_________ Jessica Chock-Goldman, DSW, LCSW, Adjunct Lecturer, New York University Silver School of Social Work, New York, NY. Copyright © 2022 Authors, Vol. 22 No. 3 (Fall 2022), 1084-1095, DOI: 10.18060/24604 This work is licensed under a Creative Commons Attribution 4.0 International License. High-Achieving Asian American Adolescents and Suicide: The Need for Culturally Sensitive Suicide Intervention Approaches in Schools, A Case Study Jessica Chock-Goldman Abstract: Within the field of suicidology, high-achieving Asian American adolescents are an under-researched at-risk population. The present paper reviews the existing literature on this topic, addressing the increase in suicidal ideation and suicide attempts within this at-risk group, and explores ecologically valid social work interventions. School social workers are first responders to these at-risk youth and must be well-versed in the risk- factors, including parental resistance to treatment, within the specific populations they serve. To illustrate the relevant issues, a case example is presented of an adolescent Bangladeshi male who attempted suicide while attending school. Finally, this paper recommends suicide prevention measures, including a culturally appropriate suicide assessment and family therapy. Keywords: Asian American, adolescent, suicide, high-achieving, high school, social work, intervention, prevention Adolescent suicide is a national public health crisis (Horowitz, et al., 2020). In 2017, 17.7% of high school students seriously considered attempting suicide, 14.6% planned their attempt, 8.6% attempted suicide, and 2.8% reported that their attempt required the medical attention of a nurse or doctor (Kann et al., 2018). Importantly, these statistics appear to vary by race. Although the overall age-adjusted rates indicate a decrease in suicide rates between 2018 and 2019 for White and American Indian or Alaska Native individuals, reflecting the decrease in total deaths, the rate increased for Black and Asian or Pacific Islander individuals (Ramchand et al., 2021). Asian American high school students are the majority population in high-performing high schools, which require a very competitive entrance exam. In fact, recent work has found that this phenomenon is increasing. A study by the Brookings Institute found that Asian American students made up 60% of the high-performing high school population, up from 50% in 2015 (Reeves & Schobert, 2019). Because of the high risk of suicide within the Asian American adolescent population, clinicians, including social workers, school counselors and psychologists, working in high-achieving high schools need an understanding of the cultural context of suicidal thoughts and behavior, especially when assessing for suicidal behavior in this type of school setting. For example, ethnic minorities are less likely to express suicidal ideation than Whites, a concept called “hidden ideations” (Chu et al., 2010, p. 29). As it stands, the suicidology field has yet to provide systematized recommendations to advance culturally-relevant suicide science and practice due to a lack of theoretical grounding and familiarity with empirical research (Chu et al., 2010). This article reviews the literature on how acculturative stress and Asian culture relate to the increased rates of suicidal ideation in high-achieving Asian American adolescents in about:blank Chock-Goldman/HIGH-ACHIEVING ASIAN ADOLESCENTS 1085 a high school setting. When broken down by race, suicide is the first leading cause of death among Asian American young adults age 15-24, which is not the case for any other racial group in this age range in America (Noor-Oshiro, 2021). We then present a specific case example of a Bangladeshi adolescent, representing one subgroup of the Asian-American population. Finally, this article provides clinical recommendations for social workers engaging with Asian American adolescents in a high school setting. As the population in high performing high schools are majority Asian-American (Reeves & Schobert, 2019), it is vital that social workers are attuned to the suicidal risks of this specific population. Further, social workers must be attuned to the way each individual client expresses suicidality, which is differentiated based on their culture (Tummala-Narra et al., 2016). The hope is that clinicians can use these suggested methods of intervention and tailor them to the specific Asian-American subgroup they are working with, as Asian-Americans make up 5.9% of the population in the United States (U.S. Census, 2020). Asian-American communities consist of approximately 50 ethnic groups speaking over 100 languages, with connections to Chinese, Indian, Japanese, Filipino, Vietnamese, Korean, Hawaiian, and other Asian and Pacific Islander ancestries. As the National Alliance of Mental Illness (2021) points out, it is important to note the diversity within this population and the multiple sub-groups. Asian American Adolescents, Acculturation, Stress, and Suicidality Individuals of Asian ancestry are among the most rapidly expanding immigrant subgroups in the United States (Tummala-Narra et al., 2016). Immigrants and their U.S.- born children number approximately 85.7 million people, or 26% of the U.S. population, according to the 2020 Current Population Survey (Batalova et al., 2021). Within the family context, there is often a cultural differentiation that emerges, commonly labeled as “acculturation,” which describes the psychological processes and subsequent adaptation associated with continuous exposure to one’s culture of origin and a new culture (Miller et al., 2011). This experience can sometimes lead to maladaptive experiences, including high levels of stress. For example, “acculturative stress” has been defined by the American Psychological Association (2013) as the challenges or stress accompanying acculturation. Others describe acculturative stress as stress specifically related to the process of adapting to the beliefs, practices, and values of a dominant culture (Berry, 1998; Gomez et al., 2011). This is particularly salient for Asian individuals, as they report higher levels of acculturative stress than other racial or ethnic groups (Gomez et al., 2011). Acculturative stress impacts environmental factors experienced by the acculturating individual (e.g., racial discrimination), change in family relationships (e.g., conflicts between family values and those of the dominant culture), diminished quality of social relationships (e.g., difficulty with language, in forming friendships), and attitudes toward the country/culture of origin (Gomez et al., 2011). Importantly, these stressors may be important risk factors for suicidality among adolescents and emerging adults, as acculturative stressors have been associated with other known predictors of suicidal behavior, such as depression and suicidal ideation (Cho & Haslam, 2010; Gomez et al., 2011). Suicidality may present differently among Asian Americans than individuals of other ethnicities (Whaley & Noel, 2013). For most adolescents, depression is linked to suicidality, but for Asian American https://doi.org/10.1037/a0032595 https://doi.org/10.1037/a0032595 https://doi.org/10.1007/s12310-018-9245-8 ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1086 adolescents, it is often depression along with the additional factors including achievement- based anxiety and acculturative stressors, which increase risk for suicidal ideation (Kim et al., 2018). These findings suggest that the acculturative stress that Asian American adolescents experience may exacerbate their likelihood of suicidal ideation and potential suicide attempts. In addition to acculturative stress, Asian Americans are often faced with stereotyping that may also negatively contribute to their mental health and risk for suicidality, including the term “High-achieving Asian American.” Asian Americans are often labeled the model minority, as their significant presence at elite schools has contributed to the narrative of Asian American exceptionalism (Lee & Zhou, 2015). In fact, there may be an assumption that Asian Americans are uniformly successful academically and professionally, minimizing the impact of the structural (i.e., social, cultural, economic) challenges and social injustices that may adversely affect their psychological well-being (Tummala-Narra et al., 2016). Lee and Zhou (2015) state that as opposed to a “stereotype threat,” which may dismantle the achievement ability of certain ethnic groups, a “stereotype promise” (p. 7) does the exact opposite. “Stereotype promise can enhance the performance of even the most mediocre Asian American students, leading them to work harder to excel in order to confirm the stereotype of Asian American exceptionalism” (Lee & Zhou, 2015, p. 7). As the model minority myth and the pressure of stereotype promise is readily expressed both within the culture and externally through stereotypes, Asian American adolescents are familiar with perceived expectations. Unfortunately, when Asian American students are perceived as outperforming their peers, their mental health needs are less likely to be addressed, as their high academic functioning may mask their depression or anxiety (Kim et al., 2018). It is plausible that these same biased perceptions systematically reduce the likelihood that a suicidal symptomatic Asian American student would be identified for a risk assessment (Kim et al., 2018). This may also affect student’s own questions/perception of personal emotional distress. Despite the stereotype of Asian Americans being consistent in their high achievements, research has found that Asian Americans are at a significantly higher risk for mental health issues and suicidal ideation compared to individuals of any other ethnicity (Kim et al., 2018). Recent research has indicated that Asian American youth are at greater risk for mental health problems, such as depression, self-injury, and suicide as compared to White and African American youth (Tummala-Narra et al., 2016). However, compared to other ethnicities, Asian Americans’ mental health needs are also less likely to be addressed due to the underutilization of mental health services among these communities (Tummala- Narra et al., 2016). Asian American Families and Suicidality While cultural context plays an important role in identifying and intervening with Asian American adolescents at risk for suicide, understanding the familial context is also critical. Among high-achieving students, familial pressures become particularly acute, instilling a sense of urgency to achieve due to a pervasive belief that unrealistic goals (such as achieving admission to all Ivy League universities) are well within reach (Luthar et al., Chock-Goldman/HIGH-ACHIEVING ASIAN ADOLESCENTS 1087 2013). In an early study, Luthar and Becker (2002) found that Asian American students who felt their parents disproportionately prioritized achievement dimensions were at a significantly greater risk for self-harm. Chronic exposure to pressure has many negative psychological consequences. Flett and colleagues (2016) have suggested that the tendency to be internally controlled provides the fuel for the urgent and relentless striving of adolescents who develop self-oriented perfectionism. This pressure can become overwhelming alongside frequent daily stressors, setting the stage for elevated anxiety, depression, and externalized behaviors. Such requirements of perfectionism and familial pressures have become commonplace, particularly in high-achieving high school settings. These findings suggest that, in general, adolescents do not always have the skills to manage perceptions of familial obligation, and therefore may be more prone to suicidal ideation (Luthar et al., 2013). Research has also found that Asian individuals who reported higher rates of familial acculturative stress had higher odds of making a previous suicide attempt (Gomez et al., 2011). Familial acculturative stress may interact with the parent-child relationship, considering that parent–child conflict is more strongly associated with suicide-related outcomes among less acculturated Asian Americans than among highly acculturated Asian Americans (Wong & Maffini, 2011). In fact, within acculturated Asian Americans, levels of distress, symptoms, and suicidal ideation have been associated with life stress, lack of parental support, and not living with both parents (Cho & Haslam, 2010). Studies have also found that children of immigrants may have both cultural and language differences with their parents that impede their ability to communicate emotions (Thapa et al., 2015). These findings have important implications for suicide prevention among immigrant adolescents and suggest that social and parental support may be protective. This work also indicates that the combination of a volatile household environment with the heightened stress and perceived academic requirements contribute to an increased cumulative stress model that Asian American adolescents must learn to process. Research has also found that Asian American youth can be less emotionally expressive than other ethnicities, have difficulties discussing problems with their family members and do not disclose suicidal ideation, as emotional expressiveness is perceived to be an undesirable personality trait (Komiya et al., 2000). This paper addresses the need for culturally-sensitive suicide intervention strategies that should be implemented by school clinicians working with high-achieving Asian American youth. Case Example The author is a social worker in a large high school and has used one case example (using a pseudonym) to demonstrate how social workers can provide interventions with a suicidal high-achieving Asian American adolescent of Bengladeshi descent. Ahmed, an only child, is a 16-year-old junior at a specialized high school with over 3000 students in a large East Coast City within the United States. He is Bangladeshi American, speaking Bengla in the home, and English with his peers and in school. He stated that his parents consistently told him that they moved to the United States for him to go to an Ivy League college. Ahmed was feeling insecure because his grades were in the B range and he felt https://www.researchgate.net/journal/Family-Process-1545-5300#CR41 https://link.springer.com/chapter/10.1007/978-3-319-89842-1_23#CR42 https://doi.org/10.1017/S0954579413000758#CR41 ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1088 that he was not achieving the goals his parents had set forth for him. Ahmed was introduced to the school social worker by his English teacher in the previous school year after he wrote an essay in his English class concerning his feelings of depression and anxiety about school, work, and his family, which were leading to acts of self-harm. When the social worker invited him into the office to conduct an assessment, he stated that he often had suicidal ideation (SI) and was currently thinking about advancing his acts of self-harm from superficial wrist cutting (horizontal cuts) to vertical and deeper cuts. Because of the high- risk indicators of his suicidal ideation, the social worker had him taken by ambulance to the school’s partnering hospital’s C-CPEP (Children's Comprehensive Psychiatric Emergency Program) to be evaluated by a psychiatric team. He was held overnight and the hospital recommended outpatient treatment. Despite this experience, Ahmed and his family did not follow-up with his post-crisis appointments at the hospital. One year later, the Assistant Principal (AP) of the Counseling Department at the school received a call from a school counselor at a sister high school. A student in that school showed her school counselor a text exchange in which Ahmed stated that he wanted to die by suicide because his grades were going down and his parents had been expressing disappointment in him. He stated in the text that his parents were also angry because he had a girlfriend and they did not believe in any relations before marriage. He said in the text that he was going to “kill himself” in school. The in-school response team (school social worker, AP of Counseling, AP of Safety and Security, and school police officer) went to find Ahmed in his class to have him assessed. When the team got to his classroom, his backpack was in the room, but the teacher stated that he was in the bathroom. The response team proceeded to the boy’s bathroom. Ahmed was found inside the bathroom with blood running down his arm from superficial cuts in horizontal strokes. Scissors were taken from him and paper towels were pressed on his arms. He was crying and stated that he wanted to die. However, he was not cutting himself in a way that would have led to death, but instead in a non-lethal method of self-harm. Ahmed stated that he has been feeling very lonely recently with his father in Bangladesh and his mother working constantly and felt overwhelmed by the pressure of his falling grades. The team decided that Ahmed must be evaluated in the hospital. Mom was not in agreement, expressing that this was not the norm for Bangladeshi children. Shame was affiliated with this prospect as she did not want her family to once again be affiliated with the hospital for mental health reasons, which was not a perceived norm for her culture (Gomez et al., 2011). After speaking with the social worker, Ahmed’s mother finally agreed to leave work early and come to the hospital. The social worker and Ahmed were taken by an ambulance to the Child CPEP unit where he was evaluated and a determination was made that he would be kept two nights and then released because he was able to create a safety plan. Staff from the school and the hospital spoke numerous times to determine a suitable intervention that the family would follow-through with, unlike the previous hospital visit where they did not go to treatment. The hospital social worker suggested telling Ahmed’s mother that if he did not come to follow-up care in the crisis outpatient clinic and subsequent outpatient counseling sessions, Mobile Crisis would be sent to their home. The school suggested that if Ahmed did not provide a note demonstrating perfect attendance for his clinical sessions, Child Welfare would be called for medical neglect. Chock-Goldman/HIGH-ACHIEVING ASIAN ADOLESCENTS 1089 These seemingly forceful interventions are sometimes felt necessary to ensure follow-up treatment and prevent another hospitalization. Upon discharge, Ahmed, his family, and the school staff agreed upon these protocols. However, Ahmed’s post-hospitalization protocol was not implemented—there was no follow-up with the social worker in the school nor the hospital after the two-week critical care appointment. Recommendations for Clinical Interventions The scenario highlighted in the previous case example is not uncommon within the Asian American population. A recent study found that there are indeed disparities in rates of follow-up mental health services for Asian American students assessed for suicide risk in schools (Kim et al., 2018), with few families moving forward with outpatient care post- hospitalization. Mandated follow-up is extremely important to reduce the likelihood of future self-harm. In Ahmed's case, mom felt both shame and a misunderstanding about the necessity of mental health care. Family therapy is also vital, as an adolescent may perceive that they are required to be highly accomplished students and must prove achievements to their primary caretaker. This obligatory stress is one of the key factors that leads to suicidal ideation in this population (Chu et al., 2010). It is also important to note that cultural norms in the family’s native country may also contribute to an adolescent’s perception of what they are required to accomplish. It is critical that clinicians understand cultural humility, or the “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [person]” (Hook et al., 2013, p. 354) when working with Asian American adolescent clients. Evidence also suggests that involving caregivers in each step of treatment, including psychoeducation about mental health disorders and intervention, and ongoing collateral sessions, are all necessary for robust treatment delivery and durability (Kim et al., 2018). Furthermore, successful suicide prevention and intervention strategies should acknowledge the role of culturally relevant factors, such as acculturative stress and perceived discrimination, to improve the identification of emerging adults who are at risk for suicidal behavior and to offer culturally competent treatment (Gomez et al., 2011). Gaining a greater understanding of cultural context may assist researchers and clinicians in developing more appropriate interventions to prevent suicidal behavior among Asian American youth (Gomez et al., 2011). Past study findings highlight the importance of properly educating social workers concerning the cultural expectations and norms of the population they are serving, particularly when life is at stake. To mitigate potential barriers to service access, social workers should actively review and implement interventions that recognize the ethno-cultural diversity of the population they are serving. Goals should be to reduce racial/ethnic disparities related to adolescent mental health problems, increase access to services, and assuage the component of shame that families may have when accessing outside services (Kim et al., 2018). ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1090 Clinical Recommendations Expanding on the clinical case presented above, the following interventions are the clinical recommendations for social workers and school counselors who work with Asian and Asian American youth and their families. In reviewing these clinical recommendations, please take the following into account: 1. this article focuses on clinical interventions in school settings, while acknowledging the importance of improving mental health awareness in Asian American communities. 2. The recommendations use Ahmed’s case as an example. Therefore, social workers working with other Asian American sub-groups are encouraged to carefully consider their clients’ specific cultural elements and tailor the recommended applications to their clients’ cultural group. Cultural Model of Suicide Research has found that the most comprehensive way to address suicidality is to be culturally specific to the populations with which you are working (Chu et al., 2010). It is important to note that no other culturally specific suicide assessment model has been created. A modification of the modality, called cultural model of suicide (Chu et al., 2010) addresses the ways that different subgroups may express suicidal ideation. There are three theoretical principles that encompass the framework of Cultural Assessment of Risk for Suicide (CARS): 1. Culture affects how suicidal ideation is expressed. This pertains to whether or not persons from a specific culture may feel comfortable sharing their suicidal thoughts. 2. Culture affects the types of precipitating factors that may lead to wanting to act on suicidal thoughts. 3. Cultural meanings and cultural sanctions include messages of acceptability associated with a stressor and moving forward with a suicidal act (Chu et al., 2010). The CARS method looks at four major categories when assessing suicide risk: cultural sanctions (acceptability of suicide as an option or shame affiliation with certain life events), idioms of distress (cultural variations in the expression of psychological symptoms), minority stress (particular stressors that cultural minorities may experience due to social identity or position), and social discord (interpersonal troubles, including conflict, alienation and lack of integration; Chu et al., 2013). Chu and colleagues (2013) found that a CARS assessment provides substantial advancement in the field of culture and suicide and provides a viable method of assessing the ways in which cultural variation is manifested in suicide risk. The cultural sanctions that may have prevented Ahmed from cutting in a vertical line might have been related to his religion, which promotes negative associations of suicide. Ahmed’s idioms of distress may have been demonstrated by texting a friend about his ideation, rather than feeling safe enough to speak to a social worker or teacher. Difficulty both regulating and expressing emotions was associated with increased severity of suicidal ideation through increases in hopelessness (Polanco-Roman et al., 2019). The shame affiliated with emotional expression in Bangladeshi males may have prevented his feelings of transparency. Acculturation was linked to Ahmed’s minority stress, which was demonstrated through the shame and familial fighting affiliated with dating before marriage. This experience of familial acculturative stress caused much tension between Ahmed and his parents. Finally, familial conflict and fighting was the Chock-Goldman/HIGH-ACHIEVING ASIAN ADOLESCENTS 1091 social discord that influenced Ahmed to move towards suicidal ideation as his only option to escape from the volatility in his family because of his falling grades. Because of this, a clinician may choose to incorporate a friend instead of a family member for social support within a safety plan, as Asian Americans may have familial conflict as a precipitant or trigger for suicide (Chu et al., 2010). The integration of cultural specificity into suicide assessment is the key to successful suicide intervention and eventual prevention in schools with a large high-achieving Asian American population. Relational Approach to Family Therapy The Ackerman Relational Approach (ARA) is a systematic approach to therapy that is designed to both strengthen and clarify relationships between family members and empower them to envision and create desired lives with the active support of their partners and/or families (Brewster & Sheinberg, 2014). This theory suggests that the therapists must be aware of their own family of origin and socio-political location and understand how this may influence their interactions with the family in treatment (Brewster & Sheinberg, 2014), who also has their own family of origin and socio-political location. Location is critical to acknowledge in the family relationship, therapeutic relationship, and when navigating the relational practice. From the perspective of the ARA, an acknowledgement of social location supports becoming a critically conscious systemic-relational therapist. Because social workers’ experiences never perfectly match that of the student and family they are serving, cultural humility is crucial for establishing the most effective communication. Cultural humility is needed when working with high-risk Asian American adolescents and their families to break through barriers that might impede therapy in order to find relevant interventions. This is an ongoing internal and external conversation in the therapeutic relationship. By relationally exploring which components play into an adolescent's suicidal ideation as well as differences in openness to therapeutic treatment, clinicians who practice from this perspective allow family members to hear each other when working through a crisis. A clinician’s use of “critical consciousness” (Verdon, 2020, p. 4) helps navigate this dynamic with the family. Critical consciousness posits that recognizing the power imbalances in social relationships can foster a reorientation of power (Freire, 1970; Verdon, 2020). A professional must acknowledge their position in social structures and uncover any invisible power structure, privilege, biases, and inequities (Verdon, 2020). Clinicians must be continuously humble in the way that they address differences within the treatment room especially when parents are not immediately open to therapeutic treatment. With regards to Ahmed’s mother, using “critical consciousness” would allow the social worker to hear what may have been barriers to treatment the first time around and what could alleviate some of these barriers. This humility allows for the parent-clinician dyad to be both constructive and fluid in helping address the potential resistance and facilitate therapeutic growth. Intersection of CARS and the ARA for High-Achieving Asian American Adolescents Chu and colleagues (2010) found that when culturally competent tools are used to screen for suicide, better outcomes result from interventions. Research has also found that ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1092 integrating families into care leads to better outcomes for the suicidal child (Kim et al., 2018). Based on the ethno/cultural diversity of high-achieving schools, the CARS model, which incorporates an individual’s culture and ethnicity when assessing suicidal ideation, may be beneficial. The ARA may also be an effective approach to implement when intervening with suicidal adolescents and their families, as clinicians must be conscious of all components brought into the room that may be influencing their therapeutic approach. Had the social worker and hospital working with Ahmed been conscious of the ways in which suicide assessment questions should be framed for Asian American youth, Ahmed may have been hospitalized the first time he made a suicide attempt. For example, one study had found that when asking an Asian American adolescent to answer a written survey versus an oral questionnaire, their answers were more honest (Okazaki, 2000). Further, had the school social worker been aware of the parent’s shame affiliated with therapeutic interventions and had exercised critical consciousness in the initial referral, Ahmed may never had made a second suicide attempt. Ahmed eventually went to therapy and found a male therapist who he aligned with. Two years after the suicide attempt, when he was graduating from high school, he thanked the social worker for being persistent with both him and his family about getting clinical services. He said that he would not have been alive had she not pushed for outside support. By integrating these two modalities, clinicians can become better practitioners of prevention and intervention for suicidal, high-achieving Asian American adolescents. Conclusion Suicide in adolescence is a public health crisis, as suicide attempt and completion rates in adolescents are increasing every year in the United States (Horowitz et al., 2020). Because adolescents spend more time in school than any other place, it is important that prevention and intervention strategies are exercised effectively within this environment (Singer et al., 2018). Further, it is vital that prevention and intervention techniques are tailored to the population the social worker is serving. Clinicians must continue to educate themselves about the cultural norms within the populations they work with. When working with high-achieving Asian American adolescents, culturally specific screening tools may be particularly beneficial to use as this population may not be as open to verbally expressing suicidal ideation. It is crucial that clinicians negotiate the dynamic between adolescents and their families to understand their environmental context and deter suicide attempts. The CARS method allows clinicians to adapt their suicide assessment questioning to the population they are serving, and the use of cultural humility and the ARA strengthens the dynamic between the social worker and clients, enabling stronger more culturally sensitive support in complex situations. By moving away from a uniform approach to suicide prevention and intervention in schools, clinicians can best serve their specific populations and ultimately save lives. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 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Email: jcg337@nyu.edu https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states-2020 https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states-2020 https://doi.org/10.1007/s10964-011-9701-3 https://doi.org/10.3390/bs5040547 https://link.springer.com/chapter/10.1007/978-3-319-89842-1_23 https://doi.org/10.1080/13575279.2018.1516626 https://doi.org/10.1007/s11218-012-9206-2 https://doi.org/10.1037/aap0000136 mailto:jcg337@nyu.edu