1. Bullying and Hazing in the Adolescent Athlete February 16, 2018
Southeast American College of Sports Medicine
46th Annual SEACSM Clinical Track Program
Bullying and Hazing in the Adolescent Athlete February 16, 2018
Alex B. Diamond, D.O., M.P.H.
Assistant Professor of Orthopaedics and Rehabilitation
Assistant Professor of Pediatrics
Director, Program for Injury Prevention in Youth Sports (PIPYS)
Vanderbilt University Medical Center
Team Physician
Vanderbilt University
Nashville Sounds & Nashville Predators
15 minutes

2. Disclosure
Neither I, Alex Diamond, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.
0:30 + 0:10

3. Practice and Research Gaps
The actions and behaviors that actually constitute hazing are poorly understood.
Data examining the epidemiology and consequences of hazing in sports is limited. 
Comprehensive and well-implemented plans that properly address the prevention of hazing as well as the subsequent physical and psychological concerns of student-athletes are presently lacking. 
When we begin to identify the practice and research gaps that exist we see both basic & more complex concerns that need to be addressed. For example, it is still poorly understood what actions & behaviors actually constitute hazing. The data we have re: epidemiology and consequences of hazing is very limited. And finally plans that get into the prevention of hazing and the subsequent physical and psychological issues of the student-athletes are lacking and in their infancy.

4. When I say the word hazing, what do you envision
When I say the word hazing, what do you envision. What images or stories come to mind. There is probably a wide range of thoughts going on in the room right now. Do you think this is a true issue or just part of our new generations & culture “being soft.” is this just fun & games or is this violent crime. What I will tell you is that this is not a grey issue. This is totally a black and white issue. this is real and life-changing and wrong and effects all of us regardless of gender, race or background.

5. Terminology: Bullying vs Hazing
US Centers for Disease Control and Prevention, 2014.
Terminology: Bullying vs Hazing
Forms of interpersonal violence where power-differential exists
Immediate and long-term consequences
Bullying
Any unwanted aggressive behavior by another
Repeated multiple times or is highly likely to be repeated
Inflicts physical, psychological, social or educational harm or distress
Hazing
Any humiliating or dangerous activity expected of a student who belongs to a group
Regardless of his or her willingness to participate
Not repetitive
The terms bullying and hazing get thrown around a lot together but what are they exactly. They both… But where they differ is...that bullying is any unwanted aggresive behavior with the purpose of inflicting some type of harm and to keep another out of the group. Whereas hazing is any humiliating or dangerous activity expected of a student who actually belongs to the group regardless of their willingness to participate. It is not repetitive while bullying typically is.

6. Mental Health Basis & Key Concepts
Fields S. Trauma Violence Abuse, 2007.
Waldron JJ. Quest, 2005.
Raalte JLV. Jrnl Sport Behavior, 2007.
Mental Health Basis & Key Concepts
Evolutionary theory / “Team Building”
“Generates group cohesion; allows for selection of committed group members”
Unity important part of being on team; hazing in sports rooted in this notion
“Deviant over-conformity” / Cycle Perpetuated
Why haze / be hazed?
Perpetrator: Power, dominance, reduction of future exploitation
Victim: Acceptance, group membership identification & benefits, protection from non-group members
Attempt to demonstrate self-worth, dedication and willingness to make sacrifices for the team
What are the psychosocial underpinnings that has allowed hazing to occur? Why haze or be hazed. There are motivations for both the perp and the victim.

7. Cognitive Dissonance
Effort involved in group initiation justified by reward of belonging to that group
Potential for significant harm often underestimated
Assumed that participation is consensual
Lack of perception of its occurrence
National study of collegiate hazing (Allan EJ, 2009)
More students perceived positive benefits of hazing experience (opposed to negative)
31% greater identification with group
22% sense of accomplishment
18% felt stronger
There is also the theory and power of cognitive dissonance and that basically means that the…
Lack of perception that hazing is actually occuring or that the ones doing the hazing have my best interest at heart

8. Psychological Sequelae
Depression
Anxiety
Eating disorders
Suicidal thoughts/behaviors
Loss of confidence & self-esteem
Aggression towards self &/or others
Interpersonal conflicts (trust issues)
Changes in weight, energy, sleep, concentration
Substance use
Sexual difficulties
Emotional instability
Delinquency/criminality
Make no mistake, hazing is Maltreatment and in some cases an Act of violence and it has consequences.

9. General Population: Hazing
Allan EJ. StopHazing.Org, 2008.
Neal TL, Diamond AB, et al. J Athl Train, 2015.
Hoover N. Alfred Univ Pub., 2000.
General Population: Hazing
Many who experience hazing may not recognize it as such
47% HS students acknowledged occurrence
Only 8% labeled behavior as hazing
Highest subsets… sports (47%), ROTC (46%), band (34%)
43% subjected to humiliating activites; 30% made to perform potentially illegal acts
71% with negative consequences
Likelihood of being hazed affected by both...
their own attitudes about hazing
experiences and attitudes of important adults in their lives
When we look at hazing in the general population we see that …
Many believe that coaches and advisors are aware of hazing activities

10. Hazing in Sports: College
Hoover NC. Alfred Univ Pub, 1999.
Fields SK. BJSM, 2010.
Allan EJ. StopHazing.Org, 2008.
Hazing in Sports: College
Remarkably common
80% described behavior during team initiation
Only 12% actually reported
Poor understanding
60-95% would not report
42% also during HS
20% subjected to illegal activity; 50% alcohol-related; 2/3rd personal humiliation
30 deaths ( )
We find hazing in collegiate sports remarkably common. 80% described behaviors consistent with hazing occuring during team initiations but only 12% reported it.
Of the types of activities they were subjected to, 20% were illegal,50% involved alcohol and 2/3rd revolved around personal humilation.

11. Hazing in Sports: Youth
Fields SK. BJSM, 2010
Gershel JC. J Adolesc Health, 2003.
Hazing in Sports: Youth
Incidence
Middle School = 5% %
High School = 17.4% - 48%
3% felt it was dangerous
22% of activities described had potential for serious physical harm
86% felt worth it to be part of team (MS & HS)
On the youth sports level, the incidence increased with age…

12. Hazing in Sports No sport spared
Waldron J. Res Q Exerc Sport, 2009.
Gershel JC. J Adloesc Health, 2003.
Hazing in Sports
No sport spared
Unclear why certain personal demographics, sports or levels of participation lead to more or less hazing-related activities
Greatest reporting rates seen…
in higher levels of competition, team sports and contact sports
in more individualistic, non-contact sports such as gymnastics and cheerleading (6th graders)
Boys = Girls
Boys subjected to more physical forms
On a general level …

13. Types of Hazing Practices
Waldron J. Res Q Exerc Sport, 2009.
Types of Hazing Practices
Categories
Physical
Psychological
Alcohol related
Can vary as to how expressed
There are 3 major categories of hazing but it can vary as to how that’s actually expressed

14. Subsets of Hazing
And that expression is through Subsets of hazing whether that be subtle, violent or harrassment forms.
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
Diamond AB et al. Br J Sports Med 2016;50:
Allan EJ. StopHazing.Org 2004.

15. Hazing Examples Physical Alcohol related Psychological
Beatings/paddling
Branding
Burning
Tattooing
Calisthenics
Head shaving
Kidnapping
Abandonment
Sexual assaults
Alcohol related
Forced binge drinking
Psychological
Forced to perform embarrassing acts
Wear embarrassing clothes or makeup
Being screamed at
Name-calling
Depriving sleep or food
Acting as a slave
Being tied or taped up and/or confined

16. Hazing Consequences Cancellation of team season
Suspension of student-athletes
Arrest of student-athletes
Loss of team cohesiveness
Serious injury (physical, psychological) or death
As we’ve alluded to before, there are serious consequences of hazing both to the individual and the team. We have seen…

17. Does Hazing Build Teams
Van Raalte JL. J Sport Behav, 2007.
Does Hazing Build Teams
As hazing increased…
the less attracted athlete became to team
the less team bonding and closeness athlete felt
However…
Higher level of team social cohesiveness if athlete participated in appropriate team building activities
Therefore…
Dangerous consequences of hazing provide no added benefit to concept of team unity and likely have opposite of intended effect

18. Hazing vs Team Building
Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
Hazing vs Team Building
Hazing
Team Building
Humiliates and degrades
Promotes respect and dignity
Tears down individuals
Supports and empowers
Creates division
Creates real teamwork
Lifelong nightmares
Lifelong memories
Shame and secrecy
Pride and integrity
Is a power trip
Is a shared positive experience
This table shows the differences in what hazing and proper team building activities provide.
Reprinted with permission from Wilfert. Copyright 2007 by the National Collegiate Athletic Association.
Diamond AB et al. Br J Sports Med 2016;50:

19. Awareness & Prevention
Global investment & comprehensive approach
Athletes, coaches, administrators, healthcare providers
Change of culture
Increased education
Incorporation of programs with validated measures
Passage of legislation
43 states with an anti-hazing statute
Establishment of clearly defined policies and penalties
Zero tolerance
Early involvement from mental health
So how do we make a difference. It can’t just be involvement, there needs to be an investment and it needs to be comprehensive. Coaches, admin, healthcare and student athletes and quite frankly, the student-athltes must take ownership of process

20. Key Roles in Hazing Awareness and Prevention
Diamond AB et al. Br J Sports Med 2016;50:
Administrators
Coaches
Student athletes
Team captains
Dispel myths/set the record straight
Create environment of total respect and dignity for all
Understand what constitutes hazing
Encourage others to speak up without fear of retribution
Ensure comprehensive approach
Address topic/consequences early and consistently
Insist on open communication among teammates and coaches
Understand potential level of accountability
Provide appropriate resources/support
Involve your team in process; be supportive
Plan alternate activities that enhance bonding
Ensure new members feel supported
Establish protocols and procedures for the process (reporting, investigating, adjudicating)
Help develop positive traditions that are significant and meaningful
Understand team acceptance and success should be based on strong work ethic, positive attitude, positive relationships
Enforce clearly defined sanctions
Discuss expectations re: character, values on/off field
Discuss among your team how to report potential incidents
Create conduct guidelines along with coaches
Take it seriously
Make caring about each other a high priority
Accept role as leader; Set proper tone with your actions and words
Avoid creating division between veterans and new players
Seek advice from trusted adults/leaders
I’m not going to go through this table but I wanted you to have it. The point is that we all have key and specific roles to play and it should be clearly defined when developing a policy for your school or institution.
Adapted with permission from Wilfert. Copyright 2007 by the National Collegiate Athletic Association.

21. Additional Action Items
Wilfert M. NCAA, 2007.
Wilfert M. NCAA, 2014.
Additional Action Items
Never use terms such as “pranks” or “stunts” that soften true nature of conduct
Allowing “a little hazing” leads to tolerance for “big hazing”
Avoid mixed messages
Media/Professional teams
Eliminate situations that involve secrecy, alcohol & power imbalance
Create support networks/open communication
Men most likely turn to teammates (27%)
Women most likely turn to parents (29%)
I can only imagine the look on my face when I saw Rookie singing or head shaving celebrated at end of sportscenter or in social media leads to loss of credibility of investigative shows on same channel when catastrophic event occurs

22. Take Home Points
Hazing victims can be willing participants; different than bullying
Approx. 3/4th of those hazed experience some degree of negative consequences
Interpersonal, physical, psychological
Hazing remains largely underreported & result of poor culture/understanding
Zero tolerance policy should exist along w/ comprehensive prevention plan
Replace w/ positive team building activities
You can’t just take things away from people or just say no and leave them without options. We need to provide better options and that is using positive team building activities.

23. Key References
Diamond AB, Callahan ST, Chain KF, Solomon GS. Qualitative review of hazing in collegiate and school sports: consequences from a lack of culture, knowledge and responsiveness. Br J Sports Med. 2016; 50(3):
Neal TL, Diamond AB, Goldman S, et al. Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement. J Athl Train 2015; 50:
Wilfert M, NCAA Education Services. Building new traditions: hazing prevention in college athletics. Indianapolis, IN: The National Collegiate Athletic Association, 2007.
Hoover NC. National survey: initiation rites and athletics for NCAA sports teams. Alfred University  

24. Thank You Twitter: @DrDiamondSports