Q-and-A: Pediatrician screens parents, kids for ACEs because her ACE score is 9

Dr. Tina Marie Hahn is a pediatrician in Alpena, Michigan. She agreed to answer these more personal questions as part of an

Dr. Tina Marie Hahn

interview about how she and other pediatricians are screening children — and parents — for adverse childhood experiences.

Q. What personal or professional moment or event in your life inspired you to work on adverse childhood experiences (ACEs)?

A. When I was four-and-a-half years old, I saw my father murder my grandmother.

My father was quite a demanding man — he felt as if everyone owed him. But he was also lazy. He didn’t work my entire childhood. He supported himself from state welfare checks intended to provide for his three children. My father wanted Grandma Hahn to give him money for cigarettes, but she refused. She told him he needed to go work at the hardware store and do something productive before she would give him more money. He became VERY angry and he pushed her down her basement steps.

After pushing her, he screamed angrily: “I don’t care if she dies. When she dies, I’m going to piss on her grave.” It terrified me. It seemed as if Satan possessed him. Even though I was frightened, I stayed at grandma’s side for a day and a half, trying to give her water from a bathroom Dixie cup because she kept saying that she was thirsty. My screaming father and my mother, ignoring the whole thing, left Grandma trapped at the bottom of those steps for almost two days until her cries ceased.

Diane, my mother, did nothing, not because she was afraid of my father, but because she followed him around like a puppy at the expense of her children. Leo was someone who mattered to her, but her children did not.

A few days after Grandma died, I heard the word “funeral”. No one spoke to me about what was happening, but they didn’t have to. I knew the truth: My grandmother was gone. I would never again see the woman whom I considered to be my mother. I would be left with two sick and crazy individuals. I was heartbroken but I didn’t shed a tear. I already had experienced parental anger and neglect — but not nearly to the extent I would learn was possible. At two years of age, my stomach had been pumped. I had gotten into baby aspirin during one of the frequent occasions when the three of us were left alone and unfed. My grandmother found me and took me to the hospital. At the age of four-and-a-half, I’d already learned from Diane and Leo how not to cry.

Leo and Diane had three children, all a year a month and a day apart: Tina, Renee, and Steven. What Leo and Diane did transformed my parents into the monsters of my days and the dread of my nights, chasing me with knives into my dreams. Sometimes they still visit me today. It was a significant tragedy for us that Grandma had been killed. Now there was no one to protect us. Grandma had bathed us, fed us, and clothed us. She had told us we were pretty; we were special; she loved us. That was all gone now. Without her, Leo had full access to us all for all the sadistic things he did to us, things which I believe would be difficult for strangers to hear, but would be even harder for me to speak of. I still hear his frequent, angry words: “You were only born because I was young, dumb and full of cum,” and I feel ashamed. I still see him beat and humiliate my brother as I was forced to watch. Inside, I still cry. This never ended until I was 17 and was made an emancipated minor and my 16-year-old sister was put in foster care.

My sister tells me we are casualties of war. I say we were casualties of a special war, the ACEs war, a war that still takes its toll today. It takes its toll on a brother who is in a psychiatric unit for bizarre somatic complaints and delusional thinking most of the time, and who has no comprehension of how his childhood abuse caused these symptoms. He now has type II diabetes, hyperlipidemia, and metabolic syndrome from the antipsychotic medications promoted by pharmaceutical companies that can make no change to the delusional thinking caused by chronic, persistent, severe, early-onset unspeakable childhood emotional, physical, and sexual abuse of years’ duration. Since he is an adult ward of the court, I cannot get him off these useless and deadly medications.

Our ACEs war also produced a sister who is so disturbed by the memories that she cannot bear to speak to Steven or me for fear of a reawakening of her own nightmares. And, finally, it created a girl with a childhood strategy of “educational perfectionist”, a medical school graduate who rarely experiences joy (not even the day she got her medical school diploma from the University of Michigan – it was just another day), except during the times when she educates a parent about the potent negative effect of ACEs on child development and that parent gets it and shows a determination to make a change. Or when one of her three dogs licks her face.

The Hippocratic Oath says, “First do no harm.” By ignoring ACEs, and instead giving people/children vague diagnoses with no real meaning, and then prescribing harmful psychotropic drugs (often in multiple meaningless combinations), all participating physicians, in my opinion, are ignorant concerning and complicit in their patients’ harm.

Q.  When did you learn about the CDC’s ACE Study and how did that change your work?

A. I learned about the ACE Study as I was reading an article in the journal Pediatrics in 2004 called The Association between Adverse Childhood Experiences and Adolescent Pregnancy, Long Term Psychosocial Consequences, and Fetal Death. Due to my 17-year apprenticeship/residency/fellowship in the field, however, I always knew about ACEs. I went to the references page and found the original ACE Study and read it. Looking at the simple graphic associations between adversity in childhood and adult psychosocial and medical conditions, I became excited. Finally, something I had known all along was published in a very easy-to-understand manner. I thought, “Wow — now the field is going to move. Physicians will now be able to understand why preventing adversity in childhood is so important.”

I found, however, that this was still a very tough sell. It seemed impossible for me to get my colleagues to sign on and work to prevent ACEs. The original study was published in 1998. We still have a very long way to go.

In my practice, I use the ACE graphs to show parents the links between some of their parenting behaviors/relational associations and the behavioral problems they are seeking help with for their children. I explain to them how adversity can lead to a lifetime of psychiatric and medical problems along with tremendous human suffering, but that this outcome is not set in stone. By understanding adversity in childhood, parents have a choice to parent differently, in a way that they and their children can be happy and healthy.

I teach physicians why preventing ACEs is so important. I have every third year medical student I teach read the ACE Study. However, this work was often frustrating and still is. It is very difficult to get the psychiatric profession to understand the depth of this important issue. However, I have been making inroads in the Department of Psychiatry at the University of Michigan, and I will continue.

The ACE Study also helped me in my own life because, though I knew that adversity in childhood was the root cause of my own difficulties and social isolation in life, now the information was there, published for all to see. I can work with my own psychiatrists, who had never asked me about trauma, to really come to see how trauma in childhood has affected me. I feel empowered.

Q. What does resilience to early childhood adversity mean to you?

A. First of all, I believe it is important to realize that resilience is not an individual characteristic. I believe resilience is a community/environmental characteristic.  Resilience is attained and maintained through a community of caring adults that can provide at-risk children and their parents with safe, stable, and nurturing relationships. It is through attunement with a safe adult that children become resilient.

Children need stress to grow and become resilient, but the stress has to be tolerable and manageable. We can relate this to lifting weights. The first time out, no one would try to lift a 200-pound weight. Assuming you could lift it, you might tear a muscle, or worse yet, drop the weight on your chest and crush your thorax. That would be overwhelming stress. It would not lead to an improved ability to lift weights and it might even kill you. Instead, one would slowly progress the weight lifted during each workout session over time.

It is similar to walking. Children don’t just one day get up and run. They pull to stand, cruise along furniture, let go and fall on their bottoms, then take small wavering steps, which improve over time until they can run. Overwhelming stress with no adult to moderate that stress will cause anyone — child or parent — to lose his or her capacity for resilience. The individual will become sensitized to toxic stress and lose their capacity for resilience through a lack of stress tolerance.

Q.  How would you like to see trauma-informed practices shape your field?

A. Well, first, I would like professionals not to see people who come in for care as diseased. Symptoms such as anxiety or depression or migraine headaches resulting from adversity in childhood are the body’s normal way of protecting itself from a dangerous world. I do not see these children or parents as psychiatrically or physically impaired. I see them as normal people whose normal reaction is to employ behaviors and experience emotions that are adaptive to the situation they experienced that promote survival in a maladaptive environment.

For example, shortly after my grandmother died, I developed pediatric migraines. They were severe. I vomited everyday. I could not lift a book bag. I had to go to a dark place and sleep and I felt like my head was going to explode. These symptoms were very real. This is the only condition for which my mother ever took me to the doctor.

The doctor did not ask about trauma. The doctor did not seem to notice that I had mutism and was extremely shy. The doctor did not notice my extreme lack of eye contact. The doctor did not write on his differential diagnosis list that psychological/developmental trauma may be the cause of my symptoms. Instead he pulled out a medication — cyproheptadine. This is a common medication used years ago for pediatric migraines. By giving me a medication, the doctor could have convinced me that I had a disease. I did not buy into this, however.

I knew I had bad headaches, but I also knew they were because of the abuse I was suffering. Even as a little kid, I was pretty sharp. The medication did not help my headaches at all. What did help was becoming an emancipated minor. I still carried around all the baggage (shame, self-hate, self-loathing, a sense of being broken) from the adversity, but I didn’t have to worry about being murdered or seeing my brother murdered. This was quite the relief. But it came with a high cost. I then lost my brother and sister, who were my only family.

I would also like the field to learn about the polyvagal theory of Steven Porges. I believe his work is right-on. Trauma is experienced in the body. My brother is not schizophrenic. My brother is living as I did when I had my migraines. My brother is a body locked in severe and chronic trauma that he has no memory of. I believe it may be very difficult to reach him, but the pills never will. Bodywork may help.

I also think that we need to work “bottom-up”, i.e. brainstem to cortex, not cortex to brainstem. The problems of trauma are in the fight/flight/freeze/death-feign (dissociative) responses and the body’s conditioned predisposition to use these strategies after the experience of prolonged, inescapable trauma (fear/terror). Play, theater group, yoga, and/or meditation offer new approaches to treating trauma that do not rely on working a memory via the verbal route through top-down circuitry. Working verbally through the memory of a car accident experienced as an adult is much different then working verbally through sexual abuse that occurred over many years when you were a pre-verbal or even early verbal child. Even trauma-focused CBT relies on being able to talk about an event.

Chronic childhood adversity is not an “event”. It is a way of growing up that leads to maladaptive behavior as an adult that was essential for survival as a child. Working on automatic (autonomic) responses mediated through the midbrain and brainstem structures seems to me a better way to go. I also like Bruce Perry’s sequence of engagement: 1. Regulate 2. Relate 3. Reason. There is no one therapy that will work with every individual. Trauma therapy should be individualized to each person.

Q.  If you encounter or deal with trauma often in your work, what coping skills do you rely on to stay healthy and happy?

A. I exercise, try to eat right, attempt meditation (though I am not very good at it), go outside for walks with my dogs when the weather is appropriate, and soon, I am going to Hawaii. But I know to express my full capacity as a human, I must let go of my still present fear of people. A very difficult task.

I would also like to make one more statement that reflects what has been useful to me. I really like the dharma talks of Thich Nhat Hanh, a Mahayana Buddhist monk who describes his work as “Enlightened Buddhism”. He talks about many subjects that I think adults psychologically traumatized as children would find very useful to help let go of self-hatred and self-blame and anger and aggression. His dharma talks are certainly worth checking out.

Q. How do you hope to contribute and gain from ACEs Connection (ACEsTooHigh’s accompanying social network)?

A. I hope to contribute by offering resources for other clinicians to use to understand psychological trauma and to educate their parents. I hope to work with others on ways of making ACE screening a part of every medical practice, be it internal medicine, family practice, ob-gyn, neurology, psychology, psychiatry and pediatrics. I would like to see a version of ACE screening become a performance improvement or maintenance of certification project — I believe this would really get ACEs out into the medical field’s focus of awareness. Ultimately I would like the medical field to realize the importance of ACEs prevention (both from a societal cost perspective and a human suffering perspective), and wish the medical field would understand and take seriously how negative environmental experiences in the context of family contributes to a multitude of medical and psychiatric derangements in children.

MY DREAM: A time when asking about childhood trauma is no longer thought of as taboo and will be a normal part of any healthcare visit. A time when everyone understands that adversity in childhood can contribute to a lifetime of health problems and personal suffering. A time when everyone realizes that we are all vested in reducing the impact of adverse childhood experiences. When this dream is realized, I will be in heaven (though heaven is always available in the here and now). 

Written By Jane Ellen Stevens

Q-and-A: Pediatrician screens parents, kids for ACEs because her ACE score is 9 was originally published @ ACEs Too High » Jane Ellen Stevens and has been syndicated with permission.