Childhood adversity can affect health for a lifetime, but it does not have to define a child’s future. Robert Sege, MD, PhD, FAAP, Director, HOPE (Health Outcomes From Positive Experiences) National Resource Center, explores how positive experiences and supportive relationships can help children heal and build resilience. From safe, stable environments to emotional growth and a strong sense of belonging, these protective factors can shape healthier outcomes and create the conditions for children to thrive.
Featuring:
Robert Sege, MD, PhD, FAAP, Director, HOPE National Resource Center
Host/Producer: Carol Vassar
TRANSCRIPT
Announcer (00:00):
Welcome to Well Beyond Medicine, the world’s top-ranked children’s health podcast, produced by Nemours Children’s Health. Subscribe on any platform at nemourswellbeyond.org or find us on YouTube.
Carol Vassar, podcast host/co-producer (00:12):
Each week we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office.
(00:24):
I’m your host, Carol Vassar, and now that you are here, let’s go.
MUSIC (00:30):
Let’s go, Well Beyond Medicine.
Carol Vassar, podcast host/co-producer (00:36):
For decades, the conversation around childhood trauma has been shaped by a landmark body of research known as ACEs, adverse childhood experiences. The findings there transformed our understanding of how abuse, neglect, and other forms of adversity can affect health and wellbeing from childhood well into adulthood. But it appears that’s not the end of the story, and that same science, that same research that helps us understand what harms children might also help us understand what helps them heal.
(01:11):
That’s what my guest is here to talk about today. His name is Dr. Robert Sege. He is a pediatrician and researcher at Tufts Medicine, founder of the HOPE framework, Healthy Outcomes from Positive Experiences, and director of the HOPE National Resource Center. His work is helping shift the conversation from risk and adversity alone to the relationships, environments, and experiences that can help promote resilience and lifelong health.
(01:42):
Dr. Sege, welcome to the podcast.
Robert Sege, MD, Tufts Medicine (01:45):
Carol, thank you so much for inviting me. I’m really delighted to be here with you today.
Carol Vassar, podcast host/co-producer (01:49):
Well, we’re glad to have you. This is an important topic. I want to start with the ACE research. Now you were not involved with that, but that seems to be the jumping-off point for your work with HOPE. Tell us what ACE taught us and what questions it left unanswered that led to your work on HOPE.
Robert Sege, MD, Tufts Medicine (02:07):
Sure. Well, the ACEs study was groundbreaking, because what they did is they took information from people about what happened during their childhood and then used that and compared it to their current adult health. And what they found was a striking association between childhood experiences of abuse, neglect, and dysfunctional homes and poor adult health, heart disease, depression, all kinds of things. And it was groundbreaking because what it showed is that childhood experiences have lifelong health consequences, and that was very important and really opened up a whole new way of thinking about what determines our health. It’s not just genes. It’s not just what we eat. It’s all the things that happen to us.
(03:00):
But what it left unanswered is what else is there besides trauma? And each of us knows people who have experienced a really difficult childhood, but seem to be okay as an adult, sometimes even great people. And how did that happen? And even in the original ACEs study, not everybody who had high ACEs – many people with high ACEs didn’t have those diseases. So the jumping-off point was really understanding how all of a child’s experiences can have an impact throughout their lives, not just the adverse ones. And that’s where we started.
Carol Vassar, podcast host/co-producer (03:36):
So what did you discover? What is it that difference between that you referred to and I’m very interested in how people deal with their childhood adversity between those who thrive in their adulthood, and I have a cousin that I think of who went on to do some great things despite having been orphaned as a child, and those who had similar adversities and kind of don’t necessarily succeed in life, or maybe have really bad health issues or outcomes as adults?
Robert Sege, MD, Tufts Medicine (04:07):
It’s a great question, and we’ve been wondering about it. We’ve had hints about it from people’s stories, like your cousin. I have a cousin who has a similar story.
(04:16):
This year we published in Pediatrics, which is the journal at the American Academy of Pediatrics, a series of surveys that ask people about both their adverse and positive childhood experiences. And it turns out that positive childhood experiences have beneficial effects on health for everybody, but for people who have ACEs, adverse childhood experiences, the results were impressive. And positive childhood experiences help a person withstand the effects of adversity. It could be that when bad stuff happens, they’re already resilient, or it could be that it helps them heal. But what we know is that many things happen to us as children, and the positive things, and we’ll talk in a minute about what those are, can really help mitigate the effects of adversity.
Carol Vassar, podcast host/co-producer (05:11):
Let’s go right there. You’re starting to frame out what HOPE is. What is HOPE, and how did it emerge both from ACEs and from your own research?
Robert Sege, MD, Tufts Medicine (05:23):
Sure. So we have developed the HOPE framework based on literature reviews, and the HOPE framework says there are four kinds of experiences that we now call the building blocks of HOPE that children need to thrive. And every child needs them whether they’re traumatized or not. And those experiences are relationships, so stable, secure relationships; safe and stable environments in which to live, learn, and grow; the opportunity for engagement with your family, with your community, that’s how we learn that we matter; and finally, opportunities for emotional growth. And these come through kids playing with each other, through peer playing, they come through encounters with nature, all kinds of things with things where you have those deep emotional experiences, which are not always great, and you make it through. And that’s how emotional growth happens.
Carol Vassar, podcast host/co-producer (06:26):
That all sounds so very easy, but it isn’t necessarily, especially in a family where there’s a lot of trauma. How did you look at ACEs and say, “Hmm, I’m going to flip this on its head and create this framework that helps children heal and thrive”?
Robert Sege, MD, Tufts Medicine (06:44):
Well, first of all, I didn’t do it all by myself. I worked with a man named Jeff Linkenbach at The Montana Institute who talked about positive community norms, and his key lesson is the good is there, you just have to find it. I worked with a doctor named Paula Duncan, who really looked at how social assets helped people get through their teen years, and on and on. What we realized, though, is that we needed to be able to look at the literature, look at everything, and boil it down to things that you could act on that were at the child level. So there are things we know about what makes strong families. There are things we know about some social policies, but what happens to a child in the child’s head that changes it?
(07:28):
And part of it came from my experience. I was a child abuse pediatrician and a primary care pediatrician for a long time, and I learned all about the different things that happened to children and how that affected them from the hundreds, maybe thousands of families that I spoke with. And I think that the origin of HOPE really is that in all my work, including the child abuse work, I realized that parents really love their children and they’ll do almost anything for them. So how can we take that love and provide guidance for them on the things that the children need? Because it doesn’t do too much good to say, “Uh-oh, don’t get in a car crash. It would be bad for your child if you become addicted to heroin.” That’s all true, but doesn’t really tell us what to do, and it doesn’t deal with the stuff that happens in life. So we needed to have more to know what helped children thrive.
Carol Vassar, podcast host/co-producer (08:28):
I want to reiterate the HOPE framework, which is supportive relationships, safe environments, opportunities for emotional growth, and social engagement. Talk about that framework and why those experiences are so powerful in helping children, and I’m assuming this also helps adults in some ways, become better suited to continue their life in a healthy way.
Robert Sege, MD, Tufts Medicine (08:57):
Sure. Let me go through them one by one. So relationships. First of all, each of us was born. And there’s the person who gave birth to us, and in that first year of life, they’re the adults who take care of everything for us. They feed us, they diaper us, they take us outside, they hopefully kiss and hug us, all those things. And that’s called attachment. That attachment to your primary parent is what forms the basis for future intimate relationships and friendships. But then when you’re, I don’t know, two or three years old, you discover there are other kids; peer relationships become important. And of course, by the time you’re a teenager, your parents are useless, and peer relationships are everything.
(09:40):
But it’s also true that other relationships matter too. Are there other adults who care about you? I had a high school science teacher, Mr. Phillip, who really got me and helped me understand what I wanted to do with my life and what I enjoyed because he just really understood me. And when we talk with people around the country, it could be a coach, it could be a teacher, it could be a minister, it could be a neighbor, it could be an aunt; for one kid, it was the parole officer, someone who gets you and sees you. And our research shows that if you can say that, “Through my childhood, more often than not, I had two adults who were not my parents who cared about me,” that’s a very powerful thing. So relationships start with your family, include your peers, and then include other adults as well who look out for you.
(10:34):
And environment is the second building block of HOPE. And environment has two sides, right? So one side is physical. Is your tummy empty? Do you have a roof over your head? And unfortunately, these things that we now call the social determinants of health, there are many children in our country who don’t have those things, and that’s terrible. How can we have children with food insecurity? So that’s one side of it. The other side that actually comes from our research that’s done in the schools is feeling psychologically safe. So in the schools, they know that a positive school environment helps children succeed, and that’s psychologically positive and makes so much sense. Because when you learn something, you start out, you don’t know what you’re doing, right?
Carol Vassar, podcast host/co-producer (11:22):
You don’t know what you don’t know.
Robert Sege, MD, Tufts Medicine (11:23):
Yeah. And you have to be psychologically comfortable to deal with that, say, “I don’t know,” and deal with the frustration of learning it and the joy of finding it out. And conversely, the ACE, the adverse childhood experience, of living in a household where there’s violence, where the parents are violent to each other, that’s not good for you because then you don’t have a safe environment in which to live, learn, and play. So all of those things matter. And as a society, we need to make sure the playgrounds are great places for kids. And very famously, Barbara Barlow, the head of pediatric surgery at Harlem Hospital, led a campaign to clean up the playgrounds in Harlem so the kids could have those experiences.
(12:06):
The next building block is engagement, and that was the most fun for me to figure out, because how do you know that you matter? And all of us as adults, we want to matter to somebody somewhere. And so if kids go to school and home and they’re given a series of tasks and they need to perform on their tests or in sports or whatever, they learn about performance, but they don’t necessarily learn that they matter. So being engaged, being part of a group really matters. So for little kids, it could just be helping out at home, like giving kids chores, or “Can you bring me your brother’s diaper,” or whatever, all kinds of things. And with doing this work, I realized that my second grade teacher, Ms. Ross, probably was capable of cleaning the blackboard all by herself, but she had a list of classroom chores that we rotated through so all of us second-graders felt that we are responsible for the cleanliness and order of the classroom. So we didn’t invent this, but they did that.
(13:12):
And then, of course, when you get to teenagers, feeling like you’re part of something, whether it’s sports or music or politics or bringing groceries to the elderly or getting involved in something else in your community, all of it really matters. And if you go to our website and see our HOPE logo, it was developed for us by 16-year-old artists who are employed by a Boston group called Artists for Humanity, which does after-school arts on contract. We contract with them to do our graphic arts. And those 16-year-olds spent a semester making our logos for us. And those kids do great. And they’re often the kids who may be not so great in school, like the teacher’s talking and they’re sitting in the back doodling or whatever. And someone said, “You’re an artist,” and it’s amazing to see what happens when you recognize a talent and enthusiasm in a teenager and call on it. So that’s engagement.
(14:11):
And emotional growth, really straightforward. If you watch kids play… Like look at five-year-olds and watch them play four square. In four square, they stand around [inaudible 00:14:20], and they have those four squares, somebody holds a red rubber ball, and what do they do? They argue about the rules.
Carol Vassar, podcast host/co-producer (14:28):
It’s so true.
Robert Sege, MD, Tufts Medicine (14:29):
And they squabble. But what they’re learning is, the psychologists call it a theory of mind, which is basically the other person has a mind too. It’s not just me. And then they’re learning to advocate for themselves, “That’s in, that’s out,” but also, ideally, to win and lose with grace and to get through those experiences. So kids’ games have all those things built in. And four square’s a perfect example because it’s not a game adults do, or we don’t teach the kids how to play, but it’s one of those kids’ games that five-year-olds have been playing forever and probably will because it meets that psychological need for emotional growth that happens through interaction, which can be unpleasant at the moment, but actually is quite safe. And interactions with nature similarly have a huge effect on children.
Carol Vassar, podcast host/co-producer (15:18):
Robert Sege, MD, Tufts Medicine (15:22):
Oh my gosh. Well, no wonder you’re now a host of a famous podcast.
Carol Vassar, podcast host/co-producer (15:27):
I love that game. I’m going to have to play it again in my older years.
(15:30):
Dr. Sege, what does the research tell us about the relationship between positive childhood experiences, long-term health outcomes, and what does it tell us about the power of positive childhood experiences?
Robert Sege, MD, Tufts Medicine (15:45):
Sure. So just for anyone who’s interested, we did surveys, or we actually analyzed data from surveys done by the CDC. They’re done in all the states. And many states added questions that we developed on positive childhood experiences. So these are surveys that are given to adults, and they ask them about your childhood, and then they ask about your current health. Do you have arthritis? Are you depressed? Do you have lung disease? All the different diseases a person might have. And what we found was that we had seven questions about positive childhood experiences, and the more of those that someone said yes to, the healthier they were as adults. So dramatically reduced depression, which you kind of expect, but also heart disease, cancer, arthritis, lung disease, diabetes, a whole long list of things that are helped.
(16:43):
And in a study that we published in the summer of 2025, the economist, Maria Aslam, and Elizabeth Swedo from the CDC used standard techniques to figure out what the economic impact of all these positive childhood experiences are. And they determined that for the four states we looked at, there were $216 billion in savings. And that’s partly through decreased medical expenditures, because if you have heart disease, whatever, you need treatment, and a lot of it is because people lived longer and lived longer without disability. So very powerful results. So that was the first thing.
(17:27):
And we had originally published a paper with my friend and colleague, Dr. Christina Bethell, that looked at one state and showed that there was reductions in depression associated with positive childhood experiences and a few other things, but this was a larger study and we were able to get much more information out from it.
(17:46):
And then the second thing that we just published a few weeks ago was among people who had adverse childhood experiences, what happened and what we found was that having these positive childhood experiences reduced the consequences of having suffered from abuse or neglect or household dysfunction, so they too went on to healthier lives. So altogether, the research is dramatic.
Carol Vassar, podcast host/co-producer (18:14):
It sounds to me like despite the adversity faced in childhood, healing remains possible. Am I on the right track here?
Robert Sege, MD, Tufts Medicine (18:25):
You’re completely on the right track. There’s this thing called neuroplasticity, which is a really big word, but what it means is our brains are constantly growing and changing and responding. So many of us remember way back in the 20th century, if a person had a stroke, the doctor would give them… Like, say, it affected their motor cortex. They’d give them a sling because they would never come back. And now we know that with about a year of therapy, you may not get back to where you were before, but you can recover a whole lot of function. And when they used modern brain imaging techniques, what they find out is that different parts of your brain take over those functions. So throughout life, our brains are constantly changing and remodeling and responding to what we do. And we know that repetitive things really leave an imprint on the brain, so being constantly loved and supported leaves an imprint on our brains.
Carol Vassar, podcast host/co-producer (19:25):
I want to talk about the fact that you can’t remove the adversity. It is there, it is experienced, it is often traumatizing. I want to know how the HOPE framework can give pediatricians, other professionals, others in the community something actionable.
Robert Sege, MD, Tufts Medicine (19:43):
Sure. And I think that’s exactly the question that we’re looking at. So you have an ACEs score; you know someone had adversity. Now what? So we worked with judges in Michigan and family court judges, and one of the things they did is if the state brought a child to them because the state wanted them to go into foster care because their family couldn’t take care of them, the judges started asking, who else cares about this child? And then they find out that maybe Aunt Susie, for whatever reason, can’t bring the child into her home, but she has a close relationship. So then maintaining that relationship between the child and Aunt Susie really matters, and that helps the child stay healthy and recover from the problems that led them to be in foster care. If children are talented gymnasts, is a famous talented gymnast, or have a difficult childhood, if they have other things that they do, being able to keep that engagement going helps protect them. So I say these things because children who end up in foster care obviously have had adverse childhood experiences, but we know that there are things that we can do in the systems that we work with that can help.
(20:58):
But there’s so much more to it than that. So one of the things… Robert Putnam wrote about the problems that happen when there are fees for afterschool activities, that children who can’t afford to it don’t get that benefit and children who can’t afford don’t get the benefit of being with the other children. But if you look at the building block of engagement and how important it is for kids to be engaged in those group activities as teenagers, and the lifelong health benefits and the economic impact of the costs averted, all of a sudden you have a policy where we should say, “Every child in our community should be able to be in afterschool activities,” whether it’s singing or sports or politics or whatever. And because we know that pay now or pay later, and I think that that’s what we’re trying to do with HOPE is develop all of those things because we know that the kids do really well when you give them an opportunity to engage and know that they matter. And we all know stories of individual children who had a difficult time, and then something happened, and they found their passion, and they got engaged in something, whether it was sports or singing or church, and they ended up being fine. And that’s what we have to do is create those opportunities.
(22:28):
So the action is when you know a person has had adversity, say… First of all, treat them. Do they need parent-child psychotherapy? Do they need this or that? There are all kinds of things you want to do. But in addition to that, say, “What are you passionate about? What relationships are really important? How do you get engaged and help the child have those experiences so they can heal?”
Carol Vassar, podcast host/co-producer (22:51):
The framework is being used, as you noted when you were talking about the judges in Michigan. I believe it’s used in healthcare, it’s used in schools, it’s used in child welfare agencies, and in entire communities. Talk about an example that is really whole-child health. It’s affecting everything, but it’s outside of the doctor’s office. How do you see growth in getting people to use this HOPE framework moving forward?
Robert Sege, MD, Tufts Medicine (23:22):
Wow, that’s a great question. And there are two parts of it. One is tell you about a system. The other one’s how to get people to engage. Let me do the first one. So one of the first places where we really dug in deep was in the YMCAs in San Diego County, California. And for those of us who are East Coasters like me, we don’t understand that counties in California are like states in the rest of the country. They have a lot of people and a lot of land. And I think the San Diego County Ys I think had 17 branches and had tens of thousands of kids in summer camp. So what they did under the direction of Aimee Zeitz was they adopted HOPE for all of their staff training.
(24:01):
And one of the things, when I visited there, you can immediately see the difference. Because you walk into the Y and there’s a person at a desk, and their job, in one sense, is to make sure that you paid your money and filled out the forms. That’s important. When I went to the Y, they thought their job was youth engagement. So it was there, and the kids were showing up for basketball, and the person at the front desk knew about them and something about them, and they were clearly engaged and happy to see them, and that just goes everywhere.
(24:34):
I went to a residential treatment program for kids with emotional disorders and all kinds of things they had, and I was being given a little tour by the CEO, and she introduced me to a psychologist who worked there. And I said, “So tell me about the kids who come here,” because I expected a long list of all their diagnoses and the horrible things. And she looked at me and said, “They’re awesome.” And can you imagine how that made me feel? Because that was a place that was using HOPE, and that’s how the professional who was charged with helping them saw the children she was caring for.
(25:13):
So that’s what it looks like in a system. And I think that the way that it spreads are several-fold. One is that we write and talk. We have our website, and we use LinkedIn, so we have a lot of ways of communicating with people. But we also very carefully work on creating networks. So we have toolkits for people who are educators or who work in child welfare, or we have a new toolkit that’s just being taken up really dramatically for healthcare workers. And we have online courses for people who’ve learned about other programs so they can use their knowledge of the other program to learn about HOPE. So we try to meet people where they are, get them what they’re doing, and time and again we find someone who was inspired, either through their personal or professional experience, and then we help them transform their organizations they work at.
Carol Vassar, podcast host/co-producer (26:13):
What’s next for you, Dr. Sege, in terms of your research and in terms of… We’ve already talked about spreading HOPE nationwide, perhaps internationally. But in terms of your research, what’s next?
Robert Sege, MD, Tufts Medicine (26:24):
So on the research side, there are two things, one I can’t do myself, and that is to interest neuroscientists and others in understanding… Because we know epidemiologically that having positive childhood experiences makes you healthy, but how does that work? There’s a famous book now called The Body Keeps Score. How does the body keep score of positive experiences? What happens in us? So why is it that we have less heart disease or less cancer because of our positive experiences? So I would love to have some basic scientists really dig into that. We have many hints. I talked about neuroplasticity, a lot of brain imaging studies. There are hormones. There’s a hormone that the internet calls the love hormone called oxytocin, and that’s released and that’s important. But I love people to really look into that, and there are more and more papers being written about positive experiences.
(27:22):
The part of the research that our team really wants to do ourselves is something called implementation science, which is: how do you take an idea and implement it, measure the effects of implementation, and improve it? Because the one thing we know for sure is we didn’t get it right. I think we’re closer to right than we used to be, but how do we use the modern technology of statistical process control, quality improvement, participant engagement to improve the work we’re doing so we can really fully take advantage of the tremendous effects of positive childhood experiences, and how do we effectively change the services we provide for children, and what’s involved in that?
Carol Vassar, podcast host/co-producer (28:13):
Dr. Robert Sege is a pediatrician and researcher at Tufts Medicine and the founder of the HOPE Framework, Healthy Outcomes From Positive Experiences.
MUSIC:
Well Beyond Medicine
Carol Vassar, podcast host/co-producer
Thank you, Dr. Sege, not just for the time spent with us on the podcast, but for the visionary work that you are doing on behalf of all kids.
You can always turn to the Well Beyond Medicine Podcast team for conversations like that with Dr. Sege – dialogues that examine whole child health from every possible angle. Learn more about the podcast and listen to previous episodes at nemourswellbeyond.org. We welcome you to visit, subscribe to the podcast and our monthly e-newsletter, and leave a voicemail with ideas for future episodes. Again, that’s nemourswellbeyond.org. You can also subscribe to the podcast on your favorite podcast app and on YouTube, and listen by asking your smart speaker to play the Nemours Well Beyond Medicine podcast.
Our product team for this episode includes Cheryl Munn, Lauren Teta, Susan Masucci, and Alex Wall. Video production by SarahKate Reger. Audio editing and production by Steve Savino and me. Join us next time as we launch a new series within a series. We’re calling it Leadership Dialogues, and I’ll be welcoming Nemours President and CEO Dr. Larry Moss as my co-host, along with Carol Naughton from Purpose Built Communities as our special guest. Don’t miss it. I’m Carol Vassar. Until then, remember that together, we can change children’s health for good – well beyond medicine.
MUSIC:
Let’s go, Well Beyond Medicine.
