Trauma in Children: An Expert Interview With Susan Coates, PhD
Trauma in Children: An Expert Interview With Susan Coates, PhD
Editor's Note:
Immediately following the terrorist attacks of September 11, 2001, Susan Coates, PhD, provided critical mental health services to children and their parents at the Family Assistance Center set up by Disaster Psychiatry Outreach at Pier 94 in New York City. Together with Jane L. Rosenthal and Daniel S. Schechter, she is co-editor of September 11th: Trauma and Human Bonds (2003), a collection of papers on the impact of human bonds on the experience of trauma. The book includes observations from their work with children and their families at the "Kids Corner" of the Family Assistance Center, as well as research findings from the Columbia Department of Psychiatry. Medscape spoke to Dr. Coates to get her thoughts about the impact of Hurricane Katrina on children in the affected area.
Medscape: As someone who has worked extensively on trauma in children, what were your first concerns when you heard about Hurricane Katrina?
Dr. Susan Coates: The first thing that is deeply shocking for an American to realize is that weeks after the Hurricane hit, there were 2000 children still separated from their parents. Even newborns were separated from their parents. It is unimaginable given our resources and psychological knowledge that it wasn't a top priority to keep children and their parents together. We have known since World War II, from the work of Anna Freud and Dorothy Burlingham in wartime nurseries, that separating children from their families is much, much more traumatic for them than being directly exposed to bombing. The degree to which children will be traumatized from Katrina will depend in part on the length of time that they were separated from their parents and what kinds of frightful experiences they were exposed to in the absence of their parents. This is different from 9/11, when children were reunited very rapidly with their families. There will be massive trauma for the children of Katrina who were separated from their families for much longer.
Medscape: Does trauma affect children differently than it affects adults?
Dr. Susan Coates: Children are more vulnerable to trauma because they are still dependent upon their parents to help them manage negative emotions such as fear and terror. I think it affects them somatically quite similarly. Children, like adults, can have flashbacks, startled responses, and nightmares. But you see their flashbacks in their play behavior. When they have been traumatized, children will compulsively rework in their play whatever was traumatic. A child who has had a traumatic hospitalization will come into the therapist's office and set up the hospital scene over and over and over again in an attempt to work it through.
Medscape: Could you describe strategies for dealing with trauma in children?
Dr. Susan Coates: I think that in the aftermath of a disaster, working with children does not require traditional psychotherapy. In the first month, the most important thing is to facilitate communication between the parent and their child and help the child to begin to express their reactions to the experience, which children will usually do spontaneously in play or in drawing, sometimes in telling stories. Parents are often surprised by how much their children have taken in. And sometimes we find that we need to shift our attention to parents who are so overwhelmed already that they cannot take in what their children are communicating and find that their own posttraumatic stress is triggered by what their children are communicating. As Selma Fraiberg once said, for those parents, we may need to hear their cries so that they can hear their children's. But we as therapists, meanwhile, can also hear their children's cries so that everyone is heard. Children need to be listened to very carefully. Parents and therapists need to clarify their confusion, and help them envision how things will get better, how things will be different, how the situation will be solved in the long run.
Medscape: How did parents communicate to their children that things would get better after 9/11? How do you recommend parents foster that kind of communication after Hurricane Katrina?
Dr. Susan Coates: After 9/11, it was very important -- if children were drawing pictures of the trauma, of the twin towers being attacked, for example -- for them to also imagine some form of repair, having the towers being built back, for the bad guys to be put in jail, so that they're not just left with an overwhelming traumatic experience without a sense of its repair. The traumatic imagery, of course, will be very specific to the nature of the disaster. Imagery from Katrina will involve flooding, being separated from parents, and the abandoning of beloved pets.
Helping a child understand how things will get better after Katrina would be to explain that Mom and Dad are not going to be separated from their children again. Children will want to know how they are going to drain the water away, how they are going to build houses and schools again. It means explaining when the child is going to be in a house with her mommy, daddy, sisters, and brothers again. It's helping children get a realistic picture of how things will get better, not just leaving them with their fantasies.
One of the things that was very important after 9/11 was to help parents and children to contextualize their feelings, because their feelings are truly very powerful, and many people worried that they were going crazy. Parents and children needed to know that everyone is having feelings like this, that those feelings are okay and expectable, and they will get better over time. Another important kind of help was restoring predictable routines in the face of so much upheaval.
Medscape: When parents are interacting with their children after a catastrophic event like 9/11 or Hurricane Katrina, there is the possibility for the parents to pass on their own experience of trauma to their children. You work on issues of intergenerational transfer of trauma. How do you prevent parents from transferring their trauma to their children?
Dr. Susan Coates: Related to what I said earlier, I certainly think, as a guiding rule, that one should use the airline strategy: that you first put the oxygen mask on the parent, and then on the child. You help the parent in any way possible to de-escalate their anxiety so that they can help become the containers of their children's anxiety and not the escalators of their anxiety.
Medscape: Can you describe to me, given your experience providing care after 9/11, what kinds of services need to be made available to the victims of Hurricane Katrina immediately?
Dr. Susan Coates: There needs to be some ongoing service that gets set up to help parents with all the problems they need to sort out around being able to return to a home that is safe and find work and return children to school when people begin to return to the city. While parents are being helped with all of these needs, there should be a place where children can be dropped off where they will feel safe and can express themselves through toys or artistic materials or by storytelling. There should be anterooms that have couches where therapists can talk to the mothers and fathers about their questions and concerns about their children.
Victims of Hurricane Katrina are very dispersed. You want to get parents and children back to normal life as soon as possible, you want to get kids back to school, you want to start reading the same bedtime stories, you want to have kids eat the same food, get children back with their siblings. As soon as you can re-establish routines, it lets children know that things are going to be okay.
Therapy dogs played an important role in the Family Assistance Center. There were kids who were really so traumatized that they would roll up into a ball on the couch and would not talk. Therapy dogs were brought in from all over the country. They're now being used by the Red Cross in every disaster because they facilitate communication in a remarkable way. Children who otherwise would not talk would oftentimes start talking and really light up when the therapy dogs were around. They'll start playing with the dog and then they will enter into conversation with an adult. They won't immediately start talking about the trauma, but you can get them out of their shell.
Medscape: What about schools? What services can schools provide?
Dr. Susan Coates: The schools are going to have to play a very prominent role in helping children when they begin to return to school. I think the schools need to have a good bit of psychological input from trauma experts, so that teachers are both sensitized to the fact that the kids have lived through a very traumatic experience and able to create a psychological space where it can be talked about openly. It's probably going to be especially hard for children who have been shipped all over the United States to be with other children who are unfamiliar to them and who haven't experienced what they have.
Over the next few months, schools will be critical in figuring out which children are really having a hard time, are not recovering and can't pay attention, and are continuing to be very upset by the events caused by Katrina. Pediatricians also need to do screenings to find out which children continue to be symptomatic. Are they having trouble sleeping? Are they having night terrors? Have they regressed to earlier stages? Are they being aggressive? Are they having eating problems? Are they withdrawn? These children will need therapy that involves desensitization to help them recover.
Medscape: Can you describe the range of reactions that providers can expect from children suffering from trauma?
Dr. Susan Coates: There can be very different expressions of trauma. Some kids become very aggressive, some become withdrawn, some become inattentive. In very young kids, it's likely to come out as sleeping problems. After 9/11, an enormous proportion of kids slept with their parents for weeks after. The normal human reaction is to want to keep children safe. I think that one of the devastating experiences for a parent in 9/11 and in Hurricane Katrina is to realize that you can't always protect your child.
Medscape: In the years since 9/11, how have you seen parents cope with that realization?
Dr. Susan Coates: I think that parents felt it for a period of time, but then life went back to normal and parents felt able to protect their children again. Now, that could be very different in Katrina. Parents lost control of their children; they were taken out of the disaster area without their parents. I think the feeling of helplessness will be much greater in Katrina. The fear that parents had about the safety of their children in 9/11 lasted only a few days. There were some children who went to school in other boroughs who were separated from their parents for a day or two. In Katrina, parents were separated from their kids for weeks. They were really made to be much more helpless in relation to their children.
Medscape: What kinds of behaviors, from families, were most productive in helping children after 9/11?
Dr. Susan Coates: The most important thing was letting children talk about whatever was on their minds, without pressure and at their own pace. There were parents who really misinterpreted things. For example, there were many children who were building up towers and crashing planes into them. One parent in particular began screaming at her kid, saying, "You're just like Osama bin Laden." So, for some parents, their child's behavior was misunderstood and in some their child's behavior activated the parent's trauma even more. Parents really need to understand that in children's play, repetition of trauma is a child's way of working through the trauma just as talking about it would be a parent's way of working through a trauma.
We really need to educate people about the range of responses that are typical of children after a disaster. Some parents on the Upper West Side [of Manhattan], far away from 9/11, sheltered their children from exposure to the media after 9/11 and then felt that their children were not upset enough about 9/11, not realizing that their children were too young to understand the enormous implications of the event. I was very struck with how easy it was for parents to reassure their young children that they were safe up here on the Upper West Side or East Side and that no one was interested in these buildings. Talking to the children about whatever they want to talk about, and letting them take the initiative about how and when they want to talk about their experience, is very important.
What helps children the most is when they experience another person, especially their parent, holding their experience in mind. When a child's experience is ignored and not attended to, especially after a very frightening experience, that will in turn create more trauma. We know that the most threatening thing for children after a very frightening event is if the mother becomes avoidant, meaning that she doesn't want to hear from her child about his or her experience and becomes afraid that the child might trigger a flashback. If a parent shuts out a child's mind in this way, that child will be more likely to develop posttraumatic stress disorder.
Parents need to be available when a child brings up their worries, and if parents are available, their child will keep bringing things up until they no longer need to. If you shut the door, they're going to withdraw, and the trauma will likely come out as a behavioral disturbance. It's very important for the parent to acknowledge feelings that the child has. "Yes, it was very scary; I was scared, and you were scared; it was scary for everybody. But we're safe now, and we're going to do everything we can to help you feel safe."
Guidelines for Responding to Trauma in Children:
Excerpted from September 11th : Trauma and Human Bonds, with permission from Dr. Susan Coates.
The following goals apply to parents:
Editor's Note:
Immediately following the terrorist attacks of September 11, 2001, Susan Coates, PhD, provided critical mental health services to children and their parents at the Family Assistance Center set up by Disaster Psychiatry Outreach at Pier 94 in New York City. Together with Jane L. Rosenthal and Daniel S. Schechter, she is co-editor of September 11th: Trauma and Human Bonds (2003), a collection of papers on the impact of human bonds on the experience of trauma. The book includes observations from their work with children and their families at the "Kids Corner" of the Family Assistance Center, as well as research findings from the Columbia Department of Psychiatry. Medscape spoke to Dr. Coates to get her thoughts about the impact of Hurricane Katrina on children in the affected area.
Medscape: As someone who has worked extensively on trauma in children, what were your first concerns when you heard about Hurricane Katrina?
Dr. Susan Coates: The first thing that is deeply shocking for an American to realize is that weeks after the Hurricane hit, there were 2000 children still separated from their parents. Even newborns were separated from their parents. It is unimaginable given our resources and psychological knowledge that it wasn't a top priority to keep children and their parents together. We have known since World War II, from the work of Anna Freud and Dorothy Burlingham in wartime nurseries, that separating children from their families is much, much more traumatic for them than being directly exposed to bombing. The degree to which children will be traumatized from Katrina will depend in part on the length of time that they were separated from their parents and what kinds of frightful experiences they were exposed to in the absence of their parents. This is different from 9/11, when children were reunited very rapidly with their families. There will be massive trauma for the children of Katrina who were separated from their families for much longer.
Medscape: Does trauma affect children differently than it affects adults?
Dr. Susan Coates: Children are more vulnerable to trauma because they are still dependent upon their parents to help them manage negative emotions such as fear and terror. I think it affects them somatically quite similarly. Children, like adults, can have flashbacks, startled responses, and nightmares. But you see their flashbacks in their play behavior. When they have been traumatized, children will compulsively rework in their play whatever was traumatic. A child who has had a traumatic hospitalization will come into the therapist's office and set up the hospital scene over and over and over again in an attempt to work it through.
Medscape: Could you describe strategies for dealing with trauma in children?
Dr. Susan Coates: I think that in the aftermath of a disaster, working with children does not require traditional psychotherapy. In the first month, the most important thing is to facilitate communication between the parent and their child and help the child to begin to express their reactions to the experience, which children will usually do spontaneously in play or in drawing, sometimes in telling stories. Parents are often surprised by how much their children have taken in. And sometimes we find that we need to shift our attention to parents who are so overwhelmed already that they cannot take in what their children are communicating and find that their own posttraumatic stress is triggered by what their children are communicating. As Selma Fraiberg once said, for those parents, we may need to hear their cries so that they can hear their children's. But we as therapists, meanwhile, can also hear their children's cries so that everyone is heard. Children need to be listened to very carefully. Parents and therapists need to clarify their confusion, and help them envision how things will get better, how things will be different, how the situation will be solved in the long run.
Medscape: How did parents communicate to their children that things would get better after 9/11? How do you recommend parents foster that kind of communication after Hurricane Katrina?
Dr. Susan Coates: After 9/11, it was very important -- if children were drawing pictures of the trauma, of the twin towers being attacked, for example -- for them to also imagine some form of repair, having the towers being built back, for the bad guys to be put in jail, so that they're not just left with an overwhelming traumatic experience without a sense of its repair. The traumatic imagery, of course, will be very specific to the nature of the disaster. Imagery from Katrina will involve flooding, being separated from parents, and the abandoning of beloved pets.
Helping a child understand how things will get better after Katrina would be to explain that Mom and Dad are not going to be separated from their children again. Children will want to know how they are going to drain the water away, how they are going to build houses and schools again. It means explaining when the child is going to be in a house with her mommy, daddy, sisters, and brothers again. It's helping children get a realistic picture of how things will get better, not just leaving them with their fantasies.
One of the things that was very important after 9/11 was to help parents and children to contextualize their feelings, because their feelings are truly very powerful, and many people worried that they were going crazy. Parents and children needed to know that everyone is having feelings like this, that those feelings are okay and expectable, and they will get better over time. Another important kind of help was restoring predictable routines in the face of so much upheaval.
Medscape: When parents are interacting with their children after a catastrophic event like 9/11 or Hurricane Katrina, there is the possibility for the parents to pass on their own experience of trauma to their children. You work on issues of intergenerational transfer of trauma. How do you prevent parents from transferring their trauma to their children?
Dr. Susan Coates: Related to what I said earlier, I certainly think, as a guiding rule, that one should use the airline strategy: that you first put the oxygen mask on the parent, and then on the child. You help the parent in any way possible to de-escalate their anxiety so that they can help become the containers of their children's anxiety and not the escalators of their anxiety.
Medscape: Can you describe to me, given your experience providing care after 9/11, what kinds of services need to be made available to the victims of Hurricane Katrina immediately?
Dr. Susan Coates: There needs to be some ongoing service that gets set up to help parents with all the problems they need to sort out around being able to return to a home that is safe and find work and return children to school when people begin to return to the city. While parents are being helped with all of these needs, there should be a place where children can be dropped off where they will feel safe and can express themselves through toys or artistic materials or by storytelling. There should be anterooms that have couches where therapists can talk to the mothers and fathers about their questions and concerns about their children.
Victims of Hurricane Katrina are very dispersed. You want to get parents and children back to normal life as soon as possible, you want to get kids back to school, you want to start reading the same bedtime stories, you want to have kids eat the same food, get children back with their siblings. As soon as you can re-establish routines, it lets children know that things are going to be okay.
Therapy dogs played an important role in the Family Assistance Center. There were kids who were really so traumatized that they would roll up into a ball on the couch and would not talk. Therapy dogs were brought in from all over the country. They're now being used by the Red Cross in every disaster because they facilitate communication in a remarkable way. Children who otherwise would not talk would oftentimes start talking and really light up when the therapy dogs were around. They'll start playing with the dog and then they will enter into conversation with an adult. They won't immediately start talking about the trauma, but you can get them out of their shell.
Medscape: What about schools? What services can schools provide?
Dr. Susan Coates: The schools are going to have to play a very prominent role in helping children when they begin to return to school. I think the schools need to have a good bit of psychological input from trauma experts, so that teachers are both sensitized to the fact that the kids have lived through a very traumatic experience and able to create a psychological space where it can be talked about openly. It's probably going to be especially hard for children who have been shipped all over the United States to be with other children who are unfamiliar to them and who haven't experienced what they have.
Over the next few months, schools will be critical in figuring out which children are really having a hard time, are not recovering and can't pay attention, and are continuing to be very upset by the events caused by Katrina. Pediatricians also need to do screenings to find out which children continue to be symptomatic. Are they having trouble sleeping? Are they having night terrors? Have they regressed to earlier stages? Are they being aggressive? Are they having eating problems? Are they withdrawn? These children will need therapy that involves desensitization to help them recover.
Medscape: Can you describe the range of reactions that providers can expect from children suffering from trauma?
Dr. Susan Coates: There can be very different expressions of trauma. Some kids become very aggressive, some become withdrawn, some become inattentive. In very young kids, it's likely to come out as sleeping problems. After 9/11, an enormous proportion of kids slept with their parents for weeks after. The normal human reaction is to want to keep children safe. I think that one of the devastating experiences for a parent in 9/11 and in Hurricane Katrina is to realize that you can't always protect your child.
Medscape: In the years since 9/11, how have you seen parents cope with that realization?
Dr. Susan Coates: I think that parents felt it for a period of time, but then life went back to normal and parents felt able to protect their children again. Now, that could be very different in Katrina. Parents lost control of their children; they were taken out of the disaster area without their parents. I think the feeling of helplessness will be much greater in Katrina. The fear that parents had about the safety of their children in 9/11 lasted only a few days. There were some children who went to school in other boroughs who were separated from their parents for a day or two. In Katrina, parents were separated from their kids for weeks. They were really made to be much more helpless in relation to their children.
Medscape: What kinds of behaviors, from families, were most productive in helping children after 9/11?
Dr. Susan Coates: The most important thing was letting children talk about whatever was on their minds, without pressure and at their own pace. There were parents who really misinterpreted things. For example, there were many children who were building up towers and crashing planes into them. One parent in particular began screaming at her kid, saying, "You're just like Osama bin Laden." So, for some parents, their child's behavior was misunderstood and in some their child's behavior activated the parent's trauma even more. Parents really need to understand that in children's play, repetition of trauma is a child's way of working through the trauma just as talking about it would be a parent's way of working through a trauma.
We really need to educate people about the range of responses that are typical of children after a disaster. Some parents on the Upper West Side [of Manhattan], far away from 9/11, sheltered their children from exposure to the media after 9/11 and then felt that their children were not upset enough about 9/11, not realizing that their children were too young to understand the enormous implications of the event. I was very struck with how easy it was for parents to reassure their young children that they were safe up here on the Upper West Side or East Side and that no one was interested in these buildings. Talking to the children about whatever they want to talk about, and letting them take the initiative about how and when they want to talk about their experience, is very important.
What helps children the most is when they experience another person, especially their parent, holding their experience in mind. When a child's experience is ignored and not attended to, especially after a very frightening experience, that will in turn create more trauma. We know that the most threatening thing for children after a very frightening event is if the mother becomes avoidant, meaning that she doesn't want to hear from her child about his or her experience and becomes afraid that the child might trigger a flashback. If a parent shuts out a child's mind in this way, that child will be more likely to develop posttraumatic stress disorder.
Parents need to be available when a child brings up their worries, and if parents are available, their child will keep bringing things up until they no longer need to. If you shut the door, they're going to withdraw, and the trauma will likely come out as a behavioral disturbance. It's very important for the parent to acknowledge feelings that the child has. "Yes, it was very scary; I was scared, and you were scared; it was scary for everybody. But we're safe now, and we're going to do everything we can to help you feel safe."
Guidelines for Responding to Trauma in Children:
Excerpted from September 11th : Trauma and Human Bonds, with permission from Dr. Susan Coates.
Facilitate. We attempted to facilitate children's symbolic expression in play and in art projects by being gently supportively interested and available to observe or join play or to talk with them while they use art and crafts materials. Children who are still unable to play or who can only paint compulsively in black should not be urged upwards to the next symbolic level; a companionable tolerant interested presence may be all it takes for the child to regain capacities for symbolization.
Listen. Some children spontaneously want to talk about what they or their parents and other family members were going through with a sensitive listener from outside the family; others readily appreciate the offer to do so. Here acknowledging the reality of trauma and loss is implicit in simply listening.
Clarify. Children who wish to talk can be helped to make sense of their feelings and to find words to name emotions. Finding words promotes containment, the development of symbolic representation and the capacity for self-regulation. Clarification of affects and events helps toward the restoration of a coherent narrative. We were careful to follow the child's lead, to avoid probing exploration, responding only to what the child spontaneously introduced, in order to support containment of overwhelming feelings.
Support the capacity to imagine repair, restoration and constructive action. Bob Pynoos (personal communication) described key moments in the crisis intervention after the bombing in Oklahoma City when he helped children to imagine reparative possibilities. When he ended a session with a child who had re-lived the trauma by telling about it or representing it, it could tend to re-traumatize them, unless he ended the session by helping the child imagine some way they might actively contribute to repairing or healing the damage. This worked to restore a sense of safety, agency, and hope. We tried to do this in play as well. We helped younger children to think about how their family and community would take care of them, and encouraged older children to imagine a future in which they would have some agency.
Contextualize feelings. Children could be helped to contextualize their feelings by letting them know that lots of other kids' were having similar feelings. We understand children's and parents' acute stress reactions, intense re-experiencing of the event, nightmares and their frequently reported sense of psychic numbing, as an expectable responses to a horrifying disaster and to traumatic grief. Contextualizing their reactions as a natural response to an extreme situation can help older children.
Support attachment bonds. For children who were ready to do this we supported the child's identification with or internalization of the attachment to the lost family member by actively facilitating the child's need to remember and talk about their lost loved one.
The following goals apply to parents:
Contextualize the parents' reactions, helping them as we did with older children and adolescents to understand that they were not going crazy and that their fears, anxieties and flashbacks were expectable reactions to a severely traumatizing event.
Support the child's surviving attachment relationships by helping parents to understand the child's feelings and by facilitating communication between them. We tried to help parents recognize how much their children understood about the events all around them. We tried to help parents, family members and friends to be more accessible by answering children's questions directly and honestly without providing more information than children needed.
Help parents to make sense of their children's perplexing and disturbing expressions and behavior in their children. For example, we worked with parents to help them understand and make meaning of the feelings being expressed through children's repetitive dramatic play, traumatized drawings, dreams or nightmares that parents often had difficulty making sense of and found upsetting. In this way, the adult's reflective function could be re-engaged.
Help parents understand their children's experience. Some parents were frightened or became angry with their children for their increased clinginess, tantrums, and aggression. Parents were afraid these reactions were signs of lasting damage and future pathology. It was hard for parents to see these reactions as expectable responses to a situation of great insecurity. Parents' anxiety or anger in turn made the children more frightened of losing them, and so more demanding or aggressive. We tried to stop this escalating cycle by working with parents to help them understand their children's experience.
We helped them to answer the questions that children raised both direct and indirect, while protecting children from exposure to adult conversations.
We encouraged families to try to return to ordinary daily life and customary routines as soon as possible.
We encouraged parents to turn off the TV and not expose children to endless repetitions of images of the attack and the towers' collapse.
