COVID-19 SPECIAL

Unhappy families in a time of coronavirus

Early trauma and abuse can stay with a person for life - a grim reminder at a time when domestic violence is on the rise during the pandemic

The rhesus macaque is a monkey species native to South and Central America as well as South-east Asia, and it shares approximately 93 per cent of its DNA with humans.

Rhesus macaques also have sophisticated problem-solving skills, and like us, they have opposable thumbs and have been known to use tools. And like us, they have complex emotional and social lives. And because they are also relatively easy to manage, they are often used in scientific research, including psychological experiments.

In the middle of the last century, Harry Harlow, a professor of psychology at the University of Wisconsin at Madison in the United States, conducted a series of rather cruel studies on infant rhesus monkeys. He took them away from their mothers and caged them with surrogate artificial mothers - some made of terrycloth, others made of wire with bottles of milk attached.

The baby monkeys largely ignored the wire mother though they might go to it for milk, and attached themselves to the cloth mother - caressing and snuggling up to it, and scurrying to it when frightened and burying their faces into the soft but unresponsive substitute of a mother.

In a later study, Harlow isolated another group of infant monkeys in a vertical chamber that he called the "pit of despair". As time went by, these monkeys became increasingly disturbed - staring vacantly, rocking to and fro for long periods of time, and mutilating themselves. He noted that 12 months of isolation "almost obliterated the animals socially"; the monkeys became permanently withdrawn when they were placed with other monkeys. They were ostracised and yet there was something about their behaviour that made the other monkeys attack them.

Repugnant though it may be (no ethics board would permit such research these days), Harlow's idea of using a humanlike primate to elucidate the devastating effects stemming from the absence of maternal love and care, dovetailed with an earlier attachment theory of British psychiatrist John Bowlby.

We have an innate need for comfort and security, Bowlby posited, and a child instinctively seeks attachment to "older, wiser" caregivers for protection. The attachment figure, usually one or both parents, is that secure base from which to explore the world, and a safe harbour to return to for comfort.

With good, caring parents who provide stable, responsive relationships, the child develops secure attachment and develops healthily; but with abusive parents, the child becomes disorganised and is likely to develop intellectual delay and profound emotional and psychological problems.

INTIMATE TERRORISM

I recently thought of the abuses of those baby monkeys and what they had taught us and of the prescient insights of Bowlby during this time of the coronavirus pandemic.

In the wake of the lockdowns imposed on entire populations in many countries, people are forced to stay at home, corralled together 24 hours a day, seven days a week. For some, it is an inconvenient situation that is not merely uncomfortable, but also dangerous and terrifying.

There has been a surge of domestic abuse or "intimate terrorism", a term preferred by many experts, which includes both physical and psychological abuse. This first surfaced in China's Hubei province, which was the epicentre of the original outbreak, and as the infection spread to other countries that locked themselves down, there were similar spikes in domestic abuse in Italy, Spain, France, Jordan, Russia, the United States, and probably many other countries.

A 2007 file photo showing a demonstration organised by the Chilean Network Against Domestic and Sexual Violence to mark the beginning of a campaign to fight violence against women, in Santiago, Chile. The lockdowns in several countries to prevent the spread of the coronavirus have been followed by a surge in domestic abuse. PHOTO: AGENCE FRANCE-PRESSE

In this anxious and uncertain time of the coronavirus, there are multifarious stresses: physical and psychological health risks, school and business closures, job losses, countless workers furloughed, strained finances, abrupt disconnection from social support systems, all of which increase the risk for violence - with women and children being especially vulnerable.

A woman abused at home is less able to provide protection and care to her child. And the child who sees his or her mother being battered is emotionally assaulted - and wounded with an indelible psychic scar.

Research has shown that higher stress levels among parents is often a major predictor of physical abuse and neglect of their children. Children could also be at risk of sexual abuse - as this is usually carried out by a family member in the home, a lockdown provides even more opportunities for the perpetrator. With the closing of schools, children are not seeing teachers, counsellors and other adults in day care centres who would normally keep an eye out for them.

ADVERSE CHILDHOOD EXPERIENCES

There are different sorts of trauma that can be afflicted on a child; research in this field usually lists 10 such adverse childhood experiences (commonly referred to by its acronym ACEs) occurring between the period from birth to 18 years of age.

They include physical abuse, emotional neglect, sexual abuse, battered mother or female guardian, and parental separation or divorce, as well as growing up with family members who suffer from mental illness, alcoholism, drug problems, or who have been jailed.

Early childhood psychological trauma has both immediate and long-term effects on the child. Researchers have observed that children who experience early trauma tend to be restless in class, have difficulty taking in instructions, and are more likely to drop out of school.

As teenagers, they are more likely to engage in high-risk behaviours and are more predisposed to be depressed and suicidal. And it would also haunt and blight their adulthood.

My colleagues and I recently completed a study on the general population of Singapore (published last month in the journal Child Abuse & Neglect) where we found that mental disorders like depression, anxiety disorders and alcohol use disorders are strongly associated with some ACEs - suggesting these childhood trauma have somehow sown the seeds for the eventual manifestation of these disorders.

One such mechanism is toxic stress. "There is excessive or prolonged activation of the stress response systems in the body that disrupts the development of brain architecture and other organ systems," said Associate Professor Mythily Subramaniam, who is the director of research at the Institute of Mental Health and the lead author of the paper. "And they have long-lasting damaging effects on learning, behaviour and health well into the adult years."

Brain imaging studies have shown that toxic stress can cause a shrinking of the hippocampus (a brain area important for memory and emotional regulation) while enlarging the amygdala, which is the brain's fear centre - the consequence is that it primes the person to be hypervigilant and overly sensitive to real and imagined threats.

And, there is another pathway, she added: "Early adversity like the lack of parental nurturing could cause epigenetic changes which alters the chemistry of DNA and alters the expression of genes and the proteins they code for, which in some complex ways predisposes the person to develop certain disturbances."

In studies done on mice, these elemental biological changes and the behavioural manifestations could be transmitted to subsequent generations. There is as yet no compelling evidence of this occurring in humans, but the idea that we carry some enduring and transmissible biological trace of our trauma and pain resonates with the often-reported observation that abusers have often themselves been victims of abuse.

An abused individual, in other words, is more likely to abuse other individuals, a vicious circle of abuse that spirals through generations. Or as those famous lines from W.H. Auden's poem September 1, 1939 have it: "I and the public know/ What all schoolchildren learn/ Those to whom evil is done/ Do evil in return."

There is another dark and not so obvious legacy of ACEs.

A seminal and landmark study on the health outcomes of ACEs was conducted more than two decades ago among patients enrolled in Kaiser Permanente (a health management organisation based in California) in the years between 1994 and 1998. They were asked to answer a questionnaire that described their personal history with these 10 ACEs.

More than 17,000 patients participated and upon returning the questionnaires, they were assigned an "ACE score" from zero to 10, a tally of the kinds of adversity experienced before the age of 18.

The investigators found that the higher the ACE score, the worse the outcome. Other than the somewhat expected mental health consequences where adults with an ACE score of four or higher were 12 times as likely to have attempted suicide than those with an ACE score of zero; and those with an ACE score of six or higher were 46 times as likely to have injected drugs than those with no history of ACEs; the investigators were surprised to find an association with physical conditions as well.

Compared with people who had no history of ACEs, those with ace scores of four or higher were twice as likely to have been diagnosed with cancer, twice as likely to have heart disease, and four times as likely to suffer from emphysema or chronic bronchitis.

Subsequent studies have backed these findings and found that the risk for these physical illnesses among those who do not drink, smoke or lead an overtly unhealthy lifestyle is still high as long as they have ACEs. Scientists believe that this is due to the noxious impact of early adversity on the immune system. The exact mechanisms still need to be worked out, but what is clear is the importance of the lasting effect of cumulative exposure to adversities in childhood.

Science has played (and will continue to play) an indispensable part in the ongoing war against this coronavirus. It has identified the pathogen and the means for detecting it; in flattening the curve; in discovering or repurposing medications that will shorten its course, and developing that urgently needed vaccine.

Science has also provided powerful evidence that ACEs not only disrupt brain circuits that lead to cognitive, emotional and psychological problems, but also affect the development of the cardiovascular, immune and metabolic regulatory systems, and increase the likelihood of cancer, diabetes, hypertension and heart disease. And science has also shown that intervening early can improve later outcomes in an individual's health.

The evidence is all there, and it is critical to incorporate and translate that into policy and action. But as we have also seen elsewhere, science has to counter with the politics and economics of the land, and the denialism in some quarters of society.

We should expect that the rate of domestic abuse would increase during this pandemic, and what is happening in these isolated households would have grim and enduring consequences if we do not act now - both to reduce the chance of such domestic abuse and to ameliorate the consequences on the abused.

The Government is cognisant of this and the Ministry of Social and Family Development has set up a national care hotline (manned by volunteer psychologists, counsellors and psychiatrists) and formed an inter-agency task force to tackle family violence and to enhance "collaboration amongst stakeholders".

But it should not be something that we leave to the authorities to handle, for there will always be instances of abuse that would not be detected or prevented by whatever agencies.

The social distancing that is mandated seems inimical to the fostering of a communal spirit, but it is exactly that exercise of neighbourliness - of doing small things to ease the stress of a family we know, or keeping a lookout for that frightened child - that can make a difference in this extraordinary crisis where human contact can be both a threat and a lifeline.

• Professor Chong Siow Ann, a psychiatrist, is vice-chairman of the medical board (research) at the Institute of Mental Health.

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A version of this article appeared in the print edition of The Straits Times on June 02, 2020, with the headline Unhappy families in a time of coronavirus. Subscribe