A Conversation with Paul Tough: How Children (Dont) Succeed

I had the privilege of speaking with Paul Tough on the very day that his new book How Children Succeed: Grit, Curiosity and the Hidden Power of Character was released. In the middle a massive publicity tour, including NPR interviews and major speaking engagements (he is speaking September 6th at Harvard), his publicist arranged for him to speak on the phone with me. Despite being under what I imagine to be intense pressure, he was very gracious and thoughtful.

It was really more of a conversation than an interview, as my hope was to introduce some ideas that were not addressed in his book. It was understandably relatively brief, and I am using my blog to elaborate on what we discussed. I am thrilled that his book is receiving the attention it is. In presenting his thesis that character, rather than cognitive skill, is the key to success,  he brings some very important research to the forefront of public discussion.

Extensive research has shown that in the setting of a safe secure caregiving relationship, children develop the capacity for emotional regulation, cognitive resourcefulness, resilience and the capacity for social adaptation. He uses somewhat different words-including grit, curiosity, self-control, and gratitude, and refers to these traits as a whole as "character."

From my view as a pediatrician and scholar of developmental theory, I see significant obstacles to promoting character development in the way he is advocating for.  I wonder if, in addition to funding programs that promote character, or funding research to study these programs, as Tough effectively argues we should be doing, we need to understand the nature of these obstacles.

With that in mind, I asked Tough about three interrelated issues. These are; our society's undervaluing of primary healthcare, overreliance on psychiatric medication, and childism.

Consider the following scenario, variations of which are exceedingly common. It starts with a mother who is under significant stress in pregnancy. Then she has a baby who "cries all the time." Stress in pregnancy is associated with this kind of behavioral "dysregulation" in the newborn.  She may struggle with postpartum depression(PPD). The combination of depression and a fussy baby makes providing the kind of attuned relationship a newborn needs extremely difficult. But in the absence of an effective PPD screening and treatment program, the pair may not get help. There is severe sleep deprivation, marital stress and many other factors that make it difficult to be responsive in the way that supports character development.

By age three, the child has significant trouble with emotional regulation. His pediatrician, under the time constraint of the 10-15 minute visit, likely will offer behavior management advice about such things as time out. She likely will not have the opportunity to hear about the stressed marriage or the mother's depression, much less to take the time necessary to make an appropriate referral.

At age four, the child is disruptive in preschool. An ADHD evaluation is recommended by his teachers. He meets diagnostic criteria as defined by DSM. He is started on stimulant medication and immediately his behaviour improves. But soon the problems resurface as the underlying issues have not been addressed. The dose is increased. The medication is changed. This continues throughout the rest of his childhood. When he gets to high school and confronts the barrage of tests Tough writes about in his book, he starts abusing his stimulants.

I'm a clinician, not a policy person, but  I do have some thoughts about what needs to happen to get children off this path and on to one where relationships and character development are supported.

1) Transform education of health care professionals, who are on the front lines with young children and families, to focus on relationships as the 4th vital sign. The American Academy of Pediatrics Early Brain and Child Development Initiative is an important step in the right direction.

2) Educate all professionals who work with children and families about practical application of contemporary developmental science  (I actually wrote my book Keeping Your Child in Mind, for this purpose)

3) Change the system of reimbursement so that primary care clinicians are among the highest rather than the lowest paid

4) Value time as a clinical intervention

5) Offer comprehensive screening and treatment for postpartum depression and other perinatal emotional complications. Representative Ellen Story working to implement just such a program in MA

6) Address the overreliance on psychiatric medication use. There is a severe shortage of qualified mental health care professionals, related in large part to low reimbursement rates for treatments other than medication. 

Just before I spoke with Tough, I read  the following from an interview with him in the Hechinger Report:

Is part of the problem in higher-education and K-12 policy circles that we’re myopic—and that it takes longer than we’re willing to wait to determine if something is working?

In general, yes. I think any time you’re talking about child development and public policy, there’s that problem, which is that any intervention is going to take a long time. There’s a good case to be made that the most effective interventions are early interventions, and quite literally you’re not going to see the payoff for years and years—and our political system is not set up to fund those sorts of things.

So we have all this evidence of the importance of promoting healthy relationships in early childhood, as well as compelling evidence from University of Chicago professor James Heckman that investing in early childhood is economically very wise, and still we are so short-sighted and impatient? I asked Tough if perhaps this was a manifestation of childism.

Childism: Confronting Prejudice Against Children is a brilliant book by Elisabeth Young-Bruehl who tragically died suddenly just before the book was released, depriving us of the opportunity to learn about her work through the kind of publicity tour that Tough is now having. I describe it in detail in a previous post, that I will summarize here.

Young-Breuhl, an analyst, political theorist and biographer, calls attention to the way human rights of children are threatened. Childism is defined as “a prejudice against children on the ground of a belief that they are property and can (or even should) be controlled, enslaved, or removed to serve adult needs.”

Young-Breuhl provides ample evidence for her assertions, including a detailed history of the field of child abuse and neglect.

She describes Child Protective Services (CPS) as a “rescue service-a child saving service-not a family service supporting child development generally and helping parents…” Rather than setting up a system of treatment, CPS became "an investigative service...a situation in which bad families suspected of making their children bad will be invaded and infiltrated." Young- Breuhl has empathy for both parent and child, arguing that failure to support families is a manifestation of childism. 

Overreliance on psychiatric medication is in her view is example of childism:

She writes of “a childism of the sort that is now fueling an epidemic of diagnoses of bipolar II disorder and the prescription of medications to children who are, in effect, being doped into acquiescence." 

Young-Breuhl compares the situation in our country with comparable developed countries that have lower rates of child abuse and neglect.

There, “children have a range of preventative and development-oriented services: universal health care, health services, and parent support services in homes after the birth of a child; maternal and parental leaves for infant care; developmental preschool programs; after-school programs; and economic supports of various kinds.”

I don't claim to have the answer to the problem of childism, but I do think that if we are going to be able to make use of Tough's very important book to implement meaningful change, it a least needs to be acknowledged.

Pediatrician T. Berry Brazelton, whose work is featured as an antidote to childism, endorses [Young-Breuhl's] book, recommending that all who are involved with children and families should read it. This book has helped me, like nothing else I've read, to understand why it is so hard to get the kind of help for children that all the best science of our time is telling us they need. I hope everyone reads it. As Young-Breuhl states, “prejudice has to be recognized in order to be overcome.

Paul Tough Speaks at Harvard: How Children Succeed

One of the highlights of Paul Tough's new book How Children Succeed:  Grit, Curiosity and the Hidden Power of Character comes in the final chapter, when he describes how he and his wife interact with their three-year-old son Ellington to help develop the qualities he spends the rest of the book demonstrating are associated with success.

He describes helping Ellington to calm down after a tantrum or bad scare, providing discipline and rules, and, in addition to lots of hugs and comfort, helping him learn to manage failure. These are exactly the parenting behaviors that research has shown lead to the capacity for emotional regulation, cognitive resourcefulness, resilience, and the ability to adapt to a complex social world.

The thesis of this book, whose primary focus is the education system-Tough is speaking on Thursday September 6th at the Gutman Library of the Harvard School of Education-, is that the conventional wisdom about the key to success has been misguided. Rather than focus on promoting cognitive abilities, our focus should be on development such things as gratitude, curiosity, self-control and grit, all of which are distilled into the word "character."

While Tough does not explicitly make this point, but rather demonstrates it in writing about his son, character develops in relationships.  When a person has a relationship with someone who not only cares about him, but also thinks about him, understands his perspective and unique challenges, helps him calm down in the face of difficult feelings, sets limits on his behavior and trusts him enough to let him fail, he is more likely to develop the "non-cognitive skills" associated with success. He will be able to think clearly and flexibly in the face of stress.

The first chapter offers an excellent overview of the current explosion in research on toxic stress, or stress in the absence of such a secure, safe relationship. Tough refers to the  ACES (Adverse Childhood Experiences) study, a huge longitudinal study that dramatically demonstrated the association between early adversity, including such things as abuse and neglect, parental mental illness and substance abuse, and family discord, with many negative health outcomes including not only mental illness but also chronic illnesses such as diabetes, asthma and heart disease.

Particularly important is the work of Alicia Lieberman, one of the pioneers in the field of infant mental health. Tough writes of Lieberman's collaboration with pediatrician Nadine Burke Harris in an innovative San Francisco based program that applies the ACES study to preventive work with children and families.  Lieberman recognizes that providing a secure attachment relationship "takes a superhuman quality" in the face of poverty, uncertainty and fear. Her model of intervention works with parent and child together.

Lieberman's treatment is relatively intensive, administered in weekly sessions that can continue for as long as one year. But the principle behind it-improving children's outcomes by promoting stronger relationships between children and their parents-is increasingly in use across the country in a wide variety of interventions. And the results, when the interventions are evaluated, are often powerful.

The rest of Tough's book focuses on interventions for school age children. The implication is that these children have had stressed early relationships, but that interventions in the school setting that focus on character development may mitigate against these early experiences. He writes:

It is hard to argue with the science behind early intervention. Those first few years matter so much in the healthy development of a child's brain; they represent a unique opportunity to make a difference in a child's future. But one of the most promising facts about programs that target emotional and psychological and neurological pathways is that they can be quite effective later on in childhood too-much more so than cognitive interventions. 

Tough describes successful school programs that have focused on character development. The Youth Advocate Program, or YAP, in Chicago offers an intensive mentoring program for high-risk teenagers.  At KIPP (Knowledge is Power Program) in the South Bronx, where there is a curriculum designed to teach character, and even a character report card, one student describes how the teachers were devoted to him and his fellow students. " They were like my second family, in essence...that's the vibe we all ended up getting, that we were like a family."

Yet another program is OneGoal in Chicago, run by CEO Jeff Nelson:

Nelson's belief is that underperforming high-school students can relatively quickly transform themselves into highly successful college students- but that it is almost impossible for them to make that transition without the help of a highly effective teacher. OneGoal has signed a unique partnership deal with the Chicago public schools that lets the organization work directly with individual teachers...the teacher sticks with the same class for three years...And when the students are freshmen in college the teacher keeps in close touch with them...providing support and advice."

Tough shows how relationships can be stressed not only for the very poor, but also the very wealthy.

Riverdale, a private school in a very different part of the Bronx from KIPP, offers an example of wealthy students who are similarly at risk. Referring to the work of psychologist Madeline Levine, he writes:

Wealthy parents today, she argues, are more likely than others to be emotionally distant from their children while at the same time insisting on high levels of achievement, a potentially toxic blend of influence that can create "intense feelings of shame and hopelessness" in affluent children. 

Stressed relationships of this kind may have a negative impact on character development. Riverdale's headmaster, Dominic Randolph, is concerned that students are lacking in important character traits.

Traditionally the purpose of a school like Riverdale is not to raise the ceiling on a child's potential achievement in life but to raise the floor. What Riverdale offers parents, above all else, is a high probability of nonfailure...The problem, as Randolph has realized, is that the best way for a young person to build character is for him to attempt something where there is a real and serious possibility of failure.

The book takes an interesting turn when, after focusing on a number of programs that measure their own success in terms of rates of college graduation, Tough reveals that he himself did not graduate from college. Clearly Tough is a highly successful person. This information led me to wish that more of the book had been devoted to exploration of the definition of success.

I thought of how Sigmund Freud defined mental health as the capacity to love and to work. I though about creativity and empathy as two qualities that are intimately tied to success. I found myself remembering Brandon Fisher, the manufacturer of drilling equipment who was recognized by President Obama in the 2011 State of the Union address for his critical role in the rescue of the Chilean miners.

These other aspects of success are mentioned in Tough's book. For example:

At KIPP, teacher Mike Witter explains to a parent, "The categories [of character traits] we ended up putting together represent qualities that have been studied and determined to be indicators of success. They mean you're more likely to to go to college. More likely to find a good job. Even surprising things, like they mean you are going to get married, or more likely to have a family."

A related body of research, coming from the fields of infant mental health and psychoanalysis, supports the notion that the way Tough interacts with Ellington will in fact lead to this broader definition of success. This literature, and in particular the work of leading researcher Peter Fonagy, refers to the central aspect of a secure attachment relationship,  a capacity that is unique to humans, as mentalization, or "holding a child in mind."

John Bowlby, considered the father of attachment theory, writes how in the setting of such a relationship a child becomes, "self-reliant and bold in his exploration of the world, cooperative with others, and also- a very important point-sympathetic and helpful to others in distress." 

Tough is applying his considerable talents as a journalist and writer to a critically important task. The question he asks is not only how children succeed, but also how the answer can inform meaningful social policy. He is bringing this issue to the forefront of public discussion.  I am thrilled to be in the company of Tough, as in my work I have also been asking:  What can we as a society do to promote healthy relationships, that in turn promote both character and success, from infancy through adolescence? Tough writes:

Parents are an excellent vehicle for those interventions, but they are not the only vehicle. Transformative help also comes regularly from social workers, teachers, clergy members, pediatricians, and neighbors. 

Tough tackles this issue in his whole body of work, including not only this book, but also his first book,  Whatever it Takes, about Geoffrey Canada and the Harlem Children's Zone, and his New Yorker article The Poverty Clinic about pediatrician Nadine Burke Harris' program.   I am eager to see what he does next.