By Peter A. Levine and Maggie Kline
Issue 110 January/February 2002

trauma art
Lisa cries hysterically every time the family prepares to get into the car.

Carlos, a painfully shy 15 year old, is chronically truant. "I don't want to feel scared all the time anymore," he says. "All I want is to feel normal."

Sarah reports dutifully to her second grade class on time every morning; invariably, by 11:00 a.m. she is in the nurse's office complaining of a stomachache, although no medical reason can be found for her symptoms.

Curtis, a popular, good-natured middle school student, tells his mother that he feels like kicking someone. He has no idea where this urge is coming from. Two weeks later he starts behaving aggressively toward his little brother.

The parents of three-year-old Kevin are concerned about his "autistic-like" play. He repeatedly lies on the floor, and stiffens his body, pretending he is dying and slowly coming back to life, saying, "Save me!"

What do these children have in common? Will their symptoms disappear on their own, or will they grow worse over time? Let's take a deeper look at their individual histories.

Lisa was strapped into her carseat when the family's station wagon was rear-ended. There were no physical injuries.

Carlos was intimidated for five years by an emotionally disturbed adult stepbrother.

During her first month of second grade, Sarah was told, abruptly and unexpectedly, that her parents were getting divorced and her father would be moving out.

While waiting for the school bus one morning, Curtis witnessed a drive-by shooting that left the victim dead on the sidewalk.

Kevin was delivered by emergency cesarean and had a lifesaving surgery within 24 hours of his birth.

Each of these youngsters has experienced an overwhelming life event, and, although the incident is over, each continues to experience life as if the event is still happening. These children are suffering from traumatic stress that has not gone away on its own.

Traumatic reactions can develop in anyone regardless of age. Those at greatest risk, however, are infants and children. Childhood abuse and neglect, the witnessing of violence, war, or auto accidents, and natural disasters such as earthquakes, tornadoes, fires, and floods are now being recognized as potentially traumatic. It is not surprising that witnessing a murder has affected Curtis, but symptoms can also have roots in what are generally considered more common occurrences, such as fender benders, invasive medical procedures, divorce, chronic bullying, and even falling off a bicycle. (See sidebar, "Common Causes of Childhood Trauma.")

It is important to note that events that may not be traumatizing to an adult may be overwhelming to a child. The good news is that, while the events themselves may be an inevitable part of growing up, traumatic symptoms are frequently preventable or can often be healed.

What Is Trauma?
The basis of trauma is physiological rather than psychological. Because there is no time to think when facing threat, our primary responses are instinctual. At the root of a traumatic reaction, is the 280-million-year heritage that we share with nearly every living creature on earth and that resides in what is known as the reptilian brain. When this primitive part of the brain perceives danger, it automatically activates an extraordinary amount of energy--like the adrenaline rush that allows a mother to lift a Chevrolet her child is trapped under. This, in turn, triggers a pounding heart and numerous other physical changes designed to help us defend ourselves or protect our loved ones.

The catch is that to avoid being traumatized all of that excess energy must be used up in dealing with the threat. When the energy is not discharged, it does not simply go away; instead, it stays trapped, creating the potential for traumatic symptoms. The younger the child, the fewer resources she has to protect herself, resulting in a greater amount of undischarged energy. The likelihood of future traumatic reactions is directly proportional to the amount of mobilized energy that was available to fight or flee.

Jack, an 11-year-old Boy Scout and straight-A student, had sudden-onset school phobia following a minor earthquake-actually a minor tremor by California standards. What made Jack's experience so traumatic? When he first felt the tremor, he was unable to predict the accurate level of danger; the only thing that registered in his reptilian brain was the "red flag" of threat. His nervous system responded to the perceived danger with full alert, and he continued to feel panicky well after the event.

The severity of this response becomes understandable when we learn that, as a young child, Jack had been confined to a body cast for several weeks following surgery. It had been a terrifying experience for him. Frightened by the procedure and then immobilized by the cast, he was powerless to respond to the dangers he perceived lurking all around him, as young children do after such a scary event. Feeling the intense impulse to flee, and yet coming up against the hard confines of his cast, he collapsed into fearful resignation--which is what any animal does in a situation where escape is impossible.

Even after Jack's cast was removed, the undischarged energy remained present in his nervous system. And then some years later he was again lying in bed when the minor earthquake occurred. His body remembered the old helplessness and responded to the present danger as though he were still confined in the cast. He feared that he would be unable to protect himself out in the world and became panicky. What looked like school phobia was really fear of his own internal sensations and loss of trust in his bodily responses instilled many years before.

Lessons from the Animal World
Since animals are nonjudgmental and instinctual, they can be powerful resources to help children connect directly with their innate healing process. In the late 1960s, Peter Levine observed that prey animals in the wild, although threatened routinely, are rarely traumatized. Further research led to the discovery that animals have a built-in ability to rebound from a steady diet of danger. They literally "shake off" the residual energy left behind through trembling, rapid eye movements, shaking, panting, and taking a deep spontaneous breath as the body returns to equilibrium. Animals do not have words to judge their feelings and sensations. There is no shame or blame, just the primitive language of the instinctual reptilian brain, the language of sensation.

Sensations that Help Your Child Heal
The "emotional first aid" presented here is intended to facilitate a journey into the inner world of a child's bodily sensations as a way of fostering resilience to the challenges and stresses that all children face. Children need caregivers to make ample time for them to experience, through bodily sensations, specific elements that relate to their recovery from things that have overwhelmed them. These healing elements include sensations of empowerment, such as strength and grounding.

Providing Support to an Overwhelmed Child
To prevent or minimize trauma, it is important that you yourself not be overwrought. The knowledge that children are both resilient and malleable can help you stay calm. When supported appropriately, children usually rebound from stressful events. In fact, as they begin to triumph over life's shocks and losses, they grow into more competent and vibrant beings.

Because the capacity to heal is innate, your role as an adult is simply to help the child access this capacity. This is similar in many ways to the function of a Band-Aid or a splint: It doesn't heal the wound but protects and supports the body as it restores itself. The suggestions provided here can help you be a good "Band-Aid" for your child.

First, it is important to let children know that any powerful emotions they may be having, such as sadness, anger, rage, fear, or pain, are not only okay but normal. Children are comforted and empowered by the knowledge that their pain is time-limited, that it won't last forever, and that whatever they are feeling now is accepted. Children will move through their feelings rather quickly when they are not rushed. Having the patience to attune your pace to your child's rhythm gives him permission to be authentic. This acceptance and respect sets the conditions for the child, in his own time, to rebound to a healthy sense of well-being.

Often children react the way they think their parents want them to. They act "strong" and "brave," overriding their own feelings, only to end up with trauma symptoms that could have been averted. Countless adults in therapy report having stifled their feelings as children to protect their parents from "feeling bad." Be alert to this pitfall and circumvent it by paying close attention to your child's expression. When there is shock, it is common not to feel much at first, as the chemicals released for "fight or flight" also serve as a kind of natural anesthesia. When a child is cut, for example, she may not notice it until she sees the blood; the pain is usually delayed until the shock begins to wear off. On the other hand, she may cry hysterically.

Validate your child's emotional and physical pain in a calming voice, assuring her that you will stay with her to do whatever needs to be done. Children benefit most from the sense that there is a calm, centered adult in charge who is accepting, knows what to do, and is able to keep them safe.

The importance of remaining calm cannot be overemphasized. When a child has been hurt or frightened, it is normal for a parent to feel shocked or scared. It is also not uncommon to respond initially with anger, which can further frighten the child. The best antidote is to tend to your own reactions first, allowing your bodily responses to settle rather than scolding or running anxiously toward your child. Our work with clients in therapy confirms that often the most frightening part of the experience for the child was a parent's reaction. The younger the child, the more he "reads" the facial expression of caregivers as a barometer of the seriousness of the situation.

Emotional First Aid for an Overwhelmed Child
After paying close attention to your child's bodily responses, support these reactions by not interrupting his natural cycle for coming out of shock. If you have an infant or young child, hold him safely on your lap. If the child is older, place one hand on his shoulder, arm, or middle of the back, being careful not to hold him too tightly or in such a way as to stop the natural discharge of physical sensations. You will likely observe shaking, trembling, tears, chills, or heat. Help your child remain calm with a reassuring voice and a few words, such as, "That's okay," "It's all right to feel," or "Just let the shaking happen."

After the trembling, tears, or other symptoms stop, validate your child's emotional responses. Let her know that whatever she is feeling is okay and that you will stay with her to listen. Resist the temptation to talk a child out of fear, sadness, anger, embarrassment, guilt, or shame to avoid your own discomfort. Trust that your child will move through these feelings when supported.

The Language of Sensation
The language of sensation is, to many, relatively foreign but fortunately is easy to learn. It is essential to recovery just as survival skills are when traveling abroad. Sensations can range from pressure or temperature changes on the skin to vibrations, gurgles, muscular tension, or constrictions. This is the language of the primitive brain, which acts on our behalf when in danger. Before an emergency occurs, it's a good idea to get acquainted with your own inner landscape. All it takes is setting aside some unhurried time without distractions to pay attention to how your body feels.

Note that sensations are different from emotions. They describe the physical way the body feels. Even preverbal children can be invited to point to where in their bodies it might feel shaky, numb, calm, and so forth.

How to Tell If Your Child Has Been Traumatized
Common indications of trauma after a stressful event are withdrawal, fearfulness, irritability, clinging, sleep problems, emotional outbursts, nightmares, excessive shyness, and aggression. Other symptoms are an exaggerated startle response and regression to earlier behaviors such as bedwetting and thumb sucking. Some children become avoidant to the point of developing phobias. These can be specific, such as a phobia of dogs after being bitten, or general, as Jack's school phobia after the earthquake. Physical symptoms are also common, such as stomachache, headache, nausea, vomiting, diarrhea, constipation, and fever. Of course, these symptoms may also be caused by an illness like the flu. If so, they should pass in a day or so; phobias and other symptoms usually do not. In fact, they often get more complex over time.

First Aid for Trauma

1. Attend to your responses first.
Pause to notice your own level of fear or concern. Next, take a full deep breath, and as you exhale slowly sense the feelings in your body until you are settled enough to respond calmly. An overly emotional or smothering adult may frighten the child as much as the accident.

2. Keep your child still and quiet.
If injuries require that he be picked up or moved, make sure he is supported properly. Do not allow him to move on his own; remember, he is probably in shock. Keep the child comfortably warm by draping a sweater or blanket over him.

3. Assess the situation.
If your child shows signs of shock (glazed eyes, pale skin, rapid or shallow breathing, disorientation, overly emotional or overly tranquil affect, or acting like nothing has happened), do not allow her to jump up and return to play. Say something like, "We're going to sit (or lie) still together for a while and wait until the shock wears off." A calm confident voice communicates that you know what's best.

4. As the shock wears off, guide your child's attention to his sensations.
Ask your child how he feels "in his body." Repeat his answer as a question-"You feel okay in your body?"-and wait for a nod or other response. Be more specific with the next question: "How do you feel in your tummy (head, arm, leg, etc.)?" If he mentions a distinct sensation, gently ask about its location, size, shape, color, or weight. Keep guiding your child to stay in the present moment with questions such as, "How does the rock (sharpness, lump, sting) feel now?" If he is too young or too startled to talk, have him point to where it hurts.

5. Allow a minute or two of silence between questions.
This may be the hardest part for the adult but the most important for the child. It allows the child to complete any cycle that she may be moving through, discharging the excess energy. Be alert for cues that let you know a cycle has been finished, such as a deep, relaxed breath, the cessation of crying or trembling, a stretch, a yawn, a smile, or the making or breaking of eye contact. Wait to see if another cycle begins or if there is a sense of enough for now.

6. Encourage your child to rest or sleep even if he doesn't want to.
Deep discharges of energy generally continue during rest and sleep. Do not stir up discussion about the mishap by asking questions. Later the child may want to tell a story about it, draw a picture, or express it through play. If a lot of energy was mobilized, the release will continue, although some cycles may be too subtle for you to notice. Rest promotes a fuller recovery, allowing the nervous system to relax. In addition, dream activity can help move the body through the necessary physiological changes. These changes happen naturally; all you have to do is provide the calm, quiet environment. (Caution: Of course, if your child has had a head injury, you want him to rest but not to sleep until it is safe to do so.)

7. Continue to validate your child's physical responses.
Resist the impulse to stop your child's tears or trembling, while reminding her that whatever has happened is over. For her to return to equilibrium, her distress needs to continue until it stops on its own. This might take from one to several minutes. Children who are able to cry and tremble after an accident have fewer problems recovering from it. Your job is to use a calm voice and reassuring hand to let the child know that "It's good to let the scary stuff shake right out of you." The key is to avoid interrupting or distracting her, holding her too tightly, or moving too far away.

8. Finally, attend to your child's emotional responses.
Later, when your child is rested and calm, set aside some time for him to talk about his feelings concerning what he experienced. Children often feel anger or shame. Help your child to know that those feelings are normal and that you understand. You might then share a similar experience that you or someone you know had.

No matter what the event, if after trying these exercises and first aid suggestions, your child is still having symptoms or problems seek professional help. Do not wait for symptoms to become full blown. Ask for referrals from your local school, pediatrician or friends that have had good experiences with a child therapist. Interview the therapist about his/her training and experience in working with children. Taking advantage of the help offered by a competent professional could be the wisest investment in your family's health that you will ever make

For additional information on trauma, see the following article in a past issue of Mothering:
"Understanding Childhood Trauma," no. 71.

Peter A. Levine, PhD, is the originator of Somatic Experiencing® and director of the Foundation for Human Enrichment in Lyons , Colorado . His book Waking the Tiger: Healing Trauma has been published in eight languages. This article is based on his Sounds True tape series It Won't Hurt Forever: Guiding Your Child through Trauma, which provides in-depth information on how to help children traumatized by hospitalization and medical procedures as well as other events. Levine has also produced the tape series Healing Trauma: Restoring the Wisdom of the Body. Sexual Trauma: Healing the Sacred Wound will be released in 2002. To order any of these call Sounds True at 800-333-9185.

Maggie Kline, MS, MFT, is a family therapist in private practice, specializing in the treatment of traumatized children and adults. She is also a school psychologist in Long Beach , California . She uses art and play therapy and Dr. Levine's work in both settings.