**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 Affecting Families and Children during the COVID-19 Pandemic: A Global Mental… DOI: http://dx.doi.org/10.5772/intechopen.104991*

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, 20–22]. 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 [23–25]. 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, 29–31]. 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].
