Massage and Bodywork Magazine for the Visually Impaired - Maximum Potential

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September/October 2013 Issue

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Maximum Potential

Helping Traumatized Children

By Tina Allen
[Feature]

The children that Chai Benson serves live in extreme poverty, have been exposed to drugs and/or alcohol in utero, and often experience neglect or sexual and physical abuse. 

“I have a client right now who witnessed brutal physical fights between his mother and father, and then later, between his mother and stepfather,” says Benson, a certified infant massage teacher from Long Beach, California, who has a master’s degree in child development and family studies. “I have been teaching his mom to massage his back for at least five minutes a day as part of their waking-up routine. At first, I was encouraging his mom to massage him when she noticed anger cues, but his anger is so quick and she becomes so overwhelmed that this approach didn’t work. [Mother and child] are still working on making massage a routine, preventative method instead of a quick fix when the problem is occurring. However, I have noticed that both the client and his mom are much more relaxed and are thinking about their relationship in new ways.”

The power of massage and bodywork is helping traumatized children like this young boy find their way out of the darkness.

Understanding Childhood Trauma

According to the National Child Trauma Stress Network, “Traumatic events have a profound sensory impact on young children—their sense of safety may be shattered by frightening visual stimuli, loud noises, violent movements, and other sensations associated with an unpredictable, frightening event. The frightening images tend to recur in the form of nightmares, new fears, and actions/play that reenact the event.”

Childhood trauma occurs when actual or perceived threats of danger overwhelm a child's ability to regulate his emotional reactions and coping abilities. Recurring traumatic experiences may lead to complex trauma and compromise all areas of child development, including body integrity, cognitive processing, identity formation, neurodevelopment, and the ability to regulate behavior.

Reactions to a traumatic event may vary according to several factors: the level of exposure to the event; the child’s age and ability to understand the situation; gender, personality, and functioning prior to the event; resulting changes in living situations; the existing support network; and previous traumatic experiences. Some children are born with different biological tendencies in how they process or respond to stressful events, and different children have different levels of resilience—some are more adaptable than others. 

Children who are at greater risk from the effects of trauma include those who have physical exposure to, or witness, a traumatic event; are near the location of a disaster or incident; have preexisting mental-health issues; have preexisting family-life stressors such as divorce or job loss; had previous traumatic experiences; have limited support networks; or whose caregivers have emotional challenges of their own.

Some events that may cause trauma for children include hospitalization or medical issues; physical, sexual, or verbal abuse; natural disasters; being a refugee of war or terrorism; community or school violence; neglect; grief; divorce; and the death of a loved one. Following is a closer look at some of these events.

Hospitalization

According to the Center for Pediatric Traumatic Stress, The Children's Hospital Philadelphia, childhood injuries and illnesses are common, with five out of 100 American children being hospitalized for a major acute or chronic illness, injury, or disability each year.2 Traumatic pediatric medical stress refers to reactions that children and their families may have to injury, pain, and serious illness, or to invasive medical procedures and treatments. These events challenge beliefs about the world as a safe place, and they are harsh reminders of one’s own vulnerability. Some children may have a fear of high-tech, intense medical treatment. Often, the child or parent may feel helpless, especially when there is uncertainty about the treatment course and outcome.

Children and their families may become anxious, irritable, or on edge, and children may have unwanted thoughts or nightmares about the illness, injury, or hospital. Some will try to find ways to avoid going to the doctor or the hospital and may lose interest in being with friends and family or in things they used to enjoy. They may show decreased performance at school and have difficulty in social situations or at home.

Abuse

There are more than 3 million reports of child abuse each year, and a new report is made every 10 seconds.3 With these abuse rates on the rise, it is quite possible that you will encounter a young client who has been a victim of emotional, physical, sexual, or verbal abuse, or some type of domestic violence. 

Benson describes one of her current clients who was exposed to drugs in utero and witnessed domestic violence as a baby. “The client has a lot of mood-regulation issues—one minute he is joyful, the next minute he is destroying the house in a rage—and has been diagnosed with pervasive developmental disorder.” On a positive note, the client has responded well to massage. “I found that he liked massage by accident, actually,” Benson says. “He was lying on the floor, rolling around and flailing his legs and arms, until his foot landed gently on my knees. I instinctively reached down and began massaging his foot, and all of a sudden, his movements became much calmer, his eyes lit up, and his body was relaxed. His grandmother looked at him and said, ‘Oh my goodness! Look at how calm he is!’ Since that time, I have been encouraging Grandma to massage his back and feet on a routine basis.”

Natural Disasters and Terrorism

Earthquakes, explosions, fires, floods, hurricanes, tornadoes, and tsunamis all fall into the category of natural disasters; man-made events like terrorist attacks can have similar effects. We often concern ourselves immediately with the children who have been directly exposed to, or impacted by, such an event. It is important to keep in mind that children who are exposed to these events through the media or by overhearing adult conversations may also show many of the same symptoms and behaviors.

Most families will recover over time, particularly with support. The length of recovery, however, will depend in part on how frightening the event was and other contributing factors such as whether they needed to evacuate, if they lost their home, or if there was extensive loss within their community. 

Dealing with Childhood Trauma

Children’s responses to trauma are unique and can be distinguished from those of adults. Young people lack the strength and cognitive emotional inhibitors necessary to cope effectively with the impact of trauma. Responses to traumatic events include physical hyperarousal, hyperactivity, and hypervigilance. Many children also experience emotional numbing or reactivity, constricted emotions, abnormal startle responses, and neuroendocrine abnormalities. Traumatized children may not possess the ability to regulate emotions, thereby compromising behavioral arousal.

A child’s perception may not be realistic. He may lack the capacity to differentiate between threatening and nonthreatening situations, and be reactive to sensory triggers reminiscent of some aspect of the trauma, such as sights, smells, sounds, tastes, and touch sensations. When we are upset, we go into the fight-or-flight response, a system designed to enable our whole body to respond to danger. For children, freezing is a signature of trauma, wherein they simply may freeze and become unresponsive. 

Some of the most common traumatic stress reactions in children include avoidance, re-experiencing, and heightened arousal. 

Avoidance

Children often try to avoid things that remind them of the traumatic event. They may withdraw from friends and social activities. Many times, children will block out information and negative details; their emotional responses may feel detached, they may be unable to express a wide range of emotion, and their expressions may be flat. 

Re-Experiencing

Nightmares about traumatic events are common occurrences. Children may show evidence of reliving aspects of the events by acting them out, participating in repetitive play, or behaving as if the experiences are happening again.

Heightened Arousal

After a traumatic event, children may show disorganized behavior, agitation, and elevated responsiveness, as well as increased sensitivity to sights, sounds, or other stimuli. Nervousness, irritability, and sleep problems, accompanied by being easily startled and crying frequently, are common presentations.

In addition to common responses, long-term childhood stress and trauma may put children at risk for anxiety and depression. Trauma and sensory deprivation in the child-parent relationship may be an underlying cause of a number of emotional disturbances in children including aggression, anxiety, attachment disorders, attention deficit disorder, depression, and sensory-integration dysfunction. Research has indicated that the long-term consequences and effects of childhood trauma may also include cardiovascular issues, chronic back pain, fibromyalgia, gut problems, irritable bowel syndrome, and many forms of arthritis in adulthood.

With appropriate, safe, and effective interventions, we can provide children with compassion, nurturing, and tools to ease the effects of trauma.

Working with Children

When using massage therapy for children who have experienced trauma, the work does not need to be aggressive to achieve its maximum potential. Professionals wishing to work with this population should have specialized training to provide effective support.

Some of the many benefits we hope to achieve through the use of nurturing touch include decreased tactile aversion, decreased production of stress hormones, improvements in social interaction, increased feelings of self-worth, improved ability to self-regulate and self-soothe, increased feelings of calm and relaxation, improved growth and development, and better sleeping habits. 

Pediatric massage may be used as a supportive therapy by specially trained massage therapists, or by caregivers who have learned massage techniques from a skilled, educated massage therapist.

The role of hands-on practitioners is never to diagnose trauma, but rather to support all clients with compassion. Practitioners should be particularly sensitive to the reactions of children who are more likely than others to be at risk for developing problems. If you do not feel comfortable working with this population under your current scope of practice, you should respectfully refer the client to a more qualified practitioner.

Providing touch therapy for children who have experienced trauma requires an ability to adapt the work to each child’s specific emotional and physical needs (see Connecting with Young Clients, page 61). Specific concerns associated with young clients may include fear of massage administered by a stranger and general apprehensions about touch. Working with children who have experienced trauma requires more sensitivity to the child’s comfort level, physical cues, and gestures, as well as a much slower, more intentional pace. 

“The child may not be comfortable with touch right away and may need songs, stories, or the parent’s gentle voice to relax them,” Benson says. “Or a child may be so hungry for attention or touch they want to sit in your lap when you first meet them. Both are extremes and require the child to learn the appropriate and healthy way to touch others.”

When working with children who have experienced any trauma, it is best to let them control the session. Always ask for their permission to perform massage therapy, no matter how young or how incapacitated they may be. Explain the massage in terms children will understand, and give phrases or code words for “yes,” “no,” and “stop.” Many children who have experienced abuse have a history of knowing they cannot say “no” to anything, and this gives them permission to control the session without using potential trigger words. 

Do your best to learn a few personal characteristics about the child before the session—not just physical or emotional issues, but general likes and dislikes—and try to incorporate or exclude these preferences in the session.

“For younger children, I like to find out their favorite color and main interest in advance and make an effort to include this in the session in some way,” says Shannon Doher, LMT, and cofounder of Touch Institute Los Angeles Inc. “For older kids and teens, I encourage them to bring in their favorite music for the session. If the child does not want to participate in the session or wants to end it at any time, for any reason, I immediately comply.” 

Provide safe positioning to help empower the child. Try beginning with the child sitting up; lying supine or prone may feel very vulnerable to your pediatric client. Giving choices is important, but do not give an overwhelming amount of choices. Also, while you want to let these children know they are in charge, as they have likely never felt in charge of anything, it is advisable that you do not give a choice of removing clothing at the first session.  Having a parent or caregiver in the room during the massage is typically standard when the child is under 18.

When providing pediatric touch therapy, use slow transitions and be consistent, predictable, and repetitive. Always try to interact with children based on emotional age, and use soothing, nonverbal interaction, such as gentle stroking of the hand or demonstrating healing touch on a stuffed animal.

Teaching the Parents

When appropriate, teaching parents and caregivers how to therapeutically touch their child is an important part of the healing process. When teaching parents to massage their infants or children, one of the first steps they must take is to be open to their children’s cues. This means seeing children for who they are, what they need, and what they are telling the parent through nonverbal communication. Then, as parents provide a soothing or gentle touch, they are not only teaching their child what healthy touch looks like, they are communicating to that child “I hear you,” “You are safe,” and “I am here for you now.” These messages, communicated by the primary caregiver, are vital for a sense of emotional healing. 

“Many children who have experienced trauma or have been exposed to drugs in utero usually have a lot of sensory needs,” Benson says. “They can be easily overwhelmed by noises; they are anxious and startle easily, and may not have experienced gentle or nurturing touch as infants.”

One benefit of pediatric massage is that once parents find a way to connect with their children through touch therapy, it is well received. You do not have to announce, “It’s time for a massage,” because children are requesting it. This benefit not only empowers the child to request healthy touch, but allows a parent to feel proactive in their child’s care.

Pediatric massage has tremendous impact, especially when offered to children who have suffered through traumatic events. The value of safe, nurturing touch is a soothing salve for these little clients. Teaching parents and caregivers how to offer the work to their children creates a strong therapeutic path for healing. 

Notes

1. National Child Traumatic Stress Network, “How Is Early Childhood Trauma Unique?” accessed August 2013, www.nctsn.org/content/how-early-childhood-trauma-unique.

2. National Child Traumatic Stress Network, “Medical Events & Traumatic Stress in Children and Families,” accessed August 2013, www.nctsnet.org/nctsn_assets/pdfs/edu_materials/MedicalTraumaticStress.pdf.

3. US Department of Health & Human Services Children’s Bureau, “Statistics & Research,” accessed August 2013, www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research.

 Tina Allen is the founder and director
of the Liddle Kidz Foundation. She is the recipient of the 2012 Massage Therapy Foundation/Performance Health Humanitarian Award. For more information on the foundation’s Global Volunteer Outreach, visit www.liddlekidz.org.

Connecting with Young Clients

Take a Moment. Relax yourself!


Meet the Child where he is at, in whatever position he is comfortable receiving massage.


Ask Permission. Use a structured permission process. Practice it.


Use Tactile Items. Initiate contact and provide a developmentally appropriate approach, such as puppets, textured balls, or fidget toys.


Start with Hands and Feet. It may be more comfortable to the child.


Use Slow Transitions. Always be consistent, predictable, and repetitive.


Careful Interaction. Interact based on the emotional age of the child.

Be Calming. Use soothing, nonverbal interactions.

Create a Friendly Environment 

No Rush. Let the child take the time she needs to get comfortable.

Clothes On?
No Problem.Consider providing touch therapy over clothing or using a cloth item between your hands and the client’s skin. Do not give a choice of removing clothing at the first session.

Speak the Language. Explain what will happen during the massage in terms the child will understand.

Use Code. Give the child phrases or code words to use during the massage in place of “yes,” “no,” and “stop.” Thumbs up and thumbs down also work well. 

Choices. Begin where the child welcomes massage and nurturing touch. Ask questions to give the child control. 

Teaching Parents and Caregivers

Here are some talking points when teaching pediatric massage to parents and caregivers:


Touch is beneficial in any way, as long as the child welcomes it. This could mean hugs, pats on the back, or even tickles. 


Work up to it. Start with touch that makes the child feel comfortable, even if that means them massaging you.


Don’t give up! The more you use positive, welcomed touch, the stronger the bond with your child will grow. 


Massage isn't just for infants. Massage can help teenagers handle stress—a simple back massage works wonders.

Positive touch is about giving the power back to the child. During a massage, children have the power to say “yes” or “no,” to lay on their stomach or their side, or to ask for a story to be told during the work. Listen to what your child says and honor those requests.

To read this article in our digital issue, click here.



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