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

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Dr. Tina Marie Hahn

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

28 responses

  1. Pingback: Q-and-A: Pediatrician screens parents, kids for trauma because her ACE score is 9 • SJS

  2. Pingback: To prevent childhood trauma, pediatricians screen children and their parents…and sometimes, just parents « ACEs Too High

  3. For 30 years, I have been working to break the cycle of child abuse and neglect. I, too, have incredibly high ACE scores. Please keep up the good work both in your private and professional lives. When you look through the trauma lens and name the experiences, it all begins to make sense. Please don’t give up. I can’t tell you how many times I’ve wanted someone to ask me what happened to me to make me the way I am and why I am willing to fight for a cause I obviously am passionate about.

  4. Thank you Dr. Hahn. As a recently retired trauma therapist I have to come to think that there is great power in the act of sharing that we too, (helping professionals that is), have experienced childhood trauma, suffer from it’s impacts, and are engaged in our own lifelong healing process. I deeply admire your openness in sharing your own experiences and your commitment to impact change through educating parents during those precious years in which there behavior can make a lifetime of difference in the lives of their children. I too feel that the incorporation of ACES by our helping/healing systems has been slow and fragmented. ACES challenges the Medical Model at its roots, as you suggest, meaning it challenges the foundations of our mental health, substance abuse and medical health systems which are content to hang the label of “disease” on constellations of symptoms, without regard for the origins of said symptoms. It is so much more societally acceptable to label a patient “diseased,” than to confront the reality of abuse and neglect that characterize so many young lives. The power of an intergenerational Patriarchal system of values, behaviors and laws, has unfortunately rendered all but invisible the fact of a social reality that sees women and children as “property” to be dealt with as we men please. When we in the helping professions advocate for reducing ACES we are challenging the powerful historic forces that have made ending domestic violence, rape and child abuse/neglect so difficult. In Western societies these forces are political, monied, religious and male dominated. Perhaps the only thing powerful enough to challenge the silence they demand is the truth of our stories, as you so beautifully demonstrated in your interview. Such sharing builds understanding, solidarity, trust, and as you point out “resilience,” as a community based reality we share in, rather than a individual possession. Thank you for sharing your voice and your story.

    • Thank you so much for your insightful and correct response. Growing up, I was property. I was told I was property often. I wanted to leave my state of slavery. It was difficult and addressing ACEs is also very difficult. However, this challenge — I will never give up or give in!!!!

  5. Pingback: Opening Our Disowned Box of Relationship Darkness | The Flowering Brain

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  7. Dear Tina, Thank you for your bravery in sharing your experience. I too, found that knowing my ACEs score, knowing how toxic stress impacts child and brain development, gave me the tools to fight a battle that I already knew I needed to fight, but did not know how to explain why or what I was fighting. And, like you, I have an ACEs score of 9. Even though I still struggle with anxiety and depression, I have found that it has been very healing for me to create systems that support youth who are living with, or have experienced, toxic stress. There isn’t anyway to erase the past, but I believe that the work you are doing, will help the next generation of youth, and the generation after that, and so on. And hopefully, you too will feel supported, cared about, and loved, by the communities you are both changing and building from within. Thank you for making this your life’s work and for making a difference for so many families and children.

  8. Pingback: Q-and-A: Pediatrician screens parents, kids for ACEs because her ACE score is 9 • SJS

  9. This is excellent. Thank you for your good work and concern for children.

    Bessel van der Kolk does extensive research in the trauma/body connection at the The Trauma Center in Boston. http://www.traumacenter.org

    This profile on Bessel van der Kolk was just published a few days ago in the NYTimes:

    http://www.nytimes.com/2014/05/25/magazine/a-revolutionary-approach-to-treating-ptsd.html?_r=0

    Also last year, Krista Tippett did a beautiful radio interview with Dr. van der Kolk. If interested, you can listen online here: http://www.onbeing.org/program/restoring-the-body-bessel-van-der-kolk-on-yoga-emdr-and-treating-trauma/5801

    Finally… I noticed that Stephen Porges is speaking at Bessel van der Kolk’s trauma conference next weekend. :) http://www.traumacenter.org/training/TraumaConfBrochure2014.pdf
    (Greg Siegle from U of Pitt is also on the roster. Very good speaker doing good work in neuroscience!)

    • Thanks…. I truly believe with all my heart that Dr. Van der Kolk really understands DTD. I have learned more from the last 3 yrs of his Boston trauma conference then ever in my life (years of unhelpful psychiatrists who just make you feel stigmatized and really know of no way to be helpful— no offense) ….so from my point of view….the unconventional….is at least worth a try…. I think for chronic early onset child abuse related trauma ….he definitely is right on. I am so hoping DTD gets in dsm somehow….

  10. Thank you for courage in telling your story.

    Any familiarity with the work of Robert Scaer?… “The body bears the burden…” Thank you for being there for the kids who would otherwise be pathologized.

  11. A miracle of a human being. I believe your Grandmother, for the short time you had her in your life, protected some of the wonderful growth and development that we see here as evidence on our screens. It was heart wrenching to read and yet I sign off in awe. Thank-you.

  12. Pingback: Opening Our Disowned Box of Relationship Darkness | Brady on the Brain

  13. I think this highlights the importance of actually using the ACEs language. I am running into people trained in therapeutic counseling who reference PTSD and depression but not specifically trauma language, and I fear they are missing a key piece of the puzzle. Thank you for being so brave and sharing your story.

    • I agree. I think it is time to come up with a standard name. The ace study was an epidemiological study of GREAT importance, however the same information can be obtained from Allan Stroufe and his Minnesota Longitudinal study, an excellent body of work, or from the work of Dr. Frank Putman, M.D. for his work with intergenerational transmission in sexually abused girls. I believe currently he is at the Mayerson Center at the University of Cincinnatti. The ACE study is great as anyone can understand it and use the information to talk to each other. However 1. Adversity in childhood produces 2. What the AAP (and Harvard center for the developing child) call Toxic Stress. Why is it toxic? Because this prolonged negative stress causes aberrant brain development and synaptic death. The brain develops in a use dependent matter..just like muscles in the body, exercise them…they become strong otherwise they will become weak and atrophy. 3. Toxic stress becomes Developmental Trauma. I believe the proposed new diagnosis of Developmental Trauma is a real consequence of childhood adversity/toxic stress and should supplant the multitude of co-morbid diagnoses the etiology of which is severe, prolonged childhood adversity.

      • Not only do ACEs directly adversely impact neural development, but many of the ancillary events that take place in the wake of trauma add even greater deficits to relational poverty. Think about what happens to a family system in the wake of incest, for example.

  14. I endured the trauma of growing up with a alcoholic mother, who, while not physically abusive was emotionally abusive. Before she went off the deep end and became a fifth of gin a day alcoholic, she had lost my twin sister only hours after our birth. Her first child had been stillborn, and her mother had refused to speak with her for a year because she thought my mother had gotten pregnant too soon after she got married. Both of my mothers parents had been alcoholics, and her father a rage-aholic to boot. But it wasn’t until my mother’s liver had failed and she was on her death bed that she told my father she had been sexually assaulted by a group of teenage boys when she was only six years old. It was the 1930’s. Nobody got help for that sort of thing. You just pretended it didn’t happen. Only in light of that, did the viciousness of my mother’s verbal assaults ever begin to make some sense to me. In my own recovery from trauma and co-dependency, I see clearly how she really did try hard not to pass down what she had received, but that’s a tall order when you don’t get help, or when high levels of anxiety are as normal as breathing. I was lucky enough to have a lot of buffers that helped minimize the impact of the emotional trauma I grew up with – chiefly performing arts that gave me a safe place to express myself and a circle of loving surrogate moms in the form of neighbors, church ladies, and teachers. I eventually found my way into somatic education and was a pretty high functioning adult until my own son developed a substance use disorder in early adolescence. I was over my head and had to get help for myself. Lucky for me, the person I reached out to was also a trauma therapist. EMDR therapy did so much for me to lay my demons to rest. Participation in 12 step groups and my somatic and spiritual practices help me keep it going. My biggest takeaway from the experience is that, despite all my work in mind/body education, particularly with Alexander Technique, a modality based on recognizing, inhibiting, and redirecting harmful fear responses, I was living with a sort of omnipresent state of low level anxiety. I liken it to a refrigerator hum, so constant that I never even noticed it, until I noticed it, and then had a choice about it. Doing my part now to break the cycles. I suppose I always was. I made a conscious decision to do that when I was only eight, but now, I’m more effective at it. Thanks for all that you are doing.

    • Thank you for the insights… All of you! Gaynelle your life experiences reflect some of my own. I was sexually abused by my stepfather from the age of 11 for a period of time. As a result I has many issues: hypervigilance, PTSD, nicotine and alcohol dependencies and was unable to form or maintain close bonds. At the age of 22 my secret was out and I began the long road to recovery from the abuse. At the age of 32 that I entered a 12 step program because I finally cared enough about somebody else, my three year old son, to do something about me. My 19 yo son now has a substance abuse issues and I am seeking further help for myself also. Your insight has given me direction. Interestingly, and maybe not by coincidence, I am a descendent of F. Matthias Alexander yet I have never engaged in any bodywork therapies. I would also be very interested to know if anyone is studying ACES here in Melbourne Australia. Thank you Tina for your courage and your work.

  15. My wish for you is to find a way to heal, Dr. Hahn. The healing aspect…whether a person believes it is possible to heal after the fact of abuse…is what interests me. I appreciate that you like the work of Hanh and find comfort, but what I really want to know is the process of forming emotional scar tissue–getting to a place where there is no scab to peel off, where the wound keeps opening–so that the fact of the bad memory is just a mark and not a constant source of injury. If healing like this happens in the physical body, what does it look like in the emotional body? Can someone come up with a way to arrive at a good description of emotional healing from ACEs? (I suspect that this definition is different for everyone–but I want everyone to find their own healing practice and definition of “heal.”)

  16. Dear Jane, thanks for sharing your story. I have an ACES of 5 and I suffer from anxiety: I believe my brother had the same score or maybe even higher. He was diagnosed bipolar and he died at age 45, serving a prison sentence for assaulting a police officer.

    I am a nurse and educator and I often see the light flip on in my students when they calculate their own ACES and they begin to realize how this impacts how they perceive stress and how they react to stress. Keep up the great work… and none of us are probably very good at meditation, but it is in the observation process of how the mind wanders that we can create new neural pathways, rescuing ourselves from our own heightened ACE induced amygdala responses.

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