Emily Sallee, Abraham Cazares-Cervantes, Kok-Mun Ng
Suicide is the second leading cause of death in adolescents (ages 12–19) in the United States, and more work is needed to shed light on the interpersonal protective factors associated with adolescent suicidality. To address this gap in the empirical literature, we examined the application of the Interpersonal Theory of Suicide (IPTS) to the middle adolescent population. We analyzed survey data using the 2017 Oregon Healthy Teen dataset, which included 10,703 students in 11th grade. Binary logistic regressions were used to examine the extent to which the IPTS constructs of perceived burdensomeness and thwarted belongingness predicted middle adolescent suicide ideation and attempt. Findings indicate that three of the five proxy items were statistically significant in each model, with consistent mediators for each. These findings have the potential to guide development of appropriate treatment strategies based on the interpersonal constructs of the IPTS for clinicians working with this population.
Keywords: adolescents, suicide ideation, suicide attempt, suicidality, Interpersonal Theory of Suicide
Suicide is a leading cause of death worldwide, spanning across all ages, ethnicities, genders, cultures, and religions. In the United States from 2000 to 2015, suicide rates increased 28%, with 44,193 people dying by suicide yearly, equating to about one death every 12 minutes. Nationally, statistics now identify suicide as the second leading cause of death in adolescent populations (Centers for Disease Control and Prevention [CDC], 2017). Specific to the state of Oregon, over 500 youth between the ages of 10–24 were hospitalized each year because of self-harm, including suicide attempts. In 2017 alone, more than 750 youth were hospitalized and 107 suicides were completed; considering that many ideations and attempts do not result in hospitalization, it is likely that there were more Oregonian youth who had attempted suicide but were never hospitalized, and an even greater number who had contemplated suicide (Oregon Suicide Prevention, n.d.).
Unfortunately, studies on suicide, particularly adolescent suicide, are rarely driven by theory. This results in a lack of integration between research findings and clinical practice (King et al., 2018). Clinicians working with the adolescent population are in need of research- and evidence-based practices ready for implementation. Although the Interpersonal Theory of Suicide (IPTS; Joiner et al., 2009) was initially developed for and then applied to adult populations, it has the potential to inform clinicians in preventative and intervention efforts in other populations, offering an evidence-based framework to understand and address suicide prevention and intervention. In an earlier study (Sallee et al., 2021), we found evidence to support its use with the early adolescent (ages 11–14) population. The present study utilizes the IPTS as a framework to examine the interpersonal drivers of suicidality among middle adolescents (ages 14–17) in Oregon.
Joiner et al.’s (2009) IPTS offers a theoretical lens to explain suicide ideation and behavior in three dynamic constructs: perceived burdensomeness, thwarted belongingness, and acquired capability. The first two are influential in suicidal desire. The dynamicity of the constructs is related to the fluctuation of interpersonal needs and cognitions over time. Together they contribute to significant risk for suicide ideation. Acquired capability is static and believed to develop in response to exposure to provocative, painful, and/or violent experiences, overpowering the human survival need of self-preservation. Acquired capability, in tandem with thwarted belongingness and perceived burdensomeness, results in a high risk for suicidal behavior/attempt (King et al., 2018).
This field of research uses terms like suicide ideation, suicidal behavior, suicidology, self-harm, self-injury, and self-inflicted death to describe the thoughts and behaviors of a person ending their own life. The CDC defines suicide ideation within a broader class of behavior called self-directed violence, referring to “behaviors directed at oneself that deliberately results in injury or the potential for injury . . . [it] may be suicidal or non-suicidal in nature” (Stone et al., 2017, p. 7). The intent of suicidal self-directed violence is death, while the intent of non-suicidal self-directed violence is not. A suicide attempt may or may not result in death or other injuries. Because we held a particular interest in adolescent suicide ideation and behavior, its differentiation of lethal intent from non-suicidal self-injury (NSSI) led us to leave NSSI ideation and/or behavior out of the scope of the study. However, recent studies addressing IPTS have included self-harm as an indicator of acquired capability (e.g., Barzilay et al., 2019) and should be included in future studies involving this construct.
Suicide ideation and attempt in adolescent populations is a serious public health concern in the United States that is growing in frequency and intensity every year. National statistics suggest that 17.2% of adolescents have experienced or currently experience suicide ideation, and 7.4% of adolescents have made a suicide attempt (CDC, 2017). Despite this growing health concern, most research in this body of work has focused primarily on adult populations (Horton et al., 2016; Stone et al., 2017). Limitations in the extant empirical literature include a lack of emphasis on theory as well as a lack of quantitative research on large samples in non-inpatient treatment settings (Czyz et al., 2015; Horton et al., 2016; Miller et al., 2014). In clinical practice, this challenges mental health practitioners’ ability to rely on evidence to serve their clients. Becker et al. (2020) found significant evidence of the applicability of IPTS to a large undergraduate (ages 18–29) population, suggesting that the interpersonal constructs might be applicable to younger non-inpatient groups. Based on the IPTS, this study examined the extent to which a specific set of interpersonal predictors of perceived burdensomeness and thwarted belonging were associated with suicide ideation and attempt in a large non-clinical sample of middle adolescents.
Adolescents and Suicidality
Adolescence marks the developmental period between childhood and adulthood, corresponding to the time from pubertal onset to guardian independence. This period is associated with increased risk-taking behaviors as well as increased emotional reactivity, occurring in the context of developmental changes influenced by external and internal factors that elicit and reinforce behaviors. Cognitively, over the course of adolescence, the prefrontal cortex of the brain continues to develop and is responsible for impulse control and delayed gratification in favor of more goal-directed choices and behaviors (Jaworska & MacQueen, 2015). One apparent risk factor for suicide ideation and behavior in adolescents is their impaired decision-making. In addition, this developmental period also accounts for half of all emotional and behavioral disorder diagnoses and the highest rates of suicide with subsequent higher risks for suicidal behavior during their lifetime (Wyman, 2014). Wasserman et al. (2015) metabolized research supporting the theory that most pathological changes occur in childhood and adolescence, suggesting that it is during this developmental time period that prevention and intervention is imperative, as the adolescent years themselves prove to be a risk factor for suicide ideation and behavior.
The typical age of 11th grade students is 16 or 17, and these students are characterized as being in the developmental period known as “middle adolescence.” By this age, puberty is typically completed for both males and females, and adolescents begin setting long-term goals, concurrently becoming more interested in the meaning of life and moral reasoning. They experience an increased drive for independence and increased self-involvement. During the overall developmental stage of adolescence, youth must adjust to their physically and sexually maturing bodies and feelings; define their personal sense of identity and adopt a personal value system; renegotiate their relationships with parents, family, and caregivers; and develop stable and productive peer relationships (Teipel, 2013).
Of relevance to the present study, it is important to note that according to Teipel (2013), adolescents in 11th grade (ages 16–17) experience an increased concern with their appearances and bodies, incorporating a personal sense of masculinity or femininity into their identities and establishing values and preferences of sexual behavior. This period of self-involvement results in high expectations of self and low self-concept, coinciding with an increased drive for peer acceptance and reliance (American Academy of Child & Adolescent Psychiatry, 2021). Additionally, as the typical adolescent is tasked with gaining autonomy and independence from the nuclear family, they will likely experience periods of sadness as the psychological loss, not so unlike grief, takes place (Teipel, 2013). Adolescents in the 11th grade school environment are preparing for the final year of high school and potentially postsecondary education after graduation, creating unique stressors related to increasing autonomy and independence as they approach the formidable ascent into adulthood.
Theories of suicide have evolved over the past 70 years to reflect research and societal influences and implications, yet they all seem to agree that “perceived disruption of interpersonal relationships may serve as one potential mechanism of the association between child maltreatment and [suicide ideation]” (Miller et al., 2014, p. 999). Durkheim and Simpson (1951) suggested that suicide was the result of social causes like isolation, altruism, and anger/frustration. Behavioral theorists like Lester (1987) believed that suicide was a learned behavior, resulting from adverse childhood experiences and psychosocial environmental factors. Schneidman (1993) thought suicidal behaviors were motivated by the desire to escape emotional pain caused by the lack of socially supportive and nurturing relationships. Joiner’s IPTS focuses on the importance of interpersonal relationships, characterized by the confluence of two negative interpersonal states (i.e., perceived burdensomeness and thwarted belongingness; Miller et al., 2014).
The present study was guided by several gaps in the literature related to the application of the IPTS to adolescent populations. Initially, the IPTS was constructed by Joiner and his colleagues (2009) through studying adults engaging in suicidal behaviors. Since its development, the theory has been studied primarily in its application to adult and college student populations (Horton et al., 2016). The lack of research on the application of the IPTS to non-inpatient adolescents may suggest its incompatibility to the uniqueness of adolescent suicidality; however, Horton et al. (2016) argued that the constructs of the theory are relevant in adolescence regardless of setting and presentation, though they may manifest in slightly different ways based on differences in developmental context. As such, they proposed that perceived burdensomeness in adolescents may manifest as low academic competency or social disconnection and thwarted belongingness may manifest as social isolation from peers or poor family cohesion. Adolescence is also a developmental period when children may begin to engage in health-risk behaviors, are particularly prone to impulsivity because of the immature nature of their prefrontal cortex, and have the increased pressure of peer behavior on their own, as well as a sense of invulnerability to consequences (Horton et al., 2016). Though adolescent suicide–related research based on the IPTS to date remains sparse, the theory’s focus on the dynamic constructs of perceived burdensomeness and thwarted belongingness appears attractive in consideration of potential application to preventative and responsive efforts.
Perceived burdensomeness is characterized by self-hatred and the belief that one is a burden to others, including family and friends, leading to the idea that they would be better off without them. It deals with the misperceptions of being a liability for family and intimate peers. As a dynamic interpersonal construct, it responds well to both interpersonal and intrapersonal interventions. However, although perceived burdensomeness responds more slowly to intervention, it may be a more significant predictor of suicide ideation and behavior than thwarted belongingness. There is also research that suggests that thwarted belongingness and perceived burdensomeness are more enmeshed in adolescents, suggesting that only one of the dynamic interpersonal constructs is necessary to be coupled with acquired capability and lead to suicidal behavior (Chu et al., 2016; Joiner et al., 2012; Stewart et al., 2017).
Thwarted belongingness is a dynamic condition of social disconnection described by the interpersonal state of loneliness in which the psychological need to belong is not met. Of the two dynamic interpersonal constructs within the IPTS that respond to both interpersonal and intrapersonal interventions (thwarted belongingness and perceived burdensomeness), research suggests that thwarted belongingness may be easier to treat and respond more quickly to intervention than perceived burdensomeness (Chu et al., 2016; Joiner et al., 2012; Stewart et al., 2017). It has been well established that positive and negative effects of close relationships are particularly formative in the adolescent years, and therein lies the difficult developmental task of establishing strong peer relationships while also maintaining familial bonds (Miller et al., 2014). Relatedly, adolescents with histories of abuse or other maltreatment are at particular risk. It has been shown that low perceived quality of family and peer connectedness and belonging contribute to thwarted belongingness and its dynamic interpersonal state.
Acquired capability is a static construct in the IPTS, describing a decrease in or lack of fear about death and an elevated tolerance of physical pain. It is suggested to be developed through repeated exposure to painful and provocative events (Chu et al., 2016; Joiner et al., 2012; Stewart et al., 2017). Stewart et al. (2017) characterized it as “the combination of increased pain tolerance and decreased fear of death [that] results in progression from suicide intent to suicidal behavior, culminating in a suicide attempt” (p. 438). This construct’s combination of pain tolerance and fearlessness about death is significant in current conversations around adolescents engaging in violent video games, which could correlate to fearlessness about death but not necessarily pain tolerance (Stewart et al., 2017). Acquired capability as the combination of pain tolerance and fearlessness is also significant to other mental health disorders, including anorexia nervosa, in which risk factors for suicide ideation and behavior are prevalent and are characterized by increased pain tolerance and fearlessness about death.
According to the IPTS, these three constructs are proximal to suicidal behavior. Horton et al. (2016) suggested that “an important strength of the theory is that it explains the lower frequency of more severe levels of suicidality (such as suicide attempt) compared to less severe levels (such as passive suicide ideation)” (p. 1134) because it is the combination of the three constructs that leads to suicidal behavior. The theory also posits that the difference between passive and active suicide ideation is the difference between the presence of one or both of the dynamic interpersonal states of thwarted belongingness and perceived burdensomeness. In other words, one dynamic interpersonal construct suggests passive ideation, two suggest active ideation, and all three constructs lead to suicidal behavior.
Purpose of the Present Study
Most previous studies that applied the IPTS to suicidal adolescents of this specific age group only addressed inpatient populations (e.g., Czyz et al., 2015; Horton et al., 2016; Miller et al., 2014). However, our recent study (Sallee et al., 2021) indicated support for using this theory in understanding suicide ideation and attempts among non-inpatient early adolescents. Specifically, the findings revealed significance in multiple mediators representing the IPTS constructs of perceived burdensomeness and thwarted belongingness. The significant drivers for suicide ideation included emotional/mental health and feeling sad/hopeless as the proxy items for perceived burdensomeness, and not straight and bullied as the proxy items for thwarted belongingness. Similarly, the significant drivers for suicide attempt included emotional/mental health and feeling sad/hopeless as the proxy items for perceived burdensomeness, and non-binary and bullied as the proxy items for thwarted belongingness. The current study extends the efforts of using the IPTS in studying suicidality among adolescents to an older age range (ages 16–17). Using the theory to examine suicidal behavior among middle adolescents in school settings can potentially extend its utility and inform practitioners who are working with youth in this age group who struggle with suicide ideation and behavior in various settings such as mental health and medical.
Based on the IPTS, the focus of this study was to examine the extent to which the interpersonal constructs of perceived burdensomeness and thwarted belongingness predict adolescent suicide ideation and attempt. In consideration of the aforementioned needs and gaps in this field of study, we formulated two research questions: 1) To what extent do feelings of perceived burdensomeness and thwarted belongingness predict suicide ideation among 11th grade students (a middle adolescent population) in Oregon? and 2) To what extent do feelings of perceived burdensomeness and thwarted belongingness predict suicide attempts among 11th grade students (a middle adolescent population) in Oregon? We hypothesized that the two dynamic IPTS constructs would both statistically significantly predict suicide ideation and suicide attempts in this population.
A dataset of 10,703 participants was selected from the randomized weighted sample of 11,895 students in 11th grade who participated in the 2017 Oregon Healthy Teen (OHT) survey, a comprehensive assessment measuring risk factors and assets shown to impact successful development (Oregon Health Authority [OHA], 2017). This dataset was selected for its representation of middle adolescents at the cusp of a monumental transition in life—finishing K–12 education and embarking on what is to come. Participants’ ages ranged from 16 to 17 years (M = 16.7 years). In terms of gender identity, 48.9% self-identified as female, 45.6% as male, and 5.5% as non-binary/gender nonconforming, which included those who identified as “transgender, gender nonconforming, genderqueer, gender fluid, intersex/intergender, or something else.” Among the participants, 85.9% spoke English at home. The racial/ethnic composition was as follows: 62.9% White, 25% Hispanic/Latino, 3.6% Asian, 2.2% Black or African American, 5.5% other, and 0.8% multiple.
We conducted a secondary analysis of archival survey data collected in the 2017 OHT survey. The 2017 OHT study utilized a probability design (i.e., all participants’ datasets had equal chances to be selected for the sample) to minimize possible selection biases and a randomization process (lottery method or computer-generated random list) to minimize sampling error with stratification of school regions. The survey was administered by school officials during one designated school period, utilizing standardized procedures to protect student privacy and facilitate anonymous participation. The researchers obtained IRB approval prior to requesting and receiving the data in SPSS format from the OHA.
The OHT Dataset
The OHT survey has origins in the Youth Risk Behavior Survey, a biennial national survey developed by the CDC. The 2017 OHT survey, administered to volunteering eighth and 11th grade students with a school response rate of 83% (R. Boyd personal communication, February 22, 2019), was chosen for this study because it explores a variety of health-related items, including suicidality, and has additional items deemed suitable for proxy descriptors of the IPTS constructs. The 11th grade dataset was selected for the study to target this specific developmental period because of its characteristic of impaired decision-making serving as a risk factor for ideation and behavior. Additionally, adolescents who experience suicidality during this age range are at a higher risk of suicide ideation and attempt in subsequent life stages compared to adolescents who did not experience suicidality at this time (Wyman, 2014).
In this study, the dynamic interpersonal constructs of the IPTS—perceived burdensomeness and thwarted belongingness—served as variables predicting the two outcome variables of suicide ideation and suicide behavior/attempt. The third construct of the IPTS, acquired capability, was not included as a predictor variable because of its staticity and ineffective response to intervention. We were also unable to locate items in the OHT survey that could be used as proxy items for acquired capability. The two predictor variables were measured with proxy items in the OHT survey (OHA, 2017). The proxy items for each predictor variable were chosen based on empirical research (Horton et al., 2016; Miller et al., 2014; Seelman & Walker, 2018; Zhao et al., 2010). Both outcome variables (suicide ideation and suicide behavior/attempt) were direct questions in the survey, surveyed as follows: 1) “During the past 12 months, did you ever seriously consider attempting suicide?” (Yes/No), and 2) “During the past 12 months, how many times did you actually attempt suicide?” (0, 1 time, 2 or 3 times, 4 or 5 times, 6 or more times). The second question was recorded to combine any number of times larger than zero, reflecting the response that either the participant had not attempted suicide (0) or had attempted suicide (1).
As previously noted, the selection of proxy items was based on previous empirical research on suicidality, adolescent suicidality, and the IPTS (Horton et al., 2016; Miller et al., 2014; Seelman & Walker, 2018; Zhao et al., 2010). The proxy items selected for this specific study differed slightly from the researchers’ previous study with a younger population (early adolescents) because of the developmentally appropriate differences in the eighth and 11th grade OHT survey tools.
The first predictor variable (perceived burdensomeness) was measured with two proxy survey items: emotional/mental health and sad/hopeless feelings. Emotional/mental health was chosen as a proxy item for the predictor variable of perceived burdensomeness because of the research connecting mental health challenges to emotional strain in the family setting, suggesting a potential perception of being a burden on loved ones (Miller et al., 2014). The survey item for emotional/mental health read: “Would you say that in general your emotional and mental health . . .” with the answer options including: 1) Excellent, 2) Very good, 3) Good, 4) Fair, and 5) Poor. The proxy item of sad/hopeless feelings was chosen because of its inclusion in the definition of perceived burdensomeness but exclusion from many studies of the IPTS (Horton et al., 2016). The survey item for sad/hopeless feelings read: “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?” with the answer options of simply Yes or No.
The second predictor variable (thwarted belongingness) was measured with three proxy survey items: sexual orientation, sexual identity, and volunteering (inverse). As previously described, thwarted belongingness constitutes the interpersonal state of loneliness and lack of social connection. Sexual orientation and sexual identity were chosen as proxy items for the variable of thwarted belongingness because sexual minority students experience higher rates of bullying and a greater likelihood of suicidal behaviors (Seelman & Walker, 2018); gay, lesbian, and bisexual adolescents attempt suicide at 2 to 6 times the rate of non–gay, lesbian, and bisexual adolescents, suggesting that a sexual minority status is in itself a risk factor for suicidal behaviors, and a child identifying as gay, lesbian, or bisexual and/or as a non-cisgender youth may experience feelings of thwarted belongingness among a peer group (Zhao et al., 2010). The survey item for sexual orientation read: “Do you think of yourself as . . .” with the answer options including: 1) Lesbian or gay; 2) Straight, that is, not lesbian or gay; 3) Bisexual; 4) Something else (Specify); and 5) Don’t know/Not sure. The survey item for sexual identity read: “How do you identify? (Select one or more responses)” with the answer options including: 1) Female, 2) Male, 3) Transgender,
4) Gender nonconforming/Genderqueer, 5) Intersex/Intergender, 6) Something else fits better (Specify), 7) I am not sure of my gender identity, and 8) I do not know what this question is asking. Volunteering (inverse) was chosen because of its suggestion of contributing to society and feeling a sense of belonging and value within the community. The survey item for volunteering read: “I volunteer to help others in my community” with the answer options including: 1) Very much true, 2) Pretty much true, 3) A little true, and 4) Not at all true. Data from this final question was inversely recoded in order to be comparable to the other proxy items.
The CDC utilized existing empirical literature to analyze the self-reported survey data, assessing for cognitive and situational factors that might affect the validity of adolescent self-reporting of behaviors. Through analysis, it was determined that self-reports are in fact affected by both cognitive and situational factors, but the factors do not threaten the validity of self-reports of each behavior equally (Brener et al., 2013).
This study addresses what impact the predictor variables of perceived burdensomeness and thwarted belongingness have on the outcome variables of suicide ideation and suicide attempt in this particular adolescent population. The selected proxy items had variable answer options (ranging from binary choice to a 7-point Likert scale), so each proxy item for the predictor variables was individually entered with the intention of disaggregating to assess whether or not different combinations of the variables are better predictors of the outcome variables.
The two outcome variables were surveyed as follows: (a) suicide ideation (“During the past 12 months, did you ever seriously consider attempting suicide?”) and (b) suicide attempt (“During the past 12 months, how many times did you actually attempt suicide?”; OHA, 2017). The second question was recoded to allow both questions to be assessed on a binary scale (no/yes), with no equaling 0 and yes equaling 1.
With binary scaled data for the outcome variables, we decided to utilize a binomial logistic regression statistical test to assess the research questions. Additionally, each predictor variable was separately analyzed in order to isolate each outcome variable and consider how the predictor variables influenced each other.
In sum, we examined the descriptive statistics of the survey, created variables based on the selected proxy survey items, and tested the assumptions for utilizing a binomial logistic regression statistical test. Finally, we executed two logistic regression models to determine the relationships between the predictor variables and the two outcome variables—suicide ideation and suicide attempt.
Table 1 presents the descriptive statistics of the study variables. Although 11,868 students in the 11th grade completed the 2017 OHT survey, data from only 10,703 students were included in the analysis because of recording and data collection errors on those excluded from the analyses, due to missing or incomplete data. Therefore, the descriptive statistics of the study variables reported in the table reflect the data of the 10,703 students applicable for use in the logistic regression model of this study. Given the large sample size, we utilized a p-value threshold of less than 0.01.
||M or %a
||SD (if applicable)
|Felt Sad/Hopeless (Yes)
a Some variables were reported as means, and some variables were reported as percentages.
A binomial logistic regression was conducted to quantify the effects of the individual proxy items measuring the predictor variables of perceived burdensomeness and thwarted belongingness on students experiencing suicide ideation (Research Question 1). All five proxy items were entered into the model for the outcome variable. During the data screening process, two proxy items were eliminated (i.e., non-binary, volunteer), as they did not indicate significant results. Regression results indicated the overall model of the three remaining predictors (emotional/mental health, felt sad/hopeless, not straight) was statistically reliable in distinguishing between 11th grade students who did not experience suicide ideation and those who did (Nagelkerke R2 = .413; p < .001). As such, the suicide ideation model was deemed statistically significant—X2(5) = 3104.194—with an overall positive predictive value of 85.5%.
Of the two proxy items for the perceived burdensomeness variable, both proved to be statistically significant (Table 2). Specifically, increased poor emotional/mental health was related to the increased likelihood and occurrence of suicide ideation. Additionally, participants who reported feeling sad or hopeless for at least 2 weeks were over twice as likely to experience suicide ideation than those who did not report feeling sad or hopeless. Of the three proxy items for the thwarted belongingness variable, only one proved to be statistically significant: Students who reported as not straight were more than twice as likely to experience suicide ideation as students who reported as straight.
Logistic Regression Predicting Likelihood of Suicide Ideation
Similarly, a binomial logistic regression test was conducted to determine the effects of the proxy items measuring the predictor variables of perceived burdensomeness and thwarted belongingness on suicide attempt (Research Question 2). Again, all five items were entered into the model for the outcome variable of suicide attempt. During the data screening process, two proxy items were eliminated (i.e., non-binary, volunteer), as they did not indicate significant results. Regression results indicated that the overall model of the three remaining predictors (emotional/mental health, felt sad/hopeless, not straight) was statistically reliable in distinguishing between 11th grade students who did not attempt suicide and those who did (Nagelkerke R2 = .271; p < .001). The suicide attempt model was deemed statistically significant—X2(5) = 1182.692—with an overall positive predictive value of 93.4%. Both proxy items for the perceived burdensomeness variable proved to be statistically significant (Table 3).
Based on the overall regression analyses, increased poor emotional/mental health was related to the increased likelihood and occurrence of suicide attempt; however, students who reported feeling sad or hopeless for at least 2 weeks were nearly twice as likely to attempt suicide than students who did not report feeling sad or hopeless. Of the three proxy items for the thwarted belongingness variable, only one proved to be statistically significant (Table 3). Students who reported as not straight were nearly twice as likely as students who reported as straight to attempt suicide.
Logistic Regression Predicting Likelihood of Suicide Attempt
|| < .001
|| < .001
|| < .001
|| < .001
These results indicated that there were significant similarities between the predictors of suicide ideation and suicide attempt, supporting our hypotheses. The proxy items that comprised perceived burdensomeness (poor emotional health [odds = 1.820] and feeling sad/hopeless [odds = 6.410]) in conjunction with the proxy item that comprised thwarted belongingness (not straight [odds = 1.704]) all factored into increased likelihood of suicide ideation and suicide attempt. In other words, the mediators of suicide ideation were similar to the mediators of suicide attempt.
In discussing the results of the study, it is important to first contextualize the descriptive statistics, as we were studying and applying results to adolescent students in Oregon. The dataset reports 18% of the participants as experiencing suicide ideation, which equates to 1,927 students in the 11th grade. This statistic for suicide ideation is a little higher than the national percentage of 17.2% (CDC, 2017). The dataset also reports 6.6% of the participants as attempting suicide, which equates to 703 students in the 11th grade. This statistic for suicide attempt is a little lower than the national 7.4% (CDC, 2017). In terms of our dataset, Oregon 11th graders were slightly higher than expected for suicide ideation and slightly lower than expected for suicide attempt.
Results from our binomial logistic regression analyses uncovered a model supporting our hypothesis that perceived burdensomeness and thwarted belongingness would significantly predict suicide ideation and attempt in 11th grade students. Further, both variables representing perceived burdensomeness were statistically significant for both suicide ideation and attempt, as was one of the three proxy variables representing thwarted belongingness. These findings align with the IPTS, proposing that perceived burdensomeness and thwarted belongingness are not only important predictors of suicidal behaviors, but are significant elements for both ideation and attempt (with the addition of acquired capability for attempt; Horton et al., 2016; King et al., 2018).
Though not a predetermined hypothesis, it seems reasonable to expect that there would be fewer predictors of suicide attempt, condensed from the predictors of suicide ideation, but that is not the case in our findings. It begs the question: What variables drove students in this population from ideation to attempt? According to the data, 18% of the 11th graders experienced suicide ideation, but only 6.6% reported being driven to attempt suicide. The IPTS would suggest that the missing component was a measure of acquired capability that moves a person from ideation to attempt (Joiner et al., 2009). According to the IPTS (Joiner et al., 2009), experiencing perceived burdensomeness and thwarted belongingness without acquired capability leads to suicide ideation, but the presence of acquired capability is needed to result in suicide attempt. This will be discussed further as a limitation of this study.
These results corroborate previous literature on adolescence and suicidality. Horton et al. (2016) described adolescent perceived burdensomeness as social disconnection and adolescent thwarted belongingness as social isolation from peers. As previously described, with regard to poor emotional/mental health and feeling sad/hopeless, Jaworska and MacQueen (2015) highlighted the increased reactivity of adolescence, and Wyman (2014) indicated that half of the diagnoses of emotional and behavioral disorders take place during this age period (highlighting the importance of mental health clinicians being aware of these findings). With regard to not being straight, this time period also includes establishing values and preferences for sexual behavior and affective orientation (Teipel, 2013). These results also corroborate our previous findings on the application of the IPTS to early adolescents (ages 13–14), suggesting similar significant mediators for both suicide ideation (perceived burdensomeness: emotional/mental health, feeling sad/hopeless; thwarted belongingness: not straight, bullied) and suicide attempt (perceived burdensomeness: emotional/mental health, feeling sad/hopeless; thwarted belongingness: non-binary, bullied; Sallee et al., 2021).
Relative to the literature on suicidality and its role in our selection of proxy items within the OHT survey, research on the connection between poor emotional/mental health and emotional strain in the family setting supports our findings of its significance within the predictor variable of perceived burdensomeness (Miller et al., 2014). The significance of feeling sad/hopeless is supported by previous research discussing its inclusion in the definition of perceived burdensomeness itself (Horton et al., 2016). Sexual minority students experience higher rates of suicidal behaviors, attempting suicide at rates of 2 to 6 times that of straight adolescents (Seelman & Walker, 2018; Zhao et al., 2010). Our findings support this body of research in the significance of being not straight in relation to mental health wellness.
The other proxy predictors examined—being non-binary and volunteering—were not statistically predictive of suicidal behavior. This may be due in part to the developmental tasks and goals characteristic of the period of middle adolescence, or the proxy items themselves may not be significant indicators of the predictor variables in the study, or the wrong indicators were chosen or were conceptualized inaccurately. If that is the case, there would be concerns regarding the construct validity of these indicators and subsequent measures, and because that cannot be proven otherwise, it is a considerable limitation to the study. If the developmental tasks and goals of middle adolescence provide the most insight into the insignificance of being non-binary and volunteering, it is important to consider the developmental period of self-involvement resulting in high expectations of self in combination with low self-concept, impacting an increased drive for peer acceptance (American Academy of Child & Adolescent Psychiatry, 2021). Eleventh grade students are also preparing for their final year of high school and making plans for what their lives will look like after graduation, requiring a high degree of autonomy and independence. It is interesting to consider the insignificant predictors through this developmental lens. Although 11th grade students are seeking peer acceptance, being non-binary may not be a driver because of developing autonomy and independence.
We consider how the findings of this study might relate to research indicating a higher rate of suicide for sexual/gender minorities compared to youth from historically well-represented communities (Teipel, 2013), but perhaps disaggregating sexual/gender minority and focusing on non-binary youth in particular may impact that conversation. Volunteering could prove to be a protective factor but drive for peer acceptance and reliance on peers may determine whether or not a student in the 11th grade chooses to volunteer as opposed to self-motivation or fulfillment.
Limitations and Suggestions for Future Research
Several limitations must be considered when evaluating the findings of this study. First, because of their correlational nature, we were unable to draw any causal conclusions from the results. Relatedly, the results from this study, despite being based on a large sample, described 11th grade students in Oregon who elected to take the survey and had a complete dataset necessary for analysis; the sample was one of convenience, and the extraction of missing datasets impacted the researchers’ ability to gauge the sample’s ability to represent the whole population. As such, generalization of the results to the larger population of adolescents is limited.
Additionally, the data was taken retrospectively from a survey managed by a state government agency; it would have been preferable for us to have input on the questions included in the 2017 OHT survey. Instead, we were forced to select best-fit proxy items that might or might not have been most representative of the predictor variables. Relatedly, and as previously mentioned, there is cause to question the construct validity of these measures, particularly because the selected proxy items do not correlate to other measures of thwarted belongingness in particular. Because we relied on the 2017 OHT survey data, the models for examining the IPTS constructs were incomplete. Lastly, there is a lack of data about unique stressors experienced by students of color related to their social locations, particularly valuable because 25% of the participants were Hispanic/Latino.
Based on our results, despite the limitations previously discussed, there are a variety of avenues for further research on this topic. The first avenue would be to analyze similar data from another state survey or the national Youth Risk Behavior Survey. This would allow researchers to compare results with this study in order to offer more supported generalization to the adolescent population. Another avenue would be to revisit this dataset and theory to consider how they might apply to other behaviors of the adolescent population, such as NSSI and school violence. Further research could revisit this study by creating a survey that would more fully target the interpersonal constructs of the IPTS or create a qualitative or mixed-methods study incorporating additional data sources to examine more in-depth the suicide-related factors and experiences during adolescence.
Another avenue for future research may be to examine additional prospective mediators that may predict the evolution from ideation to attempt because our results presented the exact same predictors for both. Finally, a valuable possibility for future research would be to study factors that might differentially affect students of color and adolescents from sexual minority groups.
This particular study offers valuable support for the application of the IPTS in working with middle adolescents as well as useful implications for targeting specific interpersonal needs when working with this population. Perceived burdensomeness and thwarted belongingness may be significant construct predictors of suicide ideation and attempt in adolescents according to the findings. Implications for clinical mental health counselors and other professionals working with this population support the importance of taking a systemic and unique approach to working with adolescents and their families that prioritizes and addresses these specific interpersonal needs individually and collectively.
Specific interventions addressing adolescent interpersonal needs of perceived burdensomeness and thwarted belongingness include an array of clinical practices, such as using a suicide screener as part of intake assessments or well-child checks that include items related to these two constructs. Existing suicide intervention modalities need to incorporate and/or integrate the constructs of the IPTS, utilizing counseling goals and interventions that specifically target belongingness and personal value. Further, clinicians must have a basic understanding of the developmental tasks of this period to attend to an adolescent’s stable and productive peer relationships, adoption of personal value systems, and renegotiation of relationships with parents/caregivers, realizing that this transitional stage is also characterized by feelings of grief and loss (Teipel, 2013).
Group counseling is an effective and efficient modality through which a mental health professional can bring together a number of adolescents and facilitate sessions normalizing these developmental tasks and associated feelings. Mental health literacy and bibliotherapy can be used in combination with group counseling, as research has demonstrated their effectiveness on providing structure in the group process, educating adolescents, and fostering connections among the group (Mumbauer & Kelchner, 2017). Groups can also offer parents and caregivers a safe space to navigate family complexities around adolescent suicidality and learn ways to promote a sense of belonging and reduce feelings of burdensomeness among adolescents.
Broader systemic outreach can involve community mental health providers and other professionals collaborating with school stakeholders to offer services such as parent workshops and educator professional development opportunities on understanding suicidality and evidence-based prevention, intervention, and postvention. Partnering with school stakeholders can include consulting on systemic interventions and programming, such as individual student behavior plans, IEPs, and 504 plans, in addition to school- or grade-wide postsecondary transition activities. These consultation and collaboration efforts are often interdependent, in the sense that clinical professionals gain referrals from school stakeholders, and school stakeholders help inform the work of clinical professionals with their adolescent clients.
Through engaging parents, families, school personnel, and their adolescent clients, clinical mental health counselors can work holistically to prevent and intervene in suicidal behaviors by targeting fulfillment and development of interpersonal needs. These findings may have the potential to inform laws and policies through legislative efforts to address adolescent suicide. Clinical mental health counselors have a professional obligation to utilize outcome data to advocate for systemic change to impact clients (Montague et al., 2016), and in this context they may also draw on these findings to provide information to society to assist in advocacy efforts and extend recommendations to professionals working with this population.
The findings of our study support the application of the IPTS in understanding suicidality among middle adolescents, particularly in the ideation model, and are significant in several ways. First, the IPTS has the potential to inform therapeutic interventions in clinical settings, as well as parents and social institutions (e.g., schools and youth development centers), on how best to support youth who experience suicidality. Another focus of our study was on interpersonal factors that are dynamic, rather than static risk factors that may not necessarily be venues for intervention and change for clinicians (e.g., family factors). Third, adolescent clients engaging in suicide ideation and behaviors require interventions that are unique from their adult counterparts and often require environmental and familial interventions as well as individual. Lastly, our findings may serve to provide information to society to assist in advocacy efforts and recommendations for serving adolescent populations within all systems, including laws and policies to address adolescent suicide. Overall, the findings of our study underscore the uniqueness and complexity of this developmental period of adolescence and the importance of theory- and research-based practices. We hope that our findings will inform mental health clinicians, educators, school counselors, parents, and policymakers in their efforts to meet adolescent mental health needs.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Emily Sallee, PhD, BC-TMH, LSC, PCLC, is an assistant professor at the University of Montana. Abraham Cazares-Cervantes, PhD, LSC, is an assistant clinical professor at Oregon State University. Kok-Mun Ng, PhD, NCC, ACS, LPC, is a professor at Oregon State University. Correspondence may be addressed to Emily Sallee, 32 Campus Drive #335, Missoula, MT 59834, email@example.com.
Diane M. Stutey, Abigail E. Solis, Kim Severn, Lori Notestine, Kodi L. Enkler, Joseph Wehrman, Molly Cammell
There is a need for mental health interventions for youth in the United States. Youth mentoring programs have proven to be successful in helping in a variety of aspects. The purpose of this phenomenological study was to gain insight into the lived experiences of participants in a therapeutic youth mentoring program. In addition to being paired 1:1 with a mentor, all of the youth had access to individual counseling with counselors-in-training throughout the program. The participants in this study were 14 youth, ages 11–15, who were considered “at-promise youth” if they were not reaching their full potential in the school setting and might be vulnerable to school dropout, substance use/misuse, and/or criminal behavior. All participants were interviewed at the beginning and end of a 12-week therapeutic mentoring program. Five themes emerged from the data: life stressors, self-awareness, trusting others, adaptability and resiliency, and hope for the future. Researchers observed an increase in participants’ self-esteem, self-efficacy, and problem-solving and coping skills. Implications for counselors, particularly those interested in adding a therapeutic component to traditional mentoring programs, are discussed along with suggestions for future research.
Keywords: mentoring programs, therapeutic, mental health interventions, at-promise youth, phenomenological
Because of a staggering dropout rate of 1.2 million students a year, as well as an increase of juvenile delinquency in the United States, there is a need for interventions that will help youth stay in school and out of the juvenile justice system (Weiler, Chesmore, et al., 2019; Weiss et al., 2019). Researchers have indicated that the absence of education, including students who do not graduate from high school, has led to an increase of youth experiencing health complications, substance abuse, social skill deficits, and premature death (Schoeneberger, 2012; Weiler, Chesmore, et al., 2019; Weiler et al., 2015; Weiss et al., 2019). In the past, youth exhibiting behaviors that might lead to juvenile delinquency were referred to as at risk. However, the term at promise is now utilized by organizations such as the California Education Code (McKenzie, 2019). The phrase at-promise youth describes youth who have the ability to reach their full potential with additional time and resources.
One way to help at-promise youth reach their full potential and feel more engaged at school might be connecting them with a young adult who understands their struggles. Youth benefit from enhanced connectedness to adults outside their immediate family to help them navigate through difficult times, and this relationship can be protective against suicidal behavior (King et al., 2018; Rhodes, 2002). Individuals within adolescent ecosystems have voiced the positive changes youth have experienced by participating in youth mentoring programs (Raposa et al., 2019). At-promise youth might benefit even more from youth mentoring programs that incorporate a therapeutic component to address mental health concerns they may be experiencing (Liang et al., 2013).
Youth Mentoring Programs
Youth mentoring is a psychosocial intervention in which a nonparental adult and a younger individual aim to develop a supportive relationship (Karcher et al., 2005; Lund et al., 2019; Sacco et al., 2014; Weiler et al., 2013). During the mentoring program, the youth mentees experience a healthy environment, which often leads to them seeking out and learning to cultivate a healthier environment beyond the youth mentoring program. This shift in environment has allowed researchers to observe improvement in self-perception, social acceptance, parent–child interaction, and academic performance of youth participating in mentoring programs (Anastasia et al., 2012). Researchers have found that mentoring programs may also buffer against the impacts of youth exposed to adverse childhood experiences and improve behavioral, social, emotional, and academic outcomes (Centers for Disease Control and Prevention, 2019; David-Ferdon et al., 2016; Durlak et al., 2010; Tolan et al., 2014). The relationship between mentor and mentee is heavily credited to the success of youth mentoring, signifying the importance of the mentee picking a mentor similar to them (e.g., appearance, culture, interests).
Researchers discovered that both mentor and mentee benefit from the dyadic relationship when there is trust and the mentor is consistent, supportive, and encouraging instead of controlling (Marshall et al., 2016; Rhodes, 2002; Weiler, Boat, & Haddock, 2019; Weiler et al., 2015; Weiss et al., 2019). A mentor should be supportive and encouraging, especially when giving advice, which helps the youth to be open to a new perspective (Lund et al., 2019; Rhodes, 2002). Youth who participated in a positive mentoring relationship had increased feelings of connectedness with a trusted adult and higher rates of pursuing purpose (Lund et al., 2019). In addition, by the end of youth mentoring programs, the majority of mentees achieved a sense of self-worth and increased levels of intimacy, communication, and trust because of the dyadic relationship they had established with their mentors (Keller & Pryce, 2012; Rhodes, 2002).
Mentors and Youth Mentees
Research on youth mentoring programs has described mentees as individuals who are at risk, may have been in the juvenile justice system, or are in danger of offending or reoffending because of a variety of variables (e.g., substance use, academic failure, absences, aggressive behavior, family stressors) present in their lives (Cavell et al., 2009; Haddock et al., 2017; Weiler et al., 2013). Weiler et al. (2013) noted that more than 60% of the youth who participated in a mentoring program in their study had acquired at least a single charge with the juvenile justice system. Numerous researchers have discussed how the role of a mentor in a mentee’s life helped the mentee with improved self-esteem, enhanced health, instilled hope for the future, and reduced reoffending behaviors (Raposa et al., 2019; Rhodes, 2002; Weiler, Boat, & Haddock, 2019; Weiss et al., 2019).
Training is required before being paired with a mentee to ensure the competency of the adult who will be mentoring the youth facing hardships. Anastasia et al. (2012) emphasized the importance of preparatory training and ongoing training so that mentors, who are not in a helping profession, will have the tools necessary to mentor an adolescent successfully. In the preparatory stage of training, mentors learn about maintaining safety, program rules, child-focused social problem–solving skills, and the activities that will be used throughout the program (Anastasia et al., 2012; Cavell et al., 2009).
At the same time, mentors may feel overwhelmed when mentees exhibit mental health issues, behavioral issues, or racial or socioeconomic differences that surpass their basic training and expertise (Marshall et al., 2016; Weiler et al., 2013). With a majority of the adolescents facing difficulties, it can be daunting for the mentor to provide adequate mentoring; therefore, ongoing training is imperative. Ongoing training is meant to help the mentor increase their effectiveness with their mentee (Anastasia et al., 2012), allowing the adult to seek guidance when they start feeling overwhelmed with their mentee’s behavior and actions (Keller & Pryce, 2012). Through ongoing training and interaction with their paired youth, the adult mentor gains a new level of insight and improved health, self-esteem, and self-awareness that they did not have before (Rhodes, 2002).
However, even with ongoing training, mentees may exhibit mental health needs that are beyond the average mentor’s training and skill set. Liang et al. (2013) highlighted that mentees might benefit from receiving traditional therapy to help with their hardships. Therefore, some mentoring programs have added a therapeutic component incorporating trained mental health personnel to positively support both mentors and mentees (Weiler et al., 2013).
Therapeutic Component to Mentoring
Mental health professionals (e.g., counselors, social workers, psychologists) learn through their education how to be culturally competent, preserve client autonomy, and maintain an unbiased perspective that is crucial when trying to develop a mentoring relationship (Anastasia et al., 2012). Liang and colleagues (2013) emphasized how youth with therapeutic needs benefit from the way therapeutic guidance and a mentoring program complement each other. For instance, if a child is stressed about how to pay for college, then a mentor can help their mentee find resources, while a therapist could focus on teaching healthier coping skills to manage stress (Liang et al., 2013). Working in tandem allows for a two-dimensional approach, a noteworthy difference between therapeutic mentoring and traditional mentoring programs (Sacco et al., 2014).
Some therapeutic mentoring programs select mentors from a helping profession and provide additional training and supervision from trained mental health clinicians to create a more therapeutic setting for mentees (Johnson & Pryce, 2013). Other youth mentoring programs include a therapeutic component by incorporating additional staff consisting of mental health professionals, such as counselors-in-training (CITs), to directly address the mental health needs of mentees and support mentors (Sacco et al., 2014; Stark et al., 2021; Weiler et al., 2013). Therapeutic mentoring programs function as an intervention for youth who are engaging in risky behavior or have experienced trauma and other developmental issues (Johnson & Pryce, 2013; Sacco et al., 2014).
Litam and Hipolito-Delgado (2021) discussed how COVID-19 highlighted that communities of color have limited access to health care and education. Marginalized youth and their families may not seek mental health services at all or may be more prone to accept help from non–mental health professionals such as mentors (Dashiff et al., 2009). Therefore, an ideal youth mentoring program might have trained mentors from a helping profession who are supervised by mental health professionals, such as counselors, who are also available to meet with youth throughout the mentoring sessions. However, many mentoring programs are volunteer-based and this may limit access to mental health professionals. In addition, there is a shortage of mental health professionals prepared to work with youth (Dashiff et al., 2009) and there is a treatment gap for mental disorders in children (Patel et al., 2013).
Often youth have access to counselors in their schools, but researchers have found that school counselors report that they have limited time to address ongoing mental health needs (Carlson & Kees, 2013). Litam and Hipolito-Delgado (2021) encouraged counselors to use creative strategies such as reduced or no-cost services when working with communities of color. Dashiff and colleagues (2009) stressed that “innovative strategies of service delivery are needed” when working with youth who may come from poverty or areas with limited access to mental health services (p. 29). Partnering with a university, with a plethora of CITs needing supervised client hours, is an innovative and low- or no-cost approach. In this scenario, the mentor takes on a therapeutic role with their mentee, but the CIT is available to address and process ongoing mental health concerns. Incorporating CITs in a youth mentoring program allows both mentor and CIT to work together to create an environment in which youth feel safe, encompassing a secure attachment to the therapeutic program (Sacco et al., 2014).
The CIT’s position facilitates insight and awareness for the youth while offering tools that will help them reach their therapeutic goals (Johnson & Pryce, 2013; Sacco et al., 2014). The role of the mentor is to serve as a role model and advocate while maintaining open communication with the CIT to facilitate necessary therapeutic modifications (Sacco et al., 2014). Some researchers have found that as the mentor models healthy behavior, the youth will eventually begin to display a healthier interpersonal and intrapersonal self (Johnson & Pryce, 2013; Sacco et al., 2014). Overall, mentoring programs appear to be an effective intervention for youth that could also benefit from the incorporation of a therapeutic component.
Despite the amount of research being done to understand the relationship between mentor and mentee from different perspectives, there is less data that examines the participants’ lived experiences of a therapeutic youth mentoring program that includes CITs. The purpose of this study was to examine and gain further insight into participants’ lived experiences with a therapeutic youth mentoring program—specifically, a therapeutic youth mentoring program in which the mentors had additional training and supervision in mental health areas and additional support was provided by CITs while under supervision. The overarching question for this study was: What were participants’ lived experiences prior to and after participating in a therapeutic youth mentoring program?
Phenomenology was utilized in this study to gather and analyze data in order to better understand participants’ lived experiences in a therapeutic youth mentoring program. According to Trusty (2011), “if little is known about a research area or target population, it is likely that a qualitative study would be needed first” (p. 262). Although some research has been conducted with participant perceptions of youth mentoring programs, there is less research with therapeutic mentoring programs; therefore, a qualitative approach was deemed appropriate.
Therapeutic Youth Mentoring Program
The therapeutic youth mentoring program in this study was at a university in the Rocky Mountain region of the United States and utilized the theoretical framework of Campus Corps (Weiler et al., 2013, 2014), now called Campus Connections (CC). CC is an innovative licensed program combining practices from mentoring, after-school programming, and integrated mental health. CC mentors were recruited and selected from a variety of undergraduate disciplines across campus, with more than half being from counseling and human services, psychology, or education majors. All mentors attended an orientation and background screening prior to being accepted for the program. The mentors who were selected spent the first 3 weeks of the semester in intensive training with counselor educators, who were also licensed professional counselors, to learn about child abuse reporting, ethics of working with minors, crises and trauma, and basic counseling skills. Potential mentees were referred by local school counselors and attended an intake with their guardians to go over the format of the program. Mentors created profiles about themselves that were utilized during the intake so that mentees could select their mentor based on preferences.
Once mentees were paired with mentors, the faculty and staff looked at the information provided by caregivers and counselors, demographics, and other relevant information to create diverse mentor families. Each mentor family consisted of approximately three mentor/mentee pairs. In this study, there were a total of three mentor families and each family was assigned a mentor coach. The mentor coaches were graduate-level counseling students who provided their mentor family with support throughout the semester. In addition, four graduate-level CITs were selected to provide ongoing counseling to mentees throughout the therapeutic mentoring program. All CITs were in their last semester of graduate studies and met weekly with counselor educators for supervision. Two counselor educators and supervisors, also licensed professional counselors, were also present each evening of CC to support mentees, mentors, and CITs.
All youth participated in the 12-week CC therapeutic youth mentoring program that met on the university campus, once a week for 4 hours. This therapeutic youth mentoring program was designed to bring youth to a college campus to help them become more comfortable and familiar with future college and career goals. Youth followed a schedule that consisted of:
- working for 60 minutes with their mentor on academic and study skills.
- going on a 30-minute “walk and talk” to learn about different locations on the university campus each week.
- participating in a 30-minute family-style meal at the dining hall with their mentor family.
- choosing two 45-minute prosocial or social justice activities.
The prosocial and social justice activities were directed at helping youth learn skills and concepts such as resiliency, coping, inclusiveness, and empathy. These activities were adapted from a manual created by the founders of CC. Each evening, two 45-minute lessons were facilitated by our graduate assistants and CITs and covered topics around the “Big 8” identities (i.e., gender/sex, race, class/socioeconomic status, sexual orientation, ethnicity, religion, age, and ability). Some examples of the activities included: Backpack, an activity adopted from Peggy Mcintosh’s (2003) The Knapsack, that examines privilege and societal benefits; Build a House, an activity designed to illustrate the differences in resources that people have based on socioeconomic status; and Pink, Blue and Purple, an activity designed to discuss assumptions made about gender.
At any point throughout their time on campus, mentors or mentees could request for the youth to have time to meet with a CIT. CITs also routinely set up check-ins with all mentees and were present throughout the entire process. Often the CITs would help with the after-dinner activities if youth weren’t requesting to meet 1:1. The participants in this study engaged in a total of 720 minutes of counseling with the average youth receiving 50 minutes of individual counseling.
This was a purposeful sample of at-promise youth participating in the same CC therapeutic youth mentoring program in the spring of 2019. Of the 18 youth enrolled in CC, 14 youth agreed to participate in the research study. The participants in this study consisted of 14 youth, ages 11–15, with the following demographics: 71% male, 21% female, and 7% transgender/gender-expansive; 57% White, 29% Black/African American, 21% Hispanic/Latino, 14% American Indian/Alaska Native, and 7% Asian; and approximately half on free and reduced lunch. School district partners were asked to consider and recommend at-promise youth if they were not reaching their full potential and might be vulnerable to school dropout, substance use/misuse, and/or criminal behavior. Local school counselors submitted referrals based on this criterion for youth to participate in CC. Participation was voluntary and participants could remove themselves from the study at any time throughout the process.
At-promise youth are considered a vulnerable population and therefore researchers must contemplate ethical considerations. Our research team went through a full IRB process to ensure youth participants were being treated with the highest ethical considerations. After obtaining IRB approval, informed consent and assent was secured and two audiotaped interviews were conducted with all participants—one at the beginning of the 12-week mentoring program and one 12 weeks later at the end. Semistructured interviews are progressive in design (Merriam, 1998); they allow the researcher to formulate questions ahead of time and adjust the questions based on the participants’ responses (Guba & Lincoln, 1989). Participants were asked a series of open-ended questions that were similar across interviews, such as how a mentor has helped them, their feelings about being on a college campus, and thoughts on meeting with a CIT (see Appendix for a complete list of interview questions). The final interview allowed the participants to describe their experience working with a mentor and CIT and their perceptions of meeting on a university campus each week for 12 weeks.
Our research team consisted of three PhD-level counselor educators, Diane Stutey, Lori Notestine, and Joseph Wehrman; one counselor education doctoral student, Kim Severn; one staff member in master’s-level student affairs and higher education, Molly Cammell; and two graduate students in counseling, Abigail E. Solis and Kodi L. Enkler. All members of the research team were present throughout the 12-week therapeutic youth mentoring program. We met on a regular basis to discuss the research protocol and any potential conflicts of interest or ethical concerns, ensuring trustworthiness of the study.
Data Analysis and Trustworthiness
All data were collected by the research team and Solis transcribed all the interviews. Data were analyzed and independently coded by Stutey, Solis, and Severn, utilizing Merriam’s (1998) two-level approach. After each researcher independently coded all the transcripts, we met to discuss and agree upon emerging themes. After data was further analyzed and organized to support each of the themes, we met again to come to consensus on the themes. Any disagreement of themes or supporting data was discussed until consensus was reached.
Several techniques were used to ensure the trustworthiness and rigor of data collection and analysis (Guba & Lincoln, 1989; Merriam, 1998). Stutey, Solis, and Severn independently coded the data and each kept their own researcher journal. To establish dependability and conformability, an audit trail was created (Lincoln & Guba, 1985). Notestine and Enkler served as peer reviewers and assisted Stutey, Solis, and Severn by providing feedback at various points. Peer reviewers were given access to initial emerging themes, final themes, researchers’ journals, and coding documentation to inform the feedback provided to Stutey, Solis, and Severn throughout the data collection and analysis process.
We also used bridling to establish trustworthiness and acknowledge the researchers’ prior and current experiences. Often qualitative researchers will use bracketing in an attempt to manage their understanding of or experience with a phenomenon. However, bridling encourages ongoing researcher reflexivity and is meant to be more intentional, with researchers maintaining openness and revisiting assumptions throughout the research process (Dahlberg, 2006; Vagle, 2009). Stutey et al. (2020) described bridling as “an ongoing reflective practice that takes place before, during, and after data collection” (p. 124). Bridling was chosen over bracketing because the researchers had personal and professional experiences with at-promise youth, making it unlikely to put aside all biases and assumptions. Development of a researcher’s stance and review of researchers’ journals were utilized throughout the data collection and analysis to bridle and manage researchers’ biases and assumptions.
In total, five themes emerged from the participant interview data: life stressors, self-awareness, trusting others, adaptability and resiliency, and hope for the future. In order to be considered a theme, at least seven out of the 14 participants had to endorse the theme. Within each theme, there were two to three aspects that were discussed by participants. Each of the themes is discussed in this section, and a sample of participant quotes is provided as evidence of each aspect of the theme. Participants all chose pseudonyms that were used throughout the research study.
Summary of Themes
|| Aspects of Themes
· Mental Health
||· Positive Self-Image
||· Qualities of a Trusted Mentor/Adult
· Feeling Understood or Heard
|Adaptability and Resiliency
||· Social-Emotional Growth
· Coping Skills
|Hope for the Future
||· Realistic Goals for School
· Future Careers
· Impact on Others
The first theme of life stressors was endorsed by all 14 participants. This theme was defined as participants’ lived experiences of how stressors in their lives were negatively impacting them. Many of the participants shared in the first interview that they were overwhelmed and a bit confused about being on a college campus. Participants were not sure why they were selected for the therapeutic mentoring program or what they might need help with beyond academics. Participants endorsed three aspects of life stressors in the areas of school, peers/bullying, and mental health.
In the initial interview, participants discussed wanting to get straight As and that math was a particularly tough subject area for them. Ball stated, “I really struggle with math. I don’t know why it’s always been something that’s really hard for me.” JT shared that they “have to get straight As” and indicated that if they did not, they would “get kicked out.” Tristonion said, “Right now, I really don’t have the motivation to try in school.”
Other participants struggled with certain teachers, behavior at school, or homework. Josh Billups shared, “Sometimes I’m afraid to talk to my teachers . . . talking to adults is kind of hard.” Drift King stated that they had problems in several areas, such as “not studying, not getting most of the work done, not understanding the work, too afraid to ask teachers, raise my hand, or [ask] questions.” Many participants said that they “don’t like homework” and that they also struggle in school because they “talk too much,” are “not turning in assignments,” and find it “really hard . . . to focus.” School and academic success were important to the majority of the participants in this study.
Besides academic stressors at schools, participants shared that they sometimes struggled with bullies and many shared having a lack of peer or other support in school. Bam shared that they struggle at school because of “getting bullied and having nobody to talk to . . . somebody told me to go commit suicide.” Isabel stated that there is a lot of “drama . . . and getting bullied” at their school. Isaiah shared feelings of isolation: “Kids were being mean and stuff so I just went and sat [alone].” Others shared that they have been called “a snitch,” “Bible head,” and “God” by students in their schools that they perceive as bullies. Participants felt they could discuss these matters with their mentors and/or CIT and seek their advice.
Participants also discussed areas of stress that impact them at school such as learning difficulties and specific physical and mental health issues. DTS shared, “I have ADHD . . . and it’s hard getting back on the schedule taking pills every day.” Several participants mentioned struggling with symptoms associated with depression. Isabel stated, “I’ve had a lot of surgeries and I have really bad anxiety and depression.” Isaiah discussed that “everyone is mean to me” and shared that they “don’t have a good memory.” Many participants mentioned that they were using the mental health services of their school counselor and/or the CIT provided through CC but sometimes felt just as comfortable talking to their mentor.
The second theme that emerged from this study was self-awareness. This theme was endorsed by 13 of the 14 participants and is defined as participants’ lived experiences of becoming more self-aware after participating in the 12-week therapeutic mentoring program. When asked about how others perceived them, participants tended to initially interpret that teachers and caregivers might have negative views; often these views were opposite of those that they held about themselves or they perceived peers had about them. After participating in the therapeutic mentoring program, youth seemed more open to talking about their strengths and shared more positive comments about themselves and their accomplishments. Participants endorsed two aspects of self-awareness: positive self-image and awareness of accomplishments.
Many of the participants shared a negative self-image in the initial interview. After spending time in the therapeutic mentoring program, they viewed themselves, and perceived that others also viewed them, in a more positive light. Andrew shared, “I learned you don’t have to be bad to get where you need to be. You don’t have to be dangerous for people to like you.” Jeffy stated, “I’ve been focusing on my schoolwork instead of messing around all the time. And [I’m] thinking before I do something . . . less getting in trouble.” Josh discussed how their image had changed since participating: “Back then I was kind of mean, but [the program] kind of helped me change that . . . I have a lot more friends now.” Several participants shared that they were getting along better with others and being “more social now,” were “able to talk and interact with other people,” and were “opening up to more people.” Several participants attributed this shift in their self-image to having a mentor and/or CIT who unconditionally accepted them.
Along with viewing themselves in more positive ways, many participants shared what they had accomplished during this semester. Andrew stated, “I used to fight a lot and now we [mentor and me] have a goal not to fight. I haven’t fought since.” Drift King shared, “I know that I’ve got to take it [school] seriously. There’s a lot more stuff that I can accomplish in life.” Isaiah discussed that their grades had improved and “I just got accepted to be a web leader.” In fact, many participants shared improvement in their overall well-being, grades, and relationships with peers: “I’ve been more happy,” “Now I have three As and four Bs,” and “I would describe myself as really helpful and caring about other people.” Participants seemed proud to share these accomplishments and were often smiling during the final interview as they discussed ways they had seen improvement.
The third theme to emerge was trusting others. This theme was endorsed by 12 of the 14 participants and is defined as participants’ lived experiences with learning to trust others, especially adults. In the initial interview, the participants were unsure of some of their relationships and especially expressed a disconnect with adults. Many participants said that they did not always ask for help or they had some past negative experiences with adults and peers. After participating in the therapeutic youth mentoring program, many participants reported having a trusting relationship with their mentor, and a few with other adults supporting the program, such as mentor coaches and CITs. There also seemed to be some shift in participants having better relationships with peers and other adults outside of the therapeutic youth mentoring program. Participants shared two aspects of trusting others: qualities of a trusted mentor/adult and feeling understood or heard.
Qualities of a Trusted Mentor/Adult
Many participants shared that they perceived their mentors as someone who will “always be there for you.” Andrew shared, “We had a lot in common. So, I can talk to her and she’ll know the answer.” Ball shared, “I just get someone to talk to other than my parents and friends . . . [he’s] a helpful person that gets you through bad times.” Drift King stated, “They help you with anything I need: anger management, class, social skills, school, someone to talk to like a counselor.” Participants described mentors as “cool,” “funny,” “nice,” “friendly,” “chill,” and “helpful.”
Participants were also asked about their perceptions of meeting with a counselor before and after participating in the therapeutic mentoring program. The majority of the participants shared positive experiences they have had with counselors both at school and during the therapeutic mentoring program, stating they helped “when I’m having a bad day,” “after my Grandpa died,” and “when I was being bullied.” Only one participant, Isabel, mentioned that she trusted the CIT more than her mentor: “She’s super there for me, and I only want to talk to her about my problems, because I don’t feel like I really know any other counselors.” Andrew seemed confused about the roles of the different adults at the therapeutic mentoring program: “I thought they were all like mentor and mentor coaches.” After clarification, he shared that the CITs “bring you up . . . if you are feeling down or unhappy.” Although there may have been some initial confusion about the difference between the CITs and coaches, it seemed that most participants felt comfortable seeking counseling support as needed.
Feeling Understood or Heard
In addition to sharing qualities that they appreciated about their mentors, participants shared that a mentor is someone who understands them and makes them feel heard. Drift King shared, “I feel like they’ve been through it too, tough times and they succeed . . . I feel they can help you.” Jeffy stated, “We’re really similar, he’s kind of like me. They talk about your weekend . . . and make you feel happier if you had a bad day.” Rene discussed how her mentor “supports me, like if I have a really bad day she helps me out to have a better rest of my day.”
Adaptability and Resiliency
The fourth theme that emerged was adaptability and resiliency. This theme was endorsed by 10 out of the 14 participants and is defined as participants’ lived experiences of the ways in which they were adapting to some of the stressors that they had shared in the first interview. Participants discussed what they had learned in the therapeutic mentoring program, and often the new resiliency skills seemed connected to experiences with their individual mentor. Participants endorsed two major aspects of this theme: social-emotional growth and coping skills.
Participants shared ways in which they had grown socially and emotionally over the semester. DTS shared, “I made some new friends.” Isaiah stated, “I open up to new people.” Bam discussed how their mentor helped them “get through rough times.” Many participants shared that working with their mentors helped them “deal with stress,” “learn how to socialize,” and “make the right decisions.” Several participants were hesitant to even attend CC initially and by the end, they expressed that they were sad to leave because of the social and emotional connections.
Participants also perceived they had better coping skills and strategies for how to approach a variety of problems. Andrew stated, “Yesterday there was a fight, and I didn’t go . . . [my mentor] said, ‘You can always walk away.’” Josh shared that they learned various coping skills such as better “communication skills and knowing people who will help me and be respectful . . . it’s helped me be able to talk and interact with other people.” Tristonion added, “Well, this place teaches us to calm down.” Participants shared that they also “started focusing,” “doing good deeds,” and “hang[ing] with other people.” Several participants shared that the coping skills they were using they had learned either from their mentor or the CITs during 1:1 time or in prosocial activity time.
Hope for the Future
The fifth and final theme that emerged was hope for the future. This theme was endorsed by 13 of the 14 participants and is defined as participants’ lived experiences surrounding their future hopes and plans. Many participants in the initial interview had lofty goals that did not always seem realistic (e.g., become an NBA or NFL player). Participants also emphasized the importance of having perfect grades and that this is how they would know they were successful. After participating in the therapeutic mentoring program, participants shared what they had learned and their hopes for the future. The three aspects of this theme centered around setting realistic goals for school, the importance of future careers, and the impact they could have on others.
Realistic Goals for School
At the end of this study, many participants reported improvement in grades but were not stressing about perfection as much. Participants were setting more realistic goals for themselves with school. Drift King shared they were planning ahead for high school and would “take it more seriously than middle school . . . to get the credit to actually graduate.” Super J stated about meeting with his mentor, “It’s probably going to help me be successful at college because they show you how important it is to not give up.” JT discussed how doing well in school would allow them to continue to wrestle and “get first place again.” Many participants seemed to have learned from their mentor and/or CIT more about the college process and what they needed to do now in order to reach future goals.
Participants were also more interested in what it might take for them to meet their future career goals. Isabel stated, “In September I’m getting my first job . . . and once I graduate high school, I want to be a lawyer in the Air Force.” Josh stated, “I want to get the highest grades I can so I can do activities and get into higher classes to set myself on the right foot for the future.” Josh mentioned the importance of “getting a good education . . . going to college and get[ting] a job.” This youth was considering a variety of occupations such as construction worker or firefighter. Some of the participants even mentioned that after working with their mentor they wanted to “go to college here” and realized that college might help them “be able to have a good job and a good house.” Participants seemed to be making the connection between college and career based on conversations with their mentor and/or CIT.
Impact on Others
At the same time that participants were discussing their hopes for the future, there were many who also wanted to have an impact on others. Isaiah knew that they wanted to help people and discussed a variety of ways they might do this by being a “teacher, nurse, or school counselor.” Rene was not sure if they wanted to help people or animals, so they were considering “being a veterinarian or a doctor.” Finally, Super J shared, “I kind of want to help other kids—like to be an orthodontist and help kids and fix their teeth.” It is important to note that the majority of the undergraduate mentors are in human services and helping degrees so this may have influenced their mentees on some level.
The overarching question for this study was: What were participants’ lived experiences prior to and after participating in a therapeutic youth mentoring program? In this section, the findings are discussed as they relate to answering this overarching question. Furthermore, a discussion of how these findings support and add to the literature on therapeutic mentoring programs is provided.
Consistent with prior research studies on mentoring programs, the participants in this study shared that having a mentor had a positive impact on their overall behavior (DuBois et al., 2011; Tolan et al., 2014; Weiler et al., 2015). Specifically, participants indicated more adaptive and resilient thinking after participating in the youth mentoring program. Lee et al. (2012) indicated that resilience is not fixed but can be learned and fostered through the protective factors in a child or adolescent’s life. Being able to walk away from a fight or potentially violent situation and asking adults for help were two of the outcomes participants described. A few participants even cited the therapeutic youth mentoring program as the reason why they have developed better coping strategies to better handle the stress they feel in their daily lives.
Another finding consistent with the research on mentoring programs was that participants acknowledged the significance of the primary mentoring relationship (Weiler et al., 2015; Weiss et al., 2019). One significant finding between the initial and final interview was the participants’ shared perspective that they trusted their mentor and the other adults supporting the youth mentoring program (e.g., mentor coaches and counselors). Griffith and Larson (2015) stated that when youth have trusting relationships with adults they become “deliberate agents of their own development” (p. 791). Mentors and CITs supporting the youth mentoring program helped to facilitate this development of trust by being present, participating in dialogue, and leading prosocial activities with the youth.
Many participants also described that because of the trust they developed with their mentor, they were able to also trust other adults in their lives, specifically parents, counselors, and teachers. When adolescents have a trusting relationship with at least one adult in their life, help-seeking behavior increases for the youth as well as their immediate peer group (DeLay et al., 2016). Although the majority of the participants shared the positive impact of having a therapeutic component to this youth mentoring program, five of the 14 participants still shared in the final interview that they were hesitant to meet with a counselor (either at school or at the therapeutic mentoring program). Haddock and colleagues (2017) posited that youth who participated in CC might be embarrassed to share about their experiences with counselors. It is important to note that some of the youth participants also did not make the distinction between CITs and mentor coaches. So, more clarity on the role of CITs in youth mentoring programs may be needed.
However, the mentors in the CC therapeutic mentoring program do learn some basic counseling skills and are also trained in crisis intervention. Although development of the relationship with the counselor may be an area of further examination with therapeutic mentoring programs, it seemed that many of the participants felt comfortable discussing mental health issues with their mentors who were being supported by counseling professionals.
Researchers have discovered that when mentees do develop a positive perception of support, this can lead to an increase in academic attitudes and self-esteem, lower frequencies of problem behaviors, and thinking more positively about the future (Chan et al., 2013; Haddock et al., 2017; Raposa et al., 2019; Weiler et al., 2014). In this current study, not only did participants indicate that their grades improved, but they also began to develop a more balanced outlook concerning school and their future college and career goals. Similarly, Weiss and colleagues (2019) discovered that positive academic mentoring relationships help youth find hope for the future and instill a belief that college and career goals can be reached.
In the initial interview, many participants discussed their perceived barriers and stressors to academic and life success, such as learning and mental health challenges. Haft and colleagues (2019) discovered that participation in a peer-mentoring program resulted in reduced depressive symptoms and increased self-esteem in youth with ADHD and learning disabilities. Relatedly, participants in our current study talked more openly about their strengths and hopes in the final interviews, demonstrating more self-awareness, fewer depressive indicators, and a higher sense of self. Perhaps gaining more hope and a higher sense of self led the participants to also focus on ways in which they might positively impact others. This finding is interesting considering that Briggs et al. (2007) posited that some youth might seek out opportunities to volunteer to help others in order to increase their self-worth.
There are a number of implications of these findings for counselors, particularly those interested in adding a therapeutic component to traditional mentoring programs. First, although many youth mentoring programs have historically focused on the connection between mentor and mentee (Marshall et al., 2016; Rhodes, 2002; Weiss et al., 2019), the results of this study indicate a significant benefit related to the additional attention to the mental health needs of mentees. Throughout the 12-week period, mentees had the opportunity to engage with mental health professionals in a non-threatening context. This added therapeutic component appeared to provide an additional support toward the connections the youth developed with trusted adults.
Another important implication emerging from the results points to the increase in self-esteem and self-efficacy in the context of the variety of relationships and settings available to the youth mentees. A number of youth reported they could envision themselves going to college in the future after having spent time on a college campus and being exposed to a wider variety of career options. Mentoring programs may find value in creating pathways to career and college exposure supported by trusted adults, such as mental health counselors.
An increase in problem-solving and coping skills is an additional finding with significant implications for youth mentoring programs. Most of the youth interviewed shared varied experiences in the program that resulted in developing new ways of adapting to life stressors. This theme emerged in various ways for the youth, indicating that it may be effective for other programs to integrate a variety of experiences, such as psychoeducational and therapeutic components, that focus on adaptive and resiliency skills.
Mentoring programs are important in aiding struggling youth but often fall short because of a lack of resources and consistency and an inability to address the mental health needs of mentees (Weiler et al., 2013). Including counselors and incorporating a therapeutic component in youth mentoring programs may be beneficial to both youth and their mentors. The implications of adding a therapeutic component in youth mentoring programs and psychoeducational activities on a college campus are extensive and indicate that further development and research are imperative.
Limitations and Future Research
There are several limitations within this current study. One limitation is that youth reported initial reluctance to participate in the research portion of the program. For many youth, participating in an individual qualitative interview was a novel experience and establishing rapport was often contingent on the overall volume of engagement. It may be helpful to allow the youth to have their mentors present during the interview because they are a trusted adult.
Further, a few participants expressed confusion regarding the difference in roles between the mentors, CITs, and mentor coaches. Youth and their caregivers do go through a formal intake process, but perhaps further psychoeducation or an orientation for youth on the different roles, in particular of the CITs, would be helpful. In addition, youth only participated in an average of 50 minutes of 1:1 counseling across the 12 weeks. However, there were many times they were interacting with CITs in small groups and large classroom guidance, similar to school counseling. Future studies with therapeutic mentoring programs could provide better clarification on the role of CITs and perhaps provide more structured weekly 1:1 counseling time with all participants.
Additionally, follow-up interviews with youth participants could help determine if identified change behaviors and attitudes continue to persist over time. In particular, it would be interesting to see if youth were more likely to reach out to their school counselor and/or counselors in the community after participating in a therapeutic youth mentoring program. Several participants mentioned they had never met with their school counselor and/or an outside counselor and that meeting with the CIT at CC was their first experience with individual counseling.
Lastly, future research regarding the experiences of mentors, parents, and key stakeholders in participants’ lives (e.g., teachers, parole officers, case workers, school counselors) could provide greater validity and confirmation of universal themes and experiences generated by the therapeutic youth mentoring program. A follow-up quantitative or mixed methods study could confirm and further validate key findings.
Mentoring programs are an effective mental health intervention for at-promise youth, and the addition of a therapeutic component might further enhance this intervention. A qualitative study was conducted to analyze youth’s lived experiences before and after participating in a therapeutic youth mentoring program. The participants in this study consisted of a diverse group of youth who were interviewed at the beginning and end of a 12-week therapeutic mentoring program. In addition to being paired 1:1 with a mentor, all of the youth had access to individual counseling with CITs throughout the program. The five themes that emerged from the data were life stressors, self-awareness, trusting others, adaptability and resiliency, and hope for the future. Some aspects discussed within these themes included peers/bullying, positive self-image, feeling heard or understood, social-emotional skills, and future careers. Researchers observed an increase in self-esteem, self-efficacy, and problem-solving and coping skills in the youth. Finally, youth participating in the therapeutic mentoring program perceived a benefit of having additional attention given to their mental health needs.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Schoeneberger, J. A. (2012). Longitudinal attendance patterns: Developing high school dropouts. The Clearing House, 85(1), 7–14.
Stark, C., Wehrman, J., Stutey, D. M., Solis, A., Severn, K., Cammell, M., Gloden, H., Enkler, K., Notestine, L., & Palacios, A. (2021). Therapeutic mentoring for at-promise youth: A grounded theory study of mentors’ adaptation during the COVID-19 crisis. Journal of Human Services: Special Interdisciplinary Issue, 40(2), 116–132.
Stutey, D. M., Givens, J., Cureton, J. L., & Henderson, A. J. (2020). The practice of bridling: Maintaining openness in phenomenological research. Journal of Humanistic Counseling, 59(2), 144–156. https://doi.org/10.1002/johc.12135
Tolan, P. H., Henry, D. B., Schoeny, M. S., Lovegrove, P., & Nichols, E. (2014). Mentoring programs to affect delinquency and associated outcomes of youth at risk: A comprehensive meta-analytic review. Journal of Experimental Criminology, 10, 179–206. https://doi.org/10.1007/s11292-013-9181-4
Trusty, J. (2011). Quantitative articles: Developing studies for publication in counseling journals. Journal of Counseling & Development, 89(3), 261–267. https://doi.org/10.1002/j.1556-6678.2011.tb00087.x
Vagle, M. D. (2009). Validity as intended: ‘Bursting forth toward’ bridling in phenomenological research. International Journal of Qualitative Studies in Education, 22(5), 585–605. https://doi.org/10.1080/09518390903048784
Weiler, L. M., Boat, A. A., & Haddock, S. A. (2019). Youth risk and mentoring relationship quality: The moderating effect of program experiences. American Journal of Community Psychology, 63(1–2), 73–87. https://doi.org/10.1002/ajcp.12304
Weiler, L. M., Chesmore, A. A., Pryce, J., Haddock, S. A., & Rhodes, T. (2019). Mentor response to youth academic support–seeking behavior: Does attunement matter? Youth & Society, 51(4), 548–569. https://doi.org/10.1177/0044118X17697235
Weiler, L. M., Haddock, S. A., Zimmerman, T. S., Henry, K. L., Krafchick, J. L., & Youngblade, L. M. (2015). Time-limited, structured youth mentoring and adolescent problem behaviors. Applied Developmental Science, 19(4), 196–205. https://doi.org/10.1080/10888691.2015.1014484
Weiler, L., Haddock, S., Zimmerman, T. S., Krafchick, J., Henry, K., & Rudisill, S. (2013). Benefits derived by college students from mentoring at-risk youth in a service-learning course. American Journal of Community Psychology, 52(3–4), 236–248. https://doi.org/10.1007/s10464-013-9589-z
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Pre Semi-Structured Interview
- Tell me what you already know about Campus Connections or having a mentor.
- Describe a typical day or week at school.
- What do you enjoy?
- What is something you struggle with?
- What are some ways you think having a mentor could help you (at school, home, in life)?
- What are your future goals or plans?
- For middle school
- High school
- After high school
- What is something that is preventing you from achieving your goals or future plans?
- How could your mentor help you with these challenges?
- Tell me about your thoughts/feelings about being on a college campus.
- What kind of jobs or careers are you thinking about?
- What are your thoughts on meeting with a counselor?
- Can you describe a time when a counselor helped you?
- How do you think people would describe you?
- Parent or guardians?
- How would you describe yourself?
- What is something you wish people knew about you?
Post Semi-Structured Interview
** Remind the student of the pseudonym they chose and ask if they want to keep or change this.
- Tell me what you now know about Campus Connections and having a mentor.
- How would you describe your mentor?
- Tell me a story about your favorite thing about Campus Connections? Least favorite?
- Describe a typical day or week at school.
- What do you enjoy?
- What is something you struggle with?
- What are some ways you think having a mentor and participating in Campus Connections helped you?
- At school
- At home
- In life
- What are your future goals or plans?
- For middle school
- High school
- After high school
- What is something that has been preventing you from achieving your goals or future plans?
- Describe how your mentor helped you with these challenges.
- Tell me about your thoughts/feelings about being on a college campus.
- What kind of jobs or careers are you thinking about?
- What are your thoughts on meeting with a counselor?
- Can you describe a time when a counselor helped you?
- How do you think people would describe you?
- Parent or guardians?
- How would you describe yourself?
- Are there things about you that you think have changed/improved since joining Campus Connections?
- What is something you wish people knew about you?
- What else would you like me or others to know about Campus Connections?
Diane M. Stutey, PhD, NCC, LPC, RPT-S, is an assistant professor and department chair at the University of Colorado Colorado Springs. Abigail E. Solis, MA, is a clinical mental health counselor at Colorado Motion. Kim Severn, MA, LPC, is an instructor at the University of Colorado Colorado Springs. Lori Notestine, PhD, LPC, is an instructor and program coordinator at the University of Colorado Colorado Springs. Kodi L. Enkler is a licensed school counselor at Swigert Aerospace Academy. Joseph Wehrman, PhD, LPC, is a professor at the University of Colorado Colorado Springs. Molly Cammell, MA, is Campus Connections program manager at the University of Colorado Colorado Springs. Correspondence may be addressed to Diane M. Stutey, 1420 Austin Bluffs Parkway, Colorado Springs, CO 80918, firstname.lastname@example.org.
Gregory T. Hatchett
The addition of disruptive mood dysregulation disorder (DMDD) to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was a controversial decision in 2013 and one that continues to the present. Researchers have found that DMDD exhibits both poor interrater reliability and discriminant validity from other common childhood-onset disorders, most notably oppositional defiant disorder (ODD). Research also indicates that DMDD might be better conceptualized as a component of ODD, and consistent with such a conceptualization, experts have recommended that effective treatments for ODD be applied to youth who fit the diagnostic pattern of DMDD. The purpose of this article is to help readers understand the problematic diagnostic validity associated with DMDD and to present recommended treatment strategies for working with youth who fit this challenging symptom profile.
Keywords: disruptive mood dysregulation disorder, oppositional defiant disorder, conceptualization, diagnostic validity, youth
A pattern of emotional and behavioral dysregulation—characterized by severe irritability, temper outbursts, and aggressive behavior—is one of the most common reasons that children and adolescents are referred to mental health service providers (Axelson et al., 2012; Brotman et al., 2017; Stringaris et al., 2018) and a common antecedent to inpatient hospitalization (Chase et al., 2020; Rao, 2014). Despite the prevalence and severity of these associated symptoms, mental health professionals have often disagreed as to how children and adolescents who fit this symptom profile should be conceptualized and properly diagnosed. Over the years, chronic irritability and temper dysregulation have been conceptualized as associated features of externalizing disorders (Carlson, 1998), developmental variations of early-onset bipolar disorder (Biederman et al., 2000), and core features of an experimental research phenotype (Leibenluft et al., 2003; Rich et al., 2005; Stringaris et al., 2010).
In 2013, the American Psychiatric Association (APA) provided a new diagnostic home for youth with chronic and severe irritability in the depressive disorders chapter in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013). This new disorder—disruptive mood dysregulation disorder (DMDD)—was specifically added to the DSM-5 to prevent clinicians from overdiagnosing a bipolar and related disorder in children and adolescents who exhibited non-episodic irritability and temper outbursts. Beginning in the 1990s, there began an exponential increase in the number of children and adolescents who were diagnosed with bipolar disorder. As just one example of this pattern, Moreno et al. (2007) reported a 40-fold increase of the number of outpatient office visits for children and adolescents treated for bipolar disorder between 1995–1996 and 2002–2003. Not only was this increase unusual from an epidemiological perspective (Van Meter et al., 2011), but researchers also began to accumulate evidence that these youth did not match the profile of either youth or adults with traditional bipolar disorder (Leibenluft, 2011; Towbin et al., 2013). To better characterize children and adolescents who exhibited chronic irritability and temper outbursts, researchers at the National Institute of Mental Health (Leibenluft et al., 2003) developed a new diagnostic phenotype, severe emotional dysregulation (SMD), to differentiate this symptom pattern from traditional bipolar disorder. SMD subsequently became the foundation for the inclusion of DMDD in the DSM-5 (APA, 2013).
Many experts disagree about DMDD as a valid and coherent diagnostic category. However, there seems to be a strong consensus that many children and adolescents are severely impaired because of chronic irritability and severe temper dysregulation (Copeland et al., 2014; Rao, 2014). Although early estimates indicate that only 1%–3% of children and adolescents may meet the full diagnostic criteria for DMDD (Copeland et al., 2013), many more may present with at least subthreshold symptoms of the disorder (Baweja, Mayes, et al., 2016; Freeman et al., 2016). Thus, counselors, especially those working in clinical settings, will likely find themselves working with many children and adolescents who exhibit symptoms of DMDD, symptoms which need to be carefully evaluated as part of any differential diagnostic process. To provide the best possible services for this population, counselors need to be familiar with the current literature on both the diagnosis and treatment of DMDD. Consequently, this article summarizes these current DMDD topics and presents treatment recommendations for working with youth diagnosed with DMDD. Because it is important for counselors to understand the questionable diagnostic validity of DMDD and how these diagnostic limitations should inform the treatment planning process, this topic will be preceded by criticisms of DMDD as a valid mental disorder. Also discussed are the challenges of diagnosing youth who present with chronic emotional and behavioral dysregulation.
The Diagnosis of DMDD
The diagnostic criteria and decisional rules for DMDD in the DSM-5 (APA, 2013) are rather detailed, so only a summary will be provided here. (Readers should consult pages 156–160 in the DSM-5 for more detailed information.) The core diagnostic features for DMDD include recurrent (3 or more times a week) temper outbursts that are developmentally inappropriate, severe, and disproportionate to any identifiable stressor along with the persistence of a chronically irritable or angry mood between these temper outbursts—a disruption in mood that is noticeable by others. These symptoms must have begun before the age of 10, persist for a minimum of a year (with no more than 3 consecutive months of symptom-free periods), and be present in at least two out of three settings (i.e., home, school, peer relationships). According to the DSM-5, this diagnosis should not be made if these symptoms occur exclusively during a major depressive episode or if the symptoms are better explained by another mental disorder, such as autism spectrum disorder. Also, a diagnosis of DMDD cannot be given concurrently with oppositional defiant disorder (ODD), bipolar disorder, or intermittent explosive disorder. If a child meets the diagnostic criteria for both DMDD and ODD, only DMDD should be given. As mentioned previously, DMDD was specifically added to the DSM-5 to prevent clinicians from overdiagnosing bipolar and related disorder in children and adolescents who exhibit non-episodic irritability and temper outbursts. However, at first glance, a youth who meets the diagnostic criteria for DMDD may be suspected of having a bipolar and related disorder. Thus, it is important for counselors to recognize the fundamental differences between the two disorder classifications.
As explained above, in DMDD, a child or adolescent experiences non-episodic irritability that is punctuated by severe and disproportionate temper outbursts. This symptom presentation must occur for at least 365 days, and during the year, have no more than a 3-month period in which the child or adolescent does not experience the core features of the disorder. In contrast, youth who meet the diagnostic criteria for bipolar disorder experience distinctive episodes of mania (at least 7 days), hypomania (at least 4 days), or depression (at least 14 days). Although irritability and temper outbursts can certainly occur in the context of a manic or hypomanic episode, there are additional symptoms that must also be present. Specifically, the irritability or temper outbursts should be episodic, accompanied by an increase in goal-directed activity/energy, and include additional symptoms, such as grandiosity, decreased need for sleep, pressured speech, racing thoughts, or reckless impulsivity (APA, 2013). More information on the differential diagnosis of bipolar disorder from DMDD and other conditions can be found in Hatchett and Motley (2016).
Diagnostic Validity of DMDD
Many have argued that adding DMDD to the DSM-5 traded one problem—overdiagnosis of bipolar disorder—for another: a poorly conceptualized diagnostic construct lacking any evidence-based treatments (e.g., S. C. Evans et al., 2017; Freeman et al., 2016; Parker & Tavella, 2018). As Malhi and Bell (2019) recently observed, “more than half a decade later, the ‘creation’ of this new diagnostic entity [DMDD] has not provided any novel insights or greater understanding and is yet to demonstrate any tangible benefits” (p. 706).
Though DMDD has been criticized for its poor interrater reliability (Regier et al., 2013) and low temporal stability across time (e.g., Axelson et al., 2012), the strongest criticism of DMDD has been directed toward its standing as an independent and coherent diagnostic construct, a concern that was not only present at the time of its introduction in the DSM-5, but one that has been bolstered by subsequent research since the publication of the DSM-5 in 2013. Ironically, the evidentiary basis for including DMDD in the DSM-5 was not based on studies of children and adolescents who actually matched the specific diagnostic criteria for DMDD. Instead, the research support for DMDD was inferred from research conducted on SMD (Baweja, Mayes, et al., 2016; Bruno et al., 2019; Rao, 2014; Towbin et al., 2013). As mentioned previously, the phenotype of SMD was developed by researchers at the National Institute of Mental Health (Leibenluft et al., 2003) to provide an alternative conceptualization to bipolar disorder for youth who exhibited chronic and severe irritability, temper dysregulation, and hyperarousal. However, there are important differences between the diagnostic criteria for SMD and DMDD. Compared to the diagnostic criteria for DMDD, SMD includes different age parameters, the presence of an abnormal mood characterized by anger or sadness, different exclusion criteria, and most importantly, the presence of hyperarousal (e.g., insomnia, agitation, distractibility; Leibenluft, 2011). As S. C. Evans et al. (2017) pointed out, “Given the differences between the operationalization of SMD in the literature and the definition of DMDD, virtually no evidence regarding DMDD existed at the time of its inclusion in DSM-5” (p. 33).
Consistent with these differences, researchers have found low levels of correspondence between the two syndromes. For example, Copeland et al. (2013) reported that only 38.9% of those who met the criteria for SMD also met the diagnostic criteria for DMDD. These differences have important implications for the treatment planning process. Specifically, it is unclear whether any of the interventions that have been found to be helpful for youth with SMD (e.g., Towbin et al., 2020) will generalize to youth who match the different diagnostic profile for DMDD (Benarous et al., 2017).
Furthermore, since the publication of the DSM-5 in 2013, researchers have increasingly challenged the validity of DMDD as a stand-alone diagnostic construct (Freeman et al., 2016). For one, there is very little evidence to suggest that DMDD can be reliably differentiated from other common childhood-onset disorders (S. C. Evans et al., 2017; Malhi & Bell, 2019). Several of the core symptoms of DMDD—chronic irritability and recurrent temper outbursts—are not exclusive to DMDD, but rather represent transdiagnostic symptoms often present in many other disorders, such as ODD, generalized anxiety disorder, depression, autism spectrum disorder, bipolar disorder, and post-traumatic stress disorder (e.g., Stringaris et al., 2018). As Parker and Tavella (2018) pointed out, “Those who meet the criteria for DMDD may in fact have a conduct disorder, ODD, attention deficit hyperactivity disorder (ADHD), or any of myriad other behavioral disorders” (p. 815). However, on the one hand, the diagnostic criteria for DMDD in the DSM-5 is very extensive and detailed, especially compared to what is commonly delineated for many other disorders in the DSM-5. Clinicians who carefully follow these detailed criteria and decisional rules should, in theory, arrive at valid and reliable diagnoses of DMDD. Yet, in real practice, the diagnostic process is often plagued by careless errors and clinician biases (Garb, 1998; Lacasse, 2014). Consequently, the issue becomes how well clinicians can apply these criteria in often complex clinical situations.
More research is needed on how well counselors and other clinicians can reliably diagnose DMDD and differentiate it from other conditions in ordinary practice settings. Concerns about the diagnostic validity of DMDD have been most pronounced in the differentiation of DMDD from ODD. In the DSM-5 (APA, 2013), a diagnosis of DMDD automatically supersedes a diagnosis of ODD; thus, these two diagnoses cannot be given concurrently. However, when researchers have removed this exclusionary rule, they have found that nearly all the children and adolescents who met the diagnostic criteria for DMDD also met the diagnostic criteria for ODD (Axelson et al., 2012; Freeman et al., 2016; Mayes et al., 2016). As just one example, Mayes, Waxmonsky, et al. (2015) reported that 91% of the children who met the criteria for DMDD in their study also qualified for a diagnosis of ODD. However, the reverse is not true. Researchers have found that diagnoses of ODD commonly occur in the absence of DMDD. Approximately one-third of children and adolescents who meet diagnostic criteria for ODD do not have significant symptoms of DMDD (Mayes et al., 2016).
According to the hierarchy or parsimony principle in the DSM-5 (APA, 2013), a clinician should diagnose the most severe disorder that best captures the multitude of symptoms that a client is experiencing instead of adding on several more minor diagnoses to the diagnostic record. For example, children and adolescents who meet the diagnostic criteria for autism spectrum disorder simultaneously meet the diagnostic criteria for social communication disorder. Therefore, an additional diagnosis of social communication disorder is unnecessary. Likewise, in the DSM-5, a diagnosis of DMDD is higher on the diagnostic hierarchy than ODD, and thus many of the symptoms of ODD are subsumed under a diagnosis of DMDD. For clinicians who carefully follow the diagnostic rules of the DSM-5, both negative affectivity and oppositional behavior can be recognized and targeted as part of a treatment plan for a youth with DMDD.
For an alternative point of view, some researchers have expressed the concern that a single, overruling diagnosis of DMDD will fail to adequately acknowledge the behavioral problems associated with ODD, resulting in suboptimal treatment planning decisions (S. C. Evans et al., 2017; Mayes et al., 2016). Mayes et al. (2016) pointed out that a diagnosis of DMDD fails to acknowledge many of the disruptive behavioral components of ODD that are nearly always present in children and adolescents who meet the diagnostic criteria for DMDD. Likewise, S. C. Evans et al. (2017) argued that
treating DMDD as a Depressive Disorder—and withholding a diagnosis of ODD, per DSM-5 hierarchical rules—may lead clinicians to conceptualize these youth as having a mood disorder rather than a behavior disorder. For primary care providers and pediatricians, treating DMDD as a mood disorder and removing the ODD label may both decrease referrals for behavioral interventions that are well established (e.g., parent management training) and increase the administration of psychotropic medications such as antidepressants, antipsychotics, and mood stabilizers, for which evidence is limited. (p. 39)
However, the concerns just mentioned may reveal more about problems in the correct use and application of the DSM-5 by clinicians rather than problems inherent in diagnostic rules prescribed by the DSM-5.
Because of the transdiagnostic nature of DMDD symptoms (e.g., Parker & Tavella, 2018), several experts have recommended that DMDD be recognized as either a subtype or specifier under other DSM-5 diagnoses (Mayes, Mathiowetz, et al., 2015), most often as a subtype or specifier under ODD (S. C. Evans et al., 2017; Malhi & Bell, 2019; Mayes et al., 2016; Mayes, Waxmonsky, et al., 2015). This was the approach recently taken by the World Health Organization (2019) in the 11th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). In the ICD-11, clinicians have the option to diagnose a youth with oppositional defiant disorder with or without chronic irritability-anger. Thus, this diagnostic code allows clinicians to concurrently recognize both symptoms of emotional dysregulation and symptoms of argumentative, oppositional, and vindictive behavior. However, at the time of this writing, the ICD-11 has not been adopted in the United States, so counselors in the United States are still using the DSM-5 (APA, 2013) and the ICD-10 (World Health Organization, 2016).
On the other hand, some have cautioned against the use of DMDD as only a subtype or specifier under ODD (e.g., Benarous et al., 2017; Stringaris et al., 2018). Brotman et al. (2017) expressed the concern that many clinicians do not record available specifiers in diagnostic records, and consequently, children and adolescents who are diagnosed with ODD under the DSM-5 might not receive targeted interventions for symptoms of severe irritability and temper outbursts. At the very least, perhaps clinicians should be allowed to diagnose DMDD and ODD concurrently.
Another concern in the differential diagnosis of DMDD is potential racial/ethnic bias. As a depressive disorder in the DSM-5 (APA, 2013), DMDD is conceptualized as an internalizing disorder, whereas ODD is conceptualized as an externalizing or disruptive behavior disorder. Researchers have found that African American youth are more likely to be diagnosed with externalizing disorders, whereas European American youth are more likely to be diagnosed with internalizing disorders (e.g., Fadus et al., 2020; Minsky et al., 2006). Though this research has not yet been replicated specifically in the diagnosis of DMDD, prior research indicates that African American youth may be less likely to be identified as having DMDD and may not receive adequate treatment for potential depressive symptoms. Furthermore, researchers have found that African Americans and other minority groups who experience higher rates of racial/ethnic discrimination also experience more mental health and psychosocial functioning difficulties compared to those with lower experienced rates of racial/ethnic discrimination (Tobler et al., 2013). Consequently, counselors should evaluate the extent to which irritability and aggression among minority youth are associated with experiences of discrimination as opposed to internal psychopathology implicit in the DSM framework (e.g., Carter et al., 2019; Mouzon et al., 2017).
Treatment Planning Strategies
Certainly, the main source of information for the proper diagnosis of DMDD is the explicit diagnostic criteria and decision rules in the DSM-5 (APA, 2013). To document these diagnostic criteria, counselors might consider using one or more of the cross-cutting measures included in Section III of the DSM-5 (pp. 733–741). Outside the DSM-5, there are currently few diagnostic tools for counselors to use in confirming a diagnosis of DMDD (Baweja, Mayes, et al., 2016). The assessment tools most often used in the research literature measure general irritability, such as the Affective Reactivity Index (Stringaris et al., 2012) or the Clinician Affective Reactivity Index (Haller et al., 2020). Specific to the diagnosis of DMDD, Wiggins et al. (2016) developed a DMDD module that was used in conjunction with the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL; Kaufman et al., 1997). However, this is a new module that has not undergone extensive psychometric evaluation.
In addition to confirming a diagnosis of DMDD, counselors should also assess for common comorbid mental disorders (Mayes et al., 2016). Youth who meet the diagnostic criteria for DMDD almost always have comorbid disorders, most often attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and specific learning disorders (Althoff et al., 2016; Bruno et al., 2019). Though one cannot technically diagnose DMDD and ODD concurrently under DSM-5 rules, counselors should also carefully assess and document symptoms of ODD, which will likely be appropriate targets in the treatment planning process (e.g., S. C. Evans et al., 2017).
Though there are currently not any clearly validated inventories for directly assessing DMDD, there are several inventories available for assessing the comorbid conditions that often accompany the DMDD symptom profile. In addition to the previously mentioned cross-cutting measures in Section III of the DSM-5 (APA, 2013), there are several commercially available inventories for assessing symptoms of ODD, such as the Achenbach Series (Achenbach & Rescorla, 2006) or the Child and Adolescent Disruptive Behavior Inventory (Cianchetti et al., 2013). Again, though a diagnosis of DMDD technically overrides a diagnosis of ODD, symptoms of ODD will likely be present and a major target area of a counseling plan. Administration of a validated measure of ODD will not only help counselors identify symptom severity at the beginning of the counseling process, but can also be repeatedly administered throughout the counseling process to evaluate areas of improvement and areas that need additional attention. This same assessment process could also be used for other conditions comorbid with DMDD. Counselors might use the Conner’s Rating Scales (Conners, 1999) to assess for ADHD and other associated symptoms, such as aggression and learning problems. Symptoms of depression can be evaluated through administering the Children’s Depression Inventory (Sitarenios & Kovacs, 1999) or the Beck Depression Inventory with older adolescents (Beck et al., 1996). As is often the case, an assessment and treatment protocol that targets specific symptoms may be more effective than one that tries to remediate global diagnostic constructs, such as DMDD (e.g., Weisz & Kazdin, 2017).
Evidence-Based Treatments for DMDD
This next section will review the currently available research on both the use of pharmacotherapy and psychosocial interventions in working with youth who meet the diagnostic criteria for DMDD. This will be followed by a review of evidence-based treatments for related clinical conditions and will end with a summary of general treatment recommendations for working with youth diagnosed with DMDD.
Researchers have conducted only a few studies on the effectiveness of pharmacotherapy in reducing symptoms of DMDD. For youth diagnosed with both DMDD and ADHD, researchers have found some evidence for the effectiveness of psychostimulant monotherapy (Baweja, Belin, et al., 2016; Winters et al., 2018) as well as the combination of methylphenidate with aripiprazole (Pan et al., 2018); however, in a small (n = 12) retrospective study, Ozyurt et al. (2017) found that methylphenidate resulted in increased irritability in children diagnosed with both DMDD and ADHD. Most recently, Rice et al. (2019) found some effectiveness for the use of amantadine with a 12-year-old diagnosed with DMDD who was admitted to a psychiatric hospital. Consistent with this limited research base, there are currently not any medications that have received Food and Drug Administration approval for treating children and adolescents specifically diagnosed with DMDD.
Parallel to the research on pharmacological interventions, very little research has been published on the use of psychosocial interventions with youth who meet the diagnostic criteria for DMDD. Perepletchikova et al. (2017) reported that a modified version of dialectical behavior therapy, which also included a parent training module, was more effective than treatment as usual (TAU) in improving irritability, temper outbursts, and overall functioning among youth diagnosed with DMDD. In a subsequent study, Miller et al. (2018) reported that a modified version of interpersonal psychotherapy—interpersonal psychotherapy for mood and behavior dysregulation (IPT-MBD)—was more effective than TAU in reducing irritability and angry outbursts. However, both treatment groups had equivalent scores on measures of depression and anxiety by the end of treatment. There have also been a couple of case studies published in the literature. Tudor et al. (2016) reported that cognitive behavioral therapy was effective in reducing irritability and aggression in a 9-year-old girl diagnosed with DMDD and ADHD. In another case study report, Linke et al. (2020) reported that an exposure-based, cognitive behavioral model was effective in treating an 11-year-old boy diagnosed with both DMDD and ADHD.
Interventions for Comorbid Disorders
In the absence of evidence-based treatments for DMDD, many experts have recommended that clinicians select evidence-based treatments for disorders that are often comorbid with DMDD, most commonly ODD (Baweja, Mayes, et al., 2016). As Freeman et al. (2016) recommended, “Until a better evidence base exists, clinicians should be cautious when diagnosing youth with DMDD, and treatment often might best start with using evidence-based practices for ODD” (p. 129). This recommendation is also consistent with the ICD-11, in which the core features of DMDD are conceptualized as a potential subtype of ODD. There are several evidence-based interventions for oppositional behavior in general and ODD in particular, such as cognitive therapy (Greene et al., 2004), parent management training (Costin & Chambers, 2007), and multisystemic therapy (Asscher et al., 2013). There are also several established treatments for ADHD, a condition that is also often comorbid with DMDD. Effective interventions include the use of psychostimulants (Castells et al., 2020) as well as several variations of behavior therapy (S. W. Evans et al., 2014).
Treatments for General Irritability
Another source of information for selecting potentially effective treatments for youth with DMDD may be found in research programs that have targeted transdiagnostic symptoms of irritability and aggressive behavior (Roy et al., 2014). Some evidence suggests that cognitive behavior therapy may be effective in reducing general symptoms of irritability in youth (Derella et al., 2020; S. C. Evans et al., 2020; Sukhodolsky et al., 2016). Along this line, Sukhodolsky and Scahill (2012) have published a treatment manual for working with youth and their families who struggle with anger and aggression. The competencies covered in this manual include, but are not limited to, relaxation training, emotional regulation, problem solving, and social skills training. With regard to pharmacotherapy, Tourian et al. (2015) conducted a literature review on the use of pharmacological agents in reducing symptoms of chronic irritability, aggression, and temper outbursts in children and adolescents. Based on their review, they found that methylphenidate, risperidone, and divalproex may offer some measure of effectiveness in reducing irritability and aggressive behavior.
General Treatment Recommendations
As mentioned earlier, one of the criticisms of adding DMDD to the DSM-5 was that DMDD provided clinicians with a new diagnostic label in the absence of any evidence-based treatments (e.g., Parker & Tavella, 2018). As evidenced by this review, this criticism continues to be valid. Based on the limited treatment literature for DMDD and the larger literature for disruptive behavior disorders, only a few general guidelines seem suitable at this time. For one, experts generally recommend that treatment commence with the use of cognitive behavior therapy combined with parent management training (Brotman et al., 2017; Bruno et al., 2019; Roy et al., 2014; Stringaris et al., 2018). As previously mentioned, recent research indicates that dialectical behavior therapy (Perepletchikova et al., 2017) and interpersonal therapy (Miller et al., 2018) may also be promising. Second, if there is comorbid ADHD, it is recommended that pharmacotherapy begin with the use of a psychostimulant (Blader et al., 2016; Roy et al., 2014). Mood stabilizers and atypical antipsychotics may also be considered if psychostimulants prove ineffective or in cases where there is a need for a quick reduction in severe irritability or aggressive behavior (e.g., Baweja, Mayes, et al., 2016; Roy et al., 2014). Stringaris et al. (2018) recommended that these medications should be used very cautiously:
Our recommendation is that antipsychotic prescriptions be reserved for those young people who have not responded to a series of other treatments and that the prescription be for a short period of time during which health indicators such as weight are tightly monitored. (p. 733)
Third, as mentioned previously, counselors should also consider the use of evidence-based interventions for ODD, a disorder that substantially overlaps with DMDD (e.g., Freeman et al., 2016).
The addition of DMDD to the fifth edition of the DSM was a controversial decision, a dispute that continues to the present. At the time of its inclusion in the DSM-5, there was no solid evidentiary foundation for including DMDD as a new diagnostic category (S. C. Evans et al., 2017). Evidence for the validity of DMDD was inferred from the research on SMD, a distinct phenotype (Bruno et al., 2019). Subsequent research since the publication of the DSM-5 in 2013 on the nature of DMDD has demonstrated that DMDD lacks discriminant validity from other common disorders, most notably ODD (Parker & Tavella, 2018).
As this literature has revealed, there continues to be a paucity of evidence-based treatments for children and adolescents who fit the common symptom profile of DMDD. Although evidence-based treatments for comorbid disorders offer promise, it is important that clinicians and researchers develop and validate psychosocial and pharmacological treatments that directly target the core symptoms of DMDD (Baweja, Mayes, et al., 2016). Yet, in addition to more effective remediation strategies (i.e., tertiary prevention), there is also a clear need for prevention processes that can identify and effectively help those children and adolescents who exhibit severe and chronic irritability (Stringaris & Goodman, 2009). Though research is still emerging, a diagnosis of DMDD seems to be a precursor for a lifetime of impairment. Youth with DMDD are at high risk for developing numerous mental health problems in adulthood, including major depressive disorder, persistent depressive disorder (dysthymia), and generalized anxiety disorder (Copeland et al., 2014; Stringaris et al., 2009; Stringaris & Goodman, 2009). The development and evaluation of such prevention processes should be taken up by professional counselors in both school and community settings, a responsibility that is part of our professional identity (Albee & Ryan-Finn, 1993).
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Gregory T. Hatchett, PhD, NCC, LPCC-S, is a professor at Northern Kentucky University. Correspondence may be addressed to Gregory T. Hatchett, MEP 211, Highland Heights, KY 41099, email@example.com.