Introduction

There are many types of psychological disturbances but no single trauma signature has emerged with COVID-19 in children and families. Instead, we are confronted with a multiform picture of trauma among which some are enduring and disabling . These include vicarious trauma, social trauma, family trauma and neuropsychiatric legacy-trauma. The already existing global burden of disease (GBD) relating to depression and anxiety rose as the background to any more specific conditions, with girls seen to be disproportionately affected, especially with anxiety [ Fig. 1 ] .

Global prevalence of major depressive disorder (A) and anxiety disorders (B) before and after adjustment for (i.e. during) the COVID-19 pandemic, 2020, by age and sex. Reproduced with permission from Damian et al. (2).

The psychological effects have been mixed, short and long term, within acute on previously chronic disadvantaged backgrounds. The impacts have been magnified by pre-existing or comorbid acute or chronic medical disorders, especially those of the central nervous system . All these factors vary greatly from region to region, even in the same country and present more dramatically in the acute phase. However, there are longer term and more universal concerns that represent ongoing threats to young people which may become organised into an enduring traumatic response. These are likely modified by age of onset, exposure to trauma, the duration of exposure, disruption to family income and function and the presence of protective factors much like all traumas.

But distress – anxiety and depression − is not a trauma syndrome until we find the anxiety and depression aggregating around the trauma experientially over an enduring period [ Fig. 2 ]. This time frame is usually significantly longer than the time most others have recovered from the initial crisis response and resulting in functional impairment pervading the sufferer’s experience. The re-experiencing of trauma, fear of re-experiencing, re-enacting aspects of the illness and unpredictable re-emergences of distress in relation to immediate context are what distinguishes mental distress from a trauma syndrome.

Global burden of major depressive disorder and anxiety disorders by age and sex, 2020. Baseline refers to pre-pandemic DALYs and additional refers to additional burden due to the COVID − 19 pandemic. DALYs = disability-adjusted life-years. Reproduced with permission from Damian et al (2).

The word trauma is a multi-meaning term so that we sometimes we may find ourselves at cross purposes believing we are talking about the same thing when in fact conditions of different kinds and severity are being discussed. It is a term that first emerged in English usage in the1690s, “physical wound,” medical Latin from the word to twist or wind around until it breaks from Greek trauma “a wound, a hurt, a defeat”. The somewhat more modern sense in English of ”psychic wound, unpleasant experience which causes abnormal stress“ is from the late 19th Century. Post-traumatic stress disorder is a term that has only been in use since the second world war – in the first world war it was called ‘shellshock’ and, later, battle fatigue . Psychiatrists and psychologists are concerned not to portray every adverse experience as trauma. As a result, it is the evidence of enduring functional impairment and the distress associated with it, which is seen as central to any interpretation of a traumatically induced disorder or disability.

The suffering that comes with the suffering of others has emerged as an important motif as children who may not have been affected themselves have watched adult family members (especially grandparents) struggle with COVID-19 both acutely, and longer term. Traditionally, it referred to health workers treating the traumatized but has increasingly been extended to the child’s empathic engagement and exposure to graphic, traumatizing material or experiences of those they love, in this case in the context of COVID-19 . This suffering assumes the role of a disorder when children cannot live, love, and play the way they did before the Pandemic. In the parents, enduring alterations in capacity to work and find pleasure in daily activities due to fatigue and other hard-to-articulate morbidities insidiously undermine the joy and smooth working of family life.

The essence of trauma is multi-faceted . It involves the threat we cannot avoid (inescapability), the harm that has reappeared in our awareness in the immediate present (immediacy), the sense we cannot make of why this has happened to us personally and to those we love (meaninglessness); the person we cannot rescue and the ‘way out’ we cannot find (helplessness and hopelessness). Parents suffer when their children suffer. Children suffer when their parents suffer (reciprocal suffering). This resonating loop of interactive suffering borne of concern for each other may make locating the source of distress less clear. When pains are too great, too raw, too many, too prolonged, help outside the family will usually be needed, either informal or professional.

There are three central functional impairments that are especially relevant for clinicians:

• 1.
  

  Traumatic memory impairment (both pathological remembering and forgetting)

  
  
• 2.
  

  Empathic swamping associated with vicarious traumatisation.

  
  
• 3.
  

  Neurodisability , especially executive system dysfunction and autonomic dysregulation – associated with a covert and unfolding trauma.

Traumatic Memory Impairment

There is no trauma without memory. Disorders in which we cannot forget (impaired forgetting such as seeing a loved one struggling to breathe), when we wish we could and cannot remember what we need to remember (such as the face of our loved one before they became unwell) are complicated by the complex nature of memory itself. Memory is not a monolithic function but an array of different ways of encoding experiences usually to enable better adaptation in the future . Sadly, in trauma memory encodes the crippling nature of overwhelming experiences in the past and present. There are five forms of memory that are particularly relevant to trauma in general and the traumatic experiences of COVID-19 in particular [ Table 1 ] :

• A)
  

  Autobiographical memory (also called declarative or contextual memory) – How does the COVID-19 pandemic affect the story of my life?

  
  
• B)
  

  Working memory – How have I been able to think, hold things in my ‘mind’, day to day since I, or my family, have had COVID-19?

  
  
• C)
  

  Threat memory – How safe do I now feel with the worst memories of COVID-19, or with public portrayal of COVID-19 or the appearance of COVID-19 in others?

  
  
• D)
  

  Procedural memory (also called ‘muscle memory’ or motor memory) – Do I behave differently in my daily routines and actions since COVID-19?

  
  
• E)
  

  Visceral memory (also referred to as interoceptive memory)– does my body react at deep level to bodily fluids, eating, drinking, coughing and breathing since COVID-19?

Table 1

Simplified representation of the five memory systems associated with trauma of any kind with examples related to long COVID (10–16).

Memory Type	Definition of memory type	Neuroanatomical Structures and neurochemistry	Metaphor for memorisation	Memory-system experiences	Long COVID related experiences
Autobiographical Memory	The personal awareness of past story, or narrative, of our lives	Hippocampus and acetylcholine	‘ Moulded and remoulded in clay’ each time the past is recalled	The conscious construction of our past and reconstruction depending on our mood and circumstances at the time of recall Integrity of self	‘I lost my adolescents to COVID’ ‘Our family has never been the same since COVID’ Extreme: Sense of being ‘broken’ irrecoverably as an individual or as a family
Working memory	The capacity to hold the facts and issues of immediate situation in order to problem-solve	Frontal and cingulate systems Dopamine and noradrenaline	‘Written in sand’ and largely lost after sleep each night	The capacity to ‘get our head around’ the predicaments we face Integrity of thought in the moment	‘I just find that I can no longer get a hold on things and what to do about them since I had COVID’ Sense of thought incoherence – brain fog or fragmentation Extreme: dysexecutive syndrome that mimics ADHD but is different in origin and likely not made better by stimulants
Threat memory	The capacity to appreciate sensory indicators of threat or danger – may be in our awareness partially or available to us cued by key sensory experiences	Amygdala and noradrenaline	‘Chiselled in granite’ after a single life-threatening experience to ourselves or those we love	The alteration in behaviour when faced with similar situations – often described as re-experiencing or ‘flash backs’ with marked autonomic response – usually, but not always, sympathetic. Integrity of environmental safety	‘It all comes flooding back – nan being sick in hospital and us looking at her through the ICU window’ ‘It is not a safe world anymore’ Extreme: Avoidance of loved ones who evoke memories and more broadly generalised and separation anxiety
Procedural memory	Sometimes referred to as ‘muscle memory’ or ‘motor memory’ is largely out of awareness until we find ourselves doing things, being in situations that require us to do things that evoke a ‘re-enactment’ of the trauma.	Basal ganglia and cerebellum Dopamine Acetylcholine Glutamate GABA	Woven with a thousand threads of repetition into the warp and weft of our motor system such as learning a musical instrument, how to type on key board and ride a bike.	Finding ourselves puzzled by our own behaviour. Children and sometimes adults being unable to explain why they are behaving the way they do. Behaviour not linked to rationality	‘I find myself avoiding crowds and don’t feel comfortable any more in the school playground’ ‘Why do people behave like that?’ Extreme: school refusal and agoraphobia
Visceral Memory	Largely out of awareness until something quite physical happens in the viscero-sensory system.	Insular cortex Acetylcholine GABA Dynorphin	Written in bone and knotted in our guts	Nausea, vomiting, difficulty breathing, disgusting smells and bodily secretions are all evocative Bodily experience no longer linked as closely to the situation	‘Dad coughed up this thick puss and sputum that makes me sick just to think about it’ ‘I don’t feel the same anymore’ Extreme: Emetophobia Hyperventilation when normal dyspnoea occurs, fear of eating or defaecating. Fearful of oral exploration by dentists

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