Most parents would do anything to protect their young children. Human evolution, compared with other species, has led to placing an enormous inves'tment of energy and time in ensuring the safety of relatively few offspring. And yet, when both caregiver and the child sense a threat, the degree to which the caregiver is available to protect and help contain the stress and anxiety of the child is variable. Multiple factors affect the caregiver's emotional and physical availability to help a child's response to stress, trauma, and loss. The caregiver's past experience, biological (ie, genetic and other constitutional) vulnerability, the nature of the specific threat, and the degree of exposure to the threat contribute to a parent's response when a child is stressed. Above all, the pressing need to ensure survival of oneself and family determines a caregiver's ability to participate in an essential developmental task of young children, namely, mutual regulation of emotion, arousal, and attention, leading to the development of selfregulation by age 5 to 6.
From an evolutionary standpoint, it may be adaptive for a threatened caregiver to attend to her own survival needs before her child's, even at the immediate expense of her child. Ironically, the very thing that a child needs most in the immediate stress situation is the reassurance of a trusted caregiver. In a Darwinian world, survival of the parent at the expense of offspring may be acceptable. For example, the loss of a parent may affect survival Of the current offspring, but more important to the species, is the abrupt loss of future genetic progeny. However, among humans, where most adults are physically safe enough to invest in a few offspring, we need to better understand the more common encounter of emotionally "unavailable" caregivers for the present child.
Survival of the fittest aside, the very young child cannot exist without a caregiver to protect and nourish him. As the pediatrician and psychoanalyst D.W. Winnicott said, "There is no such thing as a baby."1 In other words, the infant and very young child can only be understood within the context of the caregiving relationship upon which they are dependent. As such, Scheeringa et al2 found that the variable that best predicts severity of posttraumatic symptomatology, and the only variable that was associated with significantly higher rates of posttraumatic stress disorder (PTSD) in children under 4, was a situation where trauma involved an actual or perceived threat to the child's caregiver(s). Based on a meta-analysis of more than 15 papers, Scheeringa et al found that maternal psychological functioning was a critical mediator of a child's response to trauma, in a model that they labeled "relational PTSD."
The most common threats confronting the caregiver, a child, and the caregiver-child relationship may not be directly perceived by the very young child - domestic violence, terrorism, and war - but children perceive the thoughts and feelings of those around them in response to those events. Research in Israel following the SCUD missile attacks3 supports the notion that very young children's respense to trauma is intimately linked not to the actual danger of the situation but with maternai psychological functioning, particularly anxiety.
CLINICAL OBSERVATIONS FOLLOWINGTHETERRORIST ATTACKS OF SEPTEMBER 11, 2001
In the book September II: Trauma and Human Bonds,4 the author and his colleagues described clinical observations of parents who had escaped with their own lives, or had lost the lives of co-parents and also caregivers, and who, with or without their children, saw the attacks and their traumatic aftermath. The figures were shocking: 2,973 adults died and more than 3,000 children lost a pardue to the attacks. One striking observation among families that experienced losses was how the young children's separation anxiety and dire searches for missing parent broke through denial, and other psychologidefenses of older surviving family Beyond those cases involving loss, thousands of children attendschools and day-care centers Ground Zero directly witthe attacks, and untold of children around world watched the atrepeatedly on television.
Observations of these very different experiences shared a common thread: parents who had earlier trauma and/or loss, even in the absence of heavy traumatic exposure, appeared to be most affected by the events of 9/1 1 and had the most difficulty in reading and responding to their children's various reactions to 9/1 1 . These clinical observations were subsequently confirmed by epidemiologie studies of adults6 following 9/1 1 and were more recently echoed by other major disasters such as that of 325 adolescents who survived the 2005 tsunami in Sri Lanka.7 The importance of the caregiver's emotional accessibility to her child after the experience of a traumatic event, even one so indirectly experienced as on national media, was dramatically underscored by the impressive findings from a survey conducted at the New York Academy of Medicine after 9/11. B They found that children in New York City whose parents did not know how their child responded after September 1 1 were Í 1 . 1 times more likely to have behavioral problems in the 6- to 11 -year group and 4 times more likely to have behavioral problems if between 12 to 17. Parents who cannot keep their child's experience "in mind" after a traumatic event have more behaviorally disturbed children, and this effect is nearly 3 times greater in younger children than in adolescence. This important study brought into stark relief the fact that, in the aftermath of a trauma caused by an externa! catastrophic event, a child's response, especially the young child's response, depends upon the nature of their parent's relatedness to them after the trauma.
But what inhibits, rather than what fosters, this relatedness in the wake of trauma and disaster? Pynoos and colleagues found that after a traumatic event, caregivers who tried to avoid ' being confronted with reminders of the trauma and who were in numb emotional states that restricted their capacity for closeness were unable to help their children process the experience of trauma.9 These studies showed that mother's physical presence was not enough. For mothers and other caregivers to serve as what Sigmund Freud termed a "protective shield" to their child10 in the face of trauma, they need to be emotionally present as well.
Based both on the research findings reviewed above and the author and colleagues' clinical observations at the Kids Comer of the Family Disaster Relief Center at Pier 94 in the months following 9/1 14,5 the author and colleagues devised a set of guidelines for "first responder" clinicians working with young children and their caregivers following disasters similar to the attacks of 9/1 1 . This model of postdisaster work with children and families described in the following section has provided a framework for more recent efforts following Hurricane Katrina.11,12
'PSYCHOLOGICAL MOORING': CLINICALWORK ATTHE KIDS CORNER AT PIER 94, WEST SIDE OF MANHATTAN INTHEWEEKS IMMEDIATELY FOLLOWING 9/1 1
Typically, clinicians are able to control and provide services for the requirements that usual post-traumatic work with patients requires. However, in the setting following a disaster, clinicians share many obstacles with their patients, such as displacement and unpredictability. The setting for the author's clinical work after the events of 9/11 was Pier 94, a vast aluminum-sided hangar-like structure on the Hudson River on the West Side of Manhattan. The Family Assistance Center at this site was set up by the New York City Mayor's Office to expedite provision of services to families who had lost a family member, job, or housing as a consequence of the events of 9/1 1 . Dozens of temporary booths served as the workstations for representatives of numerous federal, state, and city agencies, as well as the Red Cross Disaster relief services and private agencies.
Kids Corner at Pier 94 was founded within the first weeks after the events of 9/1 1 by Desmond Heath and several other child psychiatrists under the auspices of Disaster Psychiatry Outreach (DPO). Kids Corner provided mental health services on site. Kids Corner was centrally located at Pier 94 and was easily visible so that families could leave their children and easily check back between visits to various family assistance agencies. Parents also used Kids Corner to seek advice, talk about how to parent while grieving themselves, and to be with their children in a place that offered respite from the stress of the full-time demands of distressed children.
Kids Corner was the size of a small classroom, and had an adjoining carpeted family consultation area with comfortable sofas. It had a building block and toy area, especially equipped with toy fire engines, police cars, and rescue vehicles to facilitate children's expression of trauma-related feelings, thoughts, and memories, with an emphasis on repair and restoration. Clinicians monitored the quantity and quality of the toys to ensure that the environment was not overstimulating. There was an arts, crafts, and painting table, which also promoted older children's working and talking together. It was especially meaningful and consoling for children to see their signed artwork mounted around the walls of the Kids Corner, knowing that others similarly affected would see them. Snacks and children's books for a range of ages were always available.
After reflecting on their volunteer experiences and clinical work at Kids Corner, the author and colleagues from the Columbia University Parent-Infant Program formulated the following clinical guidelines for primary care providers who serve parents and children following a disaster or crisis. These guidelines are useful as a "first response" to traumatic events.5
Guidelines Applying to Children
* Listen. Some children spontaneously want to talk about what they or their parents and family members are going through with a sensitive listener from outside the family. 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 events helps toward the restoration of a coherent narrative. It is important to follow the child's lead, to avoid probing exploration, responding only to what the child spontaneously introduces, in order to support containment of overwhelming feelings.
* Facilitate. It is important to facilitate children's symbolic expression in play and in art projects by being supportiveIy interested and available to observe or join play or to talk with them while they use arts and crafts materials.
* Support the capacity to "imagine repair." Pynoos (in a personal communication) described key moments in the crisis intervention after the bombing in Oklahoma City when he helped children to imagine reparative possibilities. When a session ends with a child who has relived the trauma by telling about it or representing it in play or drawings, this may re-traumatize the child, unless the session ends by helping the child imagine some way of repairing or healing the damage. It is important to help younger children to think about how their family and community will take care of them and try to prevent further crisis.
* Support attachment bonds. For children who are ready, when faced with the death of a parent, one can provide support for the child's identification with or internalization of the attachment to the lost family member by facilitating the child's need to remember and talk about their lost loved one.
Guidelines Applying to Parents
* Contextualize the parents' reactions by helping them to understand that their fears, anxieties, and flashbacks are understandable reactions in the context of an extremely traumatic event. Support the child's surviving attachment relationships by helping parents to understand the child's feelings and by facilitating c?mmunication between them.
* Recognize. Help parents recognize how much children understand about the events around them. Help parents, family member, and friends to be more accessible to their child by answering questions directly and honestly, without providing more information than children need.
* Clarify. Help parents to make sense of their children's perplexing and disturbing expressions and behavior. For example, help parents understand and make meaning of the feelings being expressed through children's repetitive dramatic play, traumatized drawings, dreams, or nightmares that parents find upsetting.
* Step back and take the child's perspective. Some parents are frightened or become angry with theft children for theft increased dinginess, tantrums, and aggression. Parents sometimes are afraid that these reactions are signs of lasting damage and future pathology.
* Normalize the expectable response. It can be difficult for parents to understand aggressive or demanding behaviors in their children as expected responses to a situation of great insecurity. Parents' anxiety or anger, in turn, makes the child more frightened of losing them, and so they react with more demanding or aggressive behaviors.
* Answer children's questions simply and clearly. It is important to help parents answer the questions that children raise both directly and indirectly, while protecting children from exposure to adult conversations. In this way, the adult's reflective function can be re-engaged so that they can begin to understand their child's experience.
* Encourage families to try to return to ordinary daily life and customary routines as soon as possible.
* Turn off the TV when children are present, and try not to expose children to endless repetitions of images of the traumatic event, as supported by research findings following the Oklahoma City bombing.13
From the clinical evaluations during 9/11, efforts of the Parent-Child Interaction Project at Columbia University turned toward understanding the psychobiological mechanisms of PTSD-afflicted adults and how stress in the parents effects caregiving behaviors and physiologic regulation, seeking factors that contribute to the relational PTSD phenomena described by Scheeringa and Zeanah in different trauma exposure scenarios.14
Typical child development by 5 years to participate with others in the context of routine social interactions, to tolerate frustration, and to learn an empathie stance, requires the early childhood parent-child engagement in ongoing mutual regulation of emotion, arousal, and attention.'5 Mutual regulation in the context of the infant-parent attachment relationship is a concept that developed out of observed animal models. "Hidden" or embedded within child-parent attachment relationships are a range of regulatory functions for which the infant is dependent upon the mother. These regulatory functions span from basic bodily functions (eg, temperature, feeding, elimination, sleep, arousal) to, in humans, higher psychological functions (eg, emotion, attention, sense of self in space and time).16
One early study has supported that maternal interpersonal violence-related PTSD was moderately and significantly correlated with hostile-intrusive caregiving behavior.17 Another study suggested that maternal depression alone, so often noted in the literature as accounting for significant disruption of child-parent attachment, did not account for many hypothesized effects when comorbídity was controlled, suggesting additional factors such as stress in the aftermath of adverse life events as playing important roles.18
Given that the mutual regulation model is "mutual" and bidirectional, it is not appropriate to assume that caregivers are the only ones affecting stressful situations. Very young children cannot, by nature, regulate their emotional or behavioral responses and have not yet developed the capacity to reflect on their own mental states. Crying bouts, tantrums, anger (eg, postseparation) can appear violent and frighten already traumatized parents. Following from "ghosts in the nursery" by Fraiberg et al,19 and the notion of "Frightening/Frightened Parental Behavior,"20 caregiveis often behave with "fight, flight, or freeze" during stressful interactions with their children. Frightening states in the rnind of the traumatized caregiver may be so intolerable that they are projected onto the distressed child. Even a neonate, by virtue of physical resemblance to a violence-perpetrating parent or spouse, can become a reminder to adults of prior trauma.
One factor that could counteract the effects of maternal interpersonal violent trauma and which would facilitate mutual regulation between parent and child would be a history of a secure attachment in the mother's life. Lieberman et al21 has described the "angels in the nursery," where the caregiver recalls past safe caregiving experiences of her own, when previous adults behaved in a "sensitive-enough" manner. One evidence-based marker of such a relationship is "reflective functioning."22 Reflective functioning as applied to the parent-child relationship23 is the measurement of parental capacity to think about feelings, thoughts, and intentions from the involved child's perspective. Understanding both concepts, Reflective Functioning and Mental Representations can be useful tools for child-serving providers in their clinic-settings.
Observations In the Clinic
* Maternal Mental Representations: Even in the routine pediatrie visit, listening to how a parent talks about her child and her relationship with her child, in terms of her child's personality and behavioral intentions, can help clinicians understand the emotional availability of the parent for the child.
In one study, semi-structured videotaped interviews assessed caregivers' mental representations of their child.24 Using a standardized interviewing model,25·26 two broad categories of relationships were identified: "balanced" and "non-balanced" - analogous to "secure" and "insecure" attachment, respectively. The non-balanced group could be further divided into "disengaged" and "distorted" categories. The "disengaged" category implies that the responses were characterized by pervasive emotional indifference towards the child. "Disengaged" caregivers typically had indistinct or clichéd views of the child. The "distorted" group conveyed unrealistic expectations of the child, as well as pervasively angry, critical, or negative views of the child. "Distorted" responses typically impressed the rater as insensitive or overly negative. In this study, nearly 80% of PTSD-afflicted mothers were classified as having nonbalanced, distorted mental representations of their child.24 Although more severe maternal PTSD was associated with a twofold likelihood of having non-balanced, distorted mental representations of her child, greater maternal reflective functioning skills were associated with a nearly fivefold likelihood of having "balanced" or secure interactions with a child. Moreover, greater maternal reflective functioning was associated with positive changes following a brief intervention that employed video feedback.27
MATERNAL REFLECTIVE FUNCTIONING
In order to elicit Reflective Functioning,22 one must ask a demand question, such as:
* "And what do you think makes your child act that way?"
* "How do you feel when your child acts that way?'
An example of low reflective functioning would be, "I don't know what makes him act that way. He's just a bad egg." An example of higher reflective functioning would be, "I think he acts that way because he feels nervous, and seeing him act that way makes me feel nervous. Instead of my responding the way he needs me to, given that he's only a toddler, I waiver and then he gets a mixed message that makes him even more nervous."
Even in the routine pediatrie visit, observing and understanding parent-child interactions can provide valuable information about the parent's availability and resilience in the wake of crisis and trauma.
What Helps Mothers Change their Minds about their Children?
When social problems seem so entrenched, pediatricians and mental health professionals can feel helpless and cynical about the role of early childhood mental health. However, there are a number of hidden strengths and powerful motivations for change in many of these cases. Mothers who are pregnant and/or have young children are generally quite motivated to change for several reasons. Parents are, more often than not, primed to create a better experience for their children than they had. The very young child is developing so rapidly that there is an accelerated sense of time and the need to change quickly. Seeing positive change in the child-parent relationship is often immediately rewarding, and use of clinician-assisted videofeedback of child-parent interactions can result in rapid and significant clinical change of behavior.28·29 With appropriate interventions, mothers can rapidly begin to take positive, empathie, appropriately protective stance towards their child regardless of their past experiences and current situations.
Other forms of child-parent psychotherapy that focus on the interaction between the child and parent have also been empirically found effective in changing maternal behavior with or without augmentation by videofeedback.3031 Crucial to each of these interventions is comprehensive assessment and treatment by an early childhood mental health specialist.
This article provides the primary care provider an introduction to mental health issues pertaining to parenting children through stress and trauma. The author presents a theoretical framework, a review of the literature, clinical observations, and empirical data to provide foundations for the pediatrician to participate as a "first responder" in family trauma or crisis.
Child-parent relationship assessment, as well as relationship-focused intervention, are essential components of any treatment plan because the child and parent have both developed ways of relating and not-relating to each other to accommodate the crisis or trauma facing the family.
1. Winnicott DW. Anxiety associated with insecurity. In: Winnicott DW, eds. Through Pediatrics to Psycho-Analysis: Collected Papers. New Yotk: Basic Books; 1958:99.
2. Scheeringa MS, Zeanah CH, Drell MJ, Lairieu JA. TWo approaches to the diagnosis of posttraumatic stress disorder in infancy and early childhood. JAm Acad Child Adolesc Psychiatry. 1995;34(2):191-200.
3. Laor N, Wolmer L, Cohen DJ. Mothers' functioning and children's symptoms 5 years after a SCUD missile attack. Am J Psychiatry. 2001;158(7):1020-1026.
4. Schechter DS. Intergenerational communication of maternal violent trauma: Understanding the interplay of reflective functioning and posttraumatic psychopathology. In: Coates SW, Rosenthal JL, Schechter DS, eds. September l I.Trauma and Human Bonds. Hillside, NJ.: The Analytic Press; 2003:1 15-142.
5. Coates SW, Schechter DS, First E. Brief interventions with traumatized children and families after September 11. In: Coates SW, Rosenthal, JL. Scheehter, DS, eds. September 11: Trauma and Human Bonds. Hillside, N.J.: The Analytic Press; 2003:23-50.
6. Adams RE, Boscarino JA. Predictors of PTSD and delayed PTSD alter disaster: The impact of exposure and psychosocial resources. J Nerv Ment Dis. 2006;I94(7):485493.
7. Wickrama KA, Kaspar V (2007), Family context of mental health risk in Tsunami-exposed adolescents: Findings from a pilot study in Sri Lanka. Soc Sci Med. 2007;64(3),7 13-723.
8. Stuber J, Galea S, Pfefferbaum B, Vandivere S, Moore K, Fairbrother G (2005). Behavior problems in New York City's children after the September 1 1 , 2001 terrorist attacks. Am J Orlhopsychiatry. 2005 ;75(2): 190-200.
9. Pynoos RS, Steinberg AM, Wraith R. A developmental model of childhood traumatic stress, hi: Cicchetti D, Cohen DJ, eds. Risk, Disorder and Adaptation: Voltane 2, Developmental Psychobiohgy. New York: Wiley; 1995:87.
10. Freud S. Beyond the Pleasure Principle. In: J. Strachey, ed. The Standard Edition of the Complete Psychological 'Works of 'Sigmund Freud, Vol. XVlIl. London: The Hogarth Press; 1920:27.
11. Gafney DA. The aftermath of disaster children in crisis. / Clin Psychol. 2006;62(8):1001-1016.
12. Looman WS. A developmental approach to understanding drawings and nairatives from children displaced by Hurricane Katrina. J Pediatr Health Care. 2006;20(3):158-I&6.
13. Pfefferbaum B, Scale TW, Brandt EN, Pfefferbaum RL, Doughty DE1 Rainwater SM. Media exposure in children one hundred miles from a terrorist bombing. Ann Clin Psychiatry. 2003;15(l):l-8.
14. Scheeringa MS, Zeanah CH. A relational perspective on PTSD in early childhood. J Trauma Stress. 2001;14(4):799-815.
15. Fonagy P, Gergely G, Jurist E, Target M. Affect Regulation, Mentalization, and the Development of the Self. New York: Other Books;2002.
16. Hofer MA. Relationships as regulators: a psychobiological perspective on bereavement PsychosomMed. 1984;46(3):183-187.
17. Lyons-Ruth K, Block D. The disturbed caregiving system: Relations among childhood trauma, maternal caregiving, and infant affect and attachment. Infant Ment Health J. 1996;17:257-275.
18. Carter AS, Garrity-Rokous FE, Chazan-Cohen R, Little C, Briggs-Gowan MJ. Maternal depression and comorbidity: Predicting early parenting, attachment security, and toddler social-emotional problems and competencies. JAm Acad Child Adolesc Psychiatry. 2001;40(1): 18-26.
19. Fraiberg S, Adelson E, Shapiro V. Ghosts in the nursery. A psychoanalytic approach to the problems of impaired infant-mother relationships. J Am Acad Child Psychiatry. 1975;14(3):387-421.
20. Main M, Hesse E. Parents' unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism? hi: Greenberg MT, Cicchetti, D, Cummings, EM, eds. Attachment in the Preschool Years. Chicago: University of Chicago Press; 1990:161-182.
21. Ueberman AF, Van Horn P, Ippen CG. Toward evidence-based treatment: Child-parent psychotherapy with preschoolers exposed to marital violence. J Am Acad Child Adolesc Psychiatry. 2005;44(12):1241-1248.
22. Grienenberger JF, Kelly K, Slade A1 Maternal reflective functioning, mother-infant affective communication, and infant attachment Exploring the link between mental states and observed caregiving behavior in the intergenerational transmission of attachment. Attach Hum Dev. 2005;7(3):299-311.
23. Slade A. Parental reflective functioning: An introduction. Attach Hum Dev. 2005;7(3):269281.
24. Schecftter DS, Myers MM, Brunelli SA, et al. Traumatized mothers can change their minds about their toddlers: Understanding how a novel use of videofeedback supports positive change of maternal attributions. Infant Meni Health J. 2006:27:429-47.
25. Zeanah CH, Benoit D, Barton ML, Hirshberg L. Working Model of the Child Interview Coding Manual. New Orleans: Tulane University School of Medicine; 1996.
26. Zeanah CH, Lairieu, JA, Heller SS, Valliere J. Infant-Parent Relationship Assessment, hi: Zeanah CH, eds. Handbook of Infant Mental Healtk New York: Guilford Press; 2000:222-235.
27. Schechter DS, Coots T, Zeanah CH, et al. Maternal mental representations of the child in an inner-city clinical sample: Violence-related posttraumatic stress and reflective functioning. AftachHumDev. 2005;7(3):313-331.
28. Juffer F, Hobbergen RA, Riksen-Walraven JM, Kohnstamm GA. Early intervention in adoptive families: Supporting maternal sensitive responsiveness, infant-mother attachment, and infant competence. J Child Psychol Psychiatry. 1997;38(3): 1039-1050.
29. McDonough SC. Promoting positive early parent-infant relationships through interaction guidance. Child Adolesc Clin N Am. 1995;4:661672.
30. Toth SL, Cicchetti D, Kim J. Relations among children's perceptions of maternal behavior, attribuuonal styles, and behavioral symptomatology in maltreated children. J Abnorm Child Psychol. 2002;30(5):487-501.
31. Zeanah CH, Larrieu JA, Heller SS, et al. Evaluation of a preventive intervention for maltreated infants and toddlers in foster care. J Am Acad Child Adolesc Psychiatry. 2001 ;40(2):2 14-21.