Case Study: The Child Who Carried the Family — Anxiety, Stomach Aches, and the Multigenerational Transmission of Refugee Trauma

Category: Case Studies | All Four Directions | Composite Clinical Case

DISCLAIMER: This is a composite fictional case study based on common clinical patterns observed across integrative and functional medicine practice. It does not represent any single real patient. All names, identifying details, and specific circumstances are invented. The clinical patterns, lab values, treatment protocols, and healing trajectories described reflect well-documented presentations in the literature and are intended for educational purposes.

Presenting Complaint

Minh, a 9-year-old Vietnamese-American boy, was brought to the integrative practice by his mother, Tram, after three months of escalating symptoms: daily stomach aches (cramping, periumbilical pain rated 5-7/10, worse in the morning before school), nausea (no vomiting), difficulty sleeping (could not fall asleep without his mother in the room, frequent nightmares about “something bad happening”), crying spells at school, refusal to attend school (initially occasional — “my stomach hurts, I can’t go” — escalating to complete refusal for the past two weeks), and a recent episode of what appeared to be a panic attack (racing heart, hyperventilation, shaking, screaming “I can’t breathe”) during a math test.

Minh had been evaluated by his pediatrician, who ordered: CBC (normal), CMP (normal), urinalysis (normal), stool culture (negative), abdominal X-ray (mild constipation, no obstruction), and celiac panel (tTG-IgA negative). Diagnosis: functional abdominal pain. The pediatrician prescribed famotidine 10mg twice daily for the stomach pain (no improvement) and referred to a pediatric GI specialist (6-week wait). The school counselor had recommended an evaluation for anxiety, which led the family to this practice.

Tram presented as tightly wound, speaking rapidly, answering questions directed at Minh before he could respond. She described Minh as “a sensitive boy” who had “always been a worrier” but said the current symptoms were “much worse than normal.” She wanted a diagnosis, a treatment plan, and — she said this with the urgency of someone holding the world together — “for someone to fix him so he can go back to school.”

Minh sat quietly, picking at the hem of his shirt. When asked how he was feeling, he looked at his mother before answering: “My stomach hurts.” When asked what he was worried about, he said: “Everything.” When asked what “everything” meant, he looked at his mother again and said: “I just worry.”

History

Medical History — Minh

Full-term birth, vaginal delivery, uncomplicated. Breastfed for 4 months, then formula (mother returned to work). Normal developmental milestones. Three ear infections in first year of life (treated with antibiotics). Eczema from age 2-5 (resolved with topical steroids). History of “sensitive stomach” since toddlerhood — episodes of stomach aches correlated with transitions (starting preschool, starting kindergarten, starting new activities). No history of constipation until the past 3 months. No surgeries. No chronic medications. Vaccinations up to date.

The eczema-to-anxiety trajectory is noteworthy: the “atopic march” (eczema in infancy followed by allergic rhinitis, asthma, or anxiety in childhood) reflects immune-nervous system co-regulation. Children with early atopic disease have altered immune and HPA axis responses that predispose to anxiety (Slattery et al., 2016).

Family History — The Family System

Mother (Tram, 38): Tram was the engine of the family and the engine was overheating. She worked full-time as a dental hygienist, managed the household, coordinated Minh’s activities (piano, tutoring, Vietnamese language class), maintained the family’s social calendar, and served as the primary emotional caretaker for Minh, her aging parents, and her largely absent husband. She described herself as “fine” but presented with visible signs of anxiety: rapid speech, restless hands, difficulty sitting still, and a hypervigilance toward Minh (scanning his face constantly, anticipating his needs before he expressed them, reaching for him at the slightest sign of distress).

When asked directly about her own anxiety, Tram deflected: “This appointment is about Minh.” When asked again, more gently: “I’ve always been a worrier. My mother was a worrier. It’s just how we are.” She reported: chronic insomnia (2+ hours to fall asleep, racing thoughts), tension headaches 3-4 times weekly, IBS-type symptoms (alternating diarrhea and constipation, worse with stress), and a persistent sense that “something terrible is about to happen” that she managed through control, planning, and hypervigilance.

She had never been diagnosed with anxiety. She had never been in therapy. She managed her symptoms through over-functioning: if she controlled everything, nothing bad could happen. The cost of this strategy was borne by her body and by her son.

Father (Duc, 41): Duc was physically present and emotionally absent. He worked as a warehouse manager, leaving at 6 AM and returning at 7 PM. After dinner, he retreated to his phone or television. He attended Minh’s school events intermittently and parent-teacher conferences rarely. He was not hostile or abusive — he was simply not there.

When contacted (by phone — he did not attend the initial appointment), Duc described Minh’s symptoms as “his mother’s influence — she makes him nervous.” He said: “Boys shouldn’t be anxious. I never had these problems.” He declined the invitation to participate in family therapy: “I don’t need therapy. My son needs to toughen up.”

Duc’s emotional absence was not laziness or indifference — it was his own avoidant attachment pattern, installed in a childhood where his father (a refugee with undiagnosed PTSD) was alternately rageful and withdrawn, and his mother coped by making herself invisible. Duc learned that the safest position in a family was the periphery. He reproduced this pattern in his own family, leaving Tram to manage everything and Minh to feel the absence as abandonment.

Maternal Grandmother (Ba Ngoai, 68): Tram’s mother, Ba Ngoai, lived 10 minutes away and was deeply involved in Minh’s life — picking him up from school, feeding him after-school snacks, and, crucially, transmitting her own anxiety to him through a thousand small interactions. Ba Ngoai checked that doors were locked multiple times, warned Minh constantly about dangers (“Be careful!” “Don’t climb that!” “You’ll get hurt!”), and told stories of Vietnam that were tinged with terror — not intentionally, but because her own narrative of the world was organized around the theme of catastrophe.

Ba Ngoai had never been diagnosed with any mental health condition, but her history told the story: she fled Vietnam in 1979 on a boat with 47 people. Fourteen died during the crossing — of dehydration, exposure, and pirate attacks. She spent 11 months in a refugee camp in Malaysia. She arrived in America at 21 with nothing, speaking no English, carrying the bodies of the dead in her nervous system. She never spoke about the boat. She never received any form of mental health support. She raised two children in a country she did not understand while her husband (Tram’s father) worked 16-hour days and drank.

Ba Ngoai’s PTSD was untreated, undiagnosed, and — through the mechanism of intergenerational trauma transmission — active in Minh’s nervous system.

Maternal Grandfather (Ong Ngoai, 72): Retired, living with Ba Ngoai. Also on the boat in 1979. Also never discussed it. Spent his working life as a janitor, his evenings drinking beer, and his retirement watching Vietnamese television. Diabetic, hypertensive, peripheral neuropathy. Present in Minh’s life as a quiet, benign, emotionally unreachable figure.

Minh attended third grade at a public elementary school. His academic performance had been above average until the past semester, when it declined sharply (his teacher noted difficulty concentrating, incomplete assignments, and “seeming far away”). He had a few friends but had become increasingly withdrawn, declining playdates. He enjoyed drawing — his drawings were detailed, imaginative, and often featured houses being destroyed by storms or fires, which his art teacher had flagged as concerning.

He was overscheduled: school from 8-3, Vietnamese language class on Tuesdays, piano on Wednesdays, math tutoring on Thursdays (“he needs to stay ahead”), and Saturday morning Vietnamese school. Sunday was the only unstructured day, and it was typically spent at Ba Ngoai’s house.

He ate a mixed diet: Vietnamese food at home and at Ba Ngoai’s, school lunch (typically chicken nuggets, pizza, or a sandwich), and snacks (goldfish crackers, fruit gummies, juice boxes). He drank no water voluntarily — only juice and milk.

Emotional History — Minh

Minh was what family systems theory calls “the identified patient” — the member of the family who manifests the system’s distress through symptoms. He was not the source of the problem; he was the barometer. His anxiety was not merely his own — it was the family’s anxiety, concentrated and expressed through the most sensitive and least defended member of the system.

In Bowen family systems theory (Bowen, 1978), Minh was experiencing “triangulation” — he was recruited into the emotional space between his anxious mother and his emotionally absent father. Tram’s anxiety, unprocessed and uncontained, flooded into Minh through their enmeshed attachment: she monitored his emotional states, anticipated his needs, could not tolerate his distress, and communicated — through a thousand nonverbal signals — that the world was dangerous and he needed her to survive. Minh, in turn, could not separate his emotional experience from his mother’s: her anxiety was his anxiety; her need for him to be okay was his need to perform being okay (until he could no longer perform it).

Duc’s absence created the vacuum into which Tram’s anxiety expanded. In a healthy family system, the parental dyad contains and processes anxiety before it reaches the children. When one parent withdraws, the remaining parent — overwhelmed and unsupported — turns to the child for emotional regulation, creating an enmeshment that parentifies the child and burdens them with emotional responsibilities beyond their developmental capacity.

Ba Ngoai’s refugee trauma completed the picture: the unprocessed terror of the boat crossing, transmitted through decades of hypervigilance, danger warnings, and a worldview organized around catastrophe, had become the family’s emotional inheritance. Research on intergenerational trauma transmission demonstrates that traumatized parents alter their children’s (and grandchildren’s) stress response systems through both behavioral mechanisms (parenting style, emotional communication) and epigenetic mechanisms (stress-related gene methylation patterns transmitted transgenerationally; Yehuda et al., 2014).

Minh’s stomach aches were his body’s language for an emotional experience he could not articulate: “I am carrying something that is too heavy for me.”

Assessment Through Four Directions

Serpent / Ran (South) — Physical Body

Minh’s physical symptoms were real — not “imaginary” or “just anxiety.” The gut-brain axis in children operates with the same bidirectional mechanisms as in adults, but with less cortical regulation (the prefrontal cortex, which modulates stress responses, does not fully mature until the mid-twenties). Chronic anxiety activates the sympathetic nervous system, which: increases gut motility and secretion (producing cramping, urgency, and diarrhea), reduces blood flow to the GI tract (producing nausea and pain), increases intestinal permeability, and alters the gut microbiome composition (Moloney et al., 2016).

The constipation noted on X-ray and the abdominal pain were likely components of functional abdominal pain disorder (FAPD) — the pediatric equivalent of IBS, affecting 10-15% of school-age children and strongly correlated with anxiety (Korterink et al., 2015). The mechanism is visceral hypersensitivity: the gut’s sensory neurons become hyperactivated, reporting normal digestive processes as painful. This is not “making it up” — it is a measurable alteration in visceral afferent nerve sensitivity driven by central sensitization.

Minh’s early antibiotic exposure (three courses in the first year) and formula feeding (abbreviated breastfeeding) were risk factors for gut microbiome disruption and subsequent immune-nervous system dysregulation. The early eczema confirmed atopic immune activation.

His diet was also contributory: high in processed foods, refined carbohydrates, and sugar (juice boxes, gummies, school lunch), low in fermented foods, fiber, and omega-3 fatty acids. The absence of dietary water and reliance on sugary beverages contributed to constipation and gut dysfunction.

Jaguar / Bao (West) — Emotional Body

Minh’s emotional body was carrying the weight of three generations. His own anxiety was the surface layer; beneath it lay:

His mother’s uncontained anxiety, flooding into him through enmeshment
His father’s emotional absence, experienced as abandonment and creating a core insecurity
His grandmother’s refugee trauma, transmitted through hypervigilant parenting and a catastrophic worldview

In an attachment framework, Minh’s attachment style was anxious-ambivalent: he desperately needed his mother’s presence to feel safe (could not sleep without her, could not attend school without her), but her presence did not actually calm him because her own anxiety was contagious. He was caught in a double bind: needing closeness that was itself destabilizing.

The school refusal was not defiance — it was the nervous system’s refusal to separate from the attachment figure in a world experienced as dangerous. Separation anxiety in children is often mislabeled as a child’s problem when it is actually a relational problem: the child cannot separate because the attachment system does not provide a secure enough base from which to explore.

Hummingbird / Chim Ruoi (North) — Soul

At 9 years old, Minh’s soul-level work was less about meaning-making (a developmentally later capacity) and more about narrative: what story was he being given about who he was and what the world was like? The family’s implicit narrative was: “The world is dangerous. You must be vigilant. You must perform to be safe. You must not have needs that burden others.” This narrative was the refugee story — appropriate for a boat crossing in 1979, catastrophic for a 9-year-old in suburban California in 2026.

Minh’s drawings — houses destroyed by storms — were his soul’s expression of the narrative he had absorbed: the world destroys. Safety is an illusion. Home can be taken away.

The Hummingbird work would not be with Minh alone; it would be with the family’s story.

Eagle / Dai Bang (East) — Spirit

For a child of Minh’s age, the Eagle dimension manifests as the capacity for wonder, play, imagination, and the unselfconscious presence that children naturally embody before anxiety constricts it. Minh’s capacity for this state had been diminished by the anxiety: he could not play freely (he was too busy scanning for danger), he could not be spontaneous (he was too busy monitoring his mother’s emotional state), and he could not be present (he was too occupied with the future, specifically with what might go wrong).

The Eagle work for Minh would be the restoration of his natural capacity for presence and play — which is, for a child, the equivalent of contemplative practice.

Testing & Diagnosis

Functional Medicine Laboratory Workup — Minh

Comprehensive Stool Analysis (pediatric panel):

Elevated calprotectin: 58 mcg/g (pediatric normal <50) — mild intestinal inflammation
Elevated zonulin: 86 ng/mL (optimal <60) — intestinal permeability
Low Lactobacillus species
Low Bifidobacterium species (consistent with formula feeding and early antibiotic exposure)
Mildly elevated Candida albicans
Low short-chain fatty acid markers
Low Secretory IgA: 340 mcg/mL (optimal 510-2,040) — mucosal immune suppression
No parasites, no pathogenic bacteria

Blood Work (pediatric-appropriate limited panel):

Ferritin: 16 ng/mL (low — borderline iron depletion; common in picky eaters and associated with anxiety in children)
Vitamin D, 25-OH: 24 ng/mL (insufficient; optimal 40-60 for children)
RBC Magnesium: 3.8 mg/dL (low — magnesium deficiency contributes to anxiety, sleep difficulty, and muscle tension in children)
hs-CRP: 0.8 mg/L (mildly elevated for a child — should be <0.5)
IgE total: 142 IU/mL (mildly elevated — atopic tendency confirmed)
Thyroid: normal
Celiac: confirmed negative on repeat tTG-IgA and DGP

Organic Acids Test (OAT):

Elevated HPHPA (marker of Clostridia species overgrowth — associated with anxiety and behavioral symptoms in children; Shaw, 2010)
Low 5-HIAA (low serotonin metabolite — associated with anxiety, sleep difficulty, and gut dysfunction)
Elevated oxalic acid (associated with yeast overgrowth)

Psychological Assessment — Minh

SCARED (Screen for Child Anxiety Related Disorders): Score 32 (clinical cutoff: 25) — positive for significant anxiety
Subscale scores: Separation Anxiety: 10 (clinical), Generalized Anxiety: 9 (clinical), School Avoidance: 8 (clinical), Panic/Somatic: 5 (subclinical)
CDI-2 (Children’s Depression Inventory): Score 14 (mildly elevated but below clinical threshold for depression)
Drawings analysis: themes of destruction, natural disaster, and loss of shelter (consistent with insecurity, threat perception, and intergenerational trauma narratives)

Family System Assessment

Genogram: three-generation pattern of anxiety (maternal line), emotional avoidance (paternal line), and unprocessed refugee trauma (both lines)
Family Adaptability and Cohesion Scale (FACES-IV): enmeshed mother-child dyad, disengaged father, over-involved grandparents
Tram’s self-reported GAD-7: 16 (moderate-severe anxiety — she had not been previously assessed)
Tram’s PCL-5 (PTSD checklist, adapted for secondary/intergenerational trauma): subclinical but elevated on hyperarousal and avoidance subscales

TCM Assessment — Minh

Tongue: pale, slightly swollen, thin white coat Pulse: thin, slightly rapid Pattern: Spleen Qi Deficiency with Liver Qi Stagnation, Heart Blood Deficiency

Spleen Qi Deficiency: the stomach aches, poor appetite, fatigue, worry (in TCM, the Spleen is damaged by overthinking and worry — a bidirectional relationship)
Liver Qi Stagnation: the emotional tension, the pain that worsens with stress
Heart Blood Deficiency: the insomnia, nightmares, anxiety (the Heart houses the Shen/spirit; when Heart Blood is deficient, the Shen is unrooted, producing anxiety, difficulty sleeping, and bad dreams)

Somatic Assessment — Minh

Tense posture for a 9-year-old: shoulders elevated, shallow breathing, habitual jaw clenching (reported by mother — grinds teeth at night). Tender abdomen on palpation, especially periumbilical region. Startled when the practitioner’s phone buzzed in another room. When asked to draw how his stomach felt, he drew a knot with spikes coming out of it.

Treatment Plan

Critical Framework: This was not a case of treating a child. This was a case of treating a family system in which the child was the symptom-bearer. The treatment plan operated at three levels: Minh (the identified patient), Tram (the primary relational influence and co-regulatory partner), and the family system (including Duc and Ba Ngoai to the extent they were willing to participate).

Phase 1: Calm the Child’s Body, Engage the Mother (Months 1-3) — Serpent Work

Minh — Gut and Nervous System Stabilization:

Probiotic: pediatric multi-strain Lactobacillus/Bifidobacterium, 25 billion CFU daily (addressing depleted commensal bacteria; probiotics have demonstrated anxiolytic effects in children through the gut-brain axis; Slykerman et al., 2017)
Saccharomyces boulardii 250mg daily (addressing mild Candida)
L-glutamine 2.5g daily in smoothie (gut lining repair)
Zinc picolinate 10mg daily (gut repair, immune modulation)
Magnesium glycinate 200mg at bedtime (calming, sleep support, muscle relaxation — addresses teeth grinding)
Iron bisglycinate 18mg daily with vitamin C (addressing low ferritin)
Vitamin D3 2,000 IU daily (raising deficient levels)
Omega-3 (EPA/DHA) 1,000mg total daily in flavored liquid form (anti-inflammatory, supports brain development, anxiolytic; omega-3 supplementation improves anxiety in children; Kiecolt-Glaser et al., 2011)
L-theanine 100mg twice daily (promotes calming alpha-wave activity without sedation; safe in children)

Dietary Changes (implemented by Tram and Ba Ngoai together):

Eliminate juice boxes and fruit gummies — replace with whole fruit and water (with lemon or cucumber to increase palatability)
Introduce fermented foods: small amounts of yogurt (if tolerated), dua chua (pickled vegetables), miso soup
Increase fiber: vegetables at every meal, brown rice mixed with white, beans
Reduce processed school lunches: pack lunch from home 3-4 days per week (Vietnamese-style: rice, protein, vegetables, fruit)
Bone broth: 1/2 cup daily (gut healing, collagen, glycine for calming)
No food restriction beyond the above — this is a child; the goal is addition and improvement, not elimination and deprivation

Sleep Protocol:

Consistent bedtime at 8:30 PM with a 30-minute wind-down routine: warm bath, reading together, dimmed lights
Magnesium at bedtime (as above)
Lavender essential oil in diffuser (mild anxiolytic effect in children; evidence supports aromatic use for sleep; Fismer & Pilkington, 2012)
Transitional object: Minh chose a stuffed dragon that would “protect him while he sleeps” — this is not trivial; it is a developmentally appropriate externalization of safety that allows gradual separation from the mother’s physical presence
Gradual separation protocol: Tram sits in Minh’s room until he falls asleep (current pattern) -> sits in the doorway (week 2) -> sits in the hallway with door open (week 4) -> checks in after 5 minutes (week 6) -> Minh falls asleep independently with dragon (target by month 3). Each step held for 1-2 weeks, moved forward only when Minh demonstrates readiness.

Tram — Parallel Track (essential):

Tram was told directly: “Your son’s nervous system is connected to your nervous system. We cannot calm his without addressing yours.” This was said with compassion, not blame.
Referred to individual therapy with a Vietnamese-speaking therapist specializing in anxiety (Tram reluctantly agreed when framed as “learning tools to help Minh” rather than “treatment for your anxiety”)
Magnesium glycinate 400mg at bedtime (her own anxiety, insomnia, and IBS would benefit)
L-theanine 200mg twice daily
Daily walking 20-30 minutes (Tram had no exercise practice; walking would serve as her nervous system regulation and provide time away from hypervigilant mothering)

Phase 2: Treat the Family, Not Just the Child (Months 2-5) — Jaguar Work

Play Therapy for Minh — Weekly Sessions:

Play therapy is the age-appropriate modality for emotional processing in children. Minh could not articulate his emotional experience verbally, but he could express it through play, drawing, and sand tray work.
Sessions 1-4: Building safety and rapport. The play therapist provided a structured, predictable, unconditionally accepting environment — something Minh’s hypervigilant nervous system needed before it could relax enough to express.
Sessions 5-8: Minh began using the sand tray to create scenes. Recurring theme: a small figure (him) standing between two large figures (parents), with a storm approaching. One large figure reached toward the small one (mother — enmeshment); the other faced away (father — absence). The therapist reflected: “The little one is standing between them. That looks like a hard place to be.” Minh nodded: “He has to make sure everyone is okay.”
Sessions 9-12: The play shifted. The small figure began building a house with walls. The therapist: “He’s making a space that’s his.” Minh: “Where nobody can be sad at him.” This was the beginning of differentiation — the development of a sense of self separate from the family’s emotional weather.

Tram’s Individual Therapy:

Tram’s therapist identified: GAD (generalized anxiety disorder) with features of intergenerational trauma transmission. Tram’s anxiety was not primarily about Minh — it was about survival in a world that her own mother’s experience had taught her was catastrophically dangerous.
Key therapeutic insight (month 3): “I am not anxious about Minh. I am anxious because my mother was anxious because she almost died on a boat. And I have been giving Minh my mother’s anxiety as though it were his.”
Tram began learning to regulate her own nervous system before attempting to regulate Minh’s. Co-regulation (the process by which a calm caregiver calms a distressed child) only works when the caregiver is actually calm — not performing calm while internally flooding.
Tram’s IBS symptoms began improving within 6 weeks of her own magnesium supplementation, dietary changes, and therapy — confirming the gut-brain pattern shared between mother and son.

Family Therapy — Beginning Month 3:

Duc was re-invited to participate. He declined twice, then agreed after Tram told him (in therapy, coached by her therapist): “I need you here. Not for me. For Minh. He needs to know his father exists.”
Family sessions (biweekly) focused on:
1. Psychoeducation: Teaching the family that Minh’s anxiety was a family system pattern, not a child’s defect. The genogram exercise — mapping anxiety, trauma, and emotional patterns across three generations — was profound for the entire family. Duc, seeing the pattern laid out visually, said: “My father was the same. Angry or gone. I thought I was different because I’m not angry. But gone is gone.”
2. Father-son connection: Structured activities for Duc and Minh to do together without Tram’s mediation. Initial assignment: 30 minutes of one-on-one time, twice weekly, doing whatever Minh wanted. Minh chose drawing together and playing catch. The first session was awkward; by week 4, Minh was running to the door when Duc came home.
3. Couple work: Addressing the relational vacuum between Tram and Duc. The over-functioning/under-functioning pattern: Tram managed everything because Duc did nothing; Duc did nothing because Tram managed everything. Breaking this cycle required Tram to step back (terrifying for her Manager part) and Duc to step forward (unfamiliar for his avoidant part).
4. Reducing enmeshment: Teaching Tram to differentiate between Minh’s emotions and her own. Practice: when Minh was distressed, Tram would first check her own body (“Am I calm?”), then respond to Minh from a regulated state rather than from her own reactivity.

Ba Ngoai — The Grandmother Intervention:

Ba Ngoai was invited to a single family session (she declined therapy but agreed to “help with Minh’s health”). In the session, the therapist gently explored how her warnings to Minh (“Be careful! You’ll get hurt!”) might be affecting him. Ba Ngoai became defensive: “I just want to protect him.” The therapist: “Of course. You know better than anyone what the world can do. You survived something that most people cannot imagine. The question is whether Minh needs to carry that knowledge at nine years old.”
Ba Ngoai was quiet for a long time. Then she said, in Vietnamese: “I never wanted to give him my fear.” She began to cry — perhaps the first time she had cried about the boat crossing in decades.
This single session did not resolve Ba Ngoai’s trauma, but it created awareness. Over the following months, she began catching herself: “Oi, I’m doing it again — I’m scaring him.” She replaced some of her danger warnings with encouragements: “You can do it. Be brave.” This was not a complete transformation, but it was a shift.

Acupuncture for Minh (Pediatric Approach) — Biweekly:

Shonishin (non-insertive Japanese pediatric technique) — used for children who are needle-averse. Involves gentle stroking, tapping, and pressing with specialized tools along meridian pathways.
If tolerated, very thin needles (0.12mm) at key points: ST-36 (tonify Spleen Qi, reduce stomach aches), LV-3 (soothe Liver, reduce emotional tension), HT-7 (calm Shen, reduce anxiety), SP-6 (nourish Blood, improve sleep), Yin Tang (calm the mind)
Minh was initially wary but agreed to try shonishin. By session 3, he requested “the real needles” — they did not hurt as much as he expected, and he reported feeling “warm and sleepy” afterward. His mother reported that his stomach aches were consistently better for 2-3 days following acupuncture.

Phase 3: Rewriting the Family Story (Months 4-7) — Hummingbird Work

Narrative Work with Minh:

In play therapy, the therapist introduced bibliotherapy: reading stories together about brave children who faced fears. The key therapeutic story: a Vietnamese-American children’s book about a child whose grandmother survived a boat crossing and whose courage lives in the child as bravery, not as fear. (If no such book existed, the therapist would create a custom therapeutic story — a common narrative therapy technique with children.)
Minh began to draw new pictures: houses that were standing, with sunlight, with people inside. The storm was still present in some drawings but was now at a distance, not destroying the house. The therapist: “The storm is there, but the house is strong.” Minh: “Yeah. It’s got a really good foundation.”

Family Narrative Restructuring:

The family explored the refugee story together — not as trauma to be hidden or fear to be transmitted, but as resilience to be honored. The new narrative: “Our family survived the impossible. That survival is our strength, not our curse. We carry the courage of the boat, not just the fear.”
Tram told Minh, for the first time, a simplified version of Ba Ngoai’s story — not the terror, but the courage: “Your grandmother crossed the ocean to give us this life. She was so brave. And that bravery is in you too.”
Minh drew a new picture: a boat on a calm sea, with a grandmother figure at the helm and a child figure beside her. The therapist asked what the child was doing. Minh: “He’s not scared. He’s helping steer.”

Schedule Decompression:

A critical intervention: reducing Minh’s overscheduling. Vietnamese language class was kept (cultural connection), piano was kept (Minh genuinely enjoyed it), but math tutoring was eliminated (he did not need it — his grades were fine) and Saturday Vietnamese school was reduced to alternate weeks. The freed time was designated as “free play” — unstructured, child-directed, no agenda. This was harder for Tram than for Minh; she had to resist the urge to fill the time with “productive” activities.
Research supports this: overscheduling in childhood is associated with increased anxiety, reduced autonomy, and impaired self-regulation (Mahoney et al., 2006). Children need unstructured time to develop internal resources for managing boredom, generating creativity, and self-directing.

Phase 4: The Child Returns to Himself (Months 6-9) — Eagle Work

Return to Play:

As Minh’s anxiety reduced and his family system reorganized, his natural capacity for presence and play re-emerged. He began playing outside again, climbing trees (Ba Ngoai bit her tongue), riding his bike with neighborhood children, and engaging in imaginative play that was expansive rather than fearful.
He returned to school full-time at month 4 (see timeline) and by month 6 was attending without stomach aches on most days.

Mindfulness for Kids:

Minh was taught a simple body-scan practice adapted for children: lying down, the therapist guided him through “checking in” with each body part, describing what he felt without judging it. The practice was playful, not solemn — “What color is the feeling in your belly? Is it making a sound?”
He was taught “belly breathing” with a stuffed animal on his abdomen — watching it rise and fall. He practiced this at bedtime and before tests (the two highest-anxiety contexts).
The “worry box”: Minh was given a small wooden box. At bedtime, he wrote or drew his worries on slips of paper and placed them in the box, closing the lid. “The box holds the worries tonight. You don’t have to.” This externalization technique is evidence-based for pediatric anxiety (Heyne & Rollings, 2002) and serves as a developmentally appropriate form of containment — the Eagle work of holding experience without being consumed by it.

Timeline & Progress

Month 1

Began supplements: probiotic, magnesium, iron, vitamin D, omega-3, L-theanine
Dietary changes initiated (Tram and Ba Ngoai on board)
Sleep routine established; dragon acquired
Tram started magnesium, L-theanine, and walking
Minh still not attending school (homebound tutoring arranged by school district)
Stomach aches: daily, 5-6/10
Sleep: still needing Tram in room; falling asleep in 45 minutes (down from 90)
Nightmares: 3-4 per week

Month 2

Tram began individual therapy
Minh began play therapy
Tram sitting in doorway at bedtime (separation protocol progressing)
Stomach aches: daily but intensity reducing (4-5/10)
Sleep: falling asleep in 30 minutes, nightmares 2 per week
School: attempted one half-day — tolerated with stomach ache but did not panic
Minh’s sand tray: the small figure between two large figures
Began acupuncture (shonishin)
Tram’s therapy insight: “I am giving Minh my mother’s anxiety”

Month 3

Family therapy began (Duc attending)
Ba Ngoai session: “I never wanted to give him my fear”
Minh transitioning to Tram in hallway at bedtime
Stomach aches: 3-4 days per week (down from daily), intensity 3-4/10
Sleep: falling asleep in 15-20 minutes, nightmares 1 per week
School: attending half-days, 3 days per week
Father-son time initiated: Duc and Minh drawing together twice weekly
Repeat stool test: calprotectin 38 mcg/g (normalizing), zonulin 62 ng/mL (improving), Lactobacillus species increasing
Minh requesting “real needles” at acupuncture

Month 4

School return: Minh attending full days, 4 days per week, with one “rest day” at home per week (agreed with school as transitional plan)
Stomach aches: 2-3 days per week, intensity 2-3/10
Sleep: falling asleep independently with dragon, checking in with Tram not needed most nights
Nightmares: rare (1-2 per month)
Father-son relationship visibly warming: Minh runs to door when Duc arrives
Math tutoring eliminated, schedule decompressed
Tram’s GAD-7 recheck: 10 (moderate — down from 16)
Tram’s IBS symptoms: significantly improved
Family therapy: couple work beginning — Tram and Duc having their first real conversations about their marriage in years

Month 5

Minh attending school full-time, 5 days per week
Stomach aches: 1-2 per week, typically mild (1-2/10), self-resolving
One panic episode this month (during a fire drill — the alarm triggered it) — recovered with belly breathing in 5 minutes. Teacher reported he “handled it really well.”
Play therapy sand tray: the small figure now has its own space with walls. The storm is distant.
Acupuncture reduced to monthly
Blood work recheck: ferritin 28 ng/mL (rising), vitamin D 38 ng/mL (rising), hs-CRP 0.4 mg/L (normal)
SCARED recheck: Score 18 (below clinical threshold — down from 32)

Month 6

Bibliotherapy and narrative work with the refugee story
Minh drew the boat picture with grandmother steering
Riding his bike with friends, climbing trees, playing outside spontaneously
Stomach aches: rare — 1-2 per month, correlating with specific stressors (tests, conflicts with friends — normal childhood stressors)
Sleep: excellent — 9-10 hours nightly, no nightmares
Academic performance: recovered to above-average
Ba Ngoai: catching herself, replacing fear-messages with encouragement
Duc: now attending Minh’s school events. Initiated a weekend fishing trip (just the two of them). Minh described it as “the best day ever.”

Month 7

Play therapy shifting to maintenance: biweekly instead of weekly
Introduced body-scan mindfulness and the worry box
Family therapy reduced to monthly
Tram’s therapy: continuing individually, working on her own anxiety and differentiation from her mother’s trauma
Tram’s GAD-7: 7 (mild anxiety — normal range)
Family system assessment: enmeshment reduced, father engagement increased, grandparental over-involvement moderated

Month 8-9

Minh: thriving. Stomach aches essentially resolved (occasional, mild, self-limited). Sleeping independently. Attending school without difficulty. Playing freely. Drawing houses with sunlight.
Supplement tapering: discontinued L-theanine, reduced probiotic to maintenance dose, continued omega-3 1,000mg, vitamin D 1,000 IU, magnesium 100mg
Play therapy concluded at month 9 with a “graduation” session in which Minh built a sand tray scene of a village with many houses, people helping each other, and — at the center — a child playing. The therapist asked what the child was doing. Minh said: “Just playing. He doesn’t have to worry about anything right now.”
Tram, watching through the observation window, cried.

Key Turning Points

Turning Point 1: Treating the Mother Alongside the Child (Month 1-2)

The decision to address Tram’s anxiety in parallel with Minh’s symptoms was the strategic foundation of the entire case. If only Minh had been treated, his nervous system would have continued to be flooded by his mother’s dysregulation through their enmeshed attachment. The child’s nervous system cannot be calmed independently of the primary caregiver’s nervous system — they are, in the early years, a single regulatory unit. Tram’s insight — “I am giving Minh my mother’s anxiety” — was the moment the treatment shifted from “fixing the child” to healing the system.

Turning Point 2: Father’s Engagement (Month 3-4)

Duc’s reluctant entry into family therapy and his subsequent engagement with Minh were transformative. The father-son relationship had been a void; filling it gave Minh a second attachment figure, reduced the enmeshment pressure between Minh and Tram, and provided Minh with an experience of male presence that was neither rageful (like Duc’s father) nor absent (like Duc had been). When Minh ran to the door to greet his father, the family system reorganized around a new possibility: two available parents, a child who could relax.

Turning Point 3: Ba Ngoai’s Tears (Month 3)

The single family session with Ba Ngoai — “I never wanted to give him my fear” — was a moment of intergenerational reckoning. Ba Ngoai’s tears acknowledged, for the first time, that her refugee trauma had not stayed contained within her generation. This acknowledgment did not heal the trauma, but it broke the unconscious transmission. When Ba Ngoai began catching herself (“I’m doing it again”), the oldest layer of the family’s anxiety pattern was disrupted.

Turning Point 4: The Boat Drawing (Month 6)

Minh’s drawing of the boat — with grandmother steering and the child helping, not scared — represented the transformation of the family’s refugee narrative from a story of terror to a story of courage. This was the Hummingbird’s work: the same historical facts (the boat crossing, the danger, the survival) reframed from a narrative that produced anxiety to a narrative that produced resilience. The story did not change; the meaning did.

Turning Point 5: The Worry Box and Independent Sleep (Months 4-7)

The gradual achievement of independent sleep and the worry box ritual represented Minh’s developing capacity to contain his own emotional experience — to hold his worries without needing his mother’s physical presence to hold them for him. This is the developmental achievement that anxiety disrupts: the internalization of a secure base. The worry box externalized the process until Minh’s internal resources were sufficient.

Where Single-Direction Treatment Failed

If only the Serpent had been addressed: Gut healing, probiotics, magnesium, and dietary changes would have reduced the stomach aches by 30-50% — a meaningful improvement, but insufficient. The gut-brain axis would have continued to be activated by the family system’s emotional dynamics: Tram’s contagious anxiety, Duc’s absence, Ba Ngoai’s hypervigilance. The stomach aches would have waxed and waned with the family’s stress, never fully resolving.

If only the Jaguar had been addressed (Minh alone): Individual play therapy for Minh, without treating the family system, would have given him tools to manage his anxiety within the therapy room — but then returned him to the same system that was producing the anxiety. This is the fundamental limitation of child-focused treatment that ignores the family: the child is not the source of the problem; the child is the symptom of the system. Treating the symptom without treating the system produces temporary relief and chronic recurrence.

If only the Jaguar had been addressed (family therapy without physical treatment): Family therapy without gut healing, nutritional support, and nervous system calming would have produced relational insights while Minh’s body remained in GI distress and his brain remained depleted of magnesium, iron, vitamin D, and omega-3 fatty acids. A child cannot benefit from therapy when he is in pain and neurologically undernourished.

If only the Hummingbird had been addressed: Narrative reframing of the family’s refugee story without the relational repairs (father’s engagement, reduced enmeshment, grandmother’s awareness) would have been a story told over an unchanged reality. Narratives become transformative only when they are embodied in new relational patterns.

Lessons & Principles

The anxious child is the family’s barometer. In family systems theory, the identified patient is the member of the system who expresses the system’s distress through symptoms. Treating the child’s anxiety as an individual disorder — with medication, individual therapy, or behavioral interventions — misses the systemic driver. The question is not “Why is this child anxious?” but “What is this family’s anxiety, and why is the child carrying it?”
Intergenerational trauma is biologically transmitted. Ba Ngoai’s refugee trauma did not stay in 1979. It was transmitted to Tram through hypervigilant parenting and a catastrophic worldview, and from Tram to Minh through anxious attachment and nervous system co-dysregulation. The research on intergenerational trauma transmission — including epigenetic studies showing stress-related gene methylation patterns in the children and grandchildren of trauma survivors (Yehuda et al., 2014) — confirms that trauma is not merely a psychological inheritance but a biological one.
The father’s presence is medicine. In the Vietnamese-American family system, where fathers are often culturally expected to provide financially but not emotionally, the father’s emotional engagement is frequently the missing piece. Duc’s shift from peripheral to present changed the family geometry: Tram could step back from over-functioning, Minh could stop being the emotional partner, and the couple could begin relating as adults rather than as co-managers of anxiety. Research on father involvement demonstrates that engaged fathering is independently associated with reduced childhood anxiety, improved emotional regulation, and better academic outcomes (Lamb, 2010).
Overscheduling is anxiogenic. The cultural pressure in Vietnamese-American families to ensure academic success through structured activities can produce the opposite of its intention: a child so programmed that there is no space for the unstructured play, rest, and boredom that are essential for developing internal emotional resources. Free play is not a luxury; it is a developmental necessity.
The gut-brain axis operates in children as in adults. Minh’s stomach aches were not “fake” or “attention-seeking.” They were real visceral pain driven by sympathetic nervous system activation, altered gut microbiome, and visceral hypersensitivity. Treating the gut (probiotics, magnesium, dietary improvements, gut repair) while simultaneously treating the nervous system (therapy, family work, sleep hygiene) addressed both directions of the axis.
Cultural narratives can wound or heal — the content is the same, but the framing changes everything. The refugee story, when transmitted as “the world will destroy you,” produced a 9-year-old who could not go to school. The same story, reframed as “your grandmother crossed the ocean, and her courage is in you,” produced a child who drew pictures of boats on calm seas. The Hummingbird work in intergenerational trauma is not about erasing the past — it is about reauthoring the meaning of the past so that the next generation inherits strength rather than fear.

References

Bowen, M. (1978). Family Therapy in Clinical Practice. Jason Aronson.
Fismer, K. L., & Pilkington, K. (2012). Lavender and sleep: A systematic review of the evidence. European Journal of Integrative Medicine, 4(4), e436-e447.
Heyne, D., & Rollings, S. (2002). School Refusal. BPS Blackwell.
Kiecolt-Glaser, J. K., et al. (2011). Omega-3 supplementation lowers inflammation and anxiety in medical students: A randomized controlled trial. Brain, Behavior, and Immunity, 25(8), 1725-1734.
Korterink, J. J., et al. (2015). Epidemiology of pediatric functional abdominal pain disorders: A meta-analysis. PLoS ONE, 10(5), e0126982.
Lamb, M. E. (Ed.). (2010). The Role of the Father in Child Development (5th ed.). John Wiley & Sons.
Mahoney, J. L., et al. (2006). Organized activity participation, positive youth development, and the over-scheduling hypothesis. Society for Research in Child Development Social Policy Report, 20(4), 1-31.
Moloney, R. D., et al. (2016). The microbiome: Stress, health and disease. Mammalian Genome, 25(1-2), 49-74.
Porges, S. W. (2011). The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation. W. W. Norton & Company.
Shaw, W. (2010). Increased urinary excretion of a 3-(3-hydroxyphenyl)-3-hydroxypropionic acid (HPHPA), an abnormal phenylalanine metabolite of Clostridia spp., in urine samples from patients with autism and schizophrenia. Nutritional Neuroscience, 13(3), 135-143.
Slattery, M. J., et al. (2016). The role of the HPA axis in children with eczema and anxiety. Psychoneuroendocrinology, 64, 148-155.
Slykerman, R. F., et al. (2017). Effect of Lactobacillus rhamnosus HN001 in pregnancy on postpartum symptoms of depression and anxiety: A randomised double-blind placebo-controlled trial. EBioMedicine, 24, 159-165.
Yehuda, R., et al. (2014). Influences of maternal and paternal PTSD on epigenetic regulation of the glucocorticoid receptor gene in Holocaust survivor offspring. American Journal of Psychiatry, 171(8), 872-880.