Analyzing Children’s Trauma during the Covid -19 Pandemic Using Relational-Cultural Theory: A Literature Review

The impact of the Covid-19 pandemic has been extensively discussed, but only a limited number of studies investigate how pandemics are related to traumatic experiences for children. Using a literature review of 38 peer-reviewed articles, both qualitative and quantitative published in the reputable international journals, this study examines how pandemic situations trigger trauma in children. From the literature review, we concluded a number of impacts of Covid 19 on children, including their experience of sudden and shocking changes of events, loss, grief, domestic violence, Covid-19 infections, being surrounded by an adult experiencing mental health disturbance, and becoming the victim of financial restraint faced by their parents. In the frame of relational-cultural theory, parents, caretakers, and educators must help children to reconnect with their peers and environment to face adverse experiences caused by the covid-19 pandemic by providing mutual empathy and building trustworthiness. As culture is an active factor in relational processes, we need to consider individual cultural values to support children who have experienced trauma during the pandemic.


Introduction
As the world is suffering from the uncertainty caused by Covid-19, similar to adults, children also face Covid-19 consequences.UNICEF reported that thousands of children could die due to an adverse economic impact brought on by the pandemic.Even though a pandemic allows people to spend more time with their parents and siblings, children remain to be the feeble victims of the Covid-19 pandemic (UNICEF, 2021b).As a consequence, children are more likely to experience trauma.
Trauma is a situation where someone experiences terrible, horrifying, and powerless feelings because of the unpredicted event(s) (Goodman, 2017;Stien & Kendall, 2014).The inconvenience caused by Covid-19 is most likely creating trauma to children globally.Although children still necessitate protection and care from an adult, they should encounter the pandemic situation and adapt to it.Traumatic experiences interfere with cognition, behavior, and emotion.Individuals exposed to traumatic experiences during critical development periods often experience cognitive disturbance dan learning difficulty (Donovan et al., 2019;Howard, 2018;Teague, 2013;Tobin, 2016;Zilberstein, 2014).Moreover, trauma disrupts behavior regulation while also impacting selfregulation, self-concept, dissociation, biological functioning, and self-maturity (Teague, 2013).Some problematic behavior caused by trauma includes being stubborn, irritable, liking to argue, emotionally numb, and frequently crying (Cook et al., 2017;Donovan et al., 2019;Lawson & Quinn, 2013;Tobin, 2016).
Although the psycho-social impact of the Covid-19 pandemic has been largely investigated, its impact on childhood trauma has been rarely examined.This study aims to review the traumatizing effects of the pandemic on children using relational cultural theory.To date, the relational-cultural theory has been adopted to explain situations related to trauma and professionals counseling programs (Cannon et al., 2012;Comstock et al., 2008;Duffey & Somody, 2011;Joe et al., 2020;Triplett, 2003).Nevertheless, the application of relational-cultural theory in the discussion of Covid-19's impact on children is relatively low.

Method
This study investigated 38 peer-reviewed articles reporting the situations experienced by children during the Covid-19 pandemic.Those articles were either qualitative or quantitative peerreviewed reports published in reputable international journals.Our analysis focused on the potentially traumatic situations for children.To ensure conformity of the analyzed articles with our research topic, we used the keyword of "Covid-19", "children," "trauma," and "violence" during the search processes.The articles were downloaded from APA PsycInfo and Eric Education Plus since these two platforms provide reliable articles.Three criteria were employed in search of articles; namely: (1) the research article was discussing the Covid-19 pandemic impacts on psychological aspects, (2) the research participant were children below 15 years old, and (3) the article was related to the trauma.
In the end, we selected 38 articles to be analyzed by grouping them based on their findings, then gave themes for each group.From the analysis of 38 articles, we concluded six situations that could be the sources of trauma for children.Following the result, the relational-cultural theory was employed to further discuss the result of this study.

Results
In brief, during the Covid-19 pandemic, children experience vulnerability events leading to childhood trauma.As summarized in Table 1, there are six major adverse experiences that lead to childhood trauma, including: (1) unexpected onset of the pandemic (reported in three articles), (2) loss and grief (reported in five articles), (3) domestic violence (reported in nine articles), (4) being infected by Covid-19 (reported in four articles), (5) mental health disturbance (reported in seven articles), (6) financial restraint (reported in ten articles).The situation of the Covid-19 pandemic and its correlations to the children's trauma are described in the following.

Precipitous Occurrence of the Covid-19 Pandemic
It is always exhausting to encounter unexpected situations.Similarly, the Covid-19 pandemic has started without prior notice.In a short time, million people in the world were infected by the novel coronavirus.Consequently, this abrupt infection from the unseen virus creates intense terror and trauma for society (Iqbal & Dar, 2020;Newlove-Delgado, et al., 2021;Sinha et al., 2020).This condition aligns with the definition of traumatic events, which represents sudden or unexpected events, the shocking nature of such events, death or threat to life or bodily integrity, and/or the subjective feeling of intense terror, horror, or helplessness (Cohen et al., 2016;Goodman, 2017).Further, Cozza et al. (2014) defined natural disasters, including Covid-19, as the causes of trauma.Accordingly, the sudden occurrence of Covid-19 can be a source of trauma for children.

Loss and Grief
Million people in the world have died because of Covid-19.Consequently, millions of children experience loss and grief because they lost their parents, siblings, friends, teachers, and other significant others (Cercone et al., 2022).Trauma is caused by the unexpected loss of the loved one (Bertuccio & Runion, 2020;Iqbal & Dar, 2020;Kokou-Kpolou et al., 2020;Menzies et al., 2020;Newlove-Delgado, et al., 2021;Roberton et al., 2020;UNICEF, 2021b;Zhai & Du, 2020).Therefore, in post-Covid-19, there is an excellent chance for a society experiencing chronic grief.Besides, the loss and grief experienced by children during the Covid-19 pandemic led to separation trauma (Fallot & Harris, 2008;Goodman, 2017).Aligns with the statement, research has found that children living in incomplete families, whether caused by death or divorce, are most likely experiencing trauma (Dinh et al., 2019).Additionally, a study conducted in Tulungagung, Indonesia, reported that social interactions are challenging for children who are separated from their parents because the parents are working as immigrants (Widyarto & Rifauddin, 2020).Thus, without proper treatment and help in facing loss and grief, the children's painful experience will result in trauma.
The adverse childhood experiences drawn by different forms of abuse, neglect, and household dysfunction before the age of 18 years have become a major source of public health problems in the United States that has worsened during the Covid-19 pandemic (Abrams et al., 2022;Araújo et al., 2021;Bryant et al., 2020;Phelps & Sperry, 2020).Moreover, children from low-income and communities of color face more significant challenges (Bryant et al., 2020).
Additionally, the Covid-19 lockdown also coincided with an increase in online and in-store purchases of alcohol (Avery et al., 2020;Chick, 2020;Huckle et al., 2020;Rehm et al., 2020;UNICEF, 2020).Meanwhile, alcohol is reported to be a contributing cause of domestic violence (Maguen & Price, 2020), while domestic violence causes parental distress.Further, parental or caregiver distress during disrupting and overwhelming events is positively correlated with upsurges in young children's mental health issues (Rojas-Flores et al., 2017).
Aside from children, domestic violence is also experienced by the parents.As reported in a previous study, intimate spouse violence (IPV) has been the unacknowledged and unspoken impact of the Covid-19 (Buttell & Ferreira, 2020).The violence experienced by parents affects the children's mental health (Lünnemann et al., 2019), positioning domestic violence as the trigger of trauma for children.Therefore, the increasing number of domestic violence during the Covid-19 pandemic is likely to cause trauma for children.As reported by UNICEF, over 2 million children under five could die in the next 12 months due to the impact of Covid-19 (UNICEF, 2020).The Covid-19 treatment obligates children to be under suppression and separated from their parents (Montauk & Kuhl, 2020;Newlove-Delgado, et al., 2021;Phelps & Sperry, 2020;Tezer & Demirdağ, 2020), leaving them in pain and fear.Although they will get better after the treatment, they reserve hurtful memory after undergoing the tiresome treatment.

Infected by
In addition, physical illness is also acknowledged as the cause of psychological trauma and social disturbance.Physical sicknesses such as type two diabetes and breast cancer are the cause of psychological trauma and social avoidance (Xu et al., 2020).These two illnesses present similar characteristics to the Covid-19 pandemic, such as a high rate of death.Additionally, helplessness while facing severe illness, such as Covid-19, can be a traumatic experience.

Mental Health Disturbance
The highest rate of fear is reported in regions with the highest Covid-19 cases (Fitzpatrick et al., 2020).The available data shows that mental health issues grow following a sense of uncertainty, anxiety, depression, sleep disturbances, panic attacks, and loneliness during the pandemic (Kovler et al., 2021;Newlove-Delgado, et al., 2021;Tso et al., 2022).Consequently, quarantine and mandatory restrictions affect the growing number of suicide attempts, not only on vulnerable individuals (Aquila et al., 2020;Lewit et al., 2022;Suyadi & Selvi, 2022).Suicide occurrence indicates that people with minimum mastered coping skills will lose.Furthermore, 78% of subjects experiencing traumatic stress are reported to have PTSD syndrome (Bodkin et al., 2007).Eventually, during the Covid-19 pandemic, children live in a society full of fear, anxiety, depression, stress, and trauma.As the environment results in adverse childhood experiences, it triggers traumatic experiences in the future.Linearly, children are reported to have disrupted sleep and loneliness during the pandemic (Amick et al., 2022;Becker & Gregory, 2020;Hails et al., 2022;Newlove-Delgado, et al., 2021;Phelps & Sperry, 2020;Wang et al., 2021).
Another consequence of the Covid-19 pandemic is the closing of many schools throughout the academic year.These closures affect students, because for many of them, schools are their only place to get trauma information, care, and support (Phelps & Sperry, 2020;Tso et al., 2022).Thus, being absent from school signifies losing access to their friends and support system, resulting in significant desolation.Besides, loneliness during isolation can become another adverse childhood experience (Iqbal & Dar, 2020;Parmar et al., 2021;UNICEF, 2021a).Previous research found that children's attachment to their parents determines their emotional regulation skills (Mu'arifah, 2020).
Additionally, another study uncovered that young and old adults are the loneliest populations during a pandemic (Bryant et al., 2020).Further, their mental state determines their ways of handling children.As described by He et al. ( 2022), that Covid-19 related mental health disturbance experienced by an adult impacts their parenting style and is more likely to harm their children's development.Moreover, research also reported that mothers were experiencing anxiety during the pandemic (Dewanti, 2021).Besides, families of patients in the ICU frequently experience significant psychological dysfunction, including posttraumatic stress disorder and other trauma-related reactions, especially during the patient's end-of-life period (Montauk & Kuhl, 2020).Kim et al. (2021) also revealed household dysfunction as the source of adverse childhood experiences.To conclude, being around people with mental health disturbances can be a traumatic experience for children.
The increasing unemployment rates induced by Covid-19 manifest the crucial human cost of the pandemic, while unemployment further establishes immense personal and mental distress (Crayne, 2020).The level of stress experienced by people on furlough (unpaid leave of absence) has been observed to be higher than those unemployed before the pandemic (Mimoun et al., 2020).Also, fiftysix percent of those on furlough mentioned emotional troubles, such as nervousness and anxiety, while only 26% of the unemployed participants expressed those psychological issues (Mimoun et al., 2020).
In conclusion, living with people who are focused on their financial retraining exposes children to negative experiences as children have no power to take care of themselves.They are constrained to accept the uncertain situation.Simultaneously, the children also encounter a fast-changing environment, from unrestrained outdoor play to isolation.Even more, many of these children lose their loved ones and are dealing with grief, while some others have to fight against the virus.For these children, loneliness is the absolute consequence, where the adults around them have mental issues (Parmar et al., 2021).Finally, the family's financial restraint is one of the influencing factors for the children's traumatic experiences.

Discussion
Our data analysis results are discussed using the framework of the relational-cultural theory, focusing on the role of parents, caretakers, and educators in addressing children's trauma during the Covid-19 pandemic.
Relational-cultural theory (RCT) is built on the premise that human beings grow through and toward connection throughout their life (Jordan, 2008).Thus, people need to be connected and participate in relationships that foster their growth (Jordan, 2017a;Miller & Stiver, 1997) as they grow in interaction with one another (Comstock et al., 2008).However, based on this theory, individuals with trauma are in the disconnection phase, creating obstacles to growing to be fully functioning human beings (Comstock et al., 2008;Duffey & Somody, 2011;Jordan, 2017a).The abrupt and shocking changing events, loss and grief, domestic violence, Covid-19 infection, loneliness, being surrounded by adults experiencing mental health disturbance, and being the victim of financial retrain during the pandemic possibly cause disconnection for children.
The traumatized children with less power need to articulate their experience of disconnection and pain to the more powerful person and get attentive responses (Kress et al., 2018).The pain experienced by a person with less authority affects their sense of belonging and further impacts other people.The absence of opportunity to express their hurt or anger forces them to suppress that experience and become disempowered and unseen, affecting their lifespan growth (Comstock et al., 2008;Jordan, 2017aJordan, , 2008)).Once a person experience disadvantage and a feeling of worthlessness, they develop negative relational images, where they expect nothing from their relationship, their partners, or their own growth (Cannon et al., 2012).For instance, a student with childhood trauma shows a quiet attitude in school, feels disempowered, and expects no one to help them, so they tend to be unseen and show quiet behavior.
The RCT suggests that humans need mutuality to heal from trauma because they need to reconnect and build a connection with their environment (Jordan, 2001(Jordan, , 2008(Jordan, , 2017b)).Meanwhile, studies confirm that ethnicity or race carries an essential impact on building mutuality.A study conducted on 118 adults with trauma symptoms in Pennsylvania found significant differences in the perceived mutuality scores among adults from different ethnic or racial groups (Montero, 2016).The perceived mutuality represents an active participation in the development and growth of other people, as well as another relationship resulting in mutual development.The different perceived mutuality is affected by different norms in each ethnicity and race, which influence mutuality relationships.
In the end, to help children exposed to trauma during the Covid-19 pandemic, parents or caregivers can initiate a positive dialogue to give the children chances to express their emotions and support them with love and care (Cannon et al., 2012;Comstock et al., 2008;Jordan, 2001Jordan, , 2008Jordan, , 2017b)).Those are called mutual empathy.As reported in previous studies, positive dialogue between parents and children cultivates the children's security feeling, socio-emotional development, and mental health (Parish-Morris et al., 2013;Revelle & Bowman, 2017;Visser et al., 2016).Providing a safe learning place for children with traumatic experiences is significant (Jennings, 2019) since these children mostly face difficulties in trusting people and frequently feel unsafe.Consequently, teachers have to provide thoughtful treatment and care to ensure these children feel secure.Besides, a trauma-informed program can also be a favorable alternative.
Previous studies identified that trauma-aware program in schools is effective in helping students with traumatic experiences (Howard, 2018(Howard, , 2020;;Jennings, 2019;Lipscomb et al., 2019).Further, the school counselor can also integrate creative approaches to support students who have experienced trauma.For example, the implementation of technology, games, story, and other creative activities in the guidance and counseling program improve student attachment to the school counselor (Dewanti et al., 2018;Setyaputri et al., 2018;Wulandari et al., 2022).Both parents and educators must provide mutual empathy relationship with children and provide a secure environment to help them engage and build trust with others, as well as reconstruct positive connections.In addition to the role of parents, the school counselor also carries essential tasks in providing a safe and nurturant environment in school during the post covid-19 pandemic.
In conclusion, childhood trauma causes an individual's disconnection with their environment, leading to a less powerful feeling even in their personal life.As an alternative, RCT offers a mutuality relationship approach to support individuals with childhood trauma.Further, in the school setting, the school counselor must build a mutual relationship with the students, especially those who have experienced a traumatic event.Also, school counselors have to be aware of their students' cultural diversity.For example, they have to demonstrate understanding, along with acknowledgment of the student's emotions and behaviors.It is essential for the school counselor to understand the impact of trauma, be sensitive to the trauma symptoms, support students with trauma, and be able to prevent re-traumatization.By doing so, the student will learn to connect with others and grow powerful feelings towards their life in the mutual relationship setting.Thus, they can grow to be fully functioning individuals.

Conclusion
The pandemic contributes to the children's adverse experiences, such as violence, abuse, neglect, and inability to meet their essential needs, which are the provenance of trauma.From our analysis, we concluded that the pandemic resulted in: (1) abrupt changes of events (three articles), (2) experience of loss and grief (five articles), (3) domestic violence (15 articles), (4) being infected by Covid-19 (five articles), ( 5) mental health disturbance (seven articles), and (6) financial restraint (ten articles).Referring to the RCT, the situations experienced by children during the Covid-19 pandemic are defined as disconnection.Besides, as the closest stakeholders, parents, and teachers must be aware of children's emotion and give them space to express their disconnection.Teachers, school counselors, and parents must also provide mutual empathy by recognizing and embracing students' emotions and feelings.In doing so, teachers and parents have to offer secure relationships and an environment to help the children build positive relational images.Additionally, profound research on this topic is needed.The school also needs to arrange an online session to provide compassionate and supportive activities for the student.Furthermore, mutual empathy and cultural diversity awareness are essential competencies for helping children who have experienced trauma during the Covid-19 pandemic.Home is not always a haven: The domestic violence crisis amid the COVID-19 pandemic Kofman & Garfin, 2020; Upticks in domestic violence were reported in many regions soon after stay-at-home directives were announced.In this commentary, we delineate some of the recent events leading up to the reported spike in domestic violence There was a 55% increase in violence-related trauma in the COVID period compared with the pre-COVID period.About 14% of the respondents reported an increase in alcohol use.We found an association between both stress and anxiety and increased alcohol use during pandemic.The first scenario predicts an increase in consumption for some populations, particularly men, due to distress experienced as a result of the pandemic  15.COVID-related family separation and trauma in the intensive care unit Montauk & Kuhl, 2020; the COVID-19 pandemic is increasingly resulting in family separation from loved ones admitted to intensive care units (ICUs).Even in normal circumstances, ICU families frequently experience significant psychological dysfunction-including posttraumatic stress disorder and other traumarelated reactions, especially during the end of life period.The COVID pandemic likely will exacerbate these reactions as more and more families are being barred from the ICU.Consequently, ICU families are facing additional barriers in fully understanding the complex medical needs of their loved ones (and hence being able to make informed care decisions on their behalf); establishing rapport and bonding with nurses and other members of the ICU treatment team; and, in the event that a loved one

 11 .
Stress, anxiety, and change in slcohol use during the COVID-19 pandemic: Findings among adult twin pairsAvery et al., 2020; Huckle  et al., 2020; -19 pandemic, nearly one in six children aged 5-17 years had daily or weekly symptoms of anxiety or depression, a significant increase from before the COVID-pandemic  13.The hidden disaster of COVID-19often unspoken impact of the 2019 novel coronavirus (COVID-19) has been the prevalence of intimate partner violence (IPV)

Table 1 . Covid-19 Impacts on Children's Trauma
Adverse childhood experiences, which is defined by different forms of abuse, neglect, and household dysfunction occurring before the age of 18 years, is a major public health problem in the United States that has the potential to worsen in the current COVID-19 pandemic.Instability in the global economy in the wake of COVID-19 has resulted in millions of people losing access to employment.As a result, these same individuals will be faced with the pain of job loss in the present and the stress of the job search process in the future The results showed that there was physical, emotional, and verbal child abuse and negligence during online learning.This happened because children were often assumed of neglecting studies and misusing gadgets.Furthermore, the stress levels in parents increased due to the dual role, i.e, working and being teachers at home.Overall non-accidental trauma rates due to the combination of social isolation and economic depression in children did not increase during the COVID-19 pandemic, but rates were highly variable by site and increases were seen in African-Americans and older children.Negative parenting significantly mediated the relationship between COVID-19 distress and child emotional/behavioral problems (indirect effect β = 0.07).Parents' ACEs moderated the associations between COVID-19 distress and both negative parenting and child emotional/behavioral problems, such that each relationship was stronger in the context of higher parental ACEs.Children experienced multiple drivers of caregiver stress during COVID-19, including intrapersonal (e.g.caregiver health concerns), interpersonal (e.g.parental discord, perceived dislike of child), and extrapersonal (e.g.financial insecurity, sheltering in place) stressors.Regardless of the driver, caregivers' stress was internalized by children.