A Conversation With: Robert Sege

In your essay, Balancing Adversity with HOPE: Reshaping Policies and Systems Around Positive Childhood Experiences, you discuss how practices, policies, and systems can use the Healthy Outcomes from Positive Experiences (HOPE) framework to improve children’s and families’ health and well-being. What are the implications for HOPE, and the focus on positive childhood experiences,  in the context of the Covid-19 pandemic?

The pandemic has affected families in many, many ways, but one of the most basic is that people were not—and, in many cases, still are not—in physical contact with other people in the ways we used to be. Many family members have been physically distant from others for extended periods of time. But that doesn’t mean they can’t be socially connected.

We’re beginning to understand that, for some families, their situation during COVID had some positive aspects. For some families in which parents were laid off from work, or lost a job, or had a business close down  but who obtained some cash benefits and income, adults were around the home more, with less pressure than when they were working. Simultaneously, the kids were attending school at home, and they didn’t have afterschool sports or other activities. A lot of families actually had fun during this period. Not all the time, and there was certainly family stress, as well. But it’s important to learn about the ways families generated positive experiences from their situations.

On the HOPE website, we’re collecting stories of things families did that were positive. For example: one little girl set up camp on the back steps of her house and had adventures there. Teenagers helped deliver food to elderly neighbors. In short, there were a lot of positive experiences happening. It’s a really complex situation.

We’re working with the American Academy of Pediatrics and Prevent Child Abuse America to document what’s going on and figure it out what it means. Many of us who have spent years working to prevent child abuse were really concerned that, because of family stress, things were falling apart. But we’re finding an equal number of stories of things that are working for families, ways that they’re turning this crisis into opportunity.  

What could be the impact on children of having more positive experiences than expected during the COVID-19 lockdown?

Children will remember this time for the rest of their lives. There are singular moments that can define a generation, and this certainly seems to be one of them. Given that, how do we create positive experiences around this?

An obvious lesson is, we are in this together. As families, as communities, we’ve done a huge number of different things to protect one another. We’ve shut down businesses and schools for the sole purpose of protecting ourselves and society. It’s been phenomenal to see that and to see all the different signs of engagement that have resulted from it. People are dealing with this tragedy together and with warmth.

On the HOPE website, we have a posting: 10 Ways to Create Positive Experiences for a Child in This Time of COVID. It’s in 14 languages. It’s become our most popular post. Children are managing to deal with the disruption in their own lives, in their friendships, and in their parents’ lives. Some children are seeing what their parents do for work for the first time, because parents are working from home. Others are spending more time with parents because parents are home. These are positive things, and we know that positive experiences that spring from close and loving relationships can have long-term impact on children’s health.

Of course, we can’t be simplistic about this. We must look at the situation in all its complexity. There are tremendous fears and justifiable worries about the pandemic experiences, and for some families these experiences dominate. But for many children, there are also positive experiences here, and many children will remember much about these times quite differently.

In your essay, you talk about how HOPE has implications for racial equity. Could you say more about that? In what way can a focus on positive childhood experiences contribute to more racially equitable outcomes?

We talk about HOPE as an antiracist idea. The basic argument is that deficit models transform the effects of systemic racism into individual pathologies. By ignoring the resilience that people have in dealing with adverse community environments, we’re ignoring an important piece of people’s humanity and we’re not acknowledging people’s dignity and responding to it.

More specifically, for those of us who work with families in distress, it’s critical that we think about and acknowledge people’s strength and resilience, especially for those who live in very tough environments.  We’ve been doing a lot of soul searching about this.

When I was middle-aged and less cynical, I used to talk to people in communities about adverse childhood experiences (ACEs). I heard significant pushback that ACEs further marginalizes and stigmatizes communities. At the beginning of the recent anti-racism movement, people were making maps of the distribution of ACEs that looked like old redlining maps. It was a way of portraying communities that emphasized negative experiences and didn’t say anything about strength and resilience.

In the past 18 months, of course, I’ve been deeply affected not just by George Floyd’s murder but by what it sparked:  young people of all races and ethnicities around the country, in little towns and big cities, diverse places and not, standing up and saying, “This is not us!” They’re saying we need to dismantle racism. This has been not just an awakening to racism and racist agendas, but the mobilization of an entire generation of people who have been talking about this in high schools and on college campuses, and among themselves, and are now developing a clear vision as well as pathways about what we need to dismantle. One of my favorite speakers on these topics is Camara Jones, the physician and epidemiologist. One of her many contributions is in helping all of us understand that racist systems are perpetuated whether or not the individuals in those system are White supremacists. That’s a profound observation that we have to pay attention to—and act on.

How did your personal and professional experiences contribute to the set of ideas that HOPE encompasses? And how did you build those personal experiences into a systemic framework? 

I’ve worked in disadvantaged communities since my residency in med school, through all my years as a primary care doctor and then a physician specializing in child abuse, and now in public health. As a doc, you get a look “inside” families. You hear what they’re thinking and worried about, and you experience some of how they live. From working in Alaska, for example, I now know that walrus is a bland food, and when you prescribe a bland diet in Alaska, that can be part of the diet.

More seriously, I’ve watched how kids grow up and respond to experiencing racism and how its corrosive effects can diminish their life dreams and ambitions. Having watched families struggle successfully with all these systemic issues, I realized that knowing whether someone has experienced adversity is useful, but not sufficient, to understand people’s connections to communities, their relationships, or the school environment in which kids attempt to learn. All of the ways that people build strong connections and positive  relationships really matter. Once you understand that, the knowledge can be actionable, at least to some extent—certainly at the policy level.

So, as we thought about HOPE as a framework, we tried to portray the strength that individuals and families bring into the multiple “worlds” they live in. HOPE not only tries to provide help to families individually but also to inform policies and systems so that they make positive experiences even more possible for families. We need systems that see, understand, and reinforce positive experiences. We need systems that operate on the premise that parents love their children and want to be good parents, and that they not only want to help their children, they usually are completely dedicated to their kids.

Could you provide an example of how a system can operate differently to make a positive difference?

Sure. Imagine that you’re a parent, and you show up to your first doctor’s appointment with your brand-new baby. You’re still pretty excited. You walk into the clinic and are given a sheath of forms that first ask how you’re going to pay for this visit and then ask questions like: Were you abused or neglected or sexually abused as a child? Are you experiencing violence in an intimate relationship now? When is the last time you got drunk? I’m describing the situation in a pediatrician’s office, but the same can be true about intake forms for home visitors and other programs. They all use evidence-based screening, whether for partner violence or for a lack of concrete supports—such as whether you have enough money for rent. And I learned very early on that, for a lot of people, lacking concrete supports or money is shameful.

There are pages and pages of risks that you’re asked about, even before you begin to get your care. Then, you  walk into a room where someone—a person who is better educated, often from a different class, and definitely in different economic circumstances than you are—glances at a piece of paper that describes all of the problems you’ve decided to disclose. How are you going to feel about that situation? Are you going to think that person is on your side or trying to catch you out about something? In many communities, there is fear that the child welfare system wants to take your child away from you, especially if you admit to any type of substance abuse or violence in the home. And that could well be your first encounter with someone who’s supposed to be of help to you and your  new baby.

Imagine the difference if you walk into a clinic, and you’re a little late but the receptionist at the front desk says, “It’s really good to see you, I know it’s a hassle to get here with a new baby, and would you like a glass of water?” Then someone asks how your pregnancy went and compliments you for being able to keep working through pregnancy, for keeping your two-year-old safe, and for shopping up here with your baby despite having given birth just two or three days ago. At that point, you feel more willing to open up about the realities of your life because you feel these people, and this place, “get” you, value you, respect you. People are paying caring attention to the things you want for your child and the extent to which your environment is safe and stable. They are engaging you as a person who cares deeply about your family and is willing to do anything to care for them. This is a very, very different state of mind. And I’ve seen and experienced the profound difference this makes. For instance, it might help you get into and stay in substance use recovery, if that’s an issue, and link to other people in your community who might offer support.

That’s an example of how a systemic shift can make a difference at the individual level. I’m convinced that all of us who serve families and children can take that as our direction. And, if we do, we’ll be more useful to families and help families achieve their goals much more  effectively. 

On a larger scale, those of us committed to HOPE need to help guide the development of policy that affirms positive experiences—for example, paid family leave, so families have the time to build the relationships that are so profoundly important. Paid family leave, of course, is being debated as we speak and could become a national reality. I hope it does. It must happen at some point. It’s not a hugely expensive policy but makes a big difference for many families. But that’s just one policy. Longer term, we have to build new cultural and system norms around work and family.

In short, what we’re trying to do with HOPE is take the immense amount of science that demonstrates how key childhood experience matter for lifelong health and translate that knowledge into systems of care that hold families at the center, value and respect families, and treat them with dignity by acknowledging that the individual in front of you is not just a pile of risk to be detected and services to be provided. Instead, we must see each person as someone—just like you and me—who wants nothing more than to raise their kids to be healthy, happy, and successful. That’s why we believe in HOPE. It’s that wonderful thing: a combination of science that also affirms the cultural values that people cherish.

That is what it’s about. HOPE is very powerful. At a time when the divisions in our society are crazy, where poor people are vilified and told they are lazy and worthless in so many ways, we have to dismantle all of that—and a strength-based approach leads you in that way. The experience we’ve had talking to and recruiting people around the country has been nothing short of breathtaking. HOPE taps into knowledge that many frontline works have had forever. For them, HOPE brings a sigh of relief. For example, home visitors have been working on a HOPE practice model on the down low for a while, because that’s what families need. They’ve worked around the fact that, too often from the management view, it’s all about screening and referral.

As you look to the future influence of HOPE, what additional reflections do you have? Aspirations? Concerns?

I want to make sure we don’t fall into the trap of having the understanding of positive experiences over-simplified or treated as just the “soft” side of things. When I first started hearing people talk about positive stuff, it was sometimes conceived as ”going to parents and telling them, ‘Your baby loves you.’” True. But we know so much more now. We know there are specific kinds of experiences that matter, and repetition of those experiences promotes effective brain development. So, we need to build practice around what we know from critical reviews of the literature, and help people see that the concepts and framework aren’t amorphous; it’s about helping to deconstruct solutions that people have already found in a way that allows them to build upon and expand them.  

I was at a conference talking to a man who would self-identify as an American Indian. He described how, when vets came back from the army, sweat lodges were part of how their community helped them transition back to civilian life. That’s the kind of positive experience we’re talking about. A person is using social connections, getting engaged by their community, reestablishing relationships, and there’s acknowledgement that they suffered as a soldier and need help dealing with that trauma and making the transition back into their community. They’re welcomed back but there’s something you have to do first, an experience you have to have, to cleanse yourself. Think about that. And they didn’t do any MRIs to determine that this was needed. So, while brain science is critically important to understanding the power of positive experience, ultimately it is cultural experiences that should lead in our understanding of how to build practices around positive experiences.