Understanding Childhood Trauma
Dr. Peter A. Levine
Although anyone – regardless of strength, capability, or experience – can be traumatized by a threatening event, those at greatest risk are infants and young children.
Johnny, age five, proudly riding his first bicycle, hits loose gravel and careens into a tree. He is momentarily knocked unconscious. Getting up amid a flow of tears, he feels disoriented and somehow different. His parents hug him, console him, and put him back on the bike, all the while praising his courage. They do not realize how stunned and frightened he is.
Years after the soon forgotten incident, John driving with his wife and children, swerves to avoid an oncoming car. He freezes in the midst of the turn. Fortunately, the other driver is able to maneuver successfully and avoid catastrophe.
One morning several days later, John begins to feel restless while driving to work. His heart starts racing and pounding; his hands become cold and sweaty. Feeling threatened and trapped, he has a sudden impulse to jump out of the car and run. He realizes the "craziness" of his feelings, and gradually, the symptoms subside. A vague and nagging apprehension, however, persists throughout most of his day at work. Returning home that evening without incident, he feels relieved.
The next morning, John leaves early to avoid traffic and stays late, discussing business with some colleagues. When he arrives home he is irritable and edgy. He argues with his wife and barks at the children. He goes to bed early, yet wakes up covered with sweat in the middle of the night and faintly recalling a dream in which his car is sliding out of control. More fretful nights follow.
Delayed Traumatic Reactions
John is experiencing a delayed reaction to the bike accident he had as a child. Incredible as it may seem, posttraumatic reactions of this type are common. After working for more than 20 years with people suffering from trauma, I can safely say that at least 75 percent of my clients have traumatic symptoms that remained dormant for a significant period of time before surfacing. For most people, the interval between the event and the onset of symptoms is between 6 and 18 months; for others, the latency period lasts for years or even decades. In both instances, the reactions are often triggered by seemingly insignificant events.
Of course, not every childhood accident produces a delayed traumatic reaction. Some have no residual effect at all. Others, including those viewed as "minor" and forgotten incidents in childhood, can have significant aftereffects. A fall, a seemingly benign surgical operation, the loss of a parent through death or divorce, severe illness (particularly one accompanied by high fever or poisoning), even circumcision and other routine medical procedures can all cause traumatic reactions later in life depending on how the child experiences them at the time they occur.
Of these traumatic antecedents, medical procedures are by far the most common and potentially the most impacting. Many clinical proceedings needlessly amplify the fear of an already frightened child. Infants about to undergo some routines, for example, are strapped into "papooses" to keep them from moving. A child struggling so much that he or she needs to be tied down, however, is a child too frightened to be restrained without suffering consequences. Likewise, a child who is severely frightened is not one to be anesthetized, at least not until a sense of tranquility has been restored. Children can even be traumatized by insensitively administered enemas or thermometers.
Much of the trauma associated with these and other medical procedures could be prevented if healthcare providers encouraged parents to stay with their children, to explain as much as possible in advance, and to delay interventions until their children are calm. The problem is that too few professionals really understand what trauma is about and what lasting and pervasive effects these procedures can have. Although medical personnel are often concerned, they may need more information-from you, the consumer.
What Causes Trauma?
At the root of a traumatic reaction is the 280-million-year-old heritage that we share with nearly every crawling creature on earth – a heritage that resides in the area of the nervous system known as the reptilian brain. Primitive responses that originate in this portion of the brain help the organism protect itself against circumstances that are potentially damaging or dangerous to survival. Animals in the wild routinely encounter such events, and routinely respond to them. Human beings, however, due to our more sophisticated brain structure, have an astounding proclivity for overriding these primitive responses. Thus, whereas animals are fairly quick to recover from potentially traumatic encounters, we are not. Whether or not a person will be traumatized depends largely on the individual's ability to respond to a threatening event in a specific way, with specific results.
When the reptilian brain perceives danger, it activates an extraordinary amount of energy – a phenomenon akin to an "adrenaline rush." This, in turn, triggers a pounding heart and other bodily changes designed to give the organism every advantage it needs to defend itself. The catch is that to avoid being traumatized, the organism must use up all the energy that has been mobilized to deal with the threat. Whatever energy is not discharged does not simply go away; instead, it lingers, creating the potential for traumatic reaction to occur. The fewer resources the organism has to meet the situation, the more undischarged energy there will be, and the greater the likelihood that trauma symptoms will develop in the future.
In short, an untraumatized outcome to a threatening situation depends on one's ability to remain engaged in action, to respond effectively, and to discharge the energy that has been mobilized, thereby allowing the nervous system to return to its accustomed level of functioning. Even life-threatening events may not be traumatic for people who can respond and process them in a natural and effective way. And although anyone – regardless of strength, capability, or experience – can be traumatized by a threatening event, those at greatest risk are infants and young children.
How to Tell If Your Child Has Been Traumatized
Any unusual behavior that begins shortly after a severely frightening episode may indicate that your child is traumatized. Compulsive, repetitive mannerisms – such as repeatedly zooming a toy car into a doll – are an almost sure sign of an unresolved reaction to a traumatic event. (The activity may or may not be a literal replay of the trauma.) Other signs of traumatic stress include persistent controlling behaviors, tantrums, uncontrollable rage attacks, hyperactivity, an exaggerated startle reflex, recurring night terrors or nightmares, thrashing while asleep, bedwetting, inability to concentrate in school, forgetfulness, excessive belligerence or shyness, withdrawal or fearfulness, extreme clinginess, and stomachaches or other ailments of unknown origin.
To find out whether an uncustomary behavior is indeed a traumatic reaction, try mentioning the frightening episode and see how your child responds. A traumatized child will not want to be reminded of the predisposing event – or conversely, once reminded, will become excited, or fearful and unable to stop talking about it. A traumatized child may also respond with silence.
Reminders are revealing retrospectively as well. Children who have "outgrown" unusual behavior patterns have not necessarily discharged the energy that gave rise to them. In fact, the reason traumatic reactions can hide for years is that the maturing nervous system is able to control the excess energy. By reminding your child of a frightening incident that precipitated altered behavior in years past, you may well stir up signs of traumatic residue.
Reactivating a traumatic symptom need not be cause for concern. The physiological processes involved, primitive as they are, respond well to interventions that both engage them and allow them to follow their natural course of healing. Children are wonderfully receptive to experiencing the healing side of a traumatic reaction. Your job is simply to provide an opportunity for this to occur.
Resolving a Traumatic Reaction
Creating opportunities for healing is similar to learning the customs of a new country. It is not difficult – just different. It requires you and your child to shift from the realm of thought or emotion to the much more basic realm of physical sensation, where the primary task is to pay attention to how things feel and how the body is responding. Right opportunity, in short, revolves around sensation.
A traumatized child who is in touch with internal sensations is paying attention to impulses from the reptilian core. As a result, the youngster is likely to notice subtle changes and responses, all of which are designed to help discharge excess energy and to complete feelings and responses that were previously blocked. Noticing these changes and responses enhances them.
The changes can be extremely subtle: something that feels internally like a rock, for example, may suddenly seem to melt into warm liquid. These changes have their most beneficial effect when they are simply watched, and not interpreted. Attaching meaning to them or telling a story about them at this time may shift the child's perceptions into a more evolved portion of the brain, which can easily disrupt the direct connection established with the reptilian core.
Bodily responses that emerge along with sensations typically include involuntary trembling, shaking, and crying. If suppressed or interrupted by beliefs about being strong (grown up, courageous), acting normal, or abiding by familiar feelings, these responses will not be able to effectively discharge the accumulated energy.
Another feature of the level of experience generated by the reptilian core is the importance of rhythm and timing. Think about it…everything in the wild is dictated by cycles. The seasons turn, tides come in and go out, the sun rises and sets. Animals follow the rhythms of nature – mating, birthing, feeding, hunting, sleeping, and hibernating in direct response to nature's pendulum. So, too, do the responses that bring traumatic reactions to their natural resolution.
For human beings, these rhythms pose a twofold challenge. First, they move at a much slower pace than we are accustomed to. And second, they are entirely beyond our control. Healing cycles can only be opened up to, watched, and validated; they cannot be evaluated, manipulated, hurried, or changed. When they do not get the time and attention they need, they are rarely able to complete their healing mission.
Immersed in the realm of instinctual responses, your child will undergo at least one such cycle. How can you tell when it is complete? Tune in to your child. Traumatized children who remain in they sensing mode without engaging their thought processes feel a release and opening; their attention then focuses back on the external world. You will be able to sense this shift in your child, and know that a healing has occurred.
Resolving a traumatic reaction does much more than eliminate the likelihood of reactions emerging later in life. It fosters an ability to move through threatening situations with ease. It fosters, in essence, a natural resilience to stress. Certainly, a nervous system accustomed to moving into stress and then out of it is far healthier than a nervous system burdened with an ongoing, if not accumulating, level of stress. And just as certainly, children who are encouraged to attend to their instinctual responses are rewarded with a lifelong legacy of health and vigor.
First Aid for Accidents and Falls
Accidents and falls are a normal and often benign part of growing up. Occasionally, however, they may place a child at risk for developing a traumatic reaction. Witnessing a mishap of this sort will not necessarily clue you in to its degree of severity. For one thing, a child can be traumatized by events that seem insignificant to an adult; for another, signs of traumatic impact can be easily covered up by a child who believes that "not being hurt" will keep Mommy or Daddy happy. Your best ally in responding appropriately you your child's needs is an informed perspective.
Here are some guidelines:
1. Attend to your own responses first, inwardly acknowledging your concern and fear for your child. Take a full breath, and exhale slowly while deeply sensing the feelings in your body. If you still feel upset, do it again. The time it takes to establish a sense of calm will be minuscule compared with the increase in your capacity to attend fully to your child. Accepting the accident as an accident will help you move in to give your child support, whereas being overly emotional or smothering may frighten your child at least as much as the accident itself.
2. Keep your child still and quiet. Should injuries require that your child be moved, support or carry him, even if he appears able to move on his own. (Remember, a child who shows his strength may be denying the fear he feels.) If your child seems to need extra warmth, drape a sweater or blanket over his shoulders and truck.
3. Encourage a sufficient interlude of safety and rest, particularly if your child shows signs of shock or daze (glazed eyes, pale complexion, rapid or shallow breathing, trembling, disorientation, talking as if he were somewhere else), or if his demeanor is overly emotional or overly "tranquil." Help your child know what to do by being relaxed, quiet, and still yourself. If you decide to hold him, do so in a gentle and non restricting way. Gently placing a hand in the center of his back, behind his heart, can communicate support and reassurance without interfering with his natural bodily responses. Excessive patting or rocking is unnecessary, and may interrupt the recovery process.
4. As the dazed look begins to wear off, gently guide your child's attention to his sensations. Softly ask him how he feels "in his body." Slowly and quietly, repeat his answer as a question – "You feel OK in your body?" – and wait for a nod or other response. Be a little more specific with your next question: "How do you feel in your tummy (head, arm, leg)?" If he mentions a distinct sensation, gently ask about its location, size, shape, color, weight, and other characteristics; do not, however, suggest any form of movement. In response to his answer, gently guide him to the present moment: "How does the lump (hurt, 'owie,' rock, fire) feel now?"
5. Allow a minute or two of silence between questions. This will permit any cycle that may be moving through to come to completion before your child's attention is broken by another question. If sensing the moment of completion seems too uncertain, watch your child for cues, such as a deep relaxed breath, the cessation of crying or trembling, a stretch, a smile, or the making or breaking or eye contact. (Note: The completion of this cycle may not spell the end of the recovery process, so be sure to keep your child focused on his sensations for a few more minutes. Another cycle may well begin.)
6. Do not stir up discussion about the accident. There will be plenty of time for telling stories about it, playing it through, or drawing pictures of it later. Now is the time for rest and discharge.
7. Validate your child's physical responses throughout this period of time. Children often begin to cry or tremble as they come out of shock. Parents often desire to dive in to stop the crying or trembling. Resist that impulse. The physical expression of distress needs to continue until it stops on its own or at least levels out, which may take only a minute. Indeed, studies have shown that children who cry after an accident have fewer problems recovering from it.
8. Your task at this time is to let your child know that crying and trembling are normal, healthy reactions. A reassuring hand on his back or shoulder, along with a statement such as "That's OK" or "That's good. Just let that scary stuff shake right out of you," can help immensely. The key is to avoid disrupting the responses by shifting your child's position, distracting his attention, holding him too tightly, or positioning yourself too far away to help him feel safe.
9. Finally, attend to your child's emotional responses. Once he appears safe and calm, or even later, set aside time for storytelling or for reenacting the incident. Begin by encouraging him to tell you his experience of what happened. He may be feeling anger or fear, or perhaps sadness, embarrassment, or guilt. Tell him, in turn, about a time when you or someone you know felt the same way or had a similar accident. Let your child know that whatever he is feeling is OK and worth paying attention to.
While applying these first-aid measures, try not to be overwhelmed by worries about "doing it right." Trauma that cannot be prevented can be cured, because trauma is an interrupted process that is naturally inclined to move to completion whenever it is able to. It can remain interrupted for weeks, months, years, even decades without losing its inherent capacity to move to resolution. And that is the path it will take whenever the opportunity arises.
Healing Past Trauma
Healing trauma is in many ways similar to preventing it (see "First Aid for Accidents and Falls"). Helping your child move through an established traumatic reaction, however, may be more time-consuming and may require several processing sessions.
To begin, reengage your child in the traumatic material. Remind her of the event by asking her to tell you about it or to draw a picture of it. If you do not know what precipitated the trauma, or if your child had no conscious memory of it, do not be concerned; the key to healing is in the energetic content of the experience, not the experience itself. If your child is immersed in repetitive play, use this as your entree. You can safely assume that your youngster is engaged in the traumatic material any time her behavior seems symptomatic of trauma See accompanying article).
Next, help your child focus on her sensations by gently asking questions about how she feels "in her body." Using her words, repeat each answer in the form of a question, allowing plenty of time to pass before speaking. This will help her reconnect with the healing impulses from the reptilian core. If shaking, trembling, or other bodily responses occur, be sure to validate them, for they are an extremely efficient means of discharge.
Remember that this level of experience entails no thinking – only sensation – and that changes will happen at a slower-than everyday pace. Try to reflect these soft, gentle, slow non-thinking characteristics in your demeanor and tome of voice. To help your child sustain a connection with this level of experience, keep all attention focused on physical sensations, encourage her to be gentle with herself and to take things slowly, and provide a safe, stable environment appropriate to her level of comfort (which may be different from your own).
Be on the lookout for three things. The first is any sign of release or opening up. Use this evidence to completion as your cue to move along. If you find that you have moved too fast, do not worry. Part of the grace in healing trauma is that you always get a second chance…and a third…and as many more as you need.
Also watch for any sign that your child is becoming overly emotional or upset. In the time that has elapsed since the traumatizing event, your child's nervous system may have organized the excess energy in such a way that its release could temporarily frighten her. To help your child move through this point of overload, try distracting her with a comment about something in the room – a treasured toy or favorite activity. When she regains her composure, draw her attention back to how she feels in her body. Or, if you prefer, resolve to pursue the matter at some future time.
Third, watch for signs of fatigue. The sensations, while subtle, can bring about a profound – and exhausting – change in your child's nervous system. Do not try to push the river; if your child gets tired, stop and encourage her to rest or take a nap. Be prepared to stay nearby in case she feels vulnerable. After a few moments, engage your child in another processing session. If she is still tired, put off the remedial work until another day.
Whenever you are working with your child, try to avoid drawing conclusions about what happened to her. These types of thoughts, by activating more evolved portions of the brain, will interfere with your ability to giver her the support she needs in the moment. You can always analyze the situation at a later time. One cautionary note: If you suspect that your son or daughter may have been sexually abused, be sure to enlist the aid of a trained professional to help you both.
Trauma is mysterious and frightening primarily because it is not well understood. And it is not well understood because it is too often approached from levels of experience that are far more abstract than, and in some ways incompatible with, the nonverbal realm in which it develops. The secret is to access the primitive messages emerging from the reptilian brain; the rest is simple.
Think of your child's traumatic experience as a pool of water captured behind a wall of mud on a hillside. If you poke a hole in this will of mud, the water will flow down the hill. If there is any way at all for the excess energy from your child's aroused state to "flow down the hill," it will. And if it can start to flow in manageable quantities, the outcome will surely be healing. Trust in the outpouring!