; O’Neal et al., 2015), which is also associated with increased risk for child maltreatment (McGuigan & Pratt, 2001; Taylor et al., 2009). A further limitation of the ACE assessment was that it did not capture how often children experienced particular ACEs (i.e., caregiver reported whether or not a child had ever experienced an ACE). The number of instances of ACEs like abuse and/or neglect would be a better measure of the severity and/or chronicity of children’s exposure to ACEs.

We also did not explore whether the relationships between pandemic-related hardships and ACEs varied depending on geographic regions of the country or specific neighborhood characteristics. In a study that focused on neighborhood-level factors associated with reporting of child abuse and neglect during the early months of the pandemic in Los Angeles, California, Barboza et al. (2021) found that the following neighborhood-level factors were associated with new and intensifying hot spots of reported child abuse and neglect: housing burden, number of assets children had at birth, poverty, school absenteeism, and labor force participation (Barboza et al., 2021).

4.2. Future Directions for Study

The current study focused solely on pandemic-related risk factors for ACEs. We encourage future studies on protective factors that may have mitigated the negative impact of stress on ACEs, such as positive coping strategies and positive parent-child relationships. For instance, Lawson et al. (2020) found that parental use of an emotion-focused coping strategy (i.e., positive reframing) to deal with job loss during the pandemic was related to a lower risk of increased physical abuse. The long-term impact of ACE exposure on children’s health also merits further investigation. The participants included in the current study are part of ECHO’s larger longitudinal investigation of children’s physical and mental health outcomes, thus making this study sample an ideal source of data for such a long-term study in the future.

5. Implications and conclusions

This study suggests that caregivers experiencing financial hardships and those with severe pandemic-related traumatic stress may require additional support systems during stressful events.

Supplementary Material

1

Acknowledgements

ECHO Collaborators Acknowledgment:

The authors wish to thank our ECHO colleagues; the medical, nursing, and program staff; and the children and families participating in the ECHO cohorts. We also acknowledge the contribution of the following ECHO program collaborators:

ECHO Components—Coordinating Center: Duke Clinical Research Institute, Durham, North Carolina: Smith PB, Newby KL; Data Analysis Center: Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland: Jacobson LP; Research Triangle Institute, Durham, North Carolina: Catellier DJ; Person-Reported Outcomes Core: Northwestern University, Evanston, Illinois: Gershon R, Cella D.

ECHO Awardees and Cohorts— Albert Einstein College of Medicine, Bronx, New York: Aschner J; Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio: Merhar S; Indiana University, Riley Hospital for Children, Indianapolis, IN: Ren C; University of Buffalo, Jacobson School of Medicine and Biomedical Sciences, Buffalo, NY: Reynolds A; University of California, San Francisco: Keller R; University of Rochester Medical Center, Rochester, NY: Pryhuber G; University of Texas Health Sciences Center, Houston, TX: Duncan A; Vanderbilt Children’s Hospital, Nashville, TN: Moore P; Children’s Hospital and Clinic Minneapolis, MN: Lampland A; Florida Hospital for Children, Orlando, FL: Wadhawan R; Medical University of South Carolina, Charleston, SC: Wagner C; University of Arkansas for Medical Science: Keller R; University of Florida College of Medicine, Jacksonville, FL: Hudak M; University of Washington, Seattle, WA : Mayock D; Wake Forest University School of Medicine, Winston Salem, NC: : Walshburn L; Icahn School of Medicine at Mount Sinai, New York, NY: Teitelbaum SL; Stroustrup A; Cohen Children’s Medical Center, Northwell Health: Stroustrup A; Boston Children’s Hospital, Boston, MA: Mansbach J; Children’s Hospital of Philadelphia, Philadelphia, PA: Spergel J; Norton Children’s Hospital, Louisville, KY: Stevenson M; Phoenix Children’s Hospital, Phoenix AZ: Bauer C; Rhode Island Hospital, Providence RI: Koinis Mitchell D; University of Puerto Rico, San Jaun, PR: Canino G; Emory University, Atlanta, GA: Dunlop A; Kaiser Permanente Northern California Division of Research, Oakland, CA: Croen L; University of Washington, Department of Environmental and Occupational Health Sciences, Seattle, WA: Karr C; University of Tennessee Health Science Center, Memphis, TN: Mason A; Seattle Children’s Research Institute, Seattle, WA: Sathyanarayana S; Children’s Mercy, Kansas City, MO: Carter B; Emory University, Atlanta, GA: Marsit C; Helen DeVos Children’s Hospital, Grand Rapids, MI: Pastyrnak S; Kapiolani Medical Center for Women and Children, Providence, RI: Neal C; Los Angeles Biomedical Research Institute at Harbour-UCLA Medical Center, Los Angeles CA: Smith L; Wake Forest University School of Medicine, Winston Salem, NC: Helderman J; Pennsylvania State University, University Park, PA: Neiderhiser J; Brigham and Women’s Hospital, Boston, MA: Weiss S; Boston University Medical Center, Boston, MA: O’Connor G; Kaiser Permanente, Southern California, San Diego, CA: Zeiger R; Washington University of St. Louis, St Louis, MO: Bacharier L; Indiana University, Riley Hospital for Children: Indianapolis, IN, Tepper R; Pennsylvania State University, University Park, PA: Lyall K; Johns Hopkins Bloomberg School of Public Health Kennedy Krieger Institute, Baltimore, MD: Landa R; University of California, UC Davis Medical Center Mind Institute, Sacramento, CA: Ozonoff, S; University of Washington: Dager S; Children’s Hospital of Philadelphia - Center for Autism Research: Schultz R; University of North Carolina at Chapel Hill: Piven J; Johns Hopkins Bloomberg School of Public Health: Volk H; University of California, Davis Medical Center - MIND Institute: Schmidt R; University of Pittsburgh Medical Center, Magee Women’s Hospital, Pittsburgh, PA: Simhan H; Michigan State University, East Lansing, MI: Kerver J; Henry Ford Health System, Detroit, MI: Barone, C; Michigan Department of Health and Human Services, Lansing, MI: McKane, P; Michigan State University, East Lansing, MI: Paneth N; University of Michigan, Ann Arbor, MI: Elliott, M; University of Utah, Salt Lake City, UT: Stanford J; University of Utah, Salt Lake City, UT: Porucznik C; University of Utah, Salt Lake City, UT: Silver R; University of Utah, Salt Lake City, UT: Conradt E; New York University School of Medicine, Trasande L; University of California, San Francisco, San Francisco CA: Bush N; University of Minnesota, Minneapolis, MN: Nguyen R; University of Rochester Medical Center: Rochester, NY: Barrett E.

Declaration of interest

Courtney Blackwell, Amy Elliott, Jody Ganiban, Thomas O’Connor, Allison Hipwell, Carlos Camargo Jr., Sarah Comstock, Dana Dabelea, Leslie Leve, Amy Margolis, Cindy McEvoy, Elizabeth McGowan, Aruna Chandran, Christine Hockett, and Karen Thierry received support from the NIH for the research reported in this manuscript. Amy Margolis received support from the NIEHS for the research reported in this manuscript. Cindy McEvoy received royalties for peer review from UptoDate, payment for participation in the Vanderbilt Neonatology Symposium, and participated in a DSMB for Aerogen Pharma and 2 DSMBs for the NIH. Christine Hockett received grants from the NIH, USDA, HRSA, and the JDRF & Helmsley Charitable Trust. Karen Thierry received grant support from the JDRF & Helmsley Charitable Trust.

Funding

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Research reported in this publication was supported by the Environmental influences on Child Health Outcomes (ECHO) program, Office of the Director, National Institutes of Health, under Award Numbers U2COD023375 (Coordinating Center), U24OD023382 (Data Analysis Center), U24OD023319 with co-funding from the Office of Behavioral and Social Science Research (PRO Core), UH3OD023320 (Aschner), UH3OD023253 (Camargo), UH3OD023248 (Dabelea), UH3OD023313 (Koinis-Mitchell), UH3OD023328 (Duarte), UH3OD023318 (Dunlop), UH3OD023279 (Elliott), UH3OD023289 (Ferrara), UH3OD023244 (Hipwell), UH3OD023275 (Karagas), UH3OD023271 (Karr), UH3OD023347 (Lester), UH3OD023389 (Leve), UH3OD023268 (Weiss), UH3OD023288 (McEvoy), UH3OD023342 (Lyall), UH3OD023349 (O’Connor), UH3OD023285 (Kerver), UH3OD023249 (Stanford), UH3OD023305 (Trasande).

Role of the funding source

The sponsor, NIH, participated in the overall design and implementation of the ECHO Program, which was funded as a cooperative agreement between NIH and grant awardees. The sponsor approved the Steering Committee-developed ECHO protocol and its amendments including COVID-19 measures. The sponsor had no access to the central database, which was housed at the ECHO Data Analysis Center. Data management and site monitoring were performed by the ECHO Data Analysis Center and Coordinating Center. All analyses for scientific publication were performed by the study statistician, independently of the sponsor. The lead author wrote all drafts of the manuscript and made revisions based on co-authors and the ECHO Publication Committee (a subcommittee of the ECHO Steering Committee) feedback without input from the sponsor. The study sponsor did not review nor approve the manuscript for submission to the journal.

Footnotes

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Data availability

De-identified data from the ECHO Program are available through NICHD’s Data and Specimen Hub (DASH). DASH is a centralized resource that allows researchers to access data from various studies via a controlled-access mechanism. Researchers can now request access to these data by creating a DASH account and submitting a Data Request Form. The NICHD DASH Data Access Committee will review the request and provide a response in approximately two to three weeks. Once granted access, researchers will be able to use the data for three years. See the DASH Tutorial for more detailed information on the process.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS1942240-supplement-1.pdf (821.3KB, pdf)

Data Availability Statement

De-identified data from the ECHO Program are available through NICHD’s Data and Specimen Hub (DASH). DASH is a centralized resource that allows researchers to access data from various studies via a controlled-access mechanism. Researchers can now request access to these data by creating a DASH account and submitting a Data Request Form. The NICHD DASH Data Access Committee will review the request and provide a response in approximately two to three weeks. Once granted access, researchers will be able to use the data for three years. See the DASH Tutorial for more detailed information on the process.

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