Tufts University medical professor Dr. Robert Sege directs the Center for Community-Engaged Medicine and is nationally known for his research on effective health systems approaches that address social determinants of health. He is also the principal investigator for the HOPE framework (Healthy Outcomes from Positive Experiences).The HOPE framework is based on research that shows how positive childhood experiences can mitigate the effects of adverse childhood experiences.

Sege and colleagues are holding free workshops in Northern and Southern California on February 26 and 27 for health care providers, educators, social service providers, early childhood professionals and community members who serve children and families. The workshops are hosted by Tufts Medical Center, Health+Studio and ACEs Connection. Sege spoke with ACEs Connection reporter Laurie Udesky about the HOPE framework and why he believes that conversations about childhood adversity with patients must focus on strengths and building resilience.

Laurie Udesky:  You did a study with lead author Dr. Christy Bethell and others entitled “Positive childhood experiences and adult mental and relational health in a statewide sample: Associations across adverse childhood experiences levels”, which appeared in JAMA Pediatrics.  It showed that people without positive childhood experiences fared worse than people without ACEs. What were some of the other main findings in that study?

Robert Sege: In this study we looked at certain positive childhood experiences (PCE) based on a standardized tool known as the Child Youth Resilience Measure-28 developed by Dr. Michael Ungar in Nova Scotia and used around the world. We found that adults who recalled positive childhood experiences were protected from the effects of ACEs.

Among adults who had four or more ACEs, for example, 60% of those with 0 to 2 positive childhood experiences had depression or poor mental health compared to 21% if they had six or seven PCEs. There was a 72% lower odds of depression or poor mental health among adults with 4 or more ACEs if they had 6 to 7 PCEs compared with 0 to 2 PCEs. And it goes on in the way that you would expect — that with fewer ACEs, they had lower risk [of depression or poor mental health]. But always PCEs helped. And I think what we learned from this are a couple of things. One is that adults can recall both positive and adverse childhood experiences, and that positive childhood experience can help a person become resilient or heal from adversity.

And I think that's a very important lesson because we're now looking very closely at healthy outcomes from positive experiences. So, what are those positive experiences that help our children grow and develop normally, and become resilient to adversity? Because, of course, we like to prevent adversity. We and our colleagues around the country are working very hard to prevent childhood adversity. But nevertheless, it happens and how can we be resilient or heal from it?

On January 1, 2020, California began encouraging health care providers who serve the state’s 13 million members of Medicaid to screen them for adverse childhood experiences. For each patient screened, health care providers will receive an incentive payment of $29.

Udesky: You’re coming to California for workshops, and I noticed in the study that we’re discussing that you and the coauthors mention that initiatives such as the ACEs initiative in California “may benefit from integrating assessments, including positive childhood experiences” Could you expand on that?

Sege: You're using a new tool in California called PEARLS. It ends up with a score for how many adverse experiences you've had, but it doesn't tell you as much about a family or a person as you'd like to know. If you also ask about their strengths — and we have ways to think about how to ask — you can begin to be useful and help a person in several ways. One is, we know — and science shows that adversity is not destiny— that many people who suffered quite a bit turn out okay. We can look at that and help people so they don’t feel that they're doomed or damaged in some way because they've had adversity. And secondly, we can begin to create particular things that parents can do with their kids that really help to promote resilience as the children grow up.

Udesky: What are the basic tenets of the HOPE framework?

Sege: The four tenants of HOPE were derived by looking at programs that help children and adolescents. And rather than asking does this program work or not, we looked at a bunch of programs that worked and thought: What are the common elements? What are they doing in different programs that work? And we found that there are four kinds of childhood experiences which we're calling the four pillars of HOPE that seemed to have a really specific effect.

The first is promoting relationships. So being in healthy sustained relationships is good for kids. And in early childhood the initial attachment that babies have with their parents form the template for all of our future relationships. And as kids grow up, of course, peer relationships become more important. And then as teenagers, they start to have romantic relationships. All of those kinds of relationships matter.

The second pillar of HOPE is environments. We know that children need safe, stable and equitable places to live, learn and play. Communities that have playgrounds. Kids who are exposed to nature. Kids who attend a school with a positive environment. All of these things really matter, and they're not really direct interventions that you do, but if you create those spaces, kids can thrive.  

In the [Wisconsin Behavioral Risk Surveillance Survey] that we talked about [in the JAMA Pediatrics article], one of the questions was: “Did you feel a sense of belonging at your high school?“ That sense of belonging is a reflection of a positive school environment.

The third pillar of HOPE is engagement. My colleague Charlyn Harper Browne, who is the coauthor of this 2017 report, says that we all need to develop a sense of mattering, so that we matter to other people and to our communities. That starts when children in the family are given responsibilities or chores and understand that their efforts matter to the family. When you go to school and the teacher assigns classroom tasks. There are opportunities for teenagers to volunteer in meaningful ways in their communities. So that sense of engagement that what you're doing matters is a key to developing resilience.

The fourth pillar of HOPE are opportunities to develop social and emotional intelligence. A lot of this comes from playing with peers. When children play on the playground and argue about the rules, or they play games, sometimes they win and sometimes they lose. Those are opportunities to develop social emotional intelligence, which is a key to lifelong resilience. The [JAMAPediatrics] paper showed that children who had these positive experiences were more likely to have social emotional support as adults. And we know as adults, having social supports really makes life better.

Udesky: There’s been quite a bit of research and much discussion about protective factors, which these are examples of. Would you say that the HOPE framework is putting a structure around protective factors based on evidence that you found?

Sege: Yes, so the way I think about it is – I’m a senior fellow at the Center for the Study of Social Policy. It's the home for Strengthening Families. I think that Strengthening Families provides factors at a family level that protect children and families. [The four parts of Strengthening Families include protective factors, an approach not a model, changed relationship with parents, alignment with developmental science.] Programs like Essentials for Childhood, from the Centers for Disease Control, look at social, cultural and policy aspects. And these [four pillars of HOPE] look at the individual child, so they're most equivalent to ACEs. So, what we're doing now is we're creating a similar child-focused language to talk about the effects of all of these things at the community and family level as it matters to the child.

Udesky: So why do you think this framework is necessary?

Sege: It is necessary because we need to begin to see the people we interact within a more complete 360-degree way than ACEs screening by itself does. Imagine that you had a 14-year-old girl who had immigrated to the United States and had adverse childhood experiences in her home country, with a resulting ACE score of four. You would expect a certain set of things about that child.

If you also found that she babysat her younger brothers after school, and she's a member of her church choir, which performs at different places around town. She’s doing well at school and wants to go to college. So, now you know that she's engaged in her community, that she has a positive feeling about school, that she's in decent social emotional health. You know much more about her, and you can begin to talk with her. You find out her friends smoke marijuana, but she doesn’t tell you that she does, because a 14-year-old wouldn't tell you that she did. You could say: “You’re a really strong person. You have gone through a lot. Look how successful you are! I know that you're engaged at your church and you’re doing all these things. And what can you do to keep yourself from having a problem?” And you can talk for a little bit and then you can say at the end of it: “You know, a lot of my patients have similar struggles, and there's Susie [the counselor] down the hall who you can talk with and may give some advice. But I know, because I know about you, that you have the inner strength and you have the social support to prevent this from becoming a big problem. You just have to focus. You can do that.” (For supporting data see the article on the HOPE Framework that appeared in the journal Academic Pediatrics)

What we're doing now is helping people develop the training and structure, so it can be as routine a part of what we do as screening for trauma and using trauma-informed concepts.

The other thing that HOPE adds is that there's a lot of neuroscience now that shows how our brains can rewire and heal. And these kinds of experiences that we're describing, if they happen consistently and repeatedly, literally allow the brain to heal. A lot of us have been trained that experiencing adversity may cause toxic stress, which causes changes in brain structure. But there's a lot of evidence that positive experience, positive change, also changes brain structure. You can see changes in the brains of people who've learned to meditate and adults who've learned to read. There's something called post-traumatic growth that you can see in the brains of resilient people. HOPE adds a deeper neuroscience understanding and gives us a framework and a way to talk about it.

What I found — it may not be true everywhere — that many people have told me that their job is to screen and refer. And they kind of sneak in the positive stuff when the boss isn't looking.

Udesky: Screen and refer for what?

Sege: For intimate partner violence, for drug use, or for mental health problems, all kinds of stuff. And they end up sneaking this [positive] stuff in, because they know, deep down from their own lived experience and from common sense, that this is another thing that the families need. We're trying to create it as part of this structured job.

Udesky: I know that you're holding meetings in California. Could you tell me a little bit about what will happen at those meetings, and who will be attending?

Sege: We're going to be giving people a very brief idea and background of the core of HOPE. And then we’ll be asking them to imagine what their own work would look like if HOPE was part of it, and then help us through a series of structured workshops. They’ll help us identify what resources we need to produce, whether it's training or screening, or checklists, or videos that would help people bring these new insights into the work that they and their organizations are already doing.

Udesky: Is there anything else that you think's important to add that we haven't talked about?

Sege: I think when I think about HOPE-informed care, there are several things I think about. One is that when we work with our patients or clients to acknowledge their past and what happened to them, and then to also help them understand that history is not destiny, that it's really okay to get help. Sometimes help means a professional, sometimes it means their geographic, or work, or family, or spiritual community engaging with them. All of us are constantly reinventing ourselves and our family life. One of the goals of all of our work should be helping people, by empowering them by helping them recognize their own power and strength to create a better world for themselves and their children.

Udesky: So, are you opposed to screening for ACEs?

Sege:  That’s a complicated question. I think I'm opposed to it if it's not in an environment that can lead to healing. When people disclose very personal things about themselves, there needs to be an ability to help them understand that just because they have a high ACE score doesn't mean they're doomed. I've seen it done well. And I've seen it done not so well. I think that screening needs to be done in a total environment where screening is a piece of what goes on, and is not the only thing. To be even more specific, when a person gets their ACEs score, there's a risk of labeling and stigmatizing. And many of the ACEs in the traditional model are often the results of oppression or historical trauma, and so we run the risk of further stigmatizing marginalized communities. If we also look for their strengths — individual, family and community — we can help get back to understanding an individual and their life rather than just cataloging the effects of what's happened.

Sege is a senior fellow at the Center for the Study of Social Policy in Washington and serves on the boards of the Massachusetts Children’s Trust and Prevent Child Abuse America.  He is also a member of the Massachusetts Essentials for Childhood team.He has served on the American Academy of Pediatrics’ Committee on Child Abuse and Neglect, and on its Committee on Injury, Violence, and Poisoning Prevention. (Please see the attached flyer for more details about the workshops.)