For the voiceless

Please be advised that this story delves into trauma-related topics that may be triggering to the reader

They told me about what happened to you, and my heart sank lower and lower as I heard the details. They said you had over 70% body surface area burns. That’s too much for a tiny body- you’re only 4. I imagine the body diagram we use to document burns injury, lit up with all those little palm-sized areas. With your bandages, you looked like a mummy. A tiny child-sized one.

The story your “uncle” told us kept changing- first a kettle of boiling water, then a pan of hot oil, then both a pan of hot oil and a kettle of boiling water. It was all over your face, your body and back, your bottom, your arms and legs.

I think about you standing there, skin burning red hot like nothing you’ve known before, not knowing what happened, screaming for your mama. I think about your “uncle”, and why his story keeps changing- is he in shock, is he in denial, is he guilty, and if so, guilty about what?

“Where was the mom?”, I asked. Then they told me about your family. Your family is known to our social services and legal systems- your mom had filed a personal protection order over your stepbrother’s father for domestic violence, your “uncle” arrested for rioting in the past. You don’t know who your father is, he’s not in the picture at all. Your 13-year-old stepbrother used to bring you to and from the childcare centre on his own until recently when your “uncle” came to stay with all of you.

I think about my 13-year-old nephew, in his world of privileged innocence, who still needs to be reminded to brush his teeth in the morning, who still loves his pink jellycat bunny, who can’t quite be trusted to be left alone on his own, much less be responsible for a 4-year-old. I think about what structures were in place that took away your stepbrother’s carefree childhood, and now, has also taken away yours. I wonder, is there anyone who will stand up for you, and others like you?

Adverse childhood experiences (ACEs) are stressful or traumatic events that occur during childhood and result in harm or potential for harm to a child's health, survival, development or dignity. ACEs can include emotional, physical, and sexual abuse; physical and emotional neglect; household dysfunction such as living in a home with violence; having family member(s) with alcohol and substance misuse, mental illness, or incarceration; and parental separation or divorce. Research attests to the deleterious consequences of ACEs on functioning throughout the lifespan of the individual, with ACEs on health linked to ‘toxic stress’ resulting from exposure to the traumatic experiences and a detrimental environment in childhood, possibly causing epigenetic modifications to gene expressions. Early life trauma also possibly leads to structural and functional changes in the brain and its stress regulatory systems, which affect emotional regulation and fear response and in turn predisposes individuals to harmful health behaviours like smoking and excessive drinking and their subsequent adverse health outcomes. Not surprisingly, the detrimental and enduring impact of ACEs on human health and well-being has imposed significant health care burden and costs and is increasingly seen as a public health concern.

In the delicate dance of childhood protection, imagineit as ripples in a calm blue pool, expanding outward from a protected center. Each circle represents the waves of influence that childhood experiences send through time – from the intense blue core of immediate impact to the softer, far-reaching rings that touch distant shores of adulthood. These aren't just abstract patterns; they're the visual echo of that four-year-old burn victim's story, of every child whose early years reverberate through time. The intersecting lines are the social workers, the doctors, the caregivers – all those who try to break the cycle, who reach across the ripples to offer protection. Each connecting dot is a moment of intervention, a chance to redirect those waves toward healing rather than harm. Through these simple shapes, we see both the fragility of childhood and the strength of the systems we must build to protect it.

The 2016 Singapore Mental Health study of over 6000 Singaporeans demonstrated a 63.9% lifetime prevalence of ACEs. 50.9 % of those surveyed experienced physical or emotional abuse or neglect, 33.2 % experienced some form of household dysfunction, 3.7 % experienced sexual abuse and 2.0 % experienced bullying. The most common type of ACE experienced was emotional neglect, followed by parental separation, divorce or death and battered mother/ female guardian. After controlling for sociodemographic factors, presence of any ACE was significantly associated with increased odds of all mental illnesses, with a dose-dependent effect.

The burden of healthcare cost for ACEs is also substantial - the adjusted incremental costs of ACEs in the Singapore population were estimated to be S$1.18 billion (at least one ACE) and S$680 million (≥3 ACEs) per year.

The occurrence of an ACE and the circumstances in which it occurs impacts on the bio-psychosocial health of the child that continues to ripple through his/her life course. Past trauma can also affect subsequent relationships in adulthood and leave an imprint across generations.

We often only see patients as a function of the final outcome- someone with a mental illness, delinquency, issues with addiction or risk-seeking behaviour, without necessarily seeing the tapestry of hurt and neglect trailing behind them. Part of being a paediatrician is being “kay-poh” -digging into the social history of our patients because children don’t live in isolation – their health and well-being, especially in the early years, are directly dependent on their environments and their caregivers. Failure to recognize and intervene on factors that can negatively impact on a child’s holistic growth and development has far-reaching consequences, so pardon me while I ask you a seemingly non-medical question about what school the patient goes to, and who takes him there every day.

1. M Subramaniam, E Abdin, E Seow et al. Prevalence, socio-demographic correlates and associations of adverse childhood experiences with mental illnesses: Results from the Singapore Mental Health Study. Child Abuse & Neglect. 2020; Volume 103, 104447

2. Liu, J., Tan, B. C. W., Abdin, E., Padmini, Y. S., Oh, J. Y., Chong, S. A., & Subramaniam, M. Health care utilization, productivity losses, and burden of adverse childhood experiences in Singapore: Findings from a national survey. Psychological Trauma: Theory, Research, Practice, and Policy. 2024 Advance online publication. https://doi.org/10.1037/tra0001691

3. https://www.channelnewsasia.com/today/ground-up/how-abuse-parents-divorce-mentally-unwell-affect-child-lifelong-health-relationships-4647071

Yee Hui is a paediatric intensivist with one too many creative hobbies and a room overflowing with craft supplies to prove it. She believes that stories can be healing, and help to shape the world we live in.