Daniel S. Schechter, MD

Researchers found a significant drop in life expectancy from depression, alcohol dependence, suicidality, increased divorce rates, and childhood trauma that are a direct result of social distancing. A 

 found 2.1% of the Swiss population will suffer from psychosocial stressors that arise from efforts to mitigate the spread of COVID-19. On average, their life expectancy will drop 9.79 years, say study authors Daniel S. Schechter, MD, and Dominik A. Moser, PhD, who discuss their study in this video.

Lead author, Dr Dominik Moser, observed, “On a population level, deteriorating psychosocial well-being and mental health tends to eventually manifest in reduced physical health and shortened life expectancy. Seeing the potential damage of COVID-19 confinement may be necessary to halt the spread of the virus.” However, the findings suggest COVID-19-related social distancing and confinement will take an enormous toll on mental health. 

Dr Moser continues, “It is therefore crucial that governments invest heavily in mental health and front-line rather than side-line mental health workers, both during and following mass confinement. One could also interpret the study such that in confinement situations, there is an at-risk population that is particularly likely to suffer long-term health consequences from the psychosocial stress associated with confinement and isolation, similarly to how there is an at-risk group particularly likely to suffer from contracting the virus itself.”

Senior author, Dr. Daniel Schechter added, “This is the first study to focus on mental health implications of mitigation measures to fight the spread of COVID-19 using national public health data. Our study supports the importance of attention to mental health prevention and preventive intervention as an essential added dimension to public health policy from the outset.”

Dr Schechter stresses the importance of recognizing symptoms and signs, history and risk factors that would suggest that an individual is particularly vulnerable to the stress of quarantining, isolation, and social distancing. He points out that this is only one form of stress associated with the pandemic; the other is the stress resulting from fear of infection of self and loved ones, as well as illness and death directly related to COV-19. A third form of stress is linked to unemployment and financial instability as a result of the pandemic.

These tensions together necessitate recognition of and benefit from stress reduction, using techniques such as mindfulness/meditation or yoga, physical activity, and virtual group discussion, and creative outlets such as writing, music, blogging, and visual arts. Yet they also may necessitate or trigger the desire for mental health intervention.

For those who have never had contact with a mental health provider, finding one during confinement can be challenging. There are many resources online including from professional mental health associations such as the 

American Academy of Child & Adolescent Psychiatry

. They can also contact community agencies that support individuals exposed to family violence, who feel otherwise unsafe as to what they themselves might do, and who have drug and alcohol abuse.

Internal and family medicine practitioners can often recommend an initial assessment. In the case of extreme distress, dysfunction, or sense of danger, hospital emergency services can be called or visited, without fear of increasing the risk for contracting COVID-19 if one takes appropriate precautions.

For those who have had contact and ongoing care with a mental health provider, an essential question is how to maintain continuity or to reconnect to mental health help. Does your provider offer telehealth options for assessment and care?

Are you set up with all you need to make use of those options if available? Installing Zoom, WhatsApp, Whereby or Webex is very straightforward and you can find many aides online to setting up these tools. Once you have, you will find support groups, psychoeducation options, as well as consultation and treatment in many instances.

Finally, Dr Schechter spoke about the challenges for families that may be living together in the context of all the stresses mentioned and who can be at increased risk for verbal, psychological, physical, and sexual violence and maltreatment. At-risk and affected individuals should not have to wait to get help until after the pandemic passes, even if they are afraid of reaching out for help because of a lack of privacy in their home. Many agencies provide discrete contact, encrypted confidential messaging, support and emergency services in instances of domestic violence and child maltreatment.

Just as it is important to diminish risk by acknowledging the problem and reaching out for help, it is also important to bolster resilience and maintain social support network virtually, by phone, or by social media. Let your children know if you are not your best because of stress and reassure them that together you will get better. Identify and mobilize your individual and collective family strengths. Pay attention to your mental health and your physical health. In so doing, your immunity, energy and stamina will increase. Mental and physical health work hand in hand. Each benefits the other! Keep routines, sleep hygiene, limit exposure to disturbing news, and model these health measures for your children and loved ones. Be safe and stay well!

 is Senior Attending, University Service of Child & Adolescent Psychiatry, Lausanne University Hospital, Switzerland, and Adjunct Associate Professor of Child & Adolescent Psychiatry, NYU Grossman School of Medicine. 

 is Research Associate, University Service of Child & Adolescent Psychiatry, Lausanne University Hospital, and Institute of Psychology, University of Bern, Switzerland.

1. Moser DA, Glaus J. Frangou S, Schechter DS. 

Years of Life Lost Due to the Psychosocial Consequences of COVID-19 Mitigation Strategies Based on Swiss Data

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Researchers found a significant drop in life expectancy from depression, alcohol dependence, suicidality, increased divorce rates, and childhood trauma that are a direct result of social distancing. 


Consequences of Social Mitigation Strategies

Mothers with histories of childhood maltreatment or exposure to domestic and other interpersonal violence (IPV) who have a diagnosis of PTSD display more parenting stress and have greater dysregulation of their hypothalamic-pituitary-adrenal (HPA) axis physiology. Their maternal behavior is characterized by less responsiveness to their very young (aged 12 to 42 months) children, particularly following stressful moments such as separation.

 These findings have now been extended and further elaborated by neuroimaging studies.

Functional MRI (fMRI) studies suggest that the emotional, physiological, and behavioral dysregulation associated with maternal IPV-PTSD affects the interaction between mother and child. And this interaction is mirrored in neural activity. The [[{"type":"media","view_mode":"media_crop","fid":"41240","attributes":{"alt":"Â© majivecka/shutterstock.com","class":"media-image media-image-right","id":"media_crop_3757985246743","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4316","media_crop_rotate":"0","media_crop_scale_h":"101","media_crop_scale_w":"100","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]response of mothers with IPV-PTSD to silent video stimuli of their child and unfamiliar children at the moment of separation and during free play was compared with the response of mothers without PTSD (controls) using fMRI. A characteristic pattern of significantly lower medial and ventral medial prefrontal cortical activity was seen in the IPV-PTSD mothers compared with controls and continuously in relation to their IPV-PTSD symptom severity. This pattern of neural activity has also been associated with the response seen on an MRI scan of mothers with PTSD when traumatic memories are triggered (ie, images associated with violence, trauma scripts, frightened/angry facial expressions).

These findings have helped explain the pioneering clinical observations of Fraiberg and colleagues.

 Namely, parents caught in intergenerational cycles of violence and trauma often project onto their children (beginning in infancy) attributes that are inconsistent with the age, size, and capacities of the child. Tiny tots are seen as powerful, controlling, violent, or mean because they show age-appropriate displays of negative emotion and helplessness. The traumatized mother associates these behaviors with the perpetrator-victim relationship that she has previously experienced. She thus often perceives the child as a source of danger to be avoided rather than a source of joy and vulnerability to be embraced and protected, leading to further distress by the child-and sadly, further emotional and sometimes physical distance by the parent.

Characteristic of mothers with PTSD, this perceived danger (from the child) does not diminish over time and may produce enhanced glucocorticoid receptor sensitivity. The resulting HPA axis dysregulation can lead to hypocortisolism and altered reactivity to stressors.

 On the basis of these findings, researchers have begun to turn their attention to epigenetic factors involved in HPA axis response variations.

 Of particular interest is the promoter region of the 

 gene, which codes for the glucocorticoid receptor.

Relatively few studies have looked at how the pathophysiology of PTSD is related to methylation patterns of the 

 suggests that epigenetic changes in the 

 gene in combination with PTSD conferred an increased risk of depression in the child. However, only certain types of trauma are associated with specific epigenetic signatures. Adults with histories of childhood maltreatment and domestic violence exposure are at high risk for subsequent violent experience and for PTSD and other forms of psychopathy in adulthood.

 undertook a study to determine the role of NR3C1 methylation in mothers with PTSD related to childhood physical and sexual abuse and domestic violence. The goal was to understand how these factors conferred risk to the mother-child relationship and the child’s social and emotional development.

Our study consisted of 123 women who were recruited from the metropolitan Geneva area and their children aged 12 to 42 months. Many of these women had been exposed to interpersonal violence. The mothers completed 3 videotaped visits over a period of 1 to 2 months. After the screening visit, mothers were interviewed (without their child). The mother was asked to focus on how she perceived her child and to elaborate on the trauma she had experienced. This was followed by structured diagnostic interviews and a series of dimensional measures. One to 2 weeks later, the mother was asked to bring her child for a mother-child interaction procedure involving free play and separation reunion.

This mother-child interaction procedure was followed by administration of measures that focused on the child’s life, symptoms, and development. Saliva samples were taken from both the mother and the child for DNA analysis. Two to 4 weeks after the clinical interview and the mother-child observations, mothers had an MRI scan.

The epigenetic and fMRI data in the study showed that the more severe the mother’s IPV-PTSD, the greater her level of parenting stress and the lower the level of methylation of the 

 gene promoter region. The less methylation of the 

 gene, the more disturbed were the mother-toddler interactions, with markedly less child cooperativeness in play (

). Associated with these variables, less neural activity in the medial and ventral medial prefrontal cortices was seen in response to video stimuli of separation and play activities of their own child than when they were viewing video of unfamiliar toddlers. These brain areas are implicated in emotion regulation as well as parenting stress and maternal PTSD symptom severity, which predicted less child cooperativeness in mother-child play interactions.

Early-onset, long-term, and repeated exposure to interpersonal violence that leads to PTSD can affect the parent and, in turn, the parent-child relationship at multiple levels-including behavior, physiology, epigenetics, and neural activity during the early, most sensitive periods of child development. Clinical interventions for such traumatized parents with young children must address the child’s developmental needs, the parent’s psychopathology, and the parent-child relationship.

New methods to address disturbances in the parent-child relationship are being developed that integrate elements of prolonged exposure therapy and evidence-based infant-parent interventions. One such model, the Clinician Assisted Videofeedback Exposure Session(s) (CAVES), uses video feedback of parent-toddler interactions and recontextualization of trauma-associated memory traces evoked by those interactions in the present.

 For example, a mother who sees her child as “being aggressive and trying to control her” by his distressed protest when she leaves the room is asked to watch a video clip with the therapist, who helps her mentalize the process. The therapist asks the mother to think about what is going on in the mind of both child and mother during that moment in the video and how that moment might remind the mother of her past. Therapy also focuses on the mother’s and therapist’s reactions in the present.

Recontextualizing the times and places of these different experiences helps the mother see that her small child is genuinely feeling helpless and frightened and that the mother is stressed by the child’s emotional state. Mothers come to understand that this vulnerable state of mind reminds them of the painful and emotionally dysregulating violent experiences they have avoided thinking about.

The CAVES model shows promising changes in mothers, who begin to see their children less negatively.

The question remains, however, whether patterns of neural activity and functioning of the HPA axis and associated epigenetics reflect the psychological and behavioral changes observed. If such an intervention can support and model competent parenting by traumatized mothers, the child’s distress can be alleviated and a break in familial cycles of violence and trauma becomes ever more likely.

Dr Schechter is Senior Lecturer in Psychiatry at the University of Geneva Faculty of Medicine in Switzerland; he serves as Director of the Pediatric Psychiatric Consult-Liaison Unit and Parent-Child Research and is Deputy Chief of Child and Adolescent Psychiatry at the University of Geneva Hospitals. In addition, Dr Schechter is Adjunct Assistant Professor of Psychiatry in the division of developmental neurosciences at Columbia University College of Physicians and Surgeons in New York. He reports no conflicts of interest concerning the subject matter of this article.

 Schechter DS, Willheim E, Hinojosa C, et al. Subjective and objective measures of parent-child relationship dysfunction, child separation distress, and joint attention. 

 Pat-Horenczyk R, Cohen S, Ziv Y, et al. Emotion regulation in mothers and young children faced with trauma. 

 Martinez-Torteya C, Dayton CJ, Beeghly M, et al. Maternal parenting predicts infant biobehavioral regulation among women with a history of childhood maltreatment. 

 Schechter DS, Moser DA, Wang Z, et al. An fMRI study of the brain responses of traumatized mothers to viewing their toddlers during separation and play. 

 Schechter DS, Moser DA, Paoloni-Giacobino A, et al. Methylation of NR3C1 is related to maternal PTSD, parenting stress and maternal medial prefrontal cortical activity in response to child separation among mothers with histories of violence exposure. 

 Fraiberg S, Adelson E, Shapiro V. Ghosts in the nursery: a psychoanalytic approach to the problems of impaired infant-mother relationships. 

 Schechter DS, Zeanah CH Jr, Myers MM, et al. Psychobiological dysregulation in violence-exposed mothers: salivary cortisol of mothers with very young children pre- and post-separation stress. 

 Schechter DS, Moser DA, Reliford A, et al. Negative and distorted attributions towards child, self, and primary attachment figure among posttraumatically stressed mothers: what changes with Clinician Assisted Videofeedback Exposure Sessions (CAVES). 

 Yehuda R, Teicher MH, Seckl JR, et al. Parental posttraumatic stress disorder as a vulnerability factor for low cortisol trait in offspring of holocaust survivors. 

 McGowan PO, Sasaki A, D’Alessio AC, et al. Epigenetic regulation of the glucocorticoid receptor in human brain associates with childhood abuse. 

 Tyrka AR, Price LH, Marsit C, et al. Childhood adversity and epigenetic modulation of the leukocyte glucocorticoid receptor: preliminary findings in healthy adults. 

 Weder N, Zhang H, Jensen K, et al. Child abuse, depression, and methylation in genes involved with stress, neural plasticity, and brain circuitry. 

 Breslau N. The epidemiology of trauma, PTSD, and other posttrauma disorders. 

 Schechter DS, Willheim E. When parenting becomes unthinkable: intervening with traumatized parents and their toddlers. 

 CÃ´tÃ© SM, Vaillancourt T, LeBlanc JC, et al. The development of physical aggression from toddlerhood to pre-adolescence: a nation wide longitudinal study of Canadian children. 

 Spieker S, Crittenden PM. Comparing two attachment classification methods applied to preschool strange situations. 

Articles

A look at what neuroimaging studies reveal, methylation patterns of the NR3C1 gene, and new methods to address disturbances in the parent-child relationship.

Author | Daniel S. Schechter, MD

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