Written by: Center for Care Innovations

“Positive childhood experiences can help a person become resilient or heal from adversity,” says Dr. Robert Sege, a pediatrician and a professor at the Tufts University School of Medicine.

In this episode, Dr. Sege discusses the Healthy Outcomes from Positive Experiences, or HOPE, framework, a new way of seeing and talking about experiences that support children’s growth and development into healthy, resilient adults.

Listen and subscribe to our podcast on Apple Podcasts , Spotify , and elsewhere . Below is a transcript of the episode, edited for readability.


Alexis Wielunski:

It’s my pleasure to turn the mic over to Dr. Dayna Long to introduce our keynote speaker, Dr. Long is a primary care pediatrician at Benioff Children’s Hospital in Oakland. She’s the director of the Center for Community Health and Engagement, and serves as the clinical director and a coach for the Resilient Beginnings Network. Welcome, Dr. Long.

Dayna Long:

Thank you so much, Alexis, and what a great day. You all have no idea how excited the RBN Leadership team and I are to be here at the showcase with you and to lift up the amazing HOPE framework that we’re going to hear about today. So as Alexis just mentioned, I am the clinical director for our Resilient Beginnings Network. And I have the pleasure to introduce someone who has inspired me over the years to always be better and to think about families from a place of strength and resilience. And so I’d like to introduce you to Dr. Robert Sege.

Dayna Long:

Dr. Sege is a pediatrician at the Floating Hospital for Children at Tufts medical center, and he is a professor of medicine at the Tufts University School of Medicine, where he directs the Center for Community Engaged Medicine. He more recently is also a senior fellow at the Center for the Study of Social Policy in Washington, DC. And he serves in many leadership positions. But one of those is that he is on the board of the Massachusetts Children’s Trust and Prevent Child Abuse America.

Dayna Long:

When you think about what Dr. Sege is really known for on a national level, it is his research on effective health system’s approach. That directly impacts how we talk about trauma resilience and social determinants of health. His work on the prevention of child abuse and neglect really begins with the knowledge that all parents, all caregivers love their children deeply. And he has initiated and launched many efforts that have really transformed the way that we are practicing pediatrics.

Dayna Long:

So as a result of his keynote, you will learn the skills and capacity that you all need within your clinics in order to think about how we are talking about positive childhood experiences. And so you will come away from this lecture with four main skills. The first is that you’ll be able to describe positive childhood experiences and how those positive experiences impact adult health.

Dayna Long:

You will be able to list the four building blocks of the HOPE framework, HOPE standing for healthy outcomes from positive experiences. You’ll be able to effectively tell the story or narrate a family’s resilience and their journey through this pandemic related chaos that we’ve all been in. And then lastly, you will be able to propose one short term change in your own practice that will help to identify, honor, and promote early positive childhood experiences. And so just like the rest of you, I’m going to get out my popcorn and I’m thrilled to listen to Dr. Sege. Thank you so much.

Robert Sege:

Dayna, thank you so much for that. Totally. Over the top introduction. I really appreciate it. And I just start out by saying that I want to appreciate all the people who are spending time with us today. It has been quite a year in medical care and in pediatrics, and thank you for persisting and continuing to innovate and make things better for children and families.

Robert Sege:

What I want to do today is invite everyone here to join us on the path to hope. And where we’re headed is a world that recognizes honors and promotes positive experiences because their fundamental to people’s health and wellbeing.

Robert Sege:

And this sort of starts with the core assumption of the science of the positive, Dr. Linkenbach at the Montana Institute have been talking about for years, and that is the positive exists. It’s real and it’s worth growing. And what I want to happen in your clinical encounters is for you and the families that you care for to remember this, and start with the presumption of strength. That people are there, they’ve survived so far and all those things we can do to coach them and maybe even admire some of the things that they’ve been through and the way they’ve done it.

Robert Sege:

And that’s really what HOPE is all about. We know and I’ll talk to you a little about the research positive experiences, promote children’s long term health and wellbeing. They help children to form strong relationships. They cultivate positive self-image and of worth. They provide children with a sense of belonging within their family, within their community and within their place in history. All of these things work together to build coping skills that promote resilience and all of us are going to experience stress in life when things don’t don’t go well.

Robert Sege:

The resilience, the ability to bound back is so important for child development and for adults. Even though we know that many of the systems, particularly the systems for accountability within which we all work, focus on the negative. And it’s important to note that screening tools sometimes codify implicit bias, and they create a presumption of deficit. So that when a person arrives at one of our offices and they’re asked about all their troubles, there’s a presumption that they do have troubles, and that we’re just trying to unroll them.

Robert Sege:

But what we do with HOPE is we shift their narrative and we do that because we know that people, ourselves, our patients, everyone else are defined by strengths as well as by challenges. So with that, I want to jump into the science and working with Jennifer Jones and Jeff Linkenbach in particular, we were able to add questions to the 2015 population study in Wisconsin. And for those of you who know about national surveys, this was the CDC’s behavioral risk factor surveillance survey, which is conducted by each state using questions the CDC generates. This survey already included questions about ACEs.

Robert Sege:

We added questions about positive childhood experiences that were derived from Dr. Unger’s work. And then we are able to correlate those with mental health. And out of this, we developed something called the positive childhood experiences score. And the PCEs that we chose were adapted from something called this children youth resilience measure by Dr. Unger from Canada and used by the World Health Organization around the world. And those questions for respondents were pretty simple.

Robert Sege:

As a child under 18, how often do you recall that you felt able to talk to your family about feelings, felt your family stood by you during difficult times, enjoyed participating in community traditions, felt a sense of belonging in high school. So I want to pause there for a moment. That’s not what grades you got in high school. It’s whether you felt at home there. Did you feel supported by your friends? How often do you recall that you had at least two adults in addition to your parents who took a genuine interest in you, and how often do you recall that you felt safe and protected by an adult in your home? And the numbers at the bottom were generated by Dr. Patel and her group at Johns Hopkins.

Robert Sege:

And they basically show that these seven items can be used as a score. In other words, two is better than one, three is better than two on all of those factors. So we’re able to assign people a score based on how often they answered these items with always or almost always. Each time they did that. They got one point, you can of course have zero to seven. And the results were amazing. And what it showed was that individuals in Wisconsin, this was a population survey. If they had six or seven kinds of positive experiences, they had a 72% lower odds of depression or mental health, compared to those who had a few or none, zero, one or two. So specifically if they had six or seven, they had 12.6% chance of having poor mental health or depression as an adult. If they had zero to two, almost half, or 48% had one of those conditions.

Robert Sege:

And if you had intermediate number of PCEs you got an intermediate number. I just want to call out Christie Bethell at the Child and Adolescent Health Measurement Institute at Hopkins in Baltimore, who has really spent her professional career looking at flourishing. And she conducted the analysis of these surveys. And she’s really, I think the best at doing that kind of analysis.

Robert Sege:

Now let’s look at the people who had four or more ACEs. So these were people who had four or more kinds of child abuse, child neglect, or family challenges. So really difficult childhoods. Amongst those people in Wisconsin, if they had zero one or two positive childhood experiences, over 60% reported depression or poor mental health. However, if they experienced the protective factor of six or seven positive childhood experiences, this fell by two thirds to 21%. So pretty amazing. And I think this is really important because as we think about ACEs and focus on them, there’s been a fair amount of literature that comes out in the last year or so that says that individual ACEs don’t necessarily predict outcomes, even if they do on a population.

Robert Sege:

And we think that positive childhood experiences, whether these particular ones or others, kind of explain that missing link between ACEs and outcomes. So here’s what we think is going on. Adverse childhood experiences can lead to toxic stress, toxic stress can lead to poor health outcomes. I think everyone here knows about ACEs and that whole situation, which is really important.

Robert Sege:

It’s given rise to ACEs screening and trauma informed care, all kinds of things. And we know that this is true. However, the more recent literature shows and other kinds of positive childhood experiences can prevent ACEs. They can block the development of toxic stress from children who have experienced adversity. And even among people who’ve had toxic stress, they can promote healing. So up until now, I’ve been talking about looking backwards. So you ask an adult, tell me about your childhood. And we look for both positive and adverse childhood experiences at the time when a person is looking back on their childhood.

Robert Sege:

Now that’s really interesting and it’s really important, but we all work in a different direct. We do things now for the future. So another study that I did with Charlene Harper Brown, who lives in Atlanta and works for the Center for the Study of Social Policy, we looked at programs that work for children and youth. And we tried to figure out what were the common element in those programs that might account for their success.

Robert Sege:

And we took a particular focus. And their focus was what did the kids and teenagers who participated in those programs experience. And we looked at a couple of dozen programs and we found was that in general, the kinds of experiences that these programs created for the kids could fall into four buckets, which have formed what we now call the building blocks of HOPE.

Robert Sege:

And the first one, our relationships with adults and other children, which occur through interpersonal interactions and activities. The second one is safe, stable, and equitable environments for living, playing, learning at home and at school. The third one is social and civic engagement to develop a sense of belonging and connectedness. And what Charlene refers to as a sense of mattering. And finally emotional growth. And emotional growth happens through playing and interacting with peers. And this is where we learn self-awareness and self-regulation.

Robert Sege:

So let’s dive into a little bit, so relationships to other children and other adults through interpersonal activities. And these of course begin at that first moment when we’re born. And we look around and there’s the person who gave birth to us, often, a few other people there. Some of them disappear like the doctors and nurses, and some of them become our caregivers, that early attachment of the first relationships we have. Soon, we have relationships, not only with our caregivers, but perhaps with other family members and then eventually with peers and on through adulthood.

Robert Sege:

And the importance of these cannot be overstated. And in fact, there are several constructs and programs and ideas that really dive into this. So some of you may know that Dr. David Willis has been pioneering in the area of early relational health, asking pediatricians to observe, assess, and promote relational health between children and their parents, and later between children and their peers.

Robert Sege:

A second part of this is a new focus in pediatrics on parental wellbeing. So now Medicaid allows us to screen and treat maternal depression because of the realization that mothers with a mental illness, depression being the most common, have difficulty forming these really strong early relationships. And there’s a movement now to include paternal depression, as well as maternal depression. And these are becoming within the domain of pediatricians because we know they’re important and they’re an important risk factor for child health.

Robert Sege:

The CDC, Center for Disease Control, has been promoting safe, stable, nurturing relationships through policies and social norms. And one of these in California was a pioneer in the United States in this, is paid parental leave. And as you may know, the strongest form of child abuse prevention that’s yet been demonstrated in the literature is paid parental leave, which reduces infant abusive head trauma and fatalities. Because the positive exists, parents want to do a good job with their kids. And if we remove some of the terrible stress that can happen to an under-resourced family, when a child is born or actually to any family through paid leave, we can relieve that stress and reduce abuse.

Robert Sege:

Second building block is environment. Safe, stable, and equitable environments for living, playing, learning at home and in school. And environments is kind of a two-sided coin. So there’s the physical environment. Does the child have enough to eat? Is there a roof over her head? Is her neighborhood safe? And is the school safe? So the physical environment’s really important.

Robert Sege:

And the second, and some of the questions that we had in that survey really get at that, is it emotionally safe? Do they feel a sense of belonging at school? Are the adults at home looking out for them? So again, there are a number of programs, we didn’t invent this. Many of you are familiar with the school safety, health and assessment pool, which looks at the social determinants of health. We and others work hard to help families have those concrete supports they need in times of need. Which is one of the promotive factors from strengthening families. A lot of the work on emotional safety comes from the positive school environments, which it turns out is the most effective way to reduce bullying.

Robert Sege:

Children need access to green space and nature and safe home environments. So what I’m trying to show through these is that HOPE is a unifying framework, but you may already be doing a lot of the individual items that are part of the healthy outcomes from positive experiences framework.

Robert Sege:

So we’re trying to organize it and make it coherent, measurable, and useful. The next one, which I have to say for me, came as a… Shouldn’t have, but came as a bit of a surprise is engagement. Social and civic engagement helps children and young people develop a sense of belonging and connectedness. And this can start really early in life. Like when you help your dad by bringing a diaper over for your little brother.

Robert Sege:

And it goes on through the tremendous activity of teenagers in our communities and what they contribute to the world around us. Some examples of these are parent cafes. In the parent cafe model parents, not professionals are provide some of the information to other about parenting and positive parenting. Positive youth engagement strategies have been shown to reduce drug use, delinquency, crime pregnancy, all of those things.

Robert Sege:

And this picture is a group from Artists for Humanity. They made our logo. They’re a group of Boston public high school, students who work as artists, they get paid and they do art on contract. And their students who do much better once their talent has been acknowledged and realized rather than just being the bad kid that sits in the back of a class sketching when they should be studying.

Robert Sege:

Many schools use group activities to teach this and beginning in kindergarten, classroom tasks are also examples of engagement. And I’m sure you all can think of many others. We can talk about engagement later. It’s an important and under-recognized necessity for optimal child development.

Robert Sege:

And the final one is emotional growth and emotional growth happens through, through playing with peers for self-awareness and self-regulation. And it turns out that the way we learn about other people is by interacting with them. And so psychologists call this developing a theory of mind, which simply means that at some point toddlers realize that other people have viewpoints too. And that when we’re born, it’s all about us. And for many of us, we grow out of that and we try to grow out of that.

Robert Sege:

And that happens through the rough and tumble. And honestly, some of the friction that happens through play. So if you watch kindergartners play on the playground, and my favorite example is the game of four square. Which is a game where a bunch of five year olds draw a square in chalk on the asphalt hold or red rubber ball, and start bickering about the rules. And it may seem silly from an adult point of view, but actually that’s what they need to do developmentally to learn about that, give and take and negotiation and become a little aware of each other.

Robert Sege:

Really important, and that happens. And I know from talking with school teachers, this is one area where some children fell behind, when school wasn’t in session. Because we know about the academic threat of not being in school. And this is another thing that really is troubling. So when we think about this, there’s a lot of talk, particularly in early education about child-centered play. Many of us work with programs that do out of school time activities. I know California has been a pioneer in developing those and have a sense and a theory of how important they are.

Robert Sege:

In my personal opinion knew they need to be free. Because we want every child to be able to have the benefit of those safe interactions out of school. For many of us, extended families, all those cousins. You know you have to love your cousins, whether you like them or not. There are a lot of lessons there. And just another plug, for recreational of this facilities that are available to all. In some communities, the best recreational facilities are in gated communities or otherwise unavailable to children. And that’s something that we can address.

Robert Sege:

One of my heroes in this area is Dr. Barbara Barlow from Harlem children’s hospital, who embarked on a campaign to rehabilitate playgrounds in her area. So the kids wouldn’t be planning on the street, they’d be safe. And she used a community engagement strategy to do so. All of these things sound like urban planning, but they’re really about health. So I want to step back for a second and talk about HOPE and ACEs and positive childhood experiences.

Robert Sege:

My theory, our theory is that the way ACEs work is by disrupting the necessary positive childhood experiences. So if you think about it, child abuse disrupts foundational relationships. Two children who have broken legs, one from playing and one, because daddy beat her, will have profound different, long term consequences. And the reason is because the unconditional love that children are supposed to feel from their parents is absent.

Robert Sege:

Child abuse and neglect disrupts that feeling of safety at home that allows a child to explore and be curious and do all those childlike things they need to. If you look at the family disruption in the ACEs scale, it’s also pretty easy to understand that not only do these create an unsafe emotional environment, but they can contribute to an unsafe physical environment because of the loss of resources. So when one of the breadwinners is incarcerated, which unfortunately happened far too often as a result of racism, the family’s economic status goes down and think about all of those things that happen, that connect family disruption and social determinants of health. And finally Wendy Ellis and her colleagues at George Washington have also called attention to adverse community environments, things like violence and poor housing, racism.

Robert Sege:

These all reduce the opportunity for the building block of engagement and reduce the opportunities for pure play. Many children are told by their parents to stay home after school, as an example, there is less opportunity for emotional growth because they’re not interacting with their peers. So if you think about the link between ACEs and positive childhood experiences, maybe these are some of the pathways that connect those experiences.

Robert Sege:

I also want to talk about on, this, the really brilliant work that Nadine Burke Harris and the office of the surgeon general have done. And in 2020, they released their report on resilience. And one of the things they focused on was stress busters, which looked at quality, sleep, balanced nutrition, physical activity, mindfulness, experiencing nature, mental healthcare, and supportive relationships. And we, and by we, this is a group led by Dr. Baracka Floyd from Stanford, sort of looked at this and tried to map these on to the positive childhood experiences framework. The HOPE framework.

Robert Sege:

Relationships obviously goes with supportive relationships under stress busters. Environment, quality sleep, look at housing, balanced nutrition, look at food security, experiencing nature. These are all things that contribute to the building block of environment or whether it’s through the physical environment or the emotional environment like nature.

Robert Sege:

Engagement. It’s really funny because this is a little bit more connecting the dots, but for many children opportunities for physical activity occur with out of school time activities, with very little recess now, and that’s also the opportunity for engagement. So we’re going to put it right out there. The building block of engagement and the building blocks and the stress buster of physical activity go hand in hand. And clearly emotional growth naps on easily to mindfulness practices in mental healthcare. So these two approaches are very similar. One difference is that stress busters are designed to help people who’ve experienced ACEs and the building blocks of HOPE are really a designed to pull out those things that children need for optimal development that can prevent ACEs as well as reduce toxic stress and harmful physical effects.

Robert Sege:

So when you go to work, you have to be able to assess HOPE and PCEs. We’re going to have an opportunity I think in February to spend a day with you. But I want to give you some of the ideas of where we are right now. And on our website, which is positiveexperiences.org, I’ll send that to you. We have a new set of information about how to assess positive childhood experiences and the HOPE framework. There are two general categories here. One is the positive childhood experience scale. This was validated in the population survey that I showed you. There are seven items and this is available in published for use.

Robert Sege:

You can certainly use it. That benevolent childhood experiences scale was developed at UCSF. It has 10 items. There are three or four papers where it’s been validated in small-ish groups, a few hundred people and mostly in higher risk populations. Interestingly, when they looked at benevolent childhood experiences with teenagers, the authors of that study referred to BCEs as anti-ACEs. So those are two standard publish scales that have some statistics behind them.

Robert Sege:

There are also narrative approaches. And on our website, you’ll see, we have tools to elicit child and family experiences with the four building blocks, Dr. Floyd and a group at Stanford and another group in Maine have independently made kind of worksheets that parents and kids can fill out, which is really fun. Tells you a lot about the family and also tells you areas where they Excel in areas where they may need support.

Robert Sege:

We’ve also borrowed from the psychological technique known as narrative therapy. And one thing that’s so wonderful, if you ask a parent or even a teenager, tell me about a time when things worked for you, and listen to their story. And then as you listen, think about relationships, environment, engagement, and emotional growth. Because this gives you the information that you need to coach that child, youth, or family to deal with their current challenges.

Robert Sege:

And finally, we have a series of videos that talk about using HOPE informed approaches to risk screening. For example, Dr. Floyd and her sister star in one that really talks about maternal depression, but does it in a way where you elicit all of these factors from HOPE. So, I want to just finish by talking about what HOPE ads. Many of you already know about Strengthening Families.

Robert Sege:

Help me Grow is active in California. Their early childhood systems [inaudible 00:29:32], First Fives and at a federal and state level, the Essentials for Childhood program. So Essentials for Childhood works at the policy and culture level, Help me Grow, First Fives are community responses to support families. Strengthening Families specifically looks at families and HOPE looks at it through the eyes of the child.

Robert Sege:

And we think that this provides a unifying framework as we talk to that with the building blocks, to look at a lot of ideas and programs and frameworks that are out there. And it provides that common framework. So we can talk about relational health, social determinants of health, child directed play and parental wellbeing, not as separate things, but as part of one solid framework that we can talk about. We also think from anecdotally, and we’re starting to study this, that it helps providers, all of us go into this work out of a feeling of empathy.

Robert Sege:

And it helps us because we get to understand family’s strengths and dreams as well as their problems. This becomes the basis for collaborative problem solving. And I mentioned, when we look at, when we ask someone, tell me about a time when things worked, that literally provides the basis for collaborative problem solving. And we’re working with some grad students to see whether using HOPE can reduce burnout among providers, both medical, and for example, home visitors.

Robert Sege:

The next one is that HOPE inherently promotes human dignity. And we have called that out. In all of our are trainings we highlight proven anti-bias techniques. We developed an anti-racism toolbox and we work as hard as we can to include a variety of viewpoints in the work we do. Obviously no one program or idea is the answer to the curse of racism, but it’s something that we think about and try to contribute to efforts to dismantle racist system.

Robert Sege:

I just want to tell you where we are now, this has been unbelievably successful. We are now gone over 12,000 providers around the country. We’re collaborating with the leading home visiting agencies, models with Prevent Child Abuse America, with AAP, with several First Fives, we’re currently scaling our training capacity. So we have online training, training the facilitators. And what this one shows is a portion of respondents who were implementing HOPE after their training.

Robert Sege:

And even after a one hour training and a majority said in a three month interview afterwards, they were implementing HOPE higher numbers for two hour trainings. And I’m not sure why it’s only 50/50 for four hour trainings. We’ll get there. We have a lot of ways to join the path to HOPE. You can look at our website, positiveexperience.org. You can sign up for a workshop or for our learning management system. Just send us an email and that little QR code will bring you to the website. I just want to pause before I finish and see if there are questions or comments that I can answer, or we can just have a little discussion about this in a remaining few minutes.

Dayna Long:

So there are a couple of questions that I would love to share with you. And I also love the idea of just broadening the conversation. And so let me start, I’m going to take moderator privilege here, and I’m going to ask you a doozy of a question. But it relates to one of the slides that you shared with us around how HOPE balances out experiences of ACEs. And so the question is to what extent do we about the biologic basis of HOPE in terms of how HOPE prevents and disrupts toxic stress physiology.

Robert Sege:

That is such a great question, Dayna. And when I had to reduce this talk, I decided to take the brain science out. So I’m going to go add it back in. Perfect question. So first of all, each of our brains has one or 2 billion neurons. Each neuron has up to 10,000 connections. So if you look, there’s a lot of potential wiring combinations, and one of the main discoveries in the 21st century has been the brain is constantly remolding, remodeling, rebuilding, and changing.

Robert Sege:

And there have been studies that show for example, when you learn to read that the cortical tracts between the visual cortex and the area that’s responsible for words called Broca’s center become myelinated and they really bulk up. So just learning to read cause anatomical changes in the brain. We also also know that when adults experience something terrible like a stroke and they lose part of their brain, that with intensive therapy in about a year, a long time, the brain can remodel and recover, maybe not perfectly enormous amount of function.

Robert Sege:

So in the 20th century, if you had a stroke and you lost the use of your right arm, they gave you a sling. And in the 21st century, they give you endless hours of PT and OT, and you’ll be able to use your arm again. You may not catch a baseball anymore, but you have a lot of function. And MRIs have shown that literally other parts of the brain take over from the damaged portion. So they’re rewiring the connections between your cortex and your muscles.

Robert Sege:

Similarly, when people learn to meditate, you can observe changes in an MRI that don’t happen with sort of general calming activities. I could go on and on. So rewiring is one major concept. The second is when we look at ACEs and the link between ACEs and toxic stress, there’s a lot of data about cortisol, which is the fight or flight hormone. And the children who are chronically stressed have a high level of that.

Robert Sege:

But it turns out that our bodies have another hormone system called oxytocin. And it used to be thought that oxytocin was important for childbirth and lactation. It actually is, but it’s even more important in terms of how we incorporate positive relationships into our brain architecture. When a child is born, the non-gestational parent has a sky high peak of oxytocin. And so if you’re a pediatrician and you’ve notice these big burly guys with tattoos kind of melting over the little babies, it’s not their fault, it’s all hormones. So you can think of the out that and a lot of work and Dr. Sunny Anand at Stanford is developing more sensitive assays that measure cumulative oxytocin exposure. So we believe that there are brain mechanisms that are responsible for breaking the link between adversity and toxic stress and for healing from toxic stress.

Dayna Long:

Thank you so much. It makes me think that there might be hope for those of us that are adult providers during this pandemic who have suffered trauma. That there’s an ability to also rework some of our brain that’s been traumatized so that we all can get through this together.

Robert Sege:

And Dayna, one thing about adult else is there was some studies that were done after horrible earthquakes in Japan and showed that adults have not only psychological post-traumatic brain growth, but you actually can see it on MRIs. So yes, there is an opportunity for us to grow.

Dayna Long:

So I have two more questions that are really a part one and a part two. And so these questions are related to what’s happening on the ground and practice transformation. And so clinics are screening for PEARLS. And how can they marry that screening with the positive childhood experience screening? What does that look like?

Robert Sege:

First of all it’s a what work in progress, and I know Dayna that you in particular are working on us. I’m a little humble to be talking about it with you in the room, but I’m going to pretend you’re not here. But I think what happens is that each of us can imagine easily a person we know, often quite well, who has a high ACEs score, but is flourishing as an adult. So you go into it with an attitude of curiosity.

Robert Sege:

So when a person has a high ACEs score, some have symptoms, some don’t, but they’ve all had to deal with it. So asking questions, like what challenges have you faced and how have you gotten through that? And how can we help you with your current challenges based on those strengths is really the key. But in brief they really fit hand in glove because our brains and ourselves respond. And as one of our staff members said, “We all know that bad things hurt, but now we also know that good things help.” So we can work on that.

Dayna Long:

Yeah. And I’m cognizant of the time and we have so many great questions. And so the part B of that question is, as we all know, these conversations around PEARLS and ACEs are heavy, we’re talking about very tough situations. And so how do we highlight these positive childhood experiences without minimizing or dismissing the effects of ACEs in that conversation. And the ACEs that the family’s currently going through?

Robert Sege:

Yep. That’s where we have to be humans and not robots. This is not easy. So I think that one of the things that I’ve been taught by my colleagues really is that people who’ve experienced racism for example, or marginalization have developed an enormous amount of stamina. And so when we turn around and we ask them how they’ve gotten through things, that’s helpful. Another mental trick is we can just think about it.

Robert Sege:

So when I worked at Boston medical center, they had a terrific OB program for women with substance use disorder, mostly opiates, that helped them through pregnancy. And then some of them, I would see them in their baby in my clinic. So what I trained myself to do was this really quick mental exercise. So here was a mother who had decided to carry the baby to term. And I know from talking with people that many of them have been advised not to because they were a mess, whatever nice ways people told them. Had entered into or stayed in recovery throughout pregnancy.

Robert Sege:

They came through this OB program that helped them with that. And when the baby was born, they fought with the Department of Children and Family to keep custody. So now I had a strong persistent woman and her baby, and they had this challenge of substance use disorder. So I wasn’t denying the whole cycle of the relapse and recovery and all of those things, but I was reminding myself of the strengths that brought them to that room, just because they were there. And I think that we need to sit down and talk to ourselves about that, enable us to do it. And once we kind of have figured some of that out, it becomes a little more straightforward to deal with this.

Dayna Long:

So there’s two wonderful questions that I do want to take the time to get to, and I want to bring other voices into this conversation. And so I’m actually going to call on my co-coach Ken Epstein to ask his question, because I think it’s really profound and it requires a mental shift.

Ken Epstein:

I really appreciate this presentation. I’m a big fan, I’ve seen you before and I’m seeing you again. And as a social worker, this is just close to my heart. My question really is, should we consider not using the word toxic stress, which pathologizes stress and in lieu use more words like a stress continuum. Because I’m thinking about the either or that toxic stress gives us. So I’m wondering whether as a field, as we think about positive experiences, we should also think about not pathologizing people’s stress.

Robert Sege:

Ken, that’s a great question. And I just want to go give a little bit of a response to it. Cause I think that that’s important. Toxic stress is an important concept. Allostatic load is another very fancy way of saying that. But here’s what I think. When you watch some of the original descriptions of toxic, the model they use is a house, and the foundation is cracked or something like that. And that those early childhood experiences can cause trouble.

Robert Sege:

I don’t think we’re inanimate like that. I think we’re animate, growing things. So I think of us as trees. So if you look at a tree, it has a branching pattern. If you look closely at trees, there are scars where there used to be branches. There may have been a lightning strike or a windstorm that knocked it over, but it’s still growing. So if you look closely at a tree, every tree has had positive and adverse tree experiences. But they’re often able to recover and grow and become a great tree. They provide, they do whatever it is they do.

Robert Sege:

And I think that they carry that with us. And we’re like that. We are always evolving, always responding to our environments. And sometimes the stress can kill us, like a direct lightning strike, not so good. But many times it shapes who we are, but we can still thrive. And what is it that allows trees to recover and allows us to thrive is really the key question.

Robert Sege:

So I think that you are really onto something. And using metaphors that focus on our ability to change and remodel doesn’t undermine the damage that things like child abuse can cause, but also doesn’t say that history is destiny. And I don’t really want to get into a big discussion about toxic stress. I’m one of your fans, but there are places where you just don’t necessarily want to go every day. Is that helpful, Ken?

Ken Epstein:

That’s great. I love the tree. It’s a systems approach. So thanks for that.

Dayna Long:

Thank you so much for this really wonderful session. I feel so inspired and curious and hopeful.

Robert Sege:

Thank you so much for inviting me. And I just want to just shout again to all of you for making it through this past year. I hope that next year is a little less stressful for most of us in practice.

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