A Mixed Methods Evaluation of the “Aged-Up” STAC Bullying Bystander Intervention for High School Students

April D. Johnston, Aida Midgett, Diana M. Doumas, Steve Moody

This mixed methods study assessed the appropriateness of an “aged-up,” brief bullying bystander intervention (STAC) and explored the lived experiences of high school students trained in the program. Quantitative results included an increase in knowledge and confidence to intervene in bullying situations, awareness of bullying, and use of the STAC strategies. Utilizing the consensual qualitative research methodology, we found students spoke about (a) increased awareness of bullying situations, leading to a heightened sense of responsibility to act; (b) a sense of empowerment to take action, resulting in positive feelings; (c) fears related to intervening in bullying situations; and (d) the natural fit of the intervention strategies. Implications for counselors include the role of the school counselor in program implementation and training school staff to support student “defenders,” as well as how counselors in other settings can work with clients to learn the STAC strategies through psychoeducation and skills practice.

Keywords: bullying, bystander intervention, consensual qualitative research (CQR), high school, mixed methods

Researchers have defined bullying as “when one or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again” (Centers for Disease Control & Prevention [CDCP], 2017, p. 7). Bullying includes verbal, physical, or relational aggression, as it often occurs through the use of technology (e.g., cyberbullying). National statistics indicate approximately 20.5% of high school students are victims of bullying at school and 15.8% are victims of cyberbullying (CDCP, National Center for Injury Prevention and Control, 2016). Although school bullying peaks in middle school, it remains a significant problem at the high school level, with the highest rates of cyberbullying reported by high school seniors (18.7%; U.S. Department of Education, National Center for Education Statistics, 2016).

There are wide-ranging negative consequences experienced by students who are exposed to bullying as either a target or bystander (Bauman, Toomey, & Walker, 2013; Doumas, Midgett, & Johnston, 2017; Hertz, Everett Jones, Barrios, David-Ferdon, & Holt, 2015; Rivers & Noret, 2013; Rivers, Poteat, Noret, & Ashurst, 2009; Smalley, Warren, & Barefoot, 2017). High school students who are targets of bullying report higher levels of risky health behaviors, including physical inactivity, less sleep, risky sexual practices (Hertz et al., 2015), elevated substance use (Doumas et al., 2017; Smalley et al., 2017), and higher levels of depression and suicidal ideation (Bauman et al., 2013; Smalley et al., 2017). Adolescents who observe bullying as bystanders also report associated negative consequences, and, in some instances, report more problems than students who are directly involved in bullying situations (Rivers & Noret, 2013; Rivers et al., 2009). Specifically, bystanders have been found to be at higher risk for substance abuse and overall mental health concerns than students who are targets (Rivers et al., 2009). Bystanders also are significantly more likely to report symptoms of helplessness and potential suicidal ideation compared to students not involved in bullying (Rivers & Noret, 2013). Furthermore, although bystanders are often successful when they intervene on behalf of targets of bullying (Gage, Prykanowski, & Larson, 2014), bystanders usually do not intervene because they do not know what to do (Forsberg, Thornberg, & Samuelsson, 2014; Hutchinson, 2012). Failure to respond to observed bullying leads to feelings of guilt (Hutchinson, 2012) and coping through moral disengagement (Forsberg et al., 2014). Thus, there is a need to train bystanders to intervene to both reduce bullying and buffer bystanders from the negative consequences associated with observing bullying without acting.

To address the negative effects that can result from being exposed to bullying, researchers have developed numerous bullying prevention and intervention programs for implementation within the school setting. Many of these programs are comprehensive, school-wide interventions (Polanin, Espelage, & Pigott, 2012; Ttofi, Farrington, Lösel, & Loeber, 2011). However, findings indicate these programs are most effective for students in middle and elementary school (Yeager, Fong, Lee, & Espelage, 2015). Additionally, a recent meta-analysis indicates that bystander intervention is an important component of bullying intervention; however, few comprehensive programs include a bystander component (Polanin et al., 2012). Further, those programs that do include a bystander component have been normed on children within the context of the classroom setting (Salmivalli, 2010). High school students experience greater independence at school, with less adult supervision in the hallways and at lunch, and move to different classroom locations throughout the day. Thus, there is a need for effective bullying bystander programs and interventions that have been “aged up” specifically for the high school level (Denny et al., 2015).

The STAC Program

The STAC program is a brief bystander intervention that teaches students who witness bullying to intervene as “defenders” (Midgett, Doumas, Sears, Lundquist, & Hausheer, 2015). The STAC acronym stands for the four bullying intervention strategies taught in the program: “Stealing the Show,” “Turning It Over,” “Accompanying Others,” and “Coaching Compassion.” The second author created the STAC program for the middle and elementary school level with the intention of establishing school counselors as leaders in program implementation. The program includes a 90-minute training with bi-weekly, 15-minute small group follow-up meetings, placing low demands on schools for implementation. Findings from studies conducted at the elementary and middle school level indicate students trained in the STAC program report an increase in knowledge and confidence to intervene as defenders (Midgett et al., 2015; Midgett & Doumas, 2016; Midgett, Doumas, & Trull, 2017), as well as increased use of the STAC strategies (Midgett, Doumas, Trull, & Johnston, 2017). Additionally, research demonstrates students trained in the STAC program report reductions in bullying (Midgett, Doumas, Trull, & Johnson, 2017), as well as increases in self-esteem (Midgett, Doumas, & Trull, 2017) and decreases in anxiety (Midgett, Doumas, Trull, & Johnston, 2017), compared to students in a control group.

Development of the STAC Program for High School

The authors conducted a previous qualitative study to inform the modification of the original STAC program to be appropriate for the high school level (for details, see Midgett, Doumas, Johnston, et al., 2017). Based upon data generated from high school students, the authors “aged up” the STAC program by incorporating the following content into the didactic and role-play components of the training: (a) cyberbullying through social media and texting, (b) group dynamics in bullying, and (c) bullying in dating and romantic relationships. The authors also aged up the program by including developmentally appropriate language (e.g., breaks vs. recess) and content, including common locations where bullying occurs (e.g., school parking lot vs. the school bus) and age-appropriate examples of physical bullying (e.g., covert behaviors such as “shoulder checking,” “backpack checking,” and “tripping” vs. physical fights).

Purpose of the Study

The purpose of this study was to extend the literature by evaluating the appropriateness of the aged-up STAC program for the high school level and to explore the experiences of students trained in the program. Following guidelines suggested by Leech and Onwuegbuzie (2010), the literature review guided the formulation of the study rationale, goal, objectives, and research questions. Despite the need to provide anti-bullying programs to high school students, the majority of bullying intervention research has been conducted with elementary and middle school students (Denny et al., 2015). Although intervening on behalf of students who are targets of bullying is associated with positive outcomes (Hawkins, Pepler, & Craig, 2001), research on bystander intervention programs aged up for high school students is limited. The present authors could find only one program, StandUP, developed specifically for high school students. Results of a pilot study indicated students participating in the 3-session StandUP online program reported an increase in positive bystander behavior and decreases in bullying behavior (Timmons-Mitchell, Levesque, Harris, Flannery, & Falcone, 2016). The research noted several methodological limitations that limit the generalizability and validity of the findings, including a 6.8% response rate, 22% attrition rate with differential attrition by race and bullying status, and the use of a single-group design.

Thus, the goal of this study was to add to the knowledge on bullying interventions for high school students. Our objectives were to (a) examine the influence of the STAC program on knowledge and confidence, awareness of bullying, and use of the STAC strategies, and (b) describe and explore the experience of high school students participating in the STAC intervention. We were interested in answering the following mixed method research questions: (a) Do students trained in the aged-up STAC intervention report an increase in knowledge and confidence to intervene as defenders? (b) Do students trained in the aged-up STAC intervention have an increased awareness of bullying? (c) Do students trained in the aged-up STAC intervention use the STAC strategies to intervene when they observe bullying? and (d) What were high school students’ experiences of participating in the aged-up STAC intervention and using the STAC strategies to intervene in bullying situations?


Mixed Research Design

A mixed methods design was implemented with a single group of participants who completed the STAC training. We were interested in the influence of the STAC intervention on students’ knowledge and confidence, awareness of bullying, and use of the STAC strategies. An additional interest was to understand students’ experiences of the STAC training. The purpose of selecting a mixed methods design was to maximize interpretation of findings, as mixed methods designs often result in a greater understanding of complex phenomena than either quantitative or qualitative studies can produce alone (Creswell, 2013). Hesse-Biber (2010) also advocates for the convergence of qualitative and quantitative data to enhance and triangulate findings. Following the guidelines described by Leech and Onwuegbuzie (2010), we chose to supplement the quantitative data with qualitative data to investigate the in-depth, lived experiences of high school students trained as defenders in the aged-up STAC program. Our research design was a partially mixed, sequential design (Creswell, 2009; Leech & Onwuegbuzie, 2010). The quantitative design was a single-group repeated-measures design and the qualitative component included consensual qualitative research (CQR; Hill et al., 2005).


Our sampling design was sequential-identical (Leech & Onwuegbuzie, 2010), with the same participants completing surveys followed by focus groups. The sample consisted of 22 students
(n = 15 females [68.2%]; n = 7 males [31.8%]) recruited from a public high school via stratified random sampling in the Northwestern region of the United States. Participants ranged in age from 15–18 years old (M = 16.82 and SD = 0.91), with reported racial backgrounds of 59.1% White, 18.2% Asian, 13.6% Hispanic, and 9.1% African American. Of the 22 participants trained in the STAC program, 100% participated in follow-up focus groups and follow-up data collection.


The current study was completed as part of a larger study designed to develop and test the effectiveness of the aged-up STAC intervention. Following institutional research board approval, the researchers randomly selected 200 students using stratified proportionate sampling and then obtained parental consent and student assent from 57 students, for a response rate of 28.5%. The current sample consists of the 22 students who participated in the STAC intervention. The recruiting team included school counselors, a doctoral student, and master’s students. A team member met briefly with students selected to discuss the project and provided an informed consent form to be signed by a parent or guardian. A team member met with students with parental consent to explain the research in greater detail and to obtain student assent. Researchers trained participants in the 90-minute aged-up STAC program and then conducted two 15-minute bi-weekly follow-up meetings for 30 days following the training. Students completed baseline, post-training, and 30-day follow-up surveys. Six weeks after the STAC training, team members conducted three 45-minute open-ended, semi-structured focus groups to investigate students’ experiences being trained as defenders in the aged-up STAC program. Researchers audio recorded the focus groups for transcription purposes. The team provided pizza to students after the follow-up survey and at the end of each focus group. The university and school district review boards approved all research procedures.


Knowledge and Confidence to Intervene. The Student-Advocates Pre- and Post-Scale (SAPPS; Midgett et al., 2015) was used to measure knowledge of bullying, knowledge of the STAC strategies, and confidence to intervene. The questionnaire is comprised of 11 items that measure student knowledge of bullying behaviors, knowledge of the STAC strategies, and confidence intervening in bullying situations. Examples of items include: “I know what verbal bullying looks like,” “I know how to use humor to get attention away from the student being bullied,” and “I feel confident in my ability to do something helpful to decrease bullying at my school.” Items are rated on a 4-point Likert scale ranging from 1 (I totally disagree) to 4 (I totally agree). Items are summed to create a total scale score. The SAPPS has established content validity and adequate internal consistency with Cronbach’s alpha ranging from .75–.81 (Midgett et al., 2015; Midgett & Doumas, 2016; Midgett, Doumas, & Trull, 2017; Midgett, Doumas, Trull, & Johnston, 2017). Cronbach’s alpha was .83 for this sample.

Awareness of Bullying. Awareness of bullying was assessed using one item. Students were asked to respond Yes or No to the following question: “Have you seen bullying at school in the past month?” Prior research has used this question to test the impact of the STAC program on observing and identifying bullying behavior post-training (Midgett, Doumas, Trull, & Johnston, 2017).

Use of STAC Strategies. The use of each STAC strategy was measured by a single item. Students were asked, “How often would you say that you used these strategies to stop bullying in the past month? (a) Stealing the Show—using humor to get the attention away from the bullying situation,
(b) Turning It Over—telling an adult about what you saw, (c) Accompanying Others—reaching out to the student who was the target of bullying, and (d) Coaching Compassion—helping the student who bullied develop empathy for the target.” Items were rated on a 5-point Likert scale ranging from 1 (Never/Almost Never) to 5 (Always/Almost Always). Prior research has used these items to examine use of STAC strategies post-training (Midgett, Doumas, Trull, & Johnston, 2017).

High School Students’ Experiences. Researchers followed Hill et al.’s (2005) recommendation to develop a semi-structured interview protocol to answer the question, “What were high school students’ experiences of participating in the aged-up STAC intervention and using the STAC strategies to intervene in bullying situations?” Researchers developed questions based on previous qualitative findings with middle school students (Midgett, Moody, Reilly, & Lyter, 2017), quantitative results indicating students trained in the program use the STAC strategies (Midgett, Moody, et al., 2017), and a review of the literature (Jacob & Furgerson, 2012). Researchers asked students the following questions: (1) Can you please talk about the personal values you had before the STAC training that were in line with what you learned during the STAC training? (2) Please share your experience using the STAC strategies (Stealing the Show, Turning It Over, Accompanying Others, and Coaching Compassion), (3) Can you share how using the STAC strategies made you feel about yourself? (4) How did being trained in the STAC program impact your relationships? (5) Can you please talk about your fears related to using the strategies in different bullying situations? and, (6) Overall, what was it like to be trained in the STAC program and use the STAC strategies?

The STAC Intervention

The STAC intervention began with a 90-minute training, which included information about bullying and strategies for intervening in bullying situations (Midgett et al., 2015). Following the training, facilitators met with students twice for 15 minutes throughout the subsequent 30 days to support them as they applied what they learned in the training. During these meetings, researchers reviewed the STAC strategies with students, and asked students about bullying situations they witnessed and whether they utilized a strategy. If students indicated they observed bullying but did not utilize a strategy, researchers helped students brainstorm ways in which they could utilize one of the four STAC strategies in the future.

Didactic Component. The didactic component included icebreaker exercises, an audiovisual presentation, two videos about bullying, and hands-on activities to engage students in the learning process. Students learned about (a) the complex nature of bullying in high school often involving group dynamics rather than single individuals; (b) different types of bullying, with a focus on cyberbullying and covert physical bullying; (c) characteristics of students who bully, including the likelihood they have been bullied themselves, to foster empathy and separate the behavior from the student; (d) negative associated consequences of bullying for students who are targets, perpetrate bullying, and are bystanders; (e) bystander roles and the importance of acting as a defender; and (f) the STAC strategies used for intervening in bullying situations. The four strategies are described below.

Stealing the Show. Stealing the Show involves using humor or distraction to turn students’ attention away from the bullying situation. Trainers teach bystanders to interrupt a bullying situation to displace the peer audience’s attention away from the target (e.g., tell a joke, initiate a conversation with the student who is being bullied, or invite peers to play a group game such as basketball).

Turning It Over. Turning It Over involves informing an adult about the situation and asking for help. During the training, students identify safe adults at school who can help. Students are taught to always “turn it over” if there is physical bullying taking place or if they are unsure as to how to intervene. Trainers also emphasized the importance of documenting evidence in cyberbullying cases by taking a screenshot or picture of the computer or cell phone over time for authorities (i.e., school principal and resource officer) to take action.

Accompanying Others. Accompanying Others involves the bystander reaching out to the student who was targeted to communicate that what happened is not acceptable, that the student who was targeted is not alone, and that the student bystander cares about them. Trainers provide examples of how students can use this strategy either directly, by inviting a student who was targeted to talk about the situation, or indirectly, by approaching a peer after they were targeted and inviting them to go to lunch or spend time with the bystander. This strategy focuses on communicating empathy and support to the student who was targeted.

 Coaching Compassion. Coaching Compassion involves gently confronting the student who bullied either during or after the bullying incident to communicate that his or her behavior is unacceptable. Additionally, the student bystander encourages the student who bullied to consider what it would feel like to be the target in the situation, thereby fostering empathy toward the target. Bystanders are encouraged to implement Coaching Compassion when they have a relationship with the student who bullied or if the student who bullied is in a lower grade and the bystander believes they will respect them.

Role-Plays. Trainers divided students into small groups to practice the STAC strategies through role-plays that included hypothetical bullying situations. The team developed the scenarios based on student feedback on types of bullying that occur in high school, including cyberbullying, romantic relationship issues, and covert physical bullying (Midgett, Doumas, Johnston, Trull, & Miller, 2017). See Appendix A for the STAC scenarios.

Post-Training Groups. STAC training participants met in 15-minute groups with two graduate student trainers twice in the 30 days post-training. In these meetings, students reviewed the STAC strategies, shared which strategies they used, and explained whether they felt the strategies were effective in intervening in bullying. Trainers also addressed questions and supported students in brainstorming other ways to implement the strategies, including combining strategies or working as a group to intervene together.

Data Analysis

Quantitative. The authors used quantitative analyses to test for significant changes in knowledge and confidence and to provide descriptive statistics for frequency of awareness of bullying and the use of the STAC strategies. An a priori power analysis was conducted using the G*Power 3.1.3 program (Faul, Erdfelder, Lang, & Buchner, 2007) for a repeated-measures, within-subjects ANOVA with three time points. Results of the power analysis indicated a sample size of 20 was needed for power of > 0.80 to detect a medium effect size for the main effect of time with an alpha level of .05. Thus, the final sample size of 22 met the needed size to provide adequate power for analyses.
Before conducting primary analyses, all variables were examined for outliers and normality. The authors found no outliers and all variables were within the normal range for skew and kurtosis. To assess changes in knowledge and confidence, we conducted a GLM repeated-measures ANOVA with one independent variable, time (baseline, post-intervention, follow-up), and post-hoc follow-up paired t-tests to examine differences between time points. To evaluate awareness of bullying, we computed descriptive statistics to determine how many participants observed bullying at baseline and follow-up. To evaluate the use of STAC strategies, we computed descriptive statistics to examine the frequency of use of each strategy at the follow-up assessment. The authors used an alpha level of p < .05 to determine statistical significance and used partial eta squared (h2p) as the measure of effect size for the repeated-measures ANOVA and Cohen’s d for paired t-test with magnitude of effects interpreted as follows: small (h2p > .01; d = .20), medium (h2p > .06; d = .50), and large (h2p  > .14; d = .80; Cohen, 1969; Richardson, 2011). All analyses were conducted using SPSS version 24.0.

Qualitative. The authors conducted focus groups and employed CQR methodology to investigate participant experiences (Hill et al., 2005). Specifically, CQR was chosen because it uses elements from phenomenology, grounded theory, and comprehensive process (Hill et al., 2005). CQR is predominantly constructivist with postmodern influence (Hill et al., 2005), which was a good fit for the project as we were interested in students’ experiences being trained in the aged-up STAC program. Furthermore, we selected CQR because it includes semi-structured interviews to promote the exploration of participants’ experiences, while also allowing for spontaneous probes that can uncover related experiences and insights, adding depth to findings (Hill et al., 2005). CQR was well suited for this study because it requires a team of researchers working together to reach consensus analyzing complex data (Hill et al., 2005). Focus groups were chosen because they allow researchers to observe participants’ interactions and shared experiences such as teasing, joking, and anecdotes that can add depth to the findings (Kitzinger, 1995). Focus groups have potential therapeutic benefits for participants, including increasing feelings of self-worth (Powell & Single, 1996) and empowerment (Race, Hotch, & Parker, 1994). Additionally, focus groups can be especially useful when power differentials exist between participants and decision makers (Morgan & Kreuger, 1993).

Three team members (the first and second authors and a master’s in counseling student) employed the CQR methodology to analyze the data. After the data transcription, each member worked individually to identify domains and core ideas prior to meeting as a group. The team met three times in the next month to achieve consensus. Researchers relied on participant quotations to resolve disagreements, to cross-analyze the data, and to move into more abstract levels of analysis (Hill et al., 2005). The team labeled domains as general (typical of all but one participant or all participants), typical (more than half of participants), and variant (at least two participants; Hill et al., 2005). An external auditor analyzed the data separately, utilizing NVivo qualitative analysis software (Version 10; 2012), and reported similar findings with the exception of a minor modification to one domain, which the team incorporated into final findings. Next, the researchers conducted member checks (Lincoln & Guba, 1985) by emailing all participants with an overview of the findings. All participants who responded agreed the findings were an accurate representation of their experience.

Strategies for Trustworthiness. As recommended by Hays, Wood, Dahl, and Kirk-Jenkins (2016), we used multiple strategies to strengthen the trustworthiness of the study. First, our process was reflexive with continuous awareness of expectations and biases. Prior to conducting focus groups, we discussed and wrote memos about our expectations and biases (Creswell, 2013). To triangulate data, all three analysts were involved throughout the process and in comparing findings among the team. An external auditor was included to provide oversight and increase credibility of findings. Once all researchers reached agreement about major findings, we elicited participant feedback to increase credibility and confirmability of our findings (Lincoln & Guba, 1985).


Knowledge and Confidence

The researchers examined changes in knowledge and confidence across three time points (baseline, post-intervention, and follow-up). Results indicated a significant main effect for time: Wilks’ Lambda = .31, F (2, 20) = 6.85, p < .000, h2p = .31. Follow-up paired t-tests indicated a significant difference in knowledge and confidence between baseline (M = 35.68, SD = 4.35) and post-intervention (M = 40.64, SD =3.11), t(21) = -6.52, p < .001, Cohen’s d = -1.46; and between baseline (M = 35.68, SD = 4.35) and 30-day follow-up (M = 40.68, SD = 4.10), t(21) = -4.96, p < .001, Cohen’s d = -1.06; but not between post-intervention (M = 40.64, SD = 3.11) and 30-day follow-up (M = 40.68, SD = 4.10), t(21) = -0.05, p = .96, Cohen’s d = -.01. Findings indicate students reported an increase in knowledge and confidence from baseline to post-intervention, and this increase was sustained at the 30-day follow-up.

Awareness of Bullying

The researchers examined rates of observing bullying at baseline and at the 30-day follow-up to determine if students became more aware of bullying after being trained in the STAC program. Rates of observing bullying increased from 54.5% to 63.6%, indicating that the STAC program raised awareness of bullying.

Use of the STAC Strategies

The researchers examined how frequently students in the intervention group used the STAC strategies at the 30-day follow-up. Among students who reported witnessing bullying (63.6%, n = 14), 100% indicated using one or more STAC strategies in the past month. Specifically, 64.3% reported using Stealing the Show, 42.9% reported using Turning It Over, 100% reported using Accompany Others, and 85.7% reported using Coaching Compassion.


Through CQR analysis, the team agreed on four domains with supporting core ideas. All of the domains below are general or typical and endorsed by participants via member checks.

Domain 1: Awareness and Sense of Responsibility. Participants (n = 8; 57%) talked about the STAC program enhancing their awareness of bullying behavior and increasing their sense of responsibility to act. Students spoke about some types of bullying being difficult to recognize and that the STAC training helped them become more aware of covert bullying situations. One participant gave an example about being able to recognize types of bullying that can often be overlooked. The student shared, “People look like they’re joking around and you . . . ignore it, but now it’s like they’re not [joking]. You can tell a little bit. I think . . . [the STAC program] brought . . . [awareness] out in us.” Students also talked about their experience being able to recognize different types of bullying and being equipped to intervene, as well as becoming aware that their actions can have an impact on others. One participant shared that “learning the different ways you can address . . . [bullying] also helps you realize the different forms it happens in, so it makes you value being aware of what’s going on and how your own actions affect other people.” Another student also spoke about the connection between being trained to act as a defender and a newfound sense of responsibility and shared that after STAC training, “there’s not really a reason to say that you don’t want to [get involved] because you’re scared, because you know what’s happening to the person is wrong and if you can change it, you should.” Another participant stated that “there’s some others that don’t have this training, so we’re the ones that should be stepping in if we see it. Everyone should, but . . . we know what to do.”

Domain 2: Empowerment and Positive Feelings. Participants (n = 9; 64%) spoke about a sense of empowerment and associated positive feelings that came from using the STAC strategies to intervene in bullying situations. For example, one participant stated, “It makes you feel a little bit more empowered because you realize you actually can make a difference in someone else’s life or in the whole community at your school or community in general.” Students also talked about the STAC program empowering them to make decisions about their friendships. A participant shared, “I actually told some people I didn’t want to talk to them or be friends with them [because] I can’t be around someone who is making fun of people with disabilities. . . . So, it changed the way I picked my friends.” Some students talked about the association between a sense of empowerment to make a difference in a bullying situation and feeling good about themselves and helping other students. A student said, “I feel like it made us feel good, like we made a positive difference in some way regarding the person that’s being bullied. So it makes it feel like we did something good, like a good deed.” Another student shared, “Somebody actually went to talk to him [ethnic minority student who was bullied] . . . and that was me. It was good to see him happy after he was feeling sad.”

Domain 3: Fears. Almost all participants (n = 12; 86%) spoke about how acting as a defender elicited fears related to judgment from peers or creating tension with friends. For example, one student shared, “I have a fear of being judged, which is kind of the thing of bullying. So, I try not to be so active with people at school.” Another participant also talked about fears related to peer judgment and creating tension with friends when utilizing the STAC strategy Accompanying Others by having lunch with a student who was a target of bullying. The student said, “It’s a social fear, or like ‘why are you hanging out with them?’ . . . and it’s kind of tense between you and your other friends because you brought this person that they didn’t want.” Students also talked about fears of making a situation worse. In particular, participants spoke about fears about reporting bullying situations to adults by using the STAC strategy Turning It Over. For example, one participant stated, “When you get teachers involved or your parents . . . [bullying] kind of . . . escalates . . . a lot of kids will avoid going to adults if they can until it gets physical.” However, most participants were encouraged to act despite their fears, and many discovered that the STAC program allowed them to overcome their fears. One participant stated, “I think starting out my biggest fear was that [using STAC strategies] wasn’t going to do anything, that nothing was going to change, but it really did, and I was pretty shocked that I had a positive effect on people.”

Domain 4: Natural Fit of STAC Strategies and Being Equipped to Intervene. Many participants (n = 10; 71%) indicated the STAC strategies were a natural fit and equipped them with tools to intervene when they witnessed bullying. For example, one student shared, “Stealing the Show [was a natural fit]. I think it happened during accelerated PE. Someone was making fun of someone’s bench max, and I could tell the person was uncomfortable, so I just made a joke or something and changed the subject.” Another participant spoke about Coaching Compassion: “It’s probably one of my favorite ones because it actually does something in the moment, [and] it actually taught me how I can put out the effort without feeling uncomfortable when doing it.” Further, participants shared that implementing the strategies increased their knowledge and confidence to intervene. For example, one participant shared, “You know when to use them [the strategies] and when it’s not necessary and how far you should go when using them.” The strategies seemed to successfully meet participants at their level of understanding and equip them with more structure and guidance to intervene more confidently and consistently.


The purpose of this study was to investigate the appropriateness of the aged-up STAC program for the high school level and to explore the experiences of high school students trained in the program. Quantitative data indicated students trained in the aged-up program reported an increase in knowledge and confidence to intervene and an increase in awareness of bullying, and also reported using the STAC strategies when they observed bullying at school. Qualitative data enhanced the interpretation of quantitative findings, depicting students’ experiences being trained in the program and using the STAC strategies.

Findings indicate that participating in the STAC training was associated with an increased awareness and sense of responsibility. Reported rates of observing bullying increased from baseline to the 30-day follow-up (54.5% to 63.6%). These findings are consistent with research showing students trained in the STAC program report increased awareness of bullying behavior (Midgett, Doumas, Trull, & Johnston, 2017). Further, students indicated that once they became aware of covert bullying, they felt responsible to intervene. One explanation for this finding is that participating in the training leads to an increase in awareness of bullying situations, which promotes a sense of responsibility to act. This explanation is consistent with research suggesting that awareness of negative consequences to others leads to an increase in feelings of personal responsibility, which in turn, leads to action (de Groot & Steg, 2009).

Our data also revealed that the STAC training was associated with an increase in knowledge and confidence and a sense of empowerment associated with positive feelings and changes in friendships. These findings are consistent with research showing that when students intervene in bullying situations they feel a sense of congruence, a positive sense of self (Midgett, Moody, et al., 2017), and a sense of well-being (Schwartz, Keyl, Marcum, & Bode, 2009). Researchers also have shown that when bystanders do not intervene, the lack of action leads to guilt (Hutchinson, 2012) and moral disengagement (Forsberg et al., 2014). Further, researchers have found that students have a desire to belong to a peer group with similar values in “defending” behaviors as their own (Sijtsema, Rambaran, Caravita, & Gini, 2014). Thus, it is possible that the confidence and positive feelings associated with being trained to act as defenders extended to feeling empowered to disengage from peers who do not intervene on behalf of targets of bullying.

Results indicated students used Turning It Over the least frequently among the strategies, with only 49% of students using this strategy. This finding is in direct contrast to research with middle school students suggesting Turning It Over is used by 91% of students (Midgett, Doumas, Trull, & Johnston, 2017). Qualitative data revealed that students felt fearful about intervening; specifically, students talked about being afraid that Turning It Over to an adult would make the situation worse. This finding parallels research suggesting that high school students believe adults at school do not handle bullying effectively (Midgett, Doumas, Johnston, et al., 2017) and that when they report bullying to teachers, the situation either remains the same or worsens (Fekkes, Pijpers, & Verloove-Vanhorick, 2005). Coupled with research indicating students are more likely to report bullying when they believe their teachers will act (Cortes & Kochenderfer-Ladd, 2014) and will be effective in intervening (Veenstra, Lindenberg, Huitsing, Sainio, & Salmivalli, 2014), our findings suggest it may be useful to provide teachers with knowledge and skills so that they may effectively support students who report bullying.

Finally, findings indicated that 100% of students who witnessed bullying post-training used at least one STAC strategy and that students experienced the STAC strategies as a natural fit and felt equipped with tools to act in bullying situations. These findings are consistent with prior research indicating students trained in the STAC program report using the strategies (Midgett, Moody, et al., 2017; Midgett, Doumas, Trull, & Johnston, 2017). The most frequently used strategies were Accompanying Others and Coaching Compassion, used by 100% and 85.7% of students, respectively. One explanation for these two strategies being the most natural fit for students is that the formation of peer relationships is an important developmental priority for adolescents (Wang & Eccles, 2012). Accompanying Others allows students to foster relationships in a way that feels natural and altruistic. Also, as adolescents mature emotionally and their ability to empathize grows (Allemand, Steiger, & Fend, 2015), Coaching Compassion can encourage bystanders and students who bully to develop empathy toward targets.

Limitations and Future Research

Although this study contributes to the literature regarding developmentally appropriate bullying interventions for high school students, several limitations must be considered. First, because of our small sample size and lack of control group, we cannot make causal attributions or generalize our findings to the larger high school student population. Although we enhanced the significance of our findings with a mixed methods design, there is a need for future studies investigating the efficacy of the aged-up STAC program through a randomized controlled trial. Further, since our study was intended as a first step in the development of an age-appropriate program for high school, we did not assess decreases in bullying victimization or perpetration. Therefore, future randomized controlled trial studies should include these outcome variables. Another limitation is related to the measures used. Specifically, both awareness of bullying and use of each STAC strategy were measured by a single item, which can result in decreased reliability. Further, although the developers constructed the items to have face validity, there are no studies investigating the psychometric properties of these items in measuring awareness of bullying or use of the STAC strategies. Additionally, our quantitative and qualitative findings were based on self-report data. It is possible that students’ responses were influenced by their desire to please the researchers, especially within the context of the focus groups. Thus, including objective measures of observable defending behaviors would strengthen the findings.

Practical Implications

Our findings provide important implications for counselors in both school and other settings. First, high school counselors can implement aged-up bullying intervention programs such as the STAC program. High school counselors can find encouragement in our findings indicating high school students are invested in helping reduce school bullying and that being trained to intervene can be associated with increased awareness and sense of responsibility. Further, findings suggest it might be helpful for school counselors to provide students trained in the program with an opportunity to meet in small groups to foster friendships with peers who are committed to acting as defenders.

Results also suggest that high school students believe reporting bullying to adults may not be an effective strategy. School counselors are well positioned as student advocates to establish anonymous reporting procedures to counteract potential student fears related to being negatively perceived when they report bullying to adults. In all bullying intervention efforts, school counselors should coordinate with administration to ensure success. School counselors can facilitate teacher and staff development to help them understand students’ fears related to reporting bullying and provide teachers with necessary tools to help students who report bullying to them. Additionally, although a teacher training would increase the required time and resources needed to implement the STAC program, it may be an important addition at the high school level. In this module, school counselors could educate teachers about bullying and the STAC strategies so that teachers could reinforce the strategies with students. The training would emphasize Turning It Over, explaining to teachers their important role in helping student bystanders intervene when they observe bullying.

Lastly, this study also has implications for counselors working with adolescents outside the school setting. There are negative associated consequences to witnessing bullying as a bystander (Rivers & Noret, 2013; Rivers et al., 2009). In addition, adolescents report not knowing how to intervene on behalf of targets (Forsberg et al., 2014; Hutchinson, 2012), which can lead to feelings of guilt (Hutchinson, 2012). Thus, counselors can empower clients to act as defenders by providing psychoeducation regarding the STAC strategies. They can focus on strategies that clients feel are a natural fit as a starting point. Counselors can encourage clients to share bullying situations they most commonly observe at school and invite clients to talk through how they could use a favorite STAC strategy.

Bullying is a significant problem among high school students. This study provided support for the aged-up STAC intervention as an anti-bullying approach that is appropriate for high school students. Specifically, the STAC program helped students be more aware of bullying, feel a stronger sense of responsibility to intervene, and feel empowered to use the STAC strategies.

Conflict of Interest and Funding Disclosure

The authors received internal funding for this project from a College of Education Seed Grant from Boise State University.


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Appendix A

Aged-Up STAC Scenarios

Scenario 1

In the PE locker room, you overhear some girls talking about another girl who is going through a break-up. You hear them call her a “loser” (and some other hurtful names) and gossip about the reasons she and her boyfriend broke up. They also talk about how the girl is not skinny or pretty enough to date the guy.

Scenario 2

For a few weeks during break, you have noticed a group of students stand in the middle of the hallway and “shoulder check” another student as he tries to walk by to get to his next class on the other side of the school. Today, the student is tripped by one of the students standing with a group and something he was carrying was damaged.

Scenario 3

Your friends are hanging out at your house after school, looking through Twitter. One friend decided to follow a girl from school that they do not like and then repost one of her posts making fun of her in a humiliating way. This is not the first time your friend has done something like this.

Scenario 4

You are in the parking lot and suddenly you hear yelling coming from a car that is trying to pull out of a parking spot. You see a guy yelling at his girlfriend that she can’t go to lunch with a certain friend because he saw the text messages they sent last night. You know this happens a lot with this guy, and you’ve been concerned for a while.


April D. Johnston is a doctoral student at Boise State University. Aida Midgett is an associate professor at Boise State University.  Diana M. Doumas is a professor at Boise State University. Steve Moody, NCC, is an assistant professor at Idaho State University.  Correspondence can be addressed to April Johnston, 1910 University Blvd, Boise, ID 83725, aprilwatts@u.boisestate.edu.


Indiscriminate Friendliness in Children Adopted From China to the United States: A Mixed Methods Study

Yanhong Liu, Dan Li, Yanqing Xu

Indiscriminate friendliness (IF) is a prominent issue with children adopted from China to the United States. Through a mixed methods design, the authors explored four Chinese adoptees’ experiences of IF within their real-life context, investigated potential factors associated with IF, and examined the IF–attachment relationship. This mixed methods study consisted of a qualitative case study of four children adopted from China and a quantitative investigation into IF using a sample of 92 adoptive parents with Chinese adoptees. The qualitative findings revealed crucial propositions related to children’s IF, and the quantitative results provided further evidence to corroborate the qualitative findings. This study reinforced the stance that IF should be treated as a distinct construct from attachment. Researchers and professional counselors can benefit from the results of this study to better serve Chinese adoptive families.

Keywords: indiscriminate friendliness, children, China, adoptive families, mixed methods

According to intercountry adoption statistics, the United States welcomed 261,728 children across the world from 1999 to 2015 (U.S. Department of State, Bureau of Consular Affairs, 2016). Among these adopted children, 76,026 (approximately 30%) came from China, which made China the largest country of origin for intercountry adoption. A majority of Chinese adoptees were under 3 years old at the time of adoption (U.S. Department of State, 2016). Numerous issues have been detected related to the intercountry adoption process (Kreider & Cohen, 2009; van den Dries, Juffer, van IJzendoorn, & Bakermans-Kranenburg, 2009). A prominent issue is children’s indiscriminate friendliness (IF; Bruce, Tarullo, & Gunnar, 2009; Chisholm, Carter, Ames, & Morison, 1995; van den Dries, Juffer, van IJzendoorn, Bakermans-Kranenburg, & Alink, 2012). IF refers to children’s excessively friendly behaviors toward adults (other than their primary caregivers) without appropriate screening of the adults (Tizard, 1977). IF has been consistently identified in post-institutionalized children (Bruce et al., 2009; Chisholm et al., 1995) and has been viewed as pathological in nature (American Psychiatric Association [APA], 1994, 2013).

Previous research studies have yielded different post-adoption adjustment outcomes in Chinese adoptees compared to domestic adoptees or other internationally adopted children, including optimal behavioral adjustment (Cohen, Lojkasek, Zadeh, Pugliese, & Kiefer, 2008), successful attachment formation (Liu & Hazler, 2015), and positive academic performance (Tan & Marfo, 2006). The distinction between Chinese adoptees and their research counterparts entails a closer look at this population. Investigation into IF in children adopted from China became important, as the majority of them had experienced pre-adoption institutionalization in China. Consistent with earlier findings about post-institutionalized children (Bruce et al., 2009), IF has been identified as a significant issue in children adopted from China and was supported by the only study targeting Chinese adoptees in the United States (van den Dries et al., 2012).

A dearth of knowledge on IF in Chinese adoptees in the United States necessitated an in-depth qualitative investigation into this phenomenon in the adoptees’ real-life context (Yin, 2014). However, a single qualitative study cannot offer a comprehensive view of IF, nor can it thoroughly address all research questions for this study; thus, by adding a quantitative investigation, this study sought to compensate for the inadequacy of the qualitative methodology and allow researchers to triangulate and compare dissonant data between the two research approaches (Plano-Clark, Huddleston-Casas, Churchill, Green, & Garrett, 2008).

Indiscriminate Friendliness (IF)

IF, alternatively termed indiscriminately friendly behavior or indiscriminate overfriendliness, refers to a behavioral tendency for children to seek attention and approval from adults, including strangers (Hodges & Tizard, 1989; Tizard & Hodges, 1978). IF is also referred to as disinhibited attachment behavior or disinhibited social behavior, evidencing post-institutionalized children’s overfriendly behavior toward unfamiliar adult figures (Bruce et al., 2009). IF does not fall into the traditional sense of being friendly, which is associated with a positive human trait; instead, it is deemed behaviorally inappropriate when children actively approach strangers, without a reasonable assessment of whether or not it is safe to do so (Bruce et al., 2009; O’Connor et al., 2003).

Researchers have noted that children’s institutionalization experiences play a significant role in IF development, albeit adopted children are able to form strong attachments with their adoptive parents given adequate time (Chisholm, 1998; Hodges & Tizard, 1989; Tizard & Hodges, 1978). Post-institutionalized children with IF tend to approach, make personal comments to, and initiate physical contact with strangers, and children with a high level of IF are often willing to leave locations with strangers (Bruce et al., 2009). They also allow unfamiliar adults to put them to bed and comfort them when they are hurt (Tizard & Hodges, 1978). A multitude of adoptive parents have had concerns about their children’s safety as a result of their IF behaviors (Bruce et al., 2009).

In Tizard and Hodges’ (1978) follow-up study in the United Kingdom, one third of formerly institutionalized children exhibited excessive attention-seeking behaviors and a tendency to be overfriendly to adults. A few children, from ages 4 to 8, presented indiscriminate affection toward adults. In Bruce et al.’s (2009) sample of internationally adopted children in the United States following institutionalization, 65% displayed IF characteristics. Likewise, in Chisholm’s study (1998), Romanian adoptees in Canada exhibited significantly more IF behaviors than the two comparison groups: (a) Canadian-born, non-adopted, and non-institutionalized children; and (b) early-adopted Romanian children who were adopted before the age of 4 months. In contrast to institutionalization’s role as a risk factor of IF, adoptive parents’ responsive parenting was assumed to be a protective factor for children’s post-adoption behavioral adjustment (van den Dries et al., 2012). Responsive parenting entails a high level of warmth and nurturance in the process of caretaking, including offering timely attendance to children’s needs (Darling & Steinberg, 1993).


Theorists have examined the relationship between IF and attachment (Bowlby, 1982; Sabbagh, 1995). For example, Bowlby (1982), defining attachment as a child’s behavior to seek physical proximity to his/her primary caregiver, claimed attachment as a correlate to IF. Attachment, viewed as a social behavior, occurred as a result of certain behavioral systems activated when infants interact with the “environment of evolutionary adaptedness” and the mother figure in the environment (Bowlby, 1969, p. 179). The first two to three years are the most critical period for children to develop relationships with caregivers and to develop the aforementioned behavioral systems (Bowlby, 1969). Given an environment in which evolutionary adaptedness is absent, such as an institutional rearing environment, atypical discriminating attachments may ensue (O’Connor et al., 2003). Although many securely attached children displayed IF behaviors, their unattached counterparts demonstrated a higher likelihood of being overfriendly (Bowlby, 1982).

Evolution of Diagnostic Criteria

In addition to the heated dispute on whether or not IF is related to attachment patterns, the clinical perspective on IF has been evolving. In the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994), IF was termed the disinhibited type (i.e., indiscriminate sociability), as opposed to inhibited type (i.e., social withdrawal), under the Reactive Attachment Disorder diagnostic criteria. Similarly, the International Statistical Classification of Diseases and Related Health Problems (10th rev.; ICD-10; World Health Organization [WHO], 1992) named IF as a disinhibited attachment disorder. Both the DSM-IV and ICD-10 described IF as an abnormal pattern of relatedness that begins before the age of 5 years (APA, 1994; WHO, 1993). Nevertheless, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) redefined IF as a disinhibited social engagement disorder, which is a trauma- and stressor-related disorder derived from severe neglect in the first two years of life. Hence, IF was separated from reactive attachment disorder, where it had been categorized.

The mixed findings on potential contributors to IF and the lack of in-depth qualitative input on IF reinforce the need to address IF in children adopted from China, which has rarely been discussed in counseling journals. Prevalence of IF in Chinese adoptees in the United States remains unknown, and no study was found exploring the experiences of children with IF. The purpose of this study was to better understand IF in children adopted from China by U.S. families. The authors conducted a case study on four Chinese adoptees through two in-depth semi-structured interviews with two U.S. adoptive mothers. To ensure the robustness of this study, the authors conducted a follow-up quantitative investigation into IF using a sample of 92 adoptive parents with children adopted from China. This study addressed three research questions—RQ1: How do parents perceive IF in children adopted from China?; RQ2: What are some potential factors that are associated with IF?; and RQ3: Is IF related to children’s attachment? The overarching goal of the current study was to provide an in-depth understanding of Chinese adoptees’ IF in its real-life context, to probe into the potential predictors of IF, and to examine the relationship between IF and attachment.



Participants for qualitative and quantitative investigations were drawn from U.S. adoptive parents with children adopted from China. Participants for the qualitative case study did not participate in the quantitative stage of investigation. The recruitment of participants represented a parallel relationship between qualitative and quantitative samples (Leech & Onwuegbuzie, 2010), ensuring the comparability of the two data sources. The same datasets have been investigated with different emphases, by one earlier submitted manuscript investigating child-parent attachment (Liu, 2017). The quantitative dataset was also used by another study that followed a hierarchical regression analysis on IF associative factors (Liu & Hazler, in press). Research questions for this study were distinctly independent from previous studies. Participants were recruited based on the following criteria: (a) participants were U.S. citizens who adopted children from China; (b) children adopted by participants were 3 years old or younger at the time of arrival (U.S. Department of State, 2016); and (c) children were younger than 6 years old at the time of data collection (APA, 1994, 2013; WHO, 1992).

Two White mothers, Amy and Tina, were recruited for a qualitative case study from the first author’s network from her previous work with adoptive families. Amy and Tina each adopted two children from China. The case study focused on the four children’s IF behaviors and related experiences. Parents, instead of the children, were selected as the participants, as all of the four children were under 6 years old and had limited ability in comprehending and articulating the phenomenon. Both participants were married and had tried to have biological children. Natural conception was not a possibility, so adoption became the alternative to fulfill the desire for parenthood. Amy was in her late 40s at the time of the interview. Amy had been a stay-at-home mother for her children, Amelia and Beatrice. Tina was around 50 years old at the time of the interview. Tina worked full-time at a research organization, while her husband had been the primary caregiver of their two children, Rebecca and Joshua. The ages of the four children at the time of arrival in the United States were: Amelia, 10 months; Beatrice, 3 years; Rebecca, 11 months; and Joshua, 2 years and 10 months.

Participants for the quantitative investigation consisted of 92 White parents who adopted children from China. Participants ranged from 31 to 59 years old (M = 46; SD = 6.4). Eighty-six (94%) of the participants were adoptive mothers of the children, and six (6%) were adoptive fathers. Sixty-two participants (67%) had two or more Chinese adoptees. A majority of participants (86%) held a bachelor’s degree or higher. More than half (70%) of the participants identified themselves as primary caregivers of the children, and the rest reported as equal caregivers (i.e., the participants and their spouses take an equivalent amount of caregiving responsibilities). Over half of the participants (53%) worked 20 hours or below per week or held no employment, and 47% of the respondents worked more than 20 hours per week. The average age of the children at the time of arrival in the United States was 19 months.

Sampling and Recruitment

Two separate Institutional Review Board approvals, for the qualitative case study and the quantitative investigation, were obtained from the first author’s institution where the study was conducted. The authors used the purposeful sampling method (Teddlie & Yu, 2007) to recruit the case study participants following the aforementioned screening criteria. The first author’s previous encounters with Chinese adoptees and adoptive families evoked her research interests in this population. The first author was transparent about her role as a researcher, distinct from her other roles (i.e., as a previous counselor for the children), when communicating with the participants. Amy and Tina each endorsed an informed consent form prior to their participation in the study. The form detailed the purposes and significance of this study, risk of participation, and confidentiality.

The 92 participants for the quantitative investigation were randomly recruited through adoption networks and professional organizations. The authors contacted all Children from China local chapters across all U.S. states, consisting of families with children adopted from China, and several online adoptive parent organizations. The study was endorsed by several Children from China chapters and one Chinese adoption agency. The study was also shared by administrators of several online organizations, including Chinese Adoptive Families, China Report, and Chinese Adoption. Parents who were interested in participating in the study e-mailed the first author; the first author then checked the eligibility of interested parents and provided a letter detailing the purpose, significance, risks, and confidentiality related to participation into this study. Participants were directed to the selected surveys (under the Instrumentation section) posted on PsychData. Participants of the study represented a wide geographic coverage.


A semi-structured interview was conducted with Amy and Tina, separately, to understand their children’s IF and to gain a totally fresh perspective toward IF, bracketing researchers’ worldviews (Creswell, 2013). Both interviews were performed by the first author, via phone with Amy, and in person with Tina. Each interview lasted for about one and a half hours. The interviewer asked open-ended interview questions to encourage participants to expand on answers related to IF (Creswell, 2013). The interview included five open-ended questions and allowed participants to expand on any area in which they felt it useful to communicate their understanding and children’s experiences of IF. For example, the interviewer asked: How has IF been demonstrated in your children?; What have you noted in terms of your children’s friendly behaviors?; and what has influenced your children’s behaviors based on your perceptions?

Quantitative data were generated from a self-report questionnaire posted on PsychData, consisting of measures for attachment and IF along with items measuring children’s former institutionalization experiences and parents’ caregiving quality. Attachment was measured by the adapted Attachment Q-Sort (AQS; Chisholm et al., 1995), which was based on the original AQS developed by Waters and Deane (1985). The adapted AQS contained 23 items measured by a 5-point scale, from 1 = very unlike my child to 5 = very like my child. A sample item from the adapted AQS was: “Your child clearly shows a pattern of using you as a base from which to explore, that is, he/she moves out to play, returns, and then moves out to play again.” Scores for the 23 items were summed, leading to a total attachment score. A higher attachment score means that a child was better attached with the respondent. Van IJzendoorn, Vereijken, Bakermans-Kranenburg, & Riksen-Walraven (2004) reported a modest stability of AQS for the first five years of children’s lives. In the Netherlands, Pool, Bijleveld, and Tavecchio (2000) applied the instrument to assess attachment security in 45 children with ages ranging from 2 to 6 years old. Good convergent validity of AQS has been established, with a .50 correlation (r score) between AQS and the Strange Situation Procedure (Vaughn & Waters, 1990). Reliability of the adapted AQS was manifested through Cronbach α coefficients, ranging from .65–.72 (Chisholm et al., 1995) to .77–.80 (Chisholm, 1998). The Cronbach α value for this study was .83.

IF in this study was measured by the frequently used Five-Item Indiscriminately Friendliness Measure (i.e., the 5-item IF measure; Chisholm et al., 1995). The five items represent uncommonly friendly behaviors exhibited by children. The five items measure children’s friendliness level to strangers; whether or not the children were shy/behaved in a strange manner; children’s reactions to newly met adults; children’s willingness to go home with newly met adults; and children’s tendency to wander. Respondents selected 1 = Yes if the child showed the described behavior in the item; if no untypical friendly behavior was detected in the child, a 0 = No was chosen. A higher IF score indicates that the child displayed a higher level of IF behaviors. The Cronbach α coefficients of the measure were .58–.72 in Chisholm (1998) and .78–.81 in Pears, Bruce, Fisher, and Kim (2011). The Cronbach α value of the measure in this study was .58. The internal consistency was relatively low but acceptable based on similar values generated in earlier studies by the same measure (Chisholm, 1998; van den Dries et al., 2012).

In addition to the two existing measures, a demographic survey was included in the quantitative questionnaire, including questions asking children’s ages and institutionalization experiences. Children’s institutionalization experiences were assessed using questions on children’s physical growth statuses when arriving in the United States (i.e., weight), their length of institutionalization, and participants’ perception of the institutional care that their children had received prior to adoption (i.e., 1 = was not in an orphanage; 2 = high quality care; 3 = acceptable quality care; 4 = poor quality care). A higher total institutionalization score implied more positive institutionalization that a child had experienced. Parents’ caregiving quality/responsive parenting was measured by the authoritative parenting subscale of the Parenting Styles and Dimensions Questionnaire (Robinson, Mandleco, Olsen, & Hart, 2001), with a Cronbach α value of .84 for the present study.

Research Design

The current literature on IF indicates the complexity of the phenomenon because of its frequent occurrence in post-institutionalized children and its intertwined relationships with children’s nurturing environments (APA, 1994, 2013). A mixed methods study provides a better understanding of a complex phenomenon than either a single qualitative or quantitative study (Creswell, 2013). Specifically, this study utilized a sequential mixed methods design to explore Chinese adoptees’ IF within their real-life context. It comprised a two-part process, with an initial case study exploring four Chinese adoptees’ experiences of IF and a further quantitative investigation following the propositions generated from the case study. The authors consider a qualitative case study appropriate because a case study is a robust empirical approach investigating a case unit in its real-world context (Yin, 2014). The case unit includes, but is not limited to, an individual, a group, a family, a geographic region, or a particular phenomenon that is worthy of thorough investigation. It is considered an ideal methodology when “how” or “why” research questions are asked (Yin, 2014). The case unit for this study is the four Chinese adoptees’ experiences of IF. Yin (2014) defined a proposition as an essential component within a case study, guiding data collection and analysis to avoid superfluous information. Propositions are generated through literature review and/or experiences of the researchers and/or participants (Yin, 2014). The propositions from the qualitative case study guided the quantitative investigation. Both types of findings were triangulated and integrated in the Results section (Plano-Clark et al., 2008).


Trustworthiness. Researcher reflexivity, peer debriefing, and data triangulation ensured the trustworthiness of the qualitative case study (Hunt, 2011). The authors attained researcher reflexivity through examining and suspending personal beliefs (Hunt, 2011). Qualitative data in this study were triangulated through quantitative data (Leech & Onwuegbuzie, 2010). One procedure to ensure the trustworthiness of case study methodology is to incorporate data from multiple sources (Yin, 2014). Data from the two semi-structured interviews served as the primary data source, and memo writing by the first author offered a supplemental data source. Memo writing was a documentation of the researcher’s reflections or reactions while reviewing the raw interview transcripts (Creswell, 2013). The qualitative data were transcribed by the first author and were independently analyzed by the first, second, and third authors. All three authors then thoroughly reviewed each other’s coding and reached a consensus on data categorization. An expert in adoption research served as the external reviewer of the qualitative results to ensure that data interpretations were reasonable.

Data Analysis. The authors followed the recommended data analysis strategy of pattern matching (Yin, 2014). Synthesizing the current literature and information pertaining to participants’ experiences, the research team generated five propositions: (a) children immediately bonded with adoptive parents soon after adoption; (b) children initiated IF behaviors to newly met adults; (c) children responded to affectionate behaviors by newly met adults; (d) age, institutionalization, and adoptive parents’ love/responsive parenting were potentially associated with children’s IF behaviors; and (e) there was no clear conclusion on whether children’s IF was related to their attachment to parents, which warranted a further examination of the IF–attachment relationship.

Each of the authors used the propositions to organize raw data, perform coding and data reduction, and categorize meaningful units (Creswell, 2013). The authors carefully examined all meaning units and performed pattern matching to link the meaningful data units with the propositions (Yin, 2014). Full descriptions were provided on each of the propositions with supportive data from the two in-depth interviews. The researchers analyzed the quantitative data using SPSS Statistics 20. Researchers conducted univariate, bivariate, and multiple regression analyses on the quantitative dataset, examining potential factors associated with IF, as well as the IF–attachment relationship.


Results of this study included both qualitative and quantitative findings in response to the five propositions; both types of findings were triangulated, compared, and integrated into this section. Both datasets shed light on the three research questions. Each proposition was discussed and supported by qualitative data. Quantitative evidence was integrated into this section as a way to corroborate qualitative findings. Consistencies and discrepancies were identified between the two sets of data.

Research Question 1: How do parents perceive IF in children adopted from China?

Participants Amy and Tina reported IF as a prominent issue in all four of the children. The first three propositions were highlighted in the answer to Question 1. Quantitative results were consistent with qualitative findings, both of which are discussed in depth in the following paragraphs.

Children immediately bonded with adoptive parents soon after adoption. Adoptive parents were not considered as a child’s primary caregivers back to the time of adoption because of the brief time they had spent with the child. Adoptive parents, under that circumstance, were categorized as newly met adults. Amy shared that Amelia bonded immediately with her, followed by a successful adjustment. Amy further described that, in the very first night after they adopted Amelia, “she was laughing with us, smiling, giggling, and hugging us.” Tina shared similar patterns from Rebecca, who immediately bonded with her and her husband and presented as happy despite the fresh separation from her orphanage caregivers.

 Children initiated IF behaviors to newly met adults. Initiating affectionate behaviors to newly met adults was a significant indicator of IF (Tizard & Hodges, 1978). Amy and Tina shared this pattern as a common concern, with the fear that children were likely to be taken away by strangers. Participants characterized children’s behavior or tendency to show friendliness to strangers as boundary issues. These boundary issues were manifested vividly in Joshua. Tina reflected that Joshua would wander off and approach anybody, even though he was aware of the family’s presence. Tina provided several concrete examples to explain Joshua’s IF behaviors, including his actively seeking proximity specifically to women whom he first met. Tina recalled that Joshua approached a newly met woman at an airport. He also walked up to another woman at the beach, sat down next to the woman, and demonstrated a high level of physical affection toward her (e.g., running his hands through the woman’s hair). Tina added that Joshua was never hesitant to ask for food from strangers and often managed to get snacks from people from his stroller when they were in China.

Children responded to affectionate behaviors by newly met adults. Children’s friendly behaviors also were manifested through their reactions to strangers’ affectionate behaviors. Both participants indicated that although parents were sensitive to children’s initiation of friendly behaviors, children’s reactions to strangers were not given equal attention. It could be a risk factor depending on who the stranger is and the underlying drive that the stranger had in approaching a child. Participants noted that children would accept food from unknown adults. Tina responded that it was common to witness Joshua walking to strangers and returning with food or snacks. Affectionate reactions to strangers happened frequently among the four children at different places. Tina recalled that at a local grocery store, a cashier picked up Joshua and showed him her computer screen, and Joshua responded with excitement and joy, without any sense of reservation. The participants indicated that even though children’s friendly reactions to strangers may not necessarily mean that they were indiscriminately friendly to all adult figures, the unreserved friendliness revealed a sign of social limitation.

In addition to the friendly behavioral patterns, Amy and Tina offered further explanations on the four children’s IF behaviors. The two participants offered three rationales in explaining these behaviors: (a) children’s personalities; (b) their developmental stages; and (c) their desire to have basic needs met. Being an extrovert was linked to children’s friendly behaviors, as Tina expressed that Joshua may be the most extroverted person that she could think of, just based on the fact that he always enjoyed being with people. Both participants defined some of the children’s friendly behaviors as developmentally appropriate. Particularly, expressing a high level of friendliness was not atypical for younger children. In other words, it was reasonable that children under 5 years old consistently exhibited more friendly behaviors than those who were 8 years old or above. Both participants noted that the children mostly regarded themselves as the center of the universe and assumed that others would always be interested to hear everything they had to say. Amy indicated that friendliness may simply serve as a tool for children to have their basic needs met. The friendly tendency was obvious in Beatrice, as whenever she was hungry, she would request food from strangers. Participants did not view this tendency as pathological in speaking of children’s desire to meet their internal drive.

Responses from participants for the quantitative stage echoed the qualitative findings. IF indicators were reinforced by participants’ responses to the 5-item measure. Eighty-five percent of the participants (n = 78) selected 1 for item 1, indicating that their children were friendly (i.e., sometimes or always very friendly) with new adults. Fifty-seven percent of the participants (n = 52) reported the lack of shyness or misbehaving in the presence of strangers. Twenty-five percent of the participants (n = 23) identified 0, meaning “the child has always been shy or behaved in a strange manner,” and approximately 18% (n = 17) indicated that children exhibited a reasonable level of shyness since their arrival in the United States but could not speak to children’s former friendly behaviors back in China.

For item 3, examining children’s behaviors when meeting with new adults, 27% of the participants (n = 25) selected 1, specifying that children always approached new adults, showing toys, speaking or asking questions. About 60% of parents (n = 54) indicated that children would screen new adults (i.e., observing and evaluating) prior to taking actions. The remainder (n = 13; 13%) indicated fears or indifference toward new adults. For item 4, approximately 41% of the participants (n = 38) chose 1, identifying that their children have exhibited some tendency of going home with a newly met adult. With regard to item 5, 23% of the participants (n = 21) reported that their children displayed a tendency to wander, without being subsequently distressed after realizing they were away from their parents.

Research Question 2: What are some potential factors that are associated with IF?

The fourth proposition guiding the qualitative case study was that age, institutionalization, and adoptive parents’ love and responsive parenting were potentially associated with children’s IF behaviors. Amy and Tina asserted that children’s behavioral adjustments were related to children’s ages at the time of arrival in the United States; specifically, younger children demonstrated better behavioral adjustments compared to children adopted at an older age. Comparing the behaviors of Amelia and Beatrice, Amy mentioned that Beatrice, who was adopted at the age of 3, experienced a more challenging time bonding and adjusting in comparison to Amelia, who was adopted at a younger age. Both participants maintained that children adopted at a younger age generally transitioned smoothly and quickly, because children adopted as infants were not old enough to remember their previous experiences, despite the fact that adoption involves separation and loss and itself could be considered as trauma.

The participants connected children’s institutionalization experiences with their later IF behaviors. Children’s IF behaviors were speculated to be a consequence of earlier institutionalization that children had experienced. Amy and Tina viewed IF as one of the institutionalization issues rather than an attachment issue. Amy suggested that children who were previously institutionalized mostly lacked child-parent relationships and failed to form a routine early on in life. It was assessed that something might have happened in children’s brains that made it difficult to learn to interact in later relationships. Tina assumed that Joshua’s IF behaviors represented his life experiences at the orphanage from which he was adopted. She speculated that the overfriendliness had become a pattern in his first three years in the orphanage where he had no clue about whom his next caregiver would be, and a rational way for him to gain attention from others was to be friendly (e.g., giving a hug).

The participants also tied children’s IF behaviors with the news report about suspected child abuse in the orphanage where Joshua was adopted. There was a lack of knowledge and evidence regarding the institutional care that children had received prior to adoption, but the participants held the assumption that children’s weight could be an indicator of the quality of care provided at orphanages, which might be indirectly tied to children’s behaviors of reaching out to strangers for food or other basic needs. All four children’s weight was below the average when adopted, according to the participants. This was the most evident for Joshua, as he weighed only 23 pounds when he was 2 years and 10 months old. His numbers fell off the growth chart for his developmental stage.

Both Amy and Tina highlighted the role of love and responsive parenting as a protective factor of IF behaviors and in counteracting children’s previous institutionalization experiences. In this study, parents’ love and responsive parenting were delivered through understanding of the complexity of IF, accepting the child, and attending to the individual needs of the child. Both participants perceived IF as a concern, yet understood that going through abandonment and institutionalization may have contributed to children’s IF behaviors. Adopting a child meant, according to Amy, not only bringing a child home, but also caring for the child in one’s heart. Strong emotions were provoked when participants recalled children’s atypical experiences compared to their non-adopted peers. The participants reiterated that love should be unconditional to all children, no matter by birth or adoption. Amy firmly believed that whether a child is biological or adopted, it should make no difference in terms of parenting because each child deserves high-quality love. All children should be considered as “our children, and the love is “our” love.

Separation is what adoptees go through. With strong emotions, Amy highlighted the goodbyes that the adoptees had to say in their lives, all of which apparently were out of their control. Amy elaborated that a child’s life started in the mother’s room for months, and the child was used to the mother’s presence and voice, and then had to tell the mother goodbye. That was the child’s first loss in life. The child was then delivered to the orphanage, labeled as one of many orphans, and taken care of by orphanage staff. Shortly after forming an attachment with orphanage staff and peers (referred to as “crib-mates” by Amy), the child was matched with an adoptive family from overseas and had to say goodbye again. The multiple losses and separations solidified the critical role that adoptive parents may play, so that the child is nurtured in a steady and consistent environment.

Participants believed that showing responsive parenting was vital in helping children work on IF behaviors because changes could not be made on children’s pre-adoption experiences, but could be made on post-adoption caregiving. Tina reinforced that parents should not just take a child away from strangers; a more compelling need for the child was to learn how to act appropriately with strangers. The participants emphasized the importance of selective attending, meaning that parents attend to a child when he/she was in true need (e.g., when a child wanders off without checking in) and ignore behaviors that did not matter to the child’s safety or growth. Participants suggested several techniques for fostering parental attending to children’s needs, including singing children’s tunes, encouraging eye contact, strictly following routines, and offering hugs. These techniques helped instill in the children security and stability.

Age, institutionalization, and love and responsive parenting were included in the quantitative investigation. Bivariate analyses were conducted between each of the variables and IF scores. A higher institutionalization score was significantly correlated with a lower IF score (r = -.24; p < .05); namely, the more positive institutionalization experiences a child had, the fewer IF behaviors the child exhibited (Liu & Hazler, in press). No significant correlations were identified between age and IF (r = -.10; p > .05) or responsive parenting and IF (r = -.04; p > .05). A multiple regression analysis yielded a significant model, with institutionalization as the significant predictor of IF. The results showed that institutionalization explained 9% variance in IF scores (R2 = .09, F (1, 88) = 4.16, p < .05) (Liu & Hazler, in press). Responsive caregiving was nonsignificant in predicting IF.

Research Question 3: Is IF related to children’s attachment?

In answering this question, data were matched with the fifth proposition: there was no clear conclusion on whether children’s IF was related to their attachment to parents, which warrants a further examination of the IF–attachment relationship. Neither qualitative nor quantitative results provided evidence to support a relationship between children’s attachment and IF behaviors. Amy and Tina shared an interesting fact that the children seemed to attach well with them in spite of frequent IF behaviors directed to adults other than the primary caregivers. All four children were reported to form successful attachment with their adoptive parents; in the meantime, they displayed different levels of IF toward strangers. The two participants held the opinion that IF may not necessarily be categorized as an attachment disorder. This was echoed by previous analysis concerning institutionalization, in which parents speculated that IF behaviors might be more appropriately treated as an institutionalization versus attachment issue. Tina disclosed that Joshua’s IF behaviors were described by a clinical practitioner as “nowhere near the attachment disorder.”

A bivariate analysis was conducted between attachment and IF scores using the quantitative data, which yielded a nonsignificant result (r = .12, p > .05). Therefore, no significant correlation was detected between attachment and children’s IF behaviors. A direct interpretation of the quantitative result was that an adoptee’s attachment with adoptive parents was not correlated with the level of the child’s IF. Positive attachment and IF can coexist in a child, which was consistent with the case study findings.


This mixed methods study revealed qualitative themes and quantitative evidence in addressing the three research questions. Consistent with previous findings, this study reinforced that IF appears to be a prevalent issue in Chinese adoptees. Children’s IF was demonstrated through quick bonding to new adoptive parents soon after adoption, initiating excessively friendly behaviors to strangers, and responding to strangers’ affectionate behaviors without hesitance. A child’s affectionate behaviors toward adoptive parents were deemed a sign of IF, as the child and adoptive parents did not have previous encounters with each other. Under attachment theory (Bowlby, 1969), a child selectively shows affection to and seeks proximity from the mother or the primary caregiver, and the attachment relationship is based on frequent behavioral exchanges between the child and the mother or primary caregiver (Sroufe & Waters, 1977). Naturally, children’s excessive friendliness to strangers, without the selection process under the attachment theory, is considered atypical behavior.

IF behaviors were described as a manifestation of pathology and either classified as a subtype of attachment disorder under the DSM-IV (APA, 1994) or renamed as disinhibited social engagement disorder in the most recent DSM-5 (APA, 2013). The 5-item IF measure utilized in the study was consistent with the screening questions within the DSM, which concretized the IF through specific behaviors such as wandering off and going home with strangers. Although the items provided a simplified interpretation of IF, qualitative findings revealed multiple layers tied to IF that have not been adequately attended to by researchers and professional practitioners. The DSM-IV and DSM-5 classifications were based on the presumption that IF was an outcome of pathogenic care or maltreatment that children had experienced earlier in life (APA, 1994, 2013).

There has been a lack of investigation into personal factors that may explain children’s IF behaviors. Qualitative findings of this study illuminated the complex nature of IF and directed attention to other alternative criteria, in addition to pathogenic care, including children’s personality types, developmental stage, and drive to meet personal needs. These findings were consistent with Bennett, Espie, Duncan, and Minnis’ (2009) qualitative study that explored IF through children’s lenses. Bennett and colleagues highlighted children’s two internal drives underlying their IF behaviors: seeking love/attention and striving to meet personal needs. A comprehensive literature review by Love, Minnis, and O’Connor (2015) also challenged the pathogenic care criterion within the DSM by proposing several additional factors associated with IF, including genetic differences, inhibitory control, cognitive ability, and post-adoption caregiving.

Children’s former institutionalization experiences were proposed to be a salient factor associated with children’s behaviors (Bruce et al., 2009). The significant role of institutionalization in relation to IF was supported by numerous earlier studies conducted with internationally adopted children (Bruce et al., 2009; van den Dries et al., 2012). IF has been reported as a salient issue with previously institutionalized children in comparison with children raised in their birth families (Chisholm, 1998; Tizard & Hodges, 1978). Findings seem to be unanimously significant across the literature in regards to the association between children’s institutionalized experiences and children’s IF behaviors. The quantitative results of this study echoed previous findings, with institutionalization significantly associated with children’s IF. Qualitative findings also highlighted the role of institutional care as a factor associated with children’s IF behaviors. For example, children who received inadequate care from pre-adoption institutions may appear to be friendlier or seek food and/or attention from adults, as they had to compete with other children in the institution for a limited amount of available resources.

Another variable that revealed inconsistent findings between the qualitative and quantitative datasets was responsive parenting. Quantitative results of this study did not support the significance of caregiving by adoptive parents, which was supported by Zeanah and Smyke (2008), and IF was confirmed not to be associated with post-adoption caregiving quality. Qualitative findings of this study, on the other hand, demonstrated the importance of love and responsive parenting in working with children’s behavioral adjustment. Similar findings can be retrieved from the study by van den Dries et al. (2012), which indicated that children receiving better maternal care after adoption presented less IF behaviors.

The relationship between IF and attachment has been repeatedly investigated in the literature, with two antithetical views: (a) IF is a form/subtype of attachment (APA, 1994; O’Connor et al., 2003); and (b) IF needs to be treated as a unique behavioral issue, separate from attachment (APA, 2013; Lyons-Ruth, Zeanah, & Gleason, 2015). A common theme between the two views is that IF behaviors are developmentally inappropriate. The quantitative results of this study were aligned with the latter view that IF is not significantly correlated with attachment. Qualitative responses from this study were congruent with the quantitative results, as participants indicated that positive attachment and IF behaviors indeed coexist in children. The qualitative findings furthermore challenged the pathological stance that has been historically held about IF, with an alternative explanation that children’s personalities, developmental stages, and internal drives to meet personal needs may be associated with their IF behaviors.


This study has three main limitations. The comparatively low Cronbach alpha value of the 5-item IF measure was the first concern, which brought about the question of whether or not the 5-item IF was adequate in measuring IF, although low level of internal consistency is noted to be common in short scales (Streiner, 2003). The second limitation was related to participants and self-report surveys, in which reporter bias and social desirability could confound the results; namely, participants might have chosen to respond to the items based on what they believed to be socially desirable responses. Further, using parents as the only participants is likely to arouse doubt on whether or not parental perceptions of children’s IF behaviors were accurate. The third limitation was related to data saturation. Although sample size is not emphasized in qualitative research, data saturation has been consistently suggested, meaning that data collection should continue until the point that no new information arises. A practical concern is that qualitative results based on the four Chinese adoptees’ experiences may not reach data saturation (Creswell, 2013; Teddlie & Yu, 2007), thus potentially affecting the analytical generalization of qualitative findings. Nevertheless, Teddlie and Yu (2007) offered further justification for the need of representativeness and saturation trade-off sampling in mixed methods research. This sampling technique entails unequal emphases of qualitative and quantitative sampling within a mixed methods study; namely, when quantitative representativeness is emphasized, less emphasis is directed to the qualitative saturation of the study.

Research and Clinical Implications

Results of this study provide crucial implications for future research and practice by professional counselors who work with Chinese adoptees and adoptive parents (e.g., counselors working in school or family settings). Controversies on the categorization of IF (as attachment or other mental health disorders) in the DSM, along with the additional factors proposed by participants, indicate a compelling need to develop a more mature measure for IF, considering a wider range of behaviors beyond the five items. One goal of the new measure is to offer a justification on whether IF truly exists in a child and the severity of the IF tendency. Future research studies should be considered regarding the underlying causes of IF. Researchers should consider involving children in future investigations in order to acquire diverse perspectives on IF and to obtain more generalizable results from the first-person lens.

A clinical implication from this study is that professional counselors working with adoptees and adoptive families need to attend to the complexity of IF. IF behaviors certainly need to be monitored and screened because of the risks associated with the behaviors; however, no quick diagnosis should be reached without adequate evidence on the frequency and magnitude of the behaviors. Practitioners need to reassess the criteria defining pathology—whether or not children’s friendly behaviors are truly indiscriminate and to what extent a friendly behavior should be classified as abnormal (Zeanah & Smyke, 2008). These clinical needs call for practitioners’ familiarity with evidence-based research and more exposure to the target population, IF-related training programs, and a more comprehensive clinical questionnaire asking for further evidence to support children’s IF occurrence and severity.


This study enriched the knowledge of IF through a mixture of qualitative and quantitative findings. Results of this study unveiled Chinese adoptees’ experiences of IF and shed light on factors associated with IF, strengthening the significance of institutionalization as an important factor in children’s IF behaviors. The authors also generated a significant regression model that accounted for 9% of the variance in IF (Liu & Hazler, in press). In alignment with recent research studies (Love et al., 2015; Lyons-Ruth et al., 2015) and the DSM-5, this study provided evidence to support the distinction of IF from attachment. It also introduced alternatives to the pathological perspective toward IF from previous research and diagnostic standards. The results of this study enabled a better understanding of IF and offered research recommendations and critical implications for professional counselors serving adoptive families.

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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Yanhong Liu, NCC, is an assistant professor and the School Counseling Program Coordinator at The University of Toledo. Dan Li is a doctoral candidate in counselor education at the University of Iowa. Yanqing Xu is an assistant professor at The University of Toledo. Correspondence may be addressed to Yanhong Liu, 2801 W. Bancroft St., MS 119, Toledo, OH 43606, yanhong.liu@utoledo.edu.