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"It's Not Always Depression: Working the Change Triangle to Listen to the Body, Discover Core Emotions, and Connect to Your Authentic Self" (Random House & Penguin UK, 2018) is an easy to read self-help book on everything you need to know about emotions and how to work with them to feel better. Using stories, no-jargon scientific explanations, and exercises to help you connect with your authentic self, the book will change how you understand yourself, your children, your loved ones, and everyone.


Order US book here. For Canadians, order here. If you live in UK or around the world, order here.

As a trauma- and emotion-centered psychotherapist, I am relieved that children are now being screened for toxic stress. Thinking about emotional health as a byproduct of a child’s environment is an important addition to current thinking on how to improve children’s mental health. Rushing to diagnose a child with potentially stigmatizing labels, incorrectly blaming “defective” brain chemistry, resorting to unnecessary and sometimes toxic medications, and carrying out punishments do not address the underlying cause or help a child recover their self-confidence and ability to thrive.

An energetic young boy, for example, may be diagnosed with ADHD or being oppositional, when in fact in an alternative environment he might be a delight. A belligerent teenager who is abusing drugs and getting Ds in school may appear like she is a "thug, undeserving of respect," yet if raised in another family, town, or school she might be a well-mannered honor student. Before a child is burdened and stigmatized by diagnoses and labels like “he’s mentally ill,” or a “depressive” or an “addict,” it is important to determine whether something in the environment is causing symptoms of traumatic stress, which can cause a person to feel anxious, depressed, unable to concentrate, and to want to self-medicate with substances to get some relief. To relieve toxic stress, we must focus on promoting emotional safety and connection at home and in school as we help a child manage their emotions and the crisis to self-confidence that comes from feeling bad.

Ben, 11 years old, came home from school one day and told his mother he thought he was depressed. Maggie, Ben’s mother, whipped into action, calling several child psychiatrists to find one that could see Ben to start treating him with antidepressants. When I met Maggie, I explained, “Ben’s symptoms have meaning. They are important communications that something deep inside needs tending. He doesn’t yet have words to explain what’s making him feel upset or unsafe. Depression is just the tip of the iceberg. Ben is struggling to tolerate his underlying core feelings, which are natural responses to the environment.” Ben was not at immediate risk, so I recommended they see a child and family psychotherapist with an attachment- and trauma-informed perspective.

Rates of anxiety and depression in children are skyrocketing in part because our society is not nurturing for young brains. But, in our quick-fix culture we are still geared toward treating the symptom, like depression or anxiety, and not the underlying cause. When a child like Ben reports a depressed mood, parents and doctors often respond with medication first. Medication is sometimes necessary, but there are many compelling science-based reasons to consider alternatives. Additionally, being identified as a psychiatric patient can lead a child down a road where they experience more distress from feeling ashamed and broken. And, if medications don’t work, a child can become hopeless. In fact, labeling a child with a mental illness, when the problem is in the environment, creates a “mental patient.”

I have learned, from years of practicing a type of attachment- and emotion-centered trauma psychotherapy, AEDP (Accelerated Experiential Dynamic Therapy), which is firmly rooted in current science, that symptoms like depression and anxiety are important communications indicating that something in the environment was at one time or is currently triggering a variety of emotions, like anger, sadness, fear and shame, and are too much for an adult, let alone a child, to bear alone. Adverse childhood events (ACEs) and small-t traumas are experiences that overwhelm a child’s capacity to process core emotions like sadness, fear and anger. ACEs and small-t traumas include such experiences as being bullied, parental divorce, moving, having an illness, or having a parent with an illness or an addiction, not to mention abuse and neglect.

ACEs and small-t traumas also include experiences where a child feels different, but not in a good way, for example, when a child starts to realize they are gay or transgender in a community where no one is out; or when a child grows up in an actively alcoholic family; or has a lower socioeconomic or racial status compared to other students at their school, they feel shamed, isolated and alone. Children growing up in non-nurturing, shaming environments, with no one to validate that the environment is the problem, internalize the experience and conclude something is wrong with them. If an adult can at least validate the experience -- saying, for example, “No one should grow up with all that screaming and alcoholism; that feels terrible to live though; of course you feel agitated and insecure, that is normal,” -- damage to the child’s self-esteem is mitigated.

Ben was being bullied in school. Bullying leads to mental health problems because it triggers many powerful core emotions, also known as survival emotions. The threat of being bullied causes Ben’s nervous system to go into high alert for danger. Fear is triggered in his brain along with rage, sadness and even disgust. So many emotions at one time happening in Ben’s brain causes his nervous system to become dysregulated. This is subjectively experienced by Ben as anxiety. Ben’s anxiety made it harder for him to concentrate and sit still and fueled his depression.

If core emotions are continually suppressed, they put stress on the mind and body. Too many emotions, coupled with too much aloneness, in persistently triggering environments, make it difficult, if not impossible, for a child to feel safe and calm. To cope with the anxiety of unprocessed emotions, a child’s mind erects automatic, unconscious defense mechanisms. These coping strategies lead to symptoms like depression, anxiety, aggressive behavior, substance abuse, cutting, eating disorders and difficulty concentrating or focusing, to name but a few. These are all symptoms of toxic stress.

Ben’s grades were falling at school because he was having trouble focusing and concentrating. One might jump to assume Ben was lazy or had attention problems requiring stimulants. In fact, poor focus and attention is also a result of high anxiety or depression. Both anxiety and depression signal that underlying emotions of fear, sadness, disgust, anger, shame and/or guilt need attention. Therapy where emotions are understood, named, validated and processed foster calming of a taxed nervous system.

Besides the current stressors like bullying and the crazy academic pressure to achieve, Maggie and I discussed other events in Ben’s life from the time he was born until today that might bring up big feelings. Divorce was one. Divorce brings up many emotions for children. Simply moving from mom’s house to dad’s house, even in a relatively amicable split, can be jarring, raising fears and triggering sadness from loss of the way things used to be.

Ben and Maggie went to therapy together. The therapist taught Maggie about PACE and PLACE, which are essential to healing. PACE refers to the therapist creating a setting that is Playful, Accepting, Curious and Empathic. PLACE refers to the parent creating a healing environment at home by being Playful, Loving, Accepting, Curious and Empathic.

Additionally, the therapist worked with Maggie to help her read and respond to Ben’s nonverbal communications. For example, when Ben started to twitch or get tense, Maggie learned to recognize that as anxiety and help Ben calm down by reminding him to play the “breathing game” with her, where they would take deep belly breaths together and puff out their stomachs. Maggie also learned to listen calmly, without interrupting or offering advice. Maggie learned to validate Ben’s varying emotions underneath his anxiety, saying, for example, “I would be so you angry if a kid at school insulted me. I might have to work hard not to punch them in the nose!” Once Ben’s emotions were validated and he felt better, they did their best to calmly solve problems. Maggie could help with things like working with the school to make Ben feel safer and to temporarily take some academic pressure off him. Maggie had sessions alone with Ben’s therapist to deal with her anger and fears. She had to learn how to stay connected to Ben during tough moments when she would get triggered and feel herself get angry or impatient. Maggie also stayed present in the therapy sessions, comforting Ben while he processed his sadness, getting relief through crying about the divorce. Ben’s anxiety and depression lifted, and he began to thrive.

The remedy for a child’s symptoms of distress is not necessarily medication or going alone to a psychotherapist. Children need to find a safe way to express their emotions, have them validated by their parent and other family members, and know their feelings are ok. A child needs to feel they belong, and that they are not bad or weird for feeling bad. They need help tolerating and calming the discomfort and pain their emotions bring up in their body, as well as their mind. Hugs, snuggles, talking, playing, making art and other ways children process their emotions are needed to make it safe for even the toughest of children to express their sadness, anger, fear and shame so that emotions flow through the body and release. An attachment- and emotion-centered trauma-informed approach heals the symptoms as opposed to applying a temporary Band-Aid like prescription medication does. And this approach stands in stark contrast to punishing a child for acting out or diagnosing a child with a disorder.

We must be careful not to send a message that our children are broken—as children easily interpret their distress as a personal flaw which can evoke shame and adversely affect confidence. Starting with a trauma-informed approach that includes parent and child together connecting, sharing, and solving problems sends a relieving, brain-regulating message that a child is not alone with their problems. Parent and child together can uncover the stresses in the environment, work to restore a sense of calm and safety, and further a child’s trust that talking honestly about struggles leads to relief. Trauma-informed care restores confidence and mastery that “I can feel my feelings, connect with caring others, and simultaneously deal with what life brings.” And Ben did.

To protect confidentiality, patient names and identifying information has been changed.

To learn more about trauma-informed treatment methods for children, visit my resources page here.

HILARY JACOBS HENDEL, LCSW, is author of the book, It’s Not Always Depression: Working the Change Triangle to Listen to the Body, Discover Core Emotions, and Connect to Your Authentic Self (Random House, Feb. 2018). She received her BA in biochemistry from Wesleyan University and an MSW from Fordham University. She is a certified psychoanalyst and AEDP psychotherapist and supervisor. She has published articles in The New York Times and professional journals. Hendel also consulted on the psychological development of characters on AMC’s Mad Men. She lives in New York City. Visit Hendel's website for more information and free resources for mental health.


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