Saturday, November 19, 2016

An Unstated Developmental Milestone (or Two)

It is hockey season in Minnesota.

And like Little League seasons used to be, tens of thousands of pint sized hockey players are competing and practicing almost on a 24/7 basis.  Emotions run high as teams of widely varying levels of physical ability compete for the greater glory of their team.  Like most team sports that we all played as kids, there is a high emotional investment in winning.  None of the secondary goals of personal improvement, improved conditioning, and teamwork are generally considered.  Whether or not they can be realistically considered at a young age is an open question.  Clearly the adults carting all of these kids around and in many cases coaching them - want to see them win.  I don't know what impact the participation movement has had on winning.  In talking with some graduates of those systems, it offers limited protection.  At some point there is only competitive sports and a rude awakening that participation gets you so far.  At some point everybody does not get a trophy.

That realization is a game changing event for most people.  In your high school class of 300 people, you might be the fastest person in the quarter mile but you rapidly learn through a series of track meets that you will probably not be going to the Olympics.  The adaptation to that varies from just quitting the track team, to going to all of the meets and running as fast as you can, to questioning the coaching staff,  to trying performance enhancing drugs to see if that will give you the necessary edge.  It involves more than sports.  I have seen the same sequence of events play out in music and academics.  Being demoted from second to third chair in the orchestra section.  Not getting the perfect score or academic award in school.  In relationships, the break up of a first serious romantic relationship was the commonest reason I would see college aged students admitted to my inpatient unit and yet - none of them had a serious mental illness.  They were "suicidal" and emotionally distraught because they had not dealt with that kind of failure before.  My standard pep talk to them was that someday they would be as old and emotionally resilient as me and they would have scant recollection of ever seeing a psychiatrist in their life.  In many ways, relationships more than anything else highlights the developmental milestone I am referring to and that is dealing with failure - especially when that failure seems to have very high stakes.  A large percentage of the college students in crisis did not think that they would ever find a partner as ideal as the one they had just lost.

In Psychiatry School, they teach us all the normative models of cognitive and emotional development from various schools of thought.  Reading any modern text of child psychiatry (1) - the old developmental references based on theories by Freud, Piaget, and Erickson are gone.  They are now supplanted by specific emotion, cognitive, temperament, and attachment lines of development and their associated neurobiology. It is generally agreed that it is better to be resilient than not.  We now know that psychological trauma in childhood is a major cause of decreased resilience and that a fair number of children experience one of these traumatic events during childhood.   Apart from protecting children from these traumas as parents and society - what else can be done on an individual level?  During my career as a psychiatrist, I have made two observations that originated with other people that I think would be extremely helpful.

The first is the Sara Blakely story.  She is  the CEO of Spanx, a company that she started herself that became amazingly successful.  She has told her story repeatedly on a method that her father taught her to redefine failure as not trying rather than the outcome.  Her father took an active interest in his children and always inquired aboiut one thing they had failed at that week.  She said that he actually celebrated their failures at some point.  She discloses her failures at her company and encourages her employees to do the same thing.  Having survived several corporate cultures that thrived on blaming employees for various problems, I can imagine (if I try real hard) how refreshing that approach would be.  What would happen to all of these kids playing Minnesota hockey if they were able to just talk about what they were trying to do and how they failed at it?  Would it revolutionize the game?  If you are focused only on a win-lose outcome, you lose a lot of information along the way.  Information about yourself  and everybody else.  The starkest piece of information is that at any level of competition, the odds are stacked against you being the big winner.  You have to be able to see yourself as the Big Fish in a small pond at best.  You are probably not the one person in a million who is going to be at the top of that game.  In my estimation Sara Blakely's father was a genius when it comes to parenting.

I learned about the second genius father from of my coworkers before one of my morning inpatient team meetings.  We were the first ones there and she started talking about how she got into nursing.  Her father advised her to do volunteer work in the field when she was in high school.  She was reluctant to consider that idea.  At that point her father said her would pay her to do volunteer work in a field that would help her get into the health care professions.  At the time that struck me as pure genius.  I was talking with an extremely competent nurse.  I could also relate to not wanting to do much and not realizing why volunteer work as a teenager might be important.  That single idea by her father may have been the difference in her vocational choices.        

Those are my two favorite stories about parenting ideas that seemed like pure genius to me.  I am very interested in hearing what other people have discovered in real life that might have been useful in  improving resilience and getting to a more useful perspective on life - as opposed to the dry theories that we are all taught.  I would also like to point out that these issues are very difficult to study in a double blind clinincal trial, but I did encounter an experiment that was applied to a school class that also had very good results.  The study was highlighted by Ruth Shim, MD, MPH in her presentation Prevention in Psychiatry: A Public Health Approach given at the the University of Wisconsin 4th Annual Update in Psychiatry this year.  The research presented was on the Good Behavior Game (GBG), an intervention applied in the Baltimore City Public Schools in the late 1960s.  The game starts as three 10 minute sessions per week as a team competition.  The rules were focused on working quietly, being polite to others, getting out of one's seat with permission, and following directions.  Teams were rewarded with pencils and erasers if all of the members of the team followed the rules.  As the game went on the sessions got longer and students were given stars as rewards.  The games started with 1st and 2nd grade students and continued until the 6th grade.  Students were assessed up to the age of 19-20.  When the GBG classrooms were compared to standard classrooms there were significant reductions in alcohol use, smoking, and suicidal thoughts.  Looking at the males only there was less substance use and need for behavioral and substance abuse treatments.  The highly aggressive male strata had substantially less drug abuse, violent and criminal behavior (34% versus 50%), and diagnoses of adult antisocial personality disorder ( 40% versus 100%).

All of those results from the straightforward application of behavior therapy and peer pressure.  These are all good examples of basic ideas that seem to have had very good outcomes in terms of competent and successful adults.

George Dawson, MD, DFAPA


1:  Anita Tharper, Daniel S. Pine, James F. Leckman, Stephen Scott, Margaret J. Snowling, Eric Taylor.  Rutter's Child and Adolescent Psychiatry (6th ed).  John Wiley & Sons, Ltd, The Atrium, Sounhtern Gate, Chichester, West Sussex, UK, 2015.  

2:  Embry DD. The Good Behavior Game: a best practice candidate as a universalbehavioral vaccine. Clin Child Fam Psychol Rev. 2002 Dec;5(4):273-97. Review. PubMed PMID: 12495270.


Hockey photo at the top is by y Ailura (Own work) [CC BY-SA 3.0 at (], via Wikimedia Commons at the following URL:


  1. Are you familiar with the work of child psychologist John Rosemond? I think his books for parents and his newspaper column provide the best explanation for why kids today fall apart when they fail at something.