Dr. Esti Galili-Weisstub is the Director of the Herman Dana Division of Child and Adolescent Psychiatry at Hadassah Hospital. She is the Former chairman of the Israeli union for Child and Adolescent Psychiatry, Member of the Israeli union of Child and Adolescent Psychiatry examination and was also the Secretary of the Israeli company for analytical psychology.

Transcription:

Melanie Cole (Host): In the aftermath of tragedies such as the terror attack on the Tree of Life Synagogue in the Squirrel Hill neighborhood of Pittsburgh; as parents we often find ourselves at a loss as to how to help our children, what to tell them when things like this happen. Today we are speaking with Dr. Esti Galili-Wesstub on this episode of Hadassah On-Call.

Welcome. My guest today is Dr. Esti Galili-Wesstub. She's the Director of the Herman Dana Division of Child and Adolescent Psychiatry in Hadassah Hospital. Dr. Galili-Wesstub thank you very much for taking the time to talk to our listeners on such short notice following the tragedy in Pittsburgh, Pennsylvania. Tell us a little bit about your career at Hadassah, working with children in Israel and around the world that have been traumatized by events like the shooting in Pittsburgh.

Dr. Esti Galili-Wesstub (Guest): Mine and our experience in Hadassah in charge of the lesson psychiatry basically stems from responding to the needs of children and adolescents in the Jerusalem greater area. It basically – we started to broaden our work with a second intifada starting at the late 2000s and we have seen unfortunately well over 800 victims of terror and aggression in the Middle East. But we felt very early on that we can share our experience with other areas in the world. That included the post-tsunami in 2005 in Sri Lanka. It included fires in Australia, working in Kiev a little bit, working in India and then our team from the trauma units traveled to France after the terror attack on the school. Some of our colleagues traveled to Berlin to work with refugees there. And recently even psychologists from our team traveled to Las Vegas post the shooting there of civilians by a gunman. So, I'm not sure I even mentioned everything, but we do feel an obligation to our population but also an obligation to victims of trauma anywhere in the world.

Melanie: Dr. Galili-Wesstub while we know that you are not in Pittsburgh this week; we hope that you can enlighten us on therapies and treatments for children and adolescents after traumatic events such as this one. What are you looking to do with these children?

Dr. Galili-Wesstub: So, I think there are two things that we should keep in mind. One is that we have to be very flexible both in evaluating the immediate response to trauma and also by tailor making the right therapy for each family and each child. It is not like a cooking recipe. There are several techniques. Maybe the more popular ones are trauma-focused CBT and then there is CPT something that comes from the west of the United States from California. There are other forms of therapy, MDR probably things that you have heard of or SE, but I think that the most important thing is to keep an open mind about each child and his family and to think what's right for them. But at the first stage, I think what is important is to evaluate the immediate response to try and understand the reality of each child and each family, their stressors pre-event which will make them more vulnerable to develop unfortunately symptoms after and also to evaluate their support system. Support systems can predict very well your ability to deal even with a horrific trauma.

Melanie: That is so interesting doctor and we understand that all traumas are different. From your expertise, how do these kinds of events affect children both short and long-term? What do you see if the child doesn't necessarily have that great support system that you are speaking of?

Dr. Galili-Wesstub: First of all, I don't think our traumas are that different. I do think that the big difference lies in the fact that your trauma was totally, totally out of context. Nobody expected that. And I think that's in a way unfortunately in Israel or in the Middle East we almost expect our children to experience some kind of trauma. I do think that it's unfortunate. So, I think that the problem in Israel that we have something that we call acute on chronic. So, there's a chronic reality that something might happen, so you are in a certain kind of mode and then it does happen and, in a way,, it repeats itself either by news or by somebody else you can see that happening in the south of Jerusalem around the Gaza strip again and again and again and again and again. I think the big difference is that luckily, luckily that the community and the United States does not expect something like that to happen and it is like a thunder in a sunny day, a thunder storm in a totally sunny day. So, basically there's a good chance that a large number will recover and in the long-term probably the chances of chronic PTSD are fairly, fairly small. But given that when somebody needs to be related to, they will be related to and it will not be neglected. And the ways to do it is to be in touch from the beginning, to give everybody that was exposed to the trauma whether directly or closely indirectly from that community a very accessible line to professionals and to ask questions if they are raised like of behavioral, of emotional, of any kind of symptom or suspected symptom. And when you treat things right away, you have a better chance of containing it.

The other thing is, that it's highly, highly important to support the parents of the children because there's a very strong connection between the parents' reaction and the child's reaction and it is mostly notable if the child is young. If the child builds his reality through his parents' eyes. So, if the parents are doing well, we can assume that the children will also do fairly well. Or that they'll be aware enough to look for support for their children as early as possible.

Melanie: So, you're saying that the parents, we need to process and deal with our own feelings of grief and fear before we can really help our children, that they are going to reflect based on how we react to these kinds of things, yes?

Dr. Galili-Wesstub: Exactly, but I wouldn't say before. Because I think at the same time or because we can't – it might take us if the parents were present or they lost someone dear to them in the shooting, it might take them weeks to process it. Their children can't wait weeks. But they have to be aware that what they do affects their children. It doesn't mean that the parents should be false, it doesn't mean that the parents should try and hide their feelings from their children. They should just be aware that what their children share, what their children think and in certain times they would ask for guidance or support. I think children are very aware of what their parents feel. And you can't hide anything, and you certainly want to give the children the message that being sad, being afraid, being angry, feeling helpless is normal. They can feel it. Sometimes they can see their parents feel it. It doesn't mean that their parents are not available to give them the support they need or the therapy that they need, if it comes to that.

Melanie: So, then let's talk about helping our children as we help ourselves as adults because this did affect so many of us and as you said, like a thunderstorm on a sunny day. How do we find out what our children already know? With social media, they hear things all around doctor. How important is listening to their fears and concerns and how do we approach it with them? Give parents listening some coping strategies.

Dr. Galili-Wesstub: So, nowadays you would assume that the child already is exposed, I would say certainly over six years of age at least here unfortunately. Unfortunately, they all have cell phones and they all see what's happening. So, I think that it's important to sit down with the children and to say you probably heard or I don't know if you heard but this and this happened and to ask them, what do they know about it. Do they want to ask anything? It is important to encourage them to talk but not to force a psychological or emotional openness if they are not ready for it. The idea is again, again and again, I don't know how – in how many ways I can stress it, is to be sensitive, flexible, containing and encouraging, but not to force anything. Some children do not want to verbally process their feelings. It doesn't do them any good. They want to play, they want to draw pictures, they want to spend time with their friends. If they are functioning okay, you don't need to force them to go through any kind of psychological process. You have to be open, flexible and attentive.

Melanie: Are there things we should look for? Red flags? You say if they are feeling normal, what should we be looking for?

Dr. Galili-Wesstub: So, I mean first of all, it's the basics. It's sleeping, eating, concentrating, being interested in their surroundings. Now things could be different for the first few days if somebody lost a grandfather or a grandmother, they might not have I think it's obvious to all of us a good appetite and they might not be able to do their schoolwork for a few days. That's normal. That's what we call psychoeducation. We have to understand ourselves and to understand it for our children that we are affected emotionally, and we react to it. But if you see after a week or two that things are not starting gradually to improve, then you have to be worried. If weeks after, a month after, a month and a half after you see that the kid doesn't want to see friends, doesn't want to do their extracurricular things that they used to enjoy, doesn't want to go to sports, doesn't want to play music, doesn't sleep at night or oversleeps because he is hiding away in his room and in his bed, etc. You have to look for changes in behavior to allow some changes in the immediate period and reaction, but to encourage a child that they will find strength and come back to themselves. And to show them that even if we are sad or frightened, we do have enough strength to keep on doing important things.

Melanie: Wow doctor, so is that when the parents step in and try and use their strength and support or is that the time to seek professional help and if so, who do we look to?

Dr. Galili-Wesstub: It's both. It's both. But I think it's responsible if a parent has a line and open line to contact someone professional to consult and they could come for a meeting and describe what's going on and decide together whether there's a need for an intervention or not. I think it's very important that they have some professional help available just to consult and evaluate the situation. And you can turn to a psychologist or a clinical social worker. I think usually they have enough training to be able to evaluate and give the support that's needed. I think that rarely you need a psychiatrist and very rarely you need to intervene with medications. In extreme cases, you do. And it helps and it's very good that it does. But usually we start off with therapy. Most likely, with supporting the parents, individual therapy for the child, if they are young it could be play therapy or some kind of art therapy. But if they are older, it could be individual therapy, sometimes we feel it should be a family intervention, sometimes we do group work. It really, really depends on the child, on the specific trauma they were personally exposed to and to their family needs. Sometimes if a child had a pre-existing some kind of psychiatric or psychological problem; they would be more vulnerable to develop PTSD and we should be aware of that and then we should maybe consult with a person that was treating the child before and knows then about how to best address the intervention.

Melanie: Doctor one of the schools' principals in Pittsburgh said that routines for children are essential to normalization. Is that true? How can we keep their routines normal if they are not part of that more rare group of children that have real trouble processing this or maybe had a pre-existing situation? Are we supposed to try and normalize their routine or does that make it seem like we are pretending it didn't even happen?

Dr. Galili-Wesstub: I think – there is exactly the flexibility we are talking about. Keeping their normal routine gives the message that basically the world is a good place, bad things happen, but we are not helpless. We do have control over our life. Maybe not 100%, but for the most part, we do and I'm sounding a bit- maybe a bit shallow, but it is important, and life goes on and we can enjoy life and we have enough strength to continue. Having said that, it does demand that the teachers and the parents keep their eyes open. And if adhering to their routine and the normalization is best for the majority of the children; it could be one child that it's not working for them. Then they should not have the feeling that they are damaged or there is something wrong with them. But we should be able to give them the specific support that they need and if they don't have the strength to go on with life as it was before; we will encourage them to take their time and we will assure them that we know that within days or weeks, they will go back to their normal functioning. So, for the majority of the kids, talking about the events and at the same time expecting them to go on with their life as it was before is very, very important.

Melanie: Then please give us your final thoughts on helping children cope with tragedies that directly affect their communities and you do this all over the world doctor, so, give us a little bit of advice. What would you like us to know about helping our children and proceeding forward ourselves?

Dr. Galili-Wesstub: I'll tell you – I'll share with you maybe one of the most moving experiences I had. When we were with a team in Sri Lanka post tsunami and we were giving the lecture about PTSD in children and how to deal with it and what would we expect the outcome would be. And it was a room full of doctors and social workers mainly, there weren't many psychologists in Sri Lanka. And one of the doctors stood up and said you are sharing and experience from several hundred victims of terror, but we have lost over 40,000 people in the tsunami and I cannot see how it is relevant. And I was kind of taken aback and thinking and not really knowing how to answer. And then a woman in a light blue sari stood up, later I learned that she was the head of their pediatric college, which I didn't know at the time. And she said to him, do you know where this person is coming from? She's coming from Israel. Do you know that they lost 70 years ago about half of their people and they built a state after? So, she can tell you about what it means to lose 40,000 people and to recover. So, I do want to tell you that our psyche is built for regeneration and recovery and most of us recover well. And fortunately, I do know that your community has the means, both financially and academically and professionally and emotionally to support each other and I think you should remember that and to know even though I'm not romanticizing trauma by any ways; once you have experienced trauma, and it's horrible, you do have the ability to recover and you do have the ability to grow. So, I do think that optimism is realistic, not a wish.

Melanie: Thank you so much doctor, for being on with us today. What an inspiring story you told at the end and you gave us hope, you gave us encouragement and you gave us really great coping strategies and ways that we can not only help ourselves, but more importantly our children to deal when things like this happen. It's so important that we hear your message and that we hear your word. Thank you again for joining us.

This is Hadassah On-Call, New Frontiers in Medicine brought to you by Hadassah, the Women's Zionist Organization of America. The largest Jewish Women's organization in America, Hadassah enhances the health of people worldwide through medical education, care and research innovations at the Hadassah Medical Organization. For more information on the latest advances in medicine please visit www.hadassh.org, and to hear more episodes in this podcast series please visit my.hadassah.org/podcasts, that's my.hadassah.org/podcasts. This is Melanie Cole. Thanks so much for joining us today.

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