Reasons for HOPE

Many children have experienced stronger family relationships through time spent together, supported by an uptick in community engagement. Although mental health problems have increased,²  we have heard stories³  from families who held it together for their kids, celebrating time together as a family. Facing unemployment themselves, people brought food to neighbors who were too old or too ill to venture outdoors. School systems worked to close technology gaps, providing computers and Internet service to students. Children have felt the caring of grandparents, teachers, health providers, home visitors, and others who persistently connected by phone, text, and/or video chat. Adults have created safe environments for their children with demonstrations of love, compassion, and hope. Our observations are consistent with recent publications in which childhood resilience is discussed⁴  and the importance of highlighting positive childhood experiences is recognized.⁵ 

Pediatricians focus on the experiences of individual children as they grow. On the basis of work conducted since the 1990s, we know that adverse childhood experiences risk harming child and adult health.⁶  At the same time, protective factors, which are sometimes overlooked, have emerged, requiring our clinical attention.⁷  Identifying, classifying, celebrating, and bolstering these experiences can and should become part of our new normal.

The movement toward incorporating a strengths-based approach is well underway; the evidence for such approaches has been building for decades. Bright Futures is part of this movement, calling on pediatricians to identify child and family strengths.⁸  At a policy level, the Centers for Disease Control and Prevention’s Essentials for Childhood initiative supports states in developing policies and social norms that promote safe, stable, and nurturing relationships and environments for every child.^9–11  In the Strengthening Families approach, referenced in Bright Futures, attention is focused on family-level protective factors: parental resilience, concrete support in times of need, social connection, knowledge of parenting and child development, and children’s social-emotional competence.¹² 

These policy- and family-level approaches promote opportunities for children to have experiences that help them flourish: stable and supportive relationships; safe and equitable environments in which to live, learn, and play; civic and social engagement that promotes children’s sense that they matter to others; and opportunities for social and emotional development.¹³  These childhood experiences counter the ill effects of adversity and promote adult mental health.¹³  Adults who experienced childhood adversity were protected from adult depression and poor mental health if they also recalled these important positive childhood experiences.¹⁴ 

Developing an antiracist approach to practice begins with acknowledging the struggles that families face (including their systemic roots) and paying close attention to the strengths and connections that power resilience. Attention to positive experiences illuminates the supports, practices, and policies that promote resilience in children and families. Public policies, including paid parental leave, can promote early relationships and foster positive experiences. Unemployment payments early in the pandemic, as well as eviction moratoriums, allowed some families to spend time together with lessened economic stress, beginning to address some of the pandemic’s health inequities.

Incorporating this focus on strengths provides a more holistic view of factors contributing to health. In clinical practice, that includes identifying and celebrating positive childhood experiences. Exploring child, family, and community resilience naturally lends empathy and dignity to evidence-based screening. Appreciating and bolstering resilience also creates an environment that promotes shared decision-making based on acknowledgment of families’ expertise.

Experiencing discrimination is itself an adverse childhood experience that has systemic roots and leads to other forms of childhood adversity. When clinical encounters are focused on adversity without consideration of its systemic causes, we risk recasting the effects of broader social forces into individual deficits.¹⁵  The effects of systemic racism have been clear for many years; families of color experienced disproportionate levels of coronavirus disease 2019 infection, injury, and death.¹⁶  As Ellis and Dietz¹⁵  reported in 2017, adverse childhood experiences grow from adverse community environments, including systemic racism.

Recent disruptions present an opportunity to focus on the importance of positive childhood experiences.¹⁷ 

Here are a few practical changes that can be implemented immediately:

1. Ask parents about the health of their relationships, the ways in which they are engaging with their families and communities during the pandemic, and their sources of resilience.

2. Cultivate a mindset that situates screening for serious, difficult problems within respectful relationships. Focus on building strengths in addition to addressing deficits.

3. Discuss ways that parents can create positive experiences for their children during and immediately after the pandemic.^17–19 

4. Fine-tune all elements of the process of care to ensure that parents and families feel safe and supported from the moment they walk in the door and throughout the encounter. This takes many forms, all including detailed attention to the family experience. For example, when a family arrives late because of unpredictable transit delays, clinical staff can recognize their distress and engage them in solving the problems generated by the late arrival.

We can train ourselves to see strengths in patient encounters. For example, was the infant with opioid exposure born to a mother who entered and stayed in recovery by relying on her social network as well as medication-assisted treatment? Is the tired and disconnected father exhausted from his essential (and newly risky) job? Does the teenager who smokes marijuana also bring groceries to her grandparents?

Simple actions can make a difference. When a new parent cannot think of anyone to call on for support, spend a few minutes brainstorming.²⁰  Ask them to recall a time when things worked out okay; who was there to lend a hand? Systematically asking about relationships, the child’s home and community environment, and their engagement in the community can promote the sense of admiration and empathy.

American Academy of Pediatrics guidance that addresses the effects of racism²¹  and poverty²²  lays a new foundation for child health care that incorporates antiracism and antipoverty. By noticing, celebrating, and bolstering how families exhibit resilience,²³  pediatricians can see love, joy, and strength thriving and can develop caring relationships with families. These relationships support collaborative problem-solving, which ultimately works through problems identified by parents themselves or through evidence-based screens.

Over the next few months, we can expect continued challenges as the pandemic grinds on. Identifying, celebrating, and promoting resilience factors requires reflection and hard work. This moment in time has created an opportunity to rebuild as a more just society in which equity and social justice are the new normal, benefiting all our patients now and into adulthood.

I acknowledge the editorial support of the staff of the HOPE National Resource Center at Tufts Medical Center in Boston, Chloe Yang and Dr Dina Burstein, and our National Advisory Board. Special thanks to Drs Baraka Floyd, Jeff Linkenbach, and David Willis for their editorial contributions.

HOPE

Healthy Outcomes From Positive Experiences