While I was on call in the pediatric emergency department of Harbor-UCLA Medical Center, three firefighters rolled in a gurney with little girl strapped in — but she didn’t look injured. Unlike most kids arriving in an ambulance, she had no obvious injuries, no cervical collar to support her neck, no signs of bleeding and she was alert. 

Tracy looked to be about 4 years old and was so tiny compared to the gurney. Her mocha-colored skin was flawless, and her hair was in a dozen perfect braids with white barrettes clipped at the ends. She was visibly anxious and clutching her stuffed, floppy-eared puppy for comfort. Her name has been changed because she’s a minor.

I remember thinking, “Why did the ambulance bring her to a tumultuous, busy emergency department during a pandemic?”

As a new intern, I was learning to do a quick “once over” for patients as they arrived, but I had no hint as to why Tracy was there. 

Then, I heard my supervising physician say, “There’s a little girl coming in due to sexual abuse by a family member in their house.” My heart fell, could it be Tracy?

It was. 

She was our fourth child that day who needed an evaluation for possible sexual abuse. 

When I started my pediatric training, I expected to see kids with “typical” complaints, such as asthma attacks, ear infections, lacerations or maybe a COVID-19 case.  Instead our emergency department was flooded with children and teens who suffered from anxiety, suicide attempts, and suspected physical or sexual abuse.

At least 10 times a day, the best care for my patients was for them to see a psychiatrist or a social worker. With seeing so many distressed kids, I wondered if living through the pandemic itself was an adverse childhood experience (ACE), or was it increasing the chance of exposure to adversity? 

ACEs are traumatic events incurred by children younger than 18. Living through ACEs can cause toxic stress, due to a dysregulation of stress hormones such as cortisol and adrenaline, essentially putting the kids on a constant state of “alert.” This impairs their brain’s ability to regulate emotions, develop normal connectivity or cope with even typical stressors. 

The negative effects of ACEs on physical and mental health were first reported in a study from the Centers for Disease Control and Prevention and Kaiser Permanente. ACEs can be broken into three broad categories: abuse (emotional, physical or sexual), neglect (physical or emotional needs go unmet), and household disruption, such as loss of a parent due to divorce, incarceration, death, drug addiction or mental illness. 

The researchers surveyed adults getting routine physical exams about childhood adversity and found that nearly two-thirds of them reported at least one ACE. The more ACEs reported, the higher the risk for poor physical or mental health, including early death. 

The pandemic is taking a toll on everyone due to job loss, social isolation, health fears and economic uncertainties. As of September, 15 percent of Angelenos struggled with unemployment, higher than the overall rate of 11 percent for all Californians. Those most likely to have lost jobs are low-income workers, which includes the parents of my patients at Harbor-UCLA, a county, safety-net hospital in Los Angeles. 

In addition, children and teens are struggling with the loss of going to school, where they also socialized and received meals. Nearly 80 percent of students in Los Angeles Unified School District qualify for the federal school lunch program. 

With the closing of schools and most youth activities, few outside eyes are watching kids for signs of maltreatment. Early in the pandemic, nationwide calls to child protection services were down 50 percent, including in L.A. County. A National Children’s Alliance survey found that from January through June 2020, 40,000 fewer children received services related to abuse in the 900 child advocacy centers nationwide, compared to similar period in 2019.

A rise in child maltreatment cases was expected but hasn’t been seen — perhaps because children aren’t going to activities outside of their house or even for doctor visits. Since the beginning of the pandemic, the number of ER visits has decreased significantly likely related to “stay-at-home” directives, however, injuries from trauma, from all causes, were more severe. Anecdotally, ER doctors have reported more severe abuse cases. 

Children are being forced in close quarters in their homes, with no escape from abuse. The Rape, Abuse, Incest National Network, reported that during the March lockdown there was a 22 percent rise in monthly calls from adolescents younger than 18, and 1 out of 5 of those callers reported living with their abuser. Even before the pandemic, more than three-fourths of perpetrators of abuse were parents.

Tracy’s family, like many families across California and the country, were forced to move into a relative’s home to defray expenses in an unstable economy. For Tracy, this meant confinement in the small house with her abuser. 

Tracy’s case was reported to the police and child protective services. She had a thorough physical exam by Harbor’s specially trained child abuse team to check for any signs of abuse. A social worker talked to Tracy and her mother, and they were referred for mental health care.

Calling Tracy “lucky” isn’t the right word. But at least we identified the abuse and were able to care for her. I worry about the traumatized children whom the pandemic has kept hidden.

For concerns about child abuse, call Child Help National Abuse Hotline at 1-800-4-A-CHILD or 1-800-422-4453

Christiana Santiago is a pediatric intern at Harbor-UCLA Medical Center and plans to become a neonatologist.