It is commonly believed that trauma is caused by catastrophic events or long-term abuse. While it is certainly true that these events leave humans vulnerable to trauma, symptoms are not a result of the event itself but of how a particular situation is perceived, assimilated and processed by one’s nervous system. Therefore, with effective emotional first aid even after horrific events such as Hurricane Katrina, war, 9/11 and the Indian Ocean tsunami, children’s acute stress reactions do not automatically lead to chronic stress disorders.
At the same time, a simple tumble off the sofa, ride in the car during a fender bender or routine medical procedure is capable of setting up a nasty series of long-term symptoms or a loss of resilience. This is not because the happening was horrible but because your child’s developing nervous system was overwhelmed with fear. Without first aid, this fright may get strongly imprinted, causing a disturbance in the child’s ability to withstand ordinary stress. Over time multiple problems might arise. These can range from a lack of self-confidence and low frustration tolerance to serious anxiety and other mood and behavioral disorders, such as Attention Deficit Hyperactivity Disorder (ADHD).
Fortunately, there is so much that you as parents can do to help your child maintain confidence, joy and resilience … even after a mishap! This chapter will guide you in helping with the inevitable accidents, falls and medical procedures that are part of any child’s ordinary life experience. You will be guided in preparing your child for surgery to reduce the risk of traumatic reactions. This chapter will also give you timely tips on how to bully-proof your kids. Although this chapter on first aid highlights only the aforementioned potential sources of distress, the information and skills you learn here can be applied to an entire alphabet of ailments which include these and more: Amusement park rides, Bullies, Crashes, Dental work, Elevator rides, Falls, Gunshots, High-chair tumbles, Inoculations, Jellyfish stings, Kickball injuries, Lost at the mall, Medical procedures, Nose dives, Operations, Possessions lost, Quarrels, Roller skating slip, Stitches, Tonsillectomies, Umbrella pokes, Volcanic eruptions, Witnessing violence, X-ray machines, Your choice and Zebra bites.
First Aid for Accidents and Falls
Accidents and falls are probably the most commonplace source of potential trauma. They are a natural part of growing up. In fact, as infants turn into toddlers, they must fall in order to learn to walk. It is actually the sense of moving from equilibrium to disequilibrium and back to equilibrium that spurs growth. Although falling and accidents are unavoidable nuisances, living with trauma symptoms afterwards can easily be avoided. Remember, too, that what may appear insignificant to an adult can be shocking to a child even though there is no physical injury. Also, a child can easily keep their feelings hidden if they believe that “not being hurt” or “being a big girl or big boy” who doesn’t cry will keep parents from getting upset.
Of course, most falls are not overwhelming. When the body first senses that it is off balance, it tends to do a bit of acrobatics to prevent what could be a painful landing. Especially when there is no injury or scare, minor mishaps are a gift in that they provide the opportunity for any child to enhance her sensory awareness and practice “first aid” as she builds resiliency as a kind of “stress inoculation” for whatever life brings. However, sometimes the landings are hard, even very hard, and may cause a substantial fear reaction.
The “First Aid for Accidents and Falls” guide below will appear somewhat familiar, as it overlaps with the basics that you learned in Chapter II. The “old” material will serve as a review of the “nuts and bolts” of trauma prevention, no matter what the event, while the new material pertains specifically to accidents and falls. The following guidelines can be used whatever your perception of the severity of the mishap. Beyond a doubt, an ounce of prevention is worth a pound of cure.
Eight-Step First Aid Guidelines
1. Attend to your responses first.
(This step, as outlined in Chapter II, cannot be overemphasized!)
Take time 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 own body until you are settled enough to respond calmly. An overly emotional or smothering adult may frighten the child as much, or more, as the fall or accident itself. Remember the analogy of “putting your own oxygen mask on first” when sitting next to a child on the plane.
2. Keep your child still and quiet.
If safety concerns or the nature of the injuries require that the child be picked up or moved, make sure that he is supported properly. Carry your child—do not allow him to move on his own, even though he may be able to. Remember that he is probably in shock and does not realize the extent of the injury. Because the child’s body is likely to be surging with adrenaline, this might be difficult. Use a firm, confident voice with a ring of authority that conveys in a loving manner that you are in charge of protecting him and know exactly what to do. Keep your child comfortably warm by draping a sweater or blanket over his shoulders and torso. If there is the possibility of a head injury, do not allow him to sleep until your doctor gives the “OK.”
3. Encourage plenty of time for safety and rest.
This is particularly true if your child shows signs of shock (glazed eyes, pale skin, rapid or shallow breathing, disorientation, overly emotional or overly flat expression or acting like nothing has happened). Do not allow him to jump up and return to play. Help your child know what to do by modeling a relaxed, quiet and still demeanor. You might say something like, “After a fall, it’s important to sit (or lie) still and wait until the shock wears off. Mommy’s not leaving your side until that happens.” A calm, confident voice communicates to your child that you know what’s best.
4. Hold your child.
If your child is an infant or very young, you will probably be holding him. Be sure to do so in a firm but gentle, non-restrictive way. Avoid clutching tightly, as well as excessive patting or rocking, as it might interrupt recovery by interfering with natural bodily responses. To communicate support and reassurance to an older child without disturbing the process, it is suggested that you place your hand on her back just behind her heart, or on the side of her upper arm near the shoulder. A warm, “healing hand” can help your child to feel grounded as your calmness is directly communicated through touch. This is, of course, if your child is receptive to being touched.
5. As the shock wears off, guide your child’s attention to his sensations. (Steps 5 and 6 serve as a review from Chapter II and are at the heart of preventing and healing trauma.)
The language of recovery is the language of the instinctual brain—which is the language of sensations, of time and of patience. Just as touch is important, so too is your tone. Softly 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.” Don’t worry about what these sensations mean; the important thing is that the child is able to notice and share them. Keep guiding your child to stay in the present moment with questions such as “How does the rock (sharpness, lump, “owie,” sting) feel now?” If she is too young or too startled to talk, have her point to where it hurts.
6. Allow one or two minutes of silence between questions.
This may be the hardest part for parents, but it’s the most important part for your child. This allows any physiological cycle that may be moving through your child’s system to release the excess energy and move toward completion. Be alert for cues that let you know a cycle has finished. These cues include a deep, relaxed spontaneous breath, the cessation of crying or trembling, a stretch, a yawn, color coming back into the face, a smile, orienting to her surroundings or the making of eye contact. Wait to see if another cycle begins or if there is a sense it’s time to stop. Keep in mind that there is a lot happening in your child’s nervous system that may be invisible to you. That is why waiting for a sign that things have shifted is so important.
7. Do not stir up discussion about the accident or fall during initial first aid.
It is best to not talk about the mishap by asking questions to alleviate your own anxiety or curiosity. The reason for this is that the “story” can disrupt the rest period needed for discharging the excess energy that was aroused. Telling about it can wind kids up just when they need to be settling down. It is in the quiet waiting that the involuntary sensations such as shaking, trembling and chills begin the cycle that soon leads to calm relaxation.
After the releases happen, your child may want to tell a story about it, draw a picture or play it through. If a lot of energy was mobilized, the release will continue. The next cycle may be too subtle for you to notice, but rest (rather than more talk or play) promotes a fuller recovery, allowing the body to gently vibrate, give off heat, exhibit skin color changes, etc., as the nervous system returns to equilibrium.
These changes happen naturally. All a parent has to do is provide a calm, quiet environment and a few focused questions to gently guide the process. It can be challenging to provide a tranquil space when family members gather around asking, “What happened?” In response, you might simply and politely say, “Not now … we’ll talk about it later after your sister rests a while.” Talking about the details of the accident to your child (or in front of your child) can aggravate an already activated nervous system, adding an additional layer of unnecessary fear. This can abort the healing process! If siblings want to express their care, they can follow your lead by saying something calming, such as “Stay real still so you can be good as new soon” or “It’s okay to cry, little brother. It can make you feel better.” Please refrain from shaming statements, such as “I told you that you’d get hurt playing on those stairs!” Also, refrain from judgmental statements, such as “You are such a clumsy kid!”
8. Continue to validate your child’s physical responses.
Resist the temptation to stop your child’s tears or trembling. But keep contact with her, reminding her that whatever has happened is over and she will soon be okay. In order to return to equilibrium, your child’s discharge needs to continue until it stops on its own. This part usually takes from one to several minutes. Studies have shown that children who are able to cry and tremble after an accident have fewer problems recovering from it.1
Your job is to use a calm voice and reassuring hand to let your child know that “It’s good to let the scary stuff shake right out of you.” The key is to avoid interrupting or distracting your child, holding her too tightly or moving too far away.
How Long Does It Take?
With minor tumbles, accidents and scares, the steps outlined above may be all that is needed. This relatively easy eight-step First Aid Guide for Accidents and Falls can be followed right on the spot where the calamity occurred. For example, if your child has twisted an ankle while skating on the front sidewalk, grab some ice and a blanket and minister to him at the site of the fall (if safe). The steps can take anywhere from five to twenty minutes as the physiological cycles complete. It’s not unusual for the trembling to start after the blanket and ice are applied as the child feels tended, warm and safe. Teeth may begin to chatter after a few minutes of rest and/or tears of release may begin to roll down the cheeks before a sigh of relief completes a cycle.
When the fall or accident creates a medical emergency, the first aid steps can be used by a parent while in the car or ambulance on the way to the hospital. Once your child discharges some of the excess energy, you can prepare her for what to expect at the emergency room or doctor’s office. Choose your words wisely when preparing her for the medical procedure. Use simplicity and honesty framed in a way that will benefit her. You can do this by using positive suggestions. For example, if your child needs stitches, let him know that they will sting but will make the “owie” heal faster and better. Discuss and practice what you will do to focus attention away from the pain. For example, have him squeeze your arm and imagine that with every squeeze special “cream” makes the pain float away like a balloon. See “The Power of Language to Soothe and Heal” in this chapter for more on timing and choosing words wisely.
The Purpose of Touch When Helping a Child in Shock
While paying close attention to a child’s bodily responses, you will be most effective in supporting reactions as they emerge by taking special care when giving physical support. A parent’s touch can either help or interrupt the normal cycle for coming out of shock, depending on how the touch is applied. If you are caring for an infant or young child, hold him safely on your lap. If it’s an older child, you can place one hand on her shoulder, arm or middle of her back. Physical proximity of a caring adult can help a child feel more secure. Be mindful, however, not to hold your child too tightly as this will interfere with the natural discharge that will follow. The focus of intention when touching a child is to convey:
Safety and warmth so your child knows she is not alone;
Connection to your grounded and centered adult presence;
Confidence that you have the ability to help him surrender to his sensations, emotions and involuntary reactions as he moves toward release and relief by not interrupting his process due to your own fears;
Trust in your child’s innate wisdom that allows her body to release as she moves toward resolution and recovery as her own person and at her own pace.
Your body language is more important than knowing the exact words to say. Because we are social creatures, we read each other’s clues to figure out the seriousness of a situation, especially in an emergency. Your children not only read your expression but rely on it for their sense of safety. Translated into practical terms, this means that the look on the parent’s face and shown by your posture can foster either safety or terror.
You want to minimize unnecessary upset with your own wide-eyed expression, because what you really want is to be a steady anchor. Become mindful of your own involuntary responses. Practice brings poise. Opportunities in modern life abound to practice first aid on your own self. For example, after a near collision in your car, pull over to a safe place and track your sensations until you feel a sense of relief and completion. This can also be done after witnessing violence, or experiencing a fall, injury, shocking news or other stressful event. You can even practice during a scary movie.
The Power of Language to Soothe and Heal
When something dramatic happens out of the blue, it can put a person in an altered state in which they are particularly susceptible to suggestions from those around them. And, of course, with medical procedures that require anesthesia, children are purposely put into an altered state. Skillfully selected words and the timing and tone of voice with which you use them have the power to speed recovery. This is true whatever the nature of the frightening event.
In The Worst Is Over: What to Say When Every Moment Counts by Acosta and Prager, the authors give numerous examples of verbal first aid that salvaged seemingly hopeless situations, stopped serious bleeding and even prevented scar tissue from forming in burn victims!2 We know how easy it is for words to either put us at ease or make us tense. Words can turn an ordinary experience into a romantic one, raise or lower blood pressure and bring either laughter and joy or tears and sorrow.
The following list is a useful framework for choosing words wisely. Use your tone of voice to convey to your child that you understand what it must feel like to be in her shoes. Then say something that accomplishes the following:
Shows your child that you compassionately accept what happened.
Ensures that your child feels safe and connected, rather than alone.
Reassures him that whatever happened is over (if it is).
Helps “move time ahead” from the past to the present by guiding him to notice sensations until there is a discharge and shift.
Reminds him of his resources to help him cope. (Read Chapter III to review resources.)
When an accident occurs, recount to your child what happened to him in simple, honest language that he will understand. For example, after a fall resulting in a small cut with heavy bleeding, you might simply say something like this: “That fall really took you by surprise, huh? That tiny cut sure is bleeding! Let’s clean it up real good. I’ll hold a cool cloth on it to stop the bleeding and make it feel better. Then you can pick your favorite colored band-aid. I know just what to do so you’ll be good as new. You can help put it on if you’d like.” (Or, to an older child, “You can even put the band-aid on yourself, if you’d like that.”)
Then, after the immediacy of the injury has been tended, look for bodily clues such as pale skin, cold sweaty palms, shallow breathing and wide eyes. Your child is probably still somewhat stunned so it’s best for her to be sitting or lying down. Then you might say something like, “The hard part’s over; your cut is healing already! But honey, you’re still a bit shook up … Daddy will stay right here with you until the (shaky or numb, etc.) feeling wears off. You might get a little shivery or jittery or wiggly … or maybe even a little giggly. It could be that some more tears will come. I’ll stay with you (or you can sit on my lap) until the very last tear (or jitter or shiver) is gone. Then we can make up a silly story (or draw a picture if your child enjoys this more) about what happened to share later with Mommy.”
EXERCISE: EXPERIENCING THE POWER OF WORDS
Not only are words powerful at the time they are spoken, in times of openness and vulnerability they become etched in our memory. Take a moment now to recall words that have shaped the peaks and valleys of your life, and you will have an experiential understanding of just how penetrating they are and how they have textured your life.
1. Write a paragraph or two using all of your senses to describe everything you can remember about a kind person who used words, touch, gestures and/or actions to comfort and soothe you after something bad happened. Recall in as much detail as possible what it was that they said and did that made you feel better and recover.
Find a comfortable place to rest. Recalling what you just wrote, notice how you are feeling in your body now. Take some time to focus on sensations, emotions, thoughts and images. Notice what happens to your body’s expression and posture as you sink into the experience in this moment. Notice which sensations let you know that this memory was a pleasurable one!
It’s possible that when you did this exercise, an unpleasant experience may have surfaced as well. That’s because the amygdala, the part of the brain that imprints emotional memories, stores strong surprise encounters as well. Intense experiences are registered, whether they are pleasant or unpleasant.
Because of these imprints, it may be that you recalled insensitive treatment when what you really needed was to be nurtured by an understanding adult. This can be especially hurtful when it was a parent or other close family member who wasn’t able to comprehend what you were going through. If this was the case, you can do the following exercise in order to have a different experience now. As you heal your own wounds, you are less likely to react to your child blindly by repeating your familiar pattern. Perhaps that is exactly why you are reading this book!
1. Write a paragraph or two using all of your senses to describe everything you can remember about an insensitive or unaware person who used words, touch, gestures and/or actions that made things worse instead of soothing you after something terrible happened.
2. Without dwelling on the unpleasant experience that you just described, allow an “opposite” image to help transform any images, words, sensations and/or feelings that you might have recalled. Try not to censure what pops up. Allow the newly formed opposite scene to expand, providing as many healing details as possible. What words, touch, gestures and actions are bringing you relief? What in particular is comforting you, making you feel better and soothing any wounds from the past? Allow yourself to hear the words and see the actions now that you needed back then—replay it in this moment in the same way you would hope to nurture your own child.
3. Find a comfortable place to rest. Recalling your new and restorative image, notice how you are feeling in your body. Take some time to focus on sensations, emotions, thoughts and images. Notice what happens to your body’s expression and posture as you sink into the experience now. Note what sensations let you know that this new memory, using your adult resources, is affirming or pleasurable!
Addressing the Emotions through Listening and Storytelling
In more serious or complex situations, your child may have lingering emotional responses that need tending. Children and adults alike often feel embarrassed or awkward after an accident or fall, especially if it was in front of peers. They may feel shame or guilt, especially if the accident caused damage to property, clothing or special possessions. They may have these same feelings because of medical or other expenses that were incurred that might burden the family financially.
After you have completed giving emotional first aid and your child is rested and calm, set aside some time to discuss feelings about what she experienced. This can be done later that day, the next day or whenever new emotions emerge. In addition to shame and guilt, children often feel anger, sadness and fear. Help your child to know that those feelings are normal. Listen carefully and reflect back what was said so that your child is sure that you heard and understood. Refrain from trying to fix or change her feelings. Trust that feelings change by themselves when parents or other supportive adults can “hang out” with a child in this zone of uneasiness. This kind of support not only makes the temporary discomfort tolerable; it improves the ability of children to withstand frustration without falling apart.
Working Directly with Accidents and Falls When Symptoms Are Present
When working with falls, big soft pillows can be helpful in giving a child the opportunity to practice falling safely. Have your child stand in the middle, surrounded by pillows, and calmly kneel beside him or her. Place your hands gently (but firmly) on your child’s neck, shoulders, lower back or in any configuration that will allow you to control their fall. With your hands to support your child securely, gently guide a slow fall, pausing if he seems to stiffen or startle. You can let your child know that you’re going to play a “rocking and rolling” game. It’s often best to start with your child sitting and gently rock him from side to side and then forward and backward. Make it fun by letting her rock you back and forth also, letting yourself go off center and back to center as a model. You can both roll around a little on the pillows (forward, backwards and sideways). Then she can “fall,” a little at a time, into your supporting arms and onto the pillows.
This type of “play,” which involves a guided fall with a safe landing, helps to develop good protective reflexes and restores confidence. Recovering from a fall involves re-establishing innate equilibrium responses. A child-size fitness ball can be used to practice going from balance to off-balance and returning to balance. (These balls can be purchased at any discount department store.) Again, use soft pillows on the floor around the ball so there is a safe landing. Have your child start with her eyes open and feet spread apart to form a solid base. Gently rock your child from side to side on the ball and see what emerges. Notice if your child reflexively uses her arms, legs and torso to protect herself or if she depends on you to catch her. If she’s somewhat tense and rigid, invite her to imagine how her body might respond if you weren’t next to her. Continue to explore and practice until she is able to engage her reflexes. As your child becomes more relaxed and proficient, parents can up the challenge by having their child close her eyes the next time. Once there is a sense of falling, all parts of the body prepare to prevent the fall. When prevention is not possible the arms, elbows, wrists, hands, knees, legs, ankles and feet end up in all types of configurations in an attempt to buffer the impact. Don’t be surprised if you see the whole “ballet” sequence that happened when your child took his tumble, performed in slow motion through this type of “pillow play” as you catch your child from a free fall.
If your child needs more distance from the fall because the fear is too intense, you can begin by using a doll or favorite stuffed animal to create a scene similar to your child’s real-life experience. An example would be: Babar the elephant falls backwards out of the high chair. Refer back to the story of Sammy in Chapter III to guide you in this type of play. As your child role-plays, be sure to watch his responses closely. Always leave him with a sense that he can succeed, giving him only as much support as he needs. Gradually introduce the idea of him taking turns with the stuffed animal and/or with you or his siblings, friends or parents.
More Animal Rhymes to Help Your Child Regain Self-Confidence
If your child’s fall has been extremely shocking, perhaps even compounded with an injury that required a trip to the emergency room, it may take more time, patience and approaches to help your child come completely out of the “freeze” or “shut-down” response. The best way to restore your child’s confidence is to go slowly with a pace that will encourage opening up rather than closing down even more. Just like the nature and animal verses in Chapter IIIhelped your child to feel grounded, powerful and safe, the following poems were designed to help remove any shame, shyness or self-doubt that your child might be carrying about having been too scared to protect or defend herself. Let your child know that our animal friends have the same kinds of responses we do.
In the next set of verses, Oscar Opossum demonstrates that the “freezing response” (or “playing possum”) is a very important survival mechanism. When children can’t fight, run or avoid accidents and falls, this response protects them. This instinctive behavior is, unfortunately, often judged by both adults and kids to be cowardly or weak. The Oscar Opossum rhymes demonstrate to your child that the “freeze” behavior is not only normal, but, oftentimes, the smartest choice possible.
When youngsters listen to the story of how Oscar outwits Charlie Coyote by pretending to be dead, two things will be accomplished. First, the “freezing response” will be seen as positive and empowering; second, the identification with the opossum’s ability to come out of his frozen state without fear of his own bodily reactions can help your child move through her own frozen states without fear or shame. This understanding can lead to better feelings about herself when she’s experiencing these helpless and troubling involuntary states. It is also reassuring to realize that with a little time and patience those feelings give way to a “letting go” that may be shaky at first but soon leads to relief and, perhaps, even a smile!
In the rhyme below, Oscar Opossum shows children how he temporarily freezes to protect himself. When the “coast is clear,” Oscar easily comes out of this natural protective state by simply shaking and trembling away all the “boiling energy” he was holding inside.
Oscar Opossum is
He plods right along, while everyone passes
When he sees coyote, he , so instead
He rolls up in a ball and pretends that he’s dead!
Oscar , you see, by lying quite still
like the rabbit who up the hill!
Oscar has all his energy inside
From holding his breath to pretend that he died.
Can you that you’re Oscar rolled up in a ball?
You’re barely breathing, and you feel very small.
It’s cold and it’s lonely as you hold on tight
Hoping coyote will not take a bite!
Suggestion: Pretend with your child that both of you are being chased by something bigger and faster than you. Ask your child who he wants to “chase” him. It might be a tiger, bear, other beast or monster. Stop running and, instead, roll up in a tight ball, holding as still and quiet as possible to “trick” the beast into passing you by because you are so well hidden or look like you’ve died! Take time to explore sensations without talking and hold still for as long as you can so that there is a sense of release and relief when you finally let go, get your breath back and let all your muscles relax.
The verses continue with questions to help explore normal emotional responses that may arise before and after coming out of the “freeze response.”
Do you remember ever feeling this way?
You wanted to run, but you had to stay.
Were you SCARED, were you , did it make you MAD?
Can you tell what you felt to your mom or your dad?
Suggestion: Children may “open up” with their true feelings and thoughts after you read the above verses. Allow sufficient time for them to share. Pause, observe and listen to your child carefully, showing that you care about any and all emotional expressions that may emerge. After acknowledging your child’s feelings, making it safe for him by refraining from judging or fixing; you might help him explore more deeply. Ask open-ended questions, such as “What else do you feel?” or use statements such as “Tell Daddy what else about that scared you.” Or simply, “Tell Mommy more.” The Charlie Coyote and Oscar Opossum verses continue:
You Don’t Have To Be Afraid
Oscar Opossum has to lie low
But inside his body, he’s ready to blow.
When Charlie Coyote finally takes off
Oscar Opossum and .
See Oscar , see Oscar
Just like the ground in a little earthquake.
After he trembles and shakes for a while
He feels good as new, and walks off with a SMILE!
Coyote has gone, now get up and run [whisper]
But you might and in the sun.
Before long you can jump, you can skip, you can stomp
Or play in the meadow and have a good romp.
Feel the blood flow through your HEART and your CHEST
Now you are safe and now you can rest!
Suggestion: Have your child pretend to shake and tremble, first exaggerating the movements by dramatizing them. After some fun active movement, have her lie down and rest, noticing the energy and flow inside her body. This will help her to feel more subtle sensations that will most likely be pleasant and warm.
The next set of verses, “Bowl of Jell-O,” is silly and intended to playfully expand children’s awareness of their inner landscape of sensations in order to help them prepare for a discharge.
Bowl of Jell-O
Can you’re a big bowl of Jell-O?
Red, purple, green, or even bright yellow?
Now make-believe someone gives you a jiggle
And you start to and and
As your fingers tremble, feel your heart pound,
Now feel the shaking go down to the ground,
Feel the in your arms, the in your chest,
Don’t try too hard; you’re doing your best.
In your belly and legs, feel the ,
Let it flow like a river, it’s a pleasant sensation!
Feel the energy from your head to your toes,
Feel the strength in your body, as the good feeling grows.
Suggestion: Continue by making up your own verses (together with your child if she is old enough), appropriate to her situation and needs. Verses like the ones above can help children experience bodily sensations without becoming unduly frightened. Through this heightened body awareness, the discharge of energy necessary to return to a normal state can occur safely and playfully.
Tips for Working with Automobile Accidents
When a child has been involved in any kind of accident, you may eventually need to reintroduce (and “desensitize”) her to the ordinary objects and experiences that remain “charged.” The child’s behavior when the offending object or experience is seen or mentioned will let you know which elements of the accident bring up painful or overwhelming reminders. Sometimes the connection is obvious; at other times it is not.
Sometimes the “charge” doesn’t develop into full-blown symptoms until the period of shock and denial has worn off. This often can take weeks. The main idea is to introduce the “activators” slowly so as not to overwhelm your child further. The following example of working with an automobile accident can be adapted for a variety of ages and situations.
After an automobile accident, the infant’s or toddler’s car seat could be brought into the living room. Holding the infant in your arms, or gently walking with your toddler, gradually move toward it together and eventually place the child in the seat. The key here is to take baby steps, watching and waiting for responses such as stiffening, turning away, holding the breath or heart rate changes. With each gentle approach toward the avoided or fear-provoking encounter, the same step-by-step procedure outlined in steps four through eight at the beginning of this chapter can be used as a guide. The idea is to make sure that your pacing is in tune with your child’s needs so that not too much energy or emotion is released at once. You can tell if the latter is occurring if your child seems to be getting more “wound up.” If this happens, calm her by offering gentle reassurance, touching, holding or rocking. Stop if she shows signs of fatigue. The whole sequence does not need to be done at once!
Rhymes to Help Kids after Sports Accidents
Once you have connected with your child in such a way that you are certain she feels understood, she will most likely be more receptive to your inspiration and guidance. It is at this point that sharing a similar experience that you or someone you know has had might be helpful. Another idea is to make up stories and verses like the ones provided in this book. For example, “The Story of Dory,” below, is about a girl who had a bad fall from her bicycle and became overwhelmed. One way to use this story is as a starting point or model for you and your child to make up one of your own. Customize verses to your particular child’s age, needs and situation. Another way to use the story below (and others like it) is as an “assessment” tool. Parents can use stories and drawings to consider whether a particular situation has left lingering distress. Read “The Story of Dory” aloud slowly while carefully watching your child’s reactions, as well as noticing what he has to say. Do his eyes widen like saucers? Does his body stiffen? Does he say, “I don’t like this story” and try to slam the book closed? Or does he get “squirrely” and agitated? If your child identifies with some of Dory’s reactions to the fall, the likelihood is that he has had a similar experience and relates to her feelings. When you observe a reaction, stop the story and help your child experience the sensations and emotions that he is struggling with by being present as a calm, non-judgmental witness until the uncomfortable emotional expression begins to change to relief.
After reading the story, you can have your child illustrate it and make up a picture story of his or her own (as a young friend of ours did for this book). If children are too young to draw a picture, have them scribble to indicate how they feel. Provide an assortment of colored crayons or markers and model for them how to make different lines, such as squiggles, circles, jagged, wavy and straight. They will automatically draw in a way that reflects their feelings.
The Story of Dory
Sit back, relax, and I’ll tell you a story.
The hero, my friend, is a girl named Dory.
She plays first base on her Little League team,
To have a new bike was her favorite dream.
On her last birthday, this girl’s dream came true.
She got a new bike that was bright shiny blue.
She jumped on the bike and rode down the block,
Faster and faster, then the bike hit a rock.
She felt the wheels skid, and she flew off the seat,
And then she landed real hard on the street.
She hit the pavement with a big thud,
Then she saw that her knees were covered with blood.
She started to cry, but the sound wouldn’t come,
She couldn’t breathe, and her body went numb.
When she noticed the blood on her knees,
Like Oscar Opossum, she started to freeze.
Later that day Dory felt bad.
She also felt sad, and then very mad.
On her new bike things had happened so fast
That she could do nothing at all, except crash.
It wasn’t her fault, but she took the blame,
When she thought of her bike, Dory felt shame.
If something like this ever happens to you,
Can you tell mom and dad what you might do?
Suggestion: Take time to discuss with your child how she might deal with a similar situation. Remind her of the lessons learned earlier from our animal friends, Charlie Coyote and Oscar Opossum, and the importance of letting the sensations and feelings move freely through the body.
After you shake, you can jump, you can run,
You can hide like a rabbit or play in the sun.
You can kick, you can cry, you can laugh, you can feel,
You can dance, you can sing, or do a cartwheel!
A Guide to Constructing a Healing Story
Earlier in this chapter, you were given step-by-step guidance to help prevent traumatic symptoms immediately after an event. Frequently this is all that is needed. However, when the event was particularly threatening to your child, symptoms may develop despite your best efforts. Stories and drawings are especially useful when a child’s upset continues after you have given “trauma first aid.”
When using stories, generally the adult needs to tell the story of what happened (from the adult’s perspective). The next step is to invite your child to add to this story or tell his version. A child who at first is reluctant to talk will usually be glad to chime in to “correct” his mom or dad with his version by saying, “No, that’s not what happened;———— is what really happened!” Be sure to look for certain universal elements that need to be addressed whenever your child is overwhelmed. You can find those crucial elements in the example of Dory above. They include:
The excitement before the accident
(Verses: “On her last birthday, this girl’s dream came true” and “She jumped on the bike and rode down the block.”)
The scary parts before the actual impact (where energy is mobilized)
(Verses: “Faster and faster,” “hit a rock,” “wheels skid,” and “flew off the seat.”)
The actual impact of the accident
(Verses: “landed real hard” and “hit the pavement with a thud.”)
The resulting physical injury (if there is one) and horror (Verses: “her knees were covered with blood.”)
The freeze response
(Verses: “the sound wouldn’t come,” “she couldn’t breathe,” “her body went numb,” and “like Oscar Opossum, she started to freeze.”)
The emergence of mixed emotions
(Verses: “Dory felt bad. She also felt sad, and then very mad.”)
The emergence of inevitable guilt and shame
(Verses: “she took the blame” and “Dory felt shame.”)
The discharge of activation from overwhelming sensations and emotions
(Verses: “you can shake, you can jump, you can run, you can kick, you can cry, you can laugh, you can feel.”)
The resolution of traumatic activation with a successful outcome
(Verses: “You can dance, you can sing or do a cartwheel!”)
Adults are frequently puzzled by intense reactions that appear disproportionate to the nature of the event. It is important for you to take your child’s reactions seriously. Often children are communicating lingering upset from an earlier unresolved incident that has been re-stimulated. Take the opportunity to work it through. This is more likely when the recent event stirs up reminders of a situation in which your child was more vulnerable due to age and/or the severity of the earlier mishap. The body records and remembers everything from infancy and toddlerhood. Conscious memory may be lacking since preverbal experiences have no narrative. You may be surprised at what guilt, shame or worries emerge from these stories and from the artwork your child makes to illustrate them.
More on Working with Stories
Sometimes, especially with very young children, it is best to use a make-believe child, animal or doll as a substitute for your own child in the story. This may initially help to give needed distance from the event to make it less frightening. In the tale be sure to include some of the scary stuff one element at a time. For example, if your child fell down the stairs, if it’s not too disturbing, add in the part about the stairs if your child leaves it out. Observe your child closely to see if he identifies with the reactions and feelings that the make-believe character in the story has. Stop the story to help your child work through any sensations and emotions that get triggered. If she gets anxious, follow the same steps as recommended for first aid. For example, have her point to where she feels the scary feelings and ask her to tell what “color,” size or “shape” they are. Remind your child that you will stay with him as his sensations and images change their quality, shape and size and finally disappear! Insert any of the elements listed above that are missing and seem to be essential for resolution of the trauma.
Prevention of Medical Trauma
The Importance of Preparation When Medical Procedures Are Necessary
One common and frequently overlooked source of trauma in children is routine and emergency medical procedures. Armed with the knowledge you will acquire in this section, ideally you can work together as a team with clinic and hospital staff. This joint effort can greatly reduce unnecessary overwhelm for your child from invasive medical and surgical procedures. But before we introduce you to the strategies, first read the surprising story that follows:
“Daddy, daddy, let it go, let it go!
Please don’t kill it! Let it go!” These are the terrified screams uttered by ten-year-old Teddy as he bolts from the room like a frightened jackrabbit. Puzzled, his father holds a motionless tree shrew in the palm of his hand, one that he found in the back yard and brought to his son. He thought it an excellent and scientific way to teach Teddy how animals “play possum” in order to survive. Startled by the boy’s reaction to his seemingly harmless gesture, Teddy’s father is unaware of the connection that his son has just made to a long-forgotten event.
On Teddy’s fifth birthday the family pediatrician and lifelong friend came for a visit. The whole clan gathered around the doctor as he proudly showed them a photograph he had taken at the local hospital of baby Teddy at age nine months. The boy took a brief look at the picture and then ran wildly from the room, screaming in rage and terror. How many parents have witnessed similar mysterious reactions in their children?
At nine months of age, Teddy developed a severe rash that covered his whole body. He was taken to the local hospital and strapped down to a pediatric examination table. While being poked and prodded by a team of specialists, the immobilized child screamed in terror under the glaring lights. Following the examination he was placed in isolation for seven days. When his mother, who had not been allowed to see him for over a week, arrived at the hospital to bring him home, Teddy did not recognize her. She claims that her son never again connected with her or any other family member. He did not bond with other children, grew increasingly isolated and began living in a world of his own. Though by no means the only factor, the hospital trauma experienced by nine-month-old Teddy was an important, possibly critical, component in the shaping of Theodore Kaczynski, the convicted “Unabomber,” who sent letter bombs to various people involved in technology and wielding corporate power—arguably, his revenge against the same dehumanizing forces that overwhelmed and broke him as an infant.
The Hospital Experience as a Possible Source of Trauma
Without appropriate support, children do not have the inner resources to comprehend the blinding lights, physical restraints, surgical instruments, masked monsters speaking in garbled language and drug-induced altered states of consciousness. Nor are they able to make sense of waking up alone in a recovery room to the eerie tones of electronic monitoring equipment, the random visitations of strangers and possibly moans of pain coming from a bed across the room. For infants and young children, events such as these can be as terrifying and traumatizing as being abducted and tortured by revolting alien giants. Ted Kaczynski’s “crusade” (though utterly misguided) against dehumanization by technology begins to make more sense when we learn about his traumatic hospital ordeal as an infant. This systematic and sociopathic murderer thought deeply about the ideology behind targeting corporate offenders (and left reams of writing behind in his wilderness shack), yet his unsuspecting letter-bomb victims were mere cogs in the same dehumanizing machine. It was a futile, and randomly harmful, gesture of impotent rage. It is the type of tortured adult behavior now being correlated with multiple childhood traumas, such as medical injuries coupled with separation or abandonment by parents. (You can read more about the relationship between antisocial behavior and multiple childhood traumas throughout Ghosts from the Nursery: Tracing the Roots of Violence by Robin Karr-Morse and Meredith W. Wiley, New York: The Atlantic Monthly Press, 1997.)
Unfortunately, this story is not an isolated incident. All too many parents have witnessed the disconnection, isolation, despair and bizarre behavior of their children following hospitalization and surgery. The evidence suggests that these long-term behavioral changes are connected to traumatic reactions to “routine” medical procedures. But, is this possible? The answer is yes.
Does this theory imply that if your child has been traumatized by a medical procedure, he will go berserk or become a serial killer? Not likely. Most traumatized children do not become criminally insane. Instead, events like these become internalized in a process we call “acting in,” which may later show up as anxiety, inability to concentrate or aches and pains. Or the past events may be “acted out” as hyperactivity or aggressiveness. In this regard, let’s look at a more “ordinary” story from the pages of the American magazine Reader’s Digest, entitled “Everything is Not Okay,” where a father describes his son Robbie’s “minor” knee surgery:
The doctor tells me that everything is okay. The knee is fine, but everything is not okay for the boy waking up in a drug-induced nightmare, thrashing around on his hospital bed—a sweet boy who never hurt anybody, staring out from his anesthetic haze with the eyes of a wild animal, striking the nurse, screaming, “Am I alive?” and forcing me to grab his arms.… Staring right into my eyes and not knowing who I am.
Tragically, stories like this are commonplace, often leading to the formation of avoidable psychic scars. In 1944, Dr. David Levy presented extensive evidence that children in hospitals for routine reasons often experience the same “nightmarish” symptoms as “shell-shocked” soldiers.3 Sixty years later, our medical establishment is just beginning to recognize and acknowledge this vital information. What can be done to reverse the tide of unnecessary medical trauma that harms millions of children annually?
Fortunately you do not have to wait for our medical care system to change. If the frustrated father of the boy with knee surgery had known what you are about to learn next, he could have helped prevent his son’s terror brought about by his overwhelming hospital experience. Traumatized children can have nightmares, become hyperactive, fearful, clinging, withdrawn, bed-wetters or impulsively aggressive or even violent bullies in the aftermath of medical procedures handled insensitively. Others are beset with chronic headaches, upset tummies or depression. When concern for children’s emotional safety is minimized (or worse, ignored altogether), there is a huge price to pay.
What Parents Can Do to Prepare Children for Surgery or Other Medical Procedures
All kids want a parent to be with them during treatment. According to a U.S. News and World Report cover story in June 2000, that is one point on which all experts can agree. Yet there is a good deal of apprehension among these same experts regarding the advantage of having parents present. Medical personnel frequently don’t want parents to be partners on the team—and for good reason. An emotional, demanding parent would interfere with safety and efficiency, to say nothing about upsetting the child.
In the magazine article cited above, Leora Kuttner, a psychologist who studies pain in children at British Columbia’s Children’s Hospital in Vancouver, tells of working tirelessly with a youngster about to receive a spinal tap, but she was unable to distract him from his fear of pain. Knowing how important it was for him to relax in order to prevent a terrible treatment, she continued to try. After exhausting every technique without success, she glanced around, only to discover the sideshow that was happening behind her! This is what the psychologist reported: “Behind my back was Mom, sobbing, sabotaging everything, sending the message, ‘My darling, what are they doing to you?’ Her fear got in the way, and she undermined what help could be given to her child.”4
Your presence can be helpful, but only if you are not visibly anxious yourself! During the procedure the parent needs to reassure and comfort—at times, even distract—the child. If you feel like you are going to break down in tears, you may instill fear and tears in your child. During the procedure this is not what is needed! (Even though, as we have seen, right after the child is injured and before medical procedures are begun, crying can allow the child to discharge fear and shock.)
For medical personnel, the idea of having a parent in the room may be new, may go against typical medical school training and at first glance may appear counter-productive. However, if you remain calm with a helpful presence, the staff is more likely to allow you to push the limits a bit in terms of how much you can be with your child. It is important to educate not dictate! When you select a clinic or hospital that allows you, the parent, to work as a team for the emotional well-being of your child undergoing various procedures, the pay-off can be enormous. In addition, the reputation of the medical facility will grow when the statistics begin to show improved recovery time and patient satisfaction. A shortened hospital stay and speedy recuperation cut costs for the health care and insurance companies. It’s a win-win situation for all the parties involved.
Since it is not uncommon for children to be traumatized by surgeries and other medical interventions, concrete recommendations for parents are outlined below in hopes that their adoption will ameliorate this potentially devastating situation. Three procedures that can be particularly terrifying to a child are: 1) being strapped down to an examining table (especially in an already frightened state), 2) being put under anesthesia without being properly prepared for what to expect and 3) waking up in the recovery room either with masked and “monstrous” strangers or alone. Parents can do quite a bit to help children feel more comfortable through careful groundwork. These “readiness” steps are likely to greatly reduce the inclination for your child to panic.
The organized activities listed below will support you, the parents, in becoming proactive. They are the “meat” of medical trauma prevention. Once you know what’s best to help your child, you can talk knowledgeably to the doctors or nurses responsible for your child’s care. The recommendations are arranged according to what you and your doctor can do before, during and after the medical procedure or surgery.
Before the Day of Surgery
1. Choose a doctor and hospital that are exquisitely sensitive to children’s needs. Not all doctors and facilities are created equal! Take the time to “shop around.” Find a doctor who uses kindness, playfulness, distraction and honesty to work with your child when she is fussy or resistant, not against her! You can tell by the pediatrician’s words and actions whether he or she is able to alleviate your child’s worries rather than compound them.
Look for a hospital that has social workers to help kids. Some even have specially designed programs using story and role-play with children to prepare them for what to expect. In some of these programs even the youngest children get to meet the surgeon or anesthesiologist in the role-play room. Doctors are not always aware of these programs, so investigate on your own and find a user-friendly team that will listen to what you have to say and adopt a patient-centered approach. Remember, you are the consumer!
2. Prepare your child for what will happen. Tell him the truth without unnecessary details. Children do better when they know what to expect; they do not like medical surprises. If you tell them it won’t hurt when, in fact, it will hurt, you have betrayed their trust. They will come to fear the worst when they cannot rely on you to be honest. Children and teens undergoing surgeries have been observed to be remarkably less frightened at hospitals with a staff that orients them to each and every step.
3. Staff and parents can arrange a time beforehand so your child can meet with the doctors (especially the surgeon and anesthesiologist) in their ordinary clothes before they are dressed in surgical garb and mask. It is important for your child to see that the doctor is a human being who will be helping him, not some monster from outer space! Perhaps your youngster can even put on a doctor’s costume too. If that’s not possible, he can put a disposable surgical mask on himself, a doll or favorite stuffed animal.
4. If the hospital does not have a program to prepare children, or even if it does, you can have your child dress up in a gown to play “hospital.” Children can dress puppets, dolls or stuffed animals in medical attire and play “operation” at home, going through all the steps in advance. These include riding on a gurney, getting injections and preparing for anesthesia. Have a dress rehearsal. Most toy stores have play figures and “medical kits” for children, complete with stethoscopes and injection “needles.”
5. Prepare your child both emotionally and physically for anesthesia by practicing entering into and coming out of an altered state. First, you can prepare him emotionally by making up a story similar to what your child’s experience might be like. An example would go something like this:
When Hibernating Bear is in his surgical gown, Nurse Nancy Bear puts a mask on his face or gives him a “special tonic” that goes right into the veins on his wrist (or gives him a cup of brew or some pills) to make him go to sleep very, very quickly so that he sleeps right through his operation. That way he doesn’t feel anything. When Hibernating Bear wakes up, he feels very, very, strange. It’s different from the way he feels at home when he opens his eyes in the morning. It seems like it takes forever to awaken. Very, very slowly Bear comes out of his fogginess and grogginess. Then he looks for Momma or Poppa Bear or Nurse Nancy Bear and something good to eat! (Obviously the parents need to check with the anesthesiologist to find out exactly how their child will be sedated. They also have to make sure that arrangements have been approved for them to be in the recovery room when their child wakes up if this is possible; if not, they need to know who will be there with their child as she comes out from under the effects of anesthesia.)
For older children, parents can use favorite characters from fiction, such as Harry Potter. Harry might get the “magic-potion injection” that puts him to sleep so he can recover with speed from the terrible whopping he received by the Slytherins. Or you can use fairytale characters such as Sleeping Beauty. Whatever you use, make sure that your child relates to the character and that you have fun together with the fantasy.
Second, help your child prepare for what she can expect to feel physically. Explain that the injection or IV insertion might prick for a second or two. You can ask in advance if numbing cream will be used. If so, you can show your child how and where the balm will be applied and explain that its purpose is to lessen discomfort. It’s especially important to forewarn your child that the potion or pill may make them feel like they are floating or spinning. You can help your child to practice this feeling by having them lie down and relax deeply by slowly inhaling and exhaling while counting backwards together from five on each exhale. Tell your child to breathe in through her nose, imagining that her lungs are filling up with air like a balloon and then slowly filling all the way down to the top of her belly. Have her exhale every bit of her breath out through her mouth. Once she is calm, have her pretend that she is floating on a cloud and feels as light as a feather. Or, the child can imagine that he is taking a magic carpet ride through the sky in slow motion. If your child likes water, you can have him make-believe he is floating on an air mattress in a pool or on a raft in the ocean.
Another important readiness step in preparing your child for the physical sensations of anesthesia is to get her accustomed to the feeling of dizziness. This can be done by gently and slowly spinning your child around in a circle once or twice (like parents do for piñata and “Pin the Tail on the Donkey” games). Then have her rest, noticing the different sensations that arise. Of if you have a swivel chair, you can spin her around slowly one time to see if she tolerates this feeling. If she doesn’t, give her time to settle. Later try a half-spin even more slowly, building up tolerance to this new sensation.
You can also purchase fun spinning toys in most discount department stores. Spin Around and Sit N Spin are two such toys that a child sits on top of, spinning himself around. The advantage to these is that the child is in control of the speed and number of times that they spin so they can become accustomed at their own pace. Parents still need to be cautious that their child doesn’t overdo it and become nauseated in their eagerness to have fun. The idea here is to familiarize children with sensations they might experience at the hospital so that they are not suddenly frightened by the unexpected.
6. Ensure that a local anesthetic is going to be used! Multiple studies have shown that healing from a surgical wound is more rapid, involving far less complications, when local anesthesia has been administered along the line of the actual incision (as opposed to only a general anesthesia that makes one fully unconscious).5 Unfortunately, this relatively easy-to-do procedure is still not routine, and general anesthesia given without benefit of a local is far more common, even for simple surgeries. If a general anesthesia must be administered for a particular procedure, it is still important that a local be given to your child as well. Doctors and parents together can advocate for medical facilities to adopt such policies. By all means discuss the types and methods with which anesthesia will be given well in advance of the operation date. Of course, if a local anesthetic can be used alone, and your child can be kept from being terrified, then that is generally best.
One of the graduates from our training program carried out a small pilot study at the University of California–San Francisco Medical Center. Her outpatient pediatric rheumatology patients had to undergo an extremely distressing (and repeated) procedure for which they were frequently “put under” because of their terror at having the procedure. Using techniques like the ones just described, she found a dramatic improvement in the children’s capacity to undergo the procedure without general anesthesia; and in many cases without much fuss. (See Chapter VIII for more details regarding the work at UCSFMC.)
On the Day of Surgery
1. Parents and medical personnel need to work out an arrangement whereby parents can remain with their child as much as possible before and after the operation. Children do better when a calm parent can be with them during administration of preoperative drugs. It is also best if parents can get permission to stay until the child transitions from waking consciousness to a “twilight” state.
2. A child should never be strapped down to an examining table or put under anesthesia in a terrified state. This leaves an imprint deep in his psyche and nervous system. The child should be soothed until calmed. Ask the doctor if you can hold him or her. If your child must be strapped down, explain this to the child and remain with her until she is comforted and supported enough to go on. Fear coupled with the inability to move puts a child in a terrified shock reaction—a recipe for trauma!
3. Medical staff and parents need to know that, ideally, parents should be in the post-operative room when their child is waking up. The child should never awaken in the “recovery” room alone. Without a familiar adult to comfort them, many youngsters wake up disoriented and panicked. The state is so altered that they may believe they have died or that something horrific has happened to them. It is important that parents and hospital personnel decide together who will guide the child as she comes to—and be sure to let her know in advance who it will be. If parents are absolutely not allowed, request strongly that there be a nurse or someone else there (whom the child has already met) to make soothing contact when your child awakens. To awaken alone in the post-operative room can be terrifying—even to an adult.
Whoever is with your child can gently re-orient her to the room and to time by letting her know where she is and that the surgery is over. If your child is feeling numb or reports that his body feels weird or is distorted in some way, let him know that this feeling is normal after an operation and reassure him that it won’t last forever. It can be very helpful to touch and gently squeeze the muscles on your child’s forearm in order for him to get a sense of the boundary of his body again.
After the Surgery Is Over
1. Rest speeds recovery. All of your child’s energy needs to be directed toward healing physically. This conservation of energy is important, but children may not understand this. If they want to play, it needs to be quiet play with lots of encouragement to rest.
2. If your child is in pain, have him describe the pain and then find a part of the body that is pain-free, or at least less painful. As you sit with your child, encourage the alternation of awareness between the part that hurts and the part that doesn’t hurt so much; this can often alleviate the pain. You can also distract your child a little through the tough spots by humming with them or having them clap or tap a part of his body. Suggesting that he imagine a variety of colored balloons holding the pain and taking it way up into the sky as they float away can also be useful.
When the Medical Procedure Is an Emergency
1. Once the imminent danger is over—and, for example, you are riding with your child in the ambulance—take the time to observe and assess your own reactions. Allow time to reflect and remind yourself that you now have tools to help; allow time to settle your own shakiness, and wait for your own breath to come before proceeding. A sense of relative calm should be your first task.
2. Reassure your child that everything will be OK, that the doctor knows how to make them better, help them stop bleeding, fix the broken arm, stop the pain, etc.
3. Distracting your child right before the medical procedure can be helpful. Retell her favorite story, bring out her favorite toy or talk about her favorite place, like the park—making plans, perhaps, to go there when she is better. If your child is in pain, you can have him clap, sing or tap himself to lessen the pain. Or you can ask him to tell you a place in his body that feels OK or has less pain, and direct him to focus on that part. Let him know that it’s OK to cry.
4. If children are old enough to understand, tell them what will happen at the hospital or doctor’s office. For example: “The doctor will sew up the cut so it will stop bleeding.” Or: “The nurse will give you either a pill or a needle with medicine to make the pain go away, and that will make you feel better.”
A Word about Emergency Rooms
More horror stories have been uncovered from the emergency room experience than from any other area in the hospital. By its nature, there is a frenetic atmosphere. It has been frequently reported to us that although the hospital procedure itself went well, the emergency room was outright frightening and left unforgettable images. Some hospitals have recognized the detrimental nature of exposing children to critically injured adults in the waiting room and treatment area. We encourage your family to visit the local hospitals (urban areas usually have several) before an emergency arises. You may be astonished at the variation in quality of care and nurturance among them. In one large city three local hospitals, within twenty minutes of each other, were visited in doing research for this book. One was totally chaotic and many adults were being treated for domestic violence and gunshot wounds. Another was more or less ordinary, with a pleasant waiting room and the typical long line of patients. The third hospital, refreshingly, was as conscientious about protecting children’s psyches as they were about healing their bodies.
To shield the children from the adults, both the waiting and treatment rooms were separate. The children’s waiting room had colorful child-pleasing murals on the walls, a big fish tank and no injured adults. Unlike the ward-like atmosphere of the adult treatment room, the children’s side had individual rooms to safeguard them from exposure to the frightening sights and sounds of injuries and procedures of their peers. This was not done out of economic motivation; rather, it was done because staff members recognized the importance of sheltering children from unnecessary misery. Unless twenty minutes made a life-or-death difference, which hospital would you take your child to if you knew what was available in your community? Unless your child is delivered in an ambulance, chances are the waiting room time will far exceed the few extra minutes’ driving time.
Unnecessary surgeries could easily be the topic of another entire book. Many operations that were once considered “routine,” such as tonsillectomies and operations for “lazy eye,” have now come into question. Always seek second and third opinions to assess if a surgery is really necessary. Also, without going into depth, suffice it to say that there are two procedures administered routinely due to their purported health benefits that you would be wise to question. These are circumcision and cesarean surgery. Weigh the advantages and disadvantages by reading as much as you can and talking to professionals on both sides: those who advocate and those who discourage the procedure. (If you are planning to have your first baby or more children, you can read about cesarean surgery, circumcision, healthy pre-natal and birthing practices and infant development in our first book, Trauma Through A Child’s Eyes: Awakening the Ordinary Miracle of Healing published by North Atlantic Books in 2007. Extensive information and further references on these topics can be found in Chapter Ten of that book.)
Sensitivity to Your Child’s Pain
As mentioned earlier, remember that all doctors and medical facilities are not created equal. Many pediatricians are so focused on saving lives or on the accuracy of the procedure itself that they lose sight of the vulnerability of the little human being they are treating. The “get-it-over-quick” attitude devoid of sensitive care to the terror and pain that a child is going through must not prevail. Much of this attitude comes out of two common but mistaken beliefs that seem astonishing. One is that infants and young children don’t feel or remember pain, and the other belief is that even if they do feel pain, there will be no long-term consequences! For those skeptics, let’s take a look at the long-term effects of the surgery experienced by a boy named Jeff.
As an adolescent, Jeff gathered dead animals struck by pickup trucks and cars. He brought these animals home, cut open their bellies with a knife, and removed their intestines. At four years of age, Jeff had been hospitalized for a hernia operation. When it was time to put the anesthesia mask on his face, the terrified child fought so hard that the doctors had to strap him to the operating table. Following the surgery, the boy seemed to “snap.” He withdrew from family and friends and became awkward, secretive and depressed. Do you remember the story of Teddy at the beginning of this chapter? Just as his hospital trauma was more than likely a critical factor in the shaping of Theodore Kaczynski, the alleged “Unabomber,” it is likely that the terrifying hernia operation described above figured significantly in the formative development of Jeffrey Dahmer, the serial killer who tortured, raped, dismembered and ate his victims.
The parents of both these men have spent many anguished hours trying to understand the actions of their sons. They had witnessed the disconnection, isolation, despair and bizarre behavior of their children following hospitalization and surgery.6 The evidence points to the possibility that these bizarre behavioral changes were connected to traumatic reactions to “routine” medical procedures.
Fortunately a growing number of doctors, nurses and medical centers understand the importance of easing pain at both ends of the age spectrum. Palliative care for our elderly is now being practiced by some. It is the rare pediatrician who would intentionally abuse a child. Yet, the change in mind-set regarding the reality of pain in children was only “discovered” by researchers a little over a decade ago! Doctors actually believed that newborn infants were prevented from feeling pain because of an immature nervous system. It was also thought that young children in general did not remember pain. As a result, babies as old as eighteen months underwent invasive procedures including surgery without anesthesia (this practice still occurred as late as the mid nineteen-eighties). Doctors also hesitated to use narcotics on children because they feared the drugs would cause respiratory problems and addiction.7Little did they understand that addiction is more likely to come from the disconnection caused by the trauma of cruel treatment.
What many sensitive parents and professionals may have suspected has now, auspiciously, been given credibility by discoveries in developmental science. A U.S. News & World Report article in the year 2000 stated:
Babies probably get the worst of two worlds: a mature nervous system able to feel pain coupled with an immature ability to produce neurochemicals that can inhibit pain. And even when children cannot remember the actual experience of pain, it seems to get permanently recorded at a biological level. Children who received painful bone marrow aspiration treatments without pain medication, for example, suffered more during later procedures even when those were done with painkillers, according to a 1998 study in the Archives of Pediatrics & Adolescent Medicine. “If [pain] is not dealt with early, it is worse later,” says Charles Berde, a pediatric anesthesiologist who directs the pain treatment service at Children’s Hospital in Boston.8
In other words, the initial “pain experience” leaves a deep (traumatic) imprint on the nervous system, which is then re-activated during later procedures. After reading the first section of this book on the biological nature of trauma, you probably understand better why children are the most vulnerable to overwhelm due to their inability to fight or flee. As if that were not enough, medical/surgical procedures are by their very nature the most potentially traumatizing to people of all ages due to the feelings of helplessness that come from being held down, at the mercy of strangers and in a sterile room when you are in unprecedented pain! Having to remain still while you are hurting and being hurt is the epitome of the terror of immobility! It is the prescription for trauma! Let us review the simple steps you can take as parents to minimize unnecessary traumatization.
Simple Things Parents Can Do to Ease a Child’s Pain
Be sure to ask for a local anesthetic along the line of incision for surgeries. Some facilities even go so far as to use a spray (Elemax) to numb the site of IV insertion for children. Ask your doctor what will be done to ease your child’s pain and request localized relief.
Use stuffed animals and dolls as props for playing doctor and nurse to help make the sick “puppy” or “baby” or “bear” all better. This is a great way for children to get involved in a distraction from their own pain. It gives them a chance to role-play what will happen to them, and gives the adults a chance to assess the youngster’s level of worry in order to give adequate reassurance.
Older children can be taught relaxation techniques. Audio cassettes in the health section of bookstores and in teacher supply stores have guided instructions to release tension from head to toe. Some use visual imagery as well, such as Quiet Moments with Greg and Steve (Los Angeles: Youngheart Records, 1983—www.edact.com), while other recordings use affirmations of well-being during surgery on one side of the tape or CD, with subliminal messages hidden in music on the other. Still others work specifically with breathing techniques combined with systematic tensing and releasing of various muscle groups throughout the body.
Involve your child’s mind in fantasy games and voyages, like taking a magic carpet ride and visualizing leaving the pain behind. This can work wonders. Have her keep adding details to the mental picture to keep her focused on the pleasant image.
Distractions for the younger child such as blowing bubbles or squeezing a “koosh” ball can alleviate pain.
Biofeedback is offered in some medical centers. No equipment is necessary if temperature-sensitive “sticky dots” are purchased that change color when skin warms or cools to give a remarkably simple reinforcement for deepening relaxation.
Hooray for Teens with Attitude
A terrific find for teens is a video series produced by the Starbright Foundation that prepares them for what to expect from their hospital experience and how to get the most out of it. This company has even produced a video about the often painful process of reentry to the trials and tribulations of social and academic life (if the teen’s treatment required a prolonged stay, such as with burn victims and children with cystic fibrosis, organ transplants or cancer). This candid, cool, uplifting and empowering series is called Videos with Attitude and can be found at www.starbright.org. “What Am I, Chopped Liver?” (Starbright 1998) exposes teens to the incivilities of hospital life and lays out their rights and how to communicate with their doctor rather than feeling, as one teen expressed it, “so helpless.” Below is a useful summary about the rights of teens. These rights include:
To be talked to directly by the doctor
To talk privately with the doctor (yes, this means without parents)
To be told the truth without “sugar-coating”
To decide what he wants to hear and doesn’t want to hear
To be treated as a person, not an object
To speak her mind
To ask any and all questions—medical, social, physical
To question the doctor if he or she is doing something you don’t think is right
To be informed about procedures and what will happen
To ask questions (and get answers) about side effects of medications, such as if your appearance or ability to participate in sports will change, etc.
To write a note or have your parents ask the doctor questions if you are too shy
To let someone know if you are in pain
To share fears, hopes and other emotions (don’t keep things bottled up inside)
To share his needs and personality so that the doctor knows him as a person
To change doctors
One common complaint is that the doctor often treats the teen as an object or “case” and fails to introduce himself to the patient, speaking instead to the parents as if the teen weren’t even in the room! One girl in the video expressed how much trust she had in the second doctor who “walked past my parents, shook my hand and said, ‘OK, I’m gonna get you through this.’ ”
In Plastic Eggs or Something? Cracking Hospital Life (Starbright 1998), teens get to see and hear other teens’ impressions of the harsh reality of the glaring lights, hospital attire and other things not-so-fun, such as the food. One teen described hospital life as “a cross between a battlefield and a prison.” This hilarious journey through hospital halls prepares teens for what to expect and how to roll with the punches of the unavoidable atrocities. What was the best advice from these adolescents? Make sure to bring a CD player (iPod) and headphones with plenty of your favorite music; bring your own sheets, pillows and clothing if you will be there long term; keep a notepad for questions for the doctor; and “Don’t think you’re just the receiver at the end. It’s YOUR life—be part of the whole process.”
A Timely Word about Bullies and School Shootings
It seems like barely a few months pass when we wake up to read the morning paper or hear the news about another ghastly school shooting. Bewildered, frightened and angry, we wonder if this could happen at our child’s school; another bullied misfit going crazy and taking out innocent lives along with his own. Fortunately, the statistical probability of something like this happening at a given school is remote. However, what does happen almost any day in any school throughout the world is that children are being bullied.
In fact, bullying is so common that we sometimes make the mistake of assuming that it is normal. And while a certain amount of aggression is normal among children (particularly boys), bullying is not. Although it may not be easy to change bullying in your neighborhood, you can not only help prevent your child from becoming traumatized, you can help “bully-proof” them. What we mean by “bully-proofing” refers to preventing your child from becoming either a perpetrator or the victim or both.
We don’t know much about why school massacres occur, but we do know a few facts. Although profiles of bullies and shooters vary greatly, what all have had in common is that they suffered from anxiety, depression and withdrawal from appropriate peer social activity. And many had been ostracized, made fun of and picked on by kids their own age. We also know that anxiety, depression and withdrawal are often symptoms of unresolved trauma.
It is also well known that children who feel powerless at home will often find an outlet for their rage either with their younger brother or sister, the neighborhood kids or on the school playground. Just like what happens in a domino effect when a boss takes out his fury on an employee—which can cause a stressed bread-winner to then take these frustrations out on the elder children, who in turn might take it out on their younger siblings, who in turn take it out on the family pet—so, too, does a “bully parent” give rise to the birth of a home-grown bully. Schoolyard bullies have often been the victim of abuse or physical punishment. Even without corporal punishment, authoritarian “discipline” that steamrolls over a child’s growing developmental needs can spawn a desire to torment others. Kids need to be granted a certain amount of freedom to make choices, decisions and to exert their will, especially in play and when it is safe to do so without causing distress to others.
In the next chapter on ages and stages of development, you will learn that children between the ages of two and four naturally begin to come into their power. Particularly around the age of four, they begin to initiate plans, construct, create and feel their physical prowess. When parents applaud their children’s new abilities and skills and give them plenty of “air time,” they help to build the kind of solid confidence that deters bullies from invading their children’s space. Bullies usually don’t approach strong kids with good boundaries; instead, they seem to have special radar that detects the children who are somewhat immobilized and defenseless. Often this is true despite a child’s intellectual competence. Nonverbal cues from body language are a dead give-away that a child is filled with shame or is otherwise vulnerable. This, as you already know from reading this book, is often the result of unresolved trauma. By helping your child, through body awareness, to build healthy boundaries, to develop early detection of those who might abuse him and by preventing trauma, you will automatically be “bully-proofing” your child.
It is important to remember that the innocent victims of bullying are kids who are usually anxious and depressed. They often suffer in silence. Although (fortunately) minuscule in number, these rare kids can be the anomalies that eventually explode in a homicidal rage, taking their own life along with that of the other innocents. The more adept a child becomes at suppressing his pain, the more likely he is to blow up. Therefore, it is important as parents to recognize and provide professional help for your child if he continues to suffer silently from shame, depression, anxiety or social withdrawal if your attempts to reach him have been in vain.
Those that do the bullying fare somewhat better. However, although they are outwardly self-confident, they often have fragile egos beneath the surface with a tenuous sense of self, based precariously on their physical strength and ability to intimidate. These children need adults to help them find healthy outlets to express their power in non-violent ways and to develop empathy for others.
A special section, titled “Crisis Relief with Groups,” can be found in the last chapter of this book. It was designed to help neighborhoods pull together in the event of a school shooting or any other catastrophe (such as a natural disaster), and to help the adults and children communally cope in the wake of tragedies of such magnitude.