Course Articles

Editor’s note: This text-based course is a transcript of the webinar, Elder Abuse and Child Abuse: Know the Signs and Your Role, presented by Kathleen Weissberg, OTD, OTR/L.

Learning Outcomes

• After this course, participants will be able to recognize possible clinical, behavioral, and physical indicators of suspected elder and child abuse and neglect.
• After this course, participants will be able to list possible risk factors related to elder and/or child abuse and neglect.
• After this course, participants will be able to describe the reporting procedure for abuse and neglect.
• After this course, participants will be able to list resources that can be utilized for state-specific procedures.

Elder Abuse

Today, we are going to talk about elder abuse and child abuse, and sadly this is more common than you might think. Our goal for today is to learn to spot those warning signs and then to know what your responsibilities are or could possibly be with regard to reporting.

Some Statistics

• According to the U.S. Government Accountability Office (GAO), elder abuse is a widespread and growing problem
• Data reporting is a challenge
• Recent studies indicate that elder abuse incidence rates are far higher than once thought

According to a study by the United States Government Accountability Office, the GAO, elder abuse is really a widespread and growing problem. The data reporting in this area is a challenge, but despite that, recent studies indicate that elder abuse incident rates are far higher than we probably thought. This slide show includes a few different stories that have come up in the public sector.

• In NYS, incidence rates nearly 24X greater than the number of cases referred to authorities who can help (Lifespan of Greater Rochester et al., 2011)
• One in five Americans older than age 65 had been defrauded (Kiplinger’s Personal Finance, 2011)
• In most cases, the adult children of abused elders were unaware that their mother or father had received solicitations for money (Olson, 2011)

A collaborative public-private report on elder abuse in New York State, for example, found an incident rate of elder abuse nearly 24 times greater than the number of cases referred to social service, law enforcement, or legal authorities who have the capacity and the responsibility to assist adult older victims. And, as a nation, our response is disjointed. The minimal federal investment is only about 12 million dollars, give or take, and it is spread sparsely across eight agencies and two departments with very little coordination. I am going to digress for a second and say that recently the Office of Inspector General came out with a report related to elder abuse. I am not going to go through a lot of the details, but basically they found that a lot of individuals were coming into the emergency room and had diagnosis codes or situations indicative of abuse that was never reported to state authorities. I think we are going to see a little more oversight in the near future on this topic and probably some additional training from some of these government agencies. An Investors Protection Trust Survey found that one in five Americans older than the age of 65 had been defrauded. This is something that we are hearing about quite a bit about in the news. The conservative estimates of the personal cost to victims of financial abuse are easily three billion dollars annually. These reported cases only hint at the extent of the problem. We are not hearing a lot of the other stories that are probably out there. And, in a New York Times article, they talked about financial exploitation and the knowledge of adult children. Many are unaware that their mother or father had even received solicitations for money. Even attentive children, as involved as you can be with your parents, sometimes miss the warning signs. In that particular article, they highlighted the story of Dr. Robert Parker. He is the chief of community geriatrics at the University of Texas Health Medical Center in San Antonio. He failed to notice that his own mother was a victim of financial abuse. So, no matter how involved you are, sometimes you still miss some of these things.

A Chilling Example of Neglect

Before we get into some of the definitions, I wanted to share this story. It was a widely publicized case in Michigan. An elderly female nursing home resident began coughing one night. Her caretakers were busy, and she continued to just cough throughout the night. A couple of staff observed "white things" in her sputum and near her trach collar. It was not until the next morning that somebody actually checked into her mouth, and they found maggots. The maggots had created a partial airway obstruction causing her to suffer abnormal blood oxygen levels and labored breathing. The emergency medical services staff said that they could not even suction because of the very active maggots in the airway. This is just a terrible example and there is no evidence that that staff was disciplined for clearly neglecting this woman so severely. 

Definitions

“Acts of omission or commission by a person who stands in a trust relationship that result in harm or threatened harm to the health and/or welfare of an older adult.”

Abuse Defined

• Willful infliction of injury
• Unreasonable confinement/Involuntary seclusion
• Intimidation with resulting physical harm, or pain, or mental anguish
• Punishment with resulting physical harm, or pain, or mental anguish
• Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being
• Corporal punishment & any physical or chemical restraint not required
• Abuse that includes that which is facilitated or enabled through the use of technology

I think the biggest piece here is that it is willful infliction. It can also include things like unreasonable confinement or involuntary seclusion, and that could happen in the home environment or in an institution. It might be where we are separating an individual from other individuals, from their room, or from another area where they want to go. This can be against their will or even against the will of that person's legal representative. It also could include intimidation or punishment with resulting physical harm, pain, or mental anguish. It could include things like deprivation by an individual, including a caretaker, of goods or services that are necessary to attain physical, mental, or psychosocial well-being. These are all the things that that person needs to be well. It can include corporal punishment or physical or chemical restraints that are not really required to treat that individual's symptoms or their issues. Again, it is anything that would cause pain or an issue, and it can also include things that are enabled through the use of technology. The individual acts deliberately.

• Elder abuse includes physical, emotional, or sexual harm inflicted upon an older adult, their financial exploitation, or neglect of their welfare by people who are directly responsible for their care
• Elder abuse tends to take place where the senior lives: where their abusers are often adult children, other family members such as grandchildren, or a spouse or partner. Elder abuse can also occur in institutional settings.

Now elder abuse includes, as we just said, physical, emotional, sexual harm potentially inflicted upon an older adult. It can also include financial exploitation and neglect of their welfare. It is done by somebody who is directly responsible for their care. And in the United States alone, more than half a million reports of elder abuse reach authorities every year, and many more go unreported. Now as older adults become more physically frail, they are less able to take care of themselves. They cannot stand up to bullying, and they cannot fight back a lot of times if they are attacked in some way.

The mental or physical ailment that they have can make them more trying to companions for those who live with them. They may not see, hear, or think as clearly as they used to. This leaves them open, unfortunately, for unscrupulous people to take advantage of them, and we definitely see that. The other thing to keep in mind is that elder abuse tends to take place where that individual lives. We hear stories of elder abuse that occurs somewhere out in the community, but typically, the senior lives with their abusers. The abusers can be adult children, other family members like grandchildren, a spouse, a partner, or a very good friend. The sad reality is that elder abuse can also occur in institutional settings especially long-term care facilities, that is where we hear about it most.

Forms of Abuse

• Verbal
• Physical
• Sexual
• Mental/Emotional
• Neglect
• Abandonment
• Financial exploitation
• Self-neglect

What are the different forms? Abuse of elders takes a lot of different forms. Some involve intimidation or threats against the elderly, some involve neglect and other financial trickery. The most common types are listed above. We will go through each one of these in a little more detail and look at some of the warning signs.

Verbal Abuse

• Oral, written or gestured language that includes disparaging and derogatory terms to the residents or their families to describe the resident within their hearing distance, regardless of their age &/or ability to comprehend or disability

This is almost like bullying. It is talking about that person in such a negative way so that they overhear it. The person feels, based upon this blame, diminished self-worth, or diminished ego, et cetera. This is, obviously, not something that we would want to do.

Physical Abuse

• The non-accidental use of force against an elderly person that results in physical pain, injury, or impairment. Such abuse includes not only physical assaults such as hitting or shoving but the inappropriate use of drugs, restraints, or confinement.

Physical abuse is pretty straightforward. This does not just include physical assault such as hitting or shoving, but it can also include things like the inappropriate use of drugs or medications, restraints, or even confinement. This can be in an institutional or home setting. The more common types of physical abuse that we see are things like hitting, slapping, pinching, scratching, spitting, holding that person roughly, holding them in their chair, or forcing them into their wheelchair. It also includes controlling behavior through corporal punishment. Unfortunately, we continue to see this in some of our settings. This a corporal type punishment of influence.

Sexual Abuse

• Contact with an elderly person without their consent. Includes but is not limited to humiliation, harassment, coercion, or sexual assault. Activities such as showing an elderly person pornographic material, forcing the person to watch sex acts, or forcing the elder to undress are also considered sexual elder abuse.

Again, you hear these outrageous stories on the news, and it makes you scratch your head. Sexual abuse includes but is not limited to things like humiliation, harassment, coercion, or even sexual assault. It is non-consensual sexual contact of any type with an individual. It is contact with that elderly person without their consent. It can involve physical sexual acts, but it can also involve other things like showing an elderly person pornographic materials and making them watch it or forcing the person to watch other sex acts or something else occurring in the environment. It can even include forcing the elder to undress in front of you. This would not be part of an ADL or helping them to use the restroom. This is forcing them to undress outside of those normal scenarios.

Emotional/Mental Abuse

• The treatment of an older adult in ways that cause emotional or psychological pain or distress, including:
  • Intimidation through yelling or threats
  • Humiliation and ridicule
  • Habitual blaming or scapegoating
  • Ignoring the elderly person
  • Isolating an elder from friends or activities
  • Terrorizing or menacing the elderly person
  • Harassment
  • Threats of punishment or deprivation.

This is the treatment of an older adult in ways that cause emotional or psychological pain or distress. It can be intimidation through yelling or threats, humiliation or ridicule, habitual blaming, or scapegoating. It can also be ignoring that elderly person or ignoring their requests, isolating an elder from their friends or their activities, and terrorizing or menacing the elderly person. You may not think that some of these things are necessarily emotional elder abuse, but they could be under the right set of circumstances. For example, if you take a photograph, and that person does not want to be photographed, that could constitute mental, physical, or some sort of abuse. Again, we should not be doing that in any of our settings or doing anything that might be considered humiliating toward an individual. During the delivery of care, depending on what we are doing with that individual, we need to make sure that we are keeping the person from public view like undressing to do an ADL. We need to make sure that we prevent any unnecessary exposure of body parts. That is what we do all the time normally, but if we did not, it could be potentially considered emotional or mental abuse.

My aunt, who has since passed away, was in a nursing home many years ago. She had dementia but she still knew enough to say I need to use the restroom when she truly needed to go. She had a urinary tract infection at the time was going much more frequently. I remember her saying, "I have to use the bathroom." She did not want me to take her and that was fine. She called for a nurse who came in and said, "Don't you realize you just went about an hour ago? You couldn't possibly need to go again. If you need to go, you're just going to have to go in your diaper." And I sat there and thought, "That's emotional abuse. That's humiliating to say to a person." And, this is in a premier community. There are the things that we need to look out for as they can certainly lead to emotional types of abuse. Whether that mental abuse has occurred or not is really determined by a reasonable person's standard and does not require a specific response from the individual. What I mean by that is a reasonable person would think that that is completely unacceptable. It does not necessarily have to have a response from the individual because that individual may have dementia or something else going on and cannot respond in an appropriate manner. We always use that "reasonable person standard" as our litmus test against whether or not something would be considered emotional or mental abuse.

Medication Diversion

• Knowingly, or intentionally, interrupting, obstructing, or altering the delivery, or administration of a prescription drug.

The next one is medication diversion. This is an interesting one. This is one we are hearing more and more about, but I think particularly in a home environment by a companion or caregiver (not necessarily paid) who might be looking to steal those medications for their own personal or financial gain. We are seeing a little bit more of this out in the community.

Elder Neglect

• Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. This constitutes more than half of all reported cases of elder abuse. It can be intentional or unintentional.

This is quite simply the failure to fulfill a caretaking obligation. Unfortunately, this constitutes more than half of all reported cases of elder abuse. It can be intentional or unintentional based on factors such as ignorance or denial that an elderly charge needs as much care as they do. Again, it is really just that failure to provide goods and services that are necessary for that person to avoid harm, and we will talk more about that in just a little bit.

Financial Exploitation 

• The unauthorized use of an elderly person’s funds or property, either by a caregiver or an outside scam artist
  • Misuse an elder’s personal checks, credit cards, or accounts
  • Steal cash, income checks, or household goods
  • Forge the elder’s signature
  • Engage in identity theft
  • Scams targeting the elderly

Another one that we are hearing a lot about now in the news is financial exploitation. This is the unauthorized use of an elderly person's funds or property either by a caregiver or by some outside person, a scam artist. It is deliberate misplacement, exploitation, wrongful temporary or permanent use of an individual's belongings or money without their consent. The important distinction is without their consent. An unscrupulous caregiver might do things like misuse a person's personal checks, their credit cards, or their accounts. They may steal cash, income checks, household goods, or get access to their accounts. They may be under the guise of helping the client with their bills, but they are skimming out of their accounts without that elder knowing. Forging the elder's signature and engaging in identity theft is very common. Another example is an announcement of a prize that the elderly person has won, but they have to pay money to claim. There can be phony charities and investment fraud. I have even heard of scammers showing up on an elder's doorstep. They claim to be from the utility company, or what have you, and they tell the homeowner that they need to pay their bill in cash.  

Healthcare Fraud and Abuse

• Not providing healthcare, but charging for it
• Overcharging or double-billing
• Getting kickbacks for referrals
• Overmedicating or under medicating
• Recommending fraudulent remedies for illnesses
• Medicaid fraud

You may not think of this as elder abuse but it really is. This is carried out by unethical individuals like doctors, nurses, hospital personnel, and other professional providers. This includes not providing healthcare but charging for it, overcharging or double-billing from medical care or services, getting kickbacks for referrals to other providers, prescribing certain drugs, over-medicating or under-medicating, or recommending fraudulent remedies for illnesses or other medical conditions. This is anything that benefits the medical professional, not the client.

Elder Self-Neglect

• Physical or mental impairment or diminished capacity can mean that an older adult is no longer able to perform essential self-care
• May lack basic personal hygiene, appear malnourished, live in dirty conditions, be unable to pay bills or manage medications
• Can be a sign of depression, grief, dementia, or other medical problem

We already talked about neglect, but this is self-neglect. This is a common form of elder abuse that we see in healthcare. Physical or mental impairment or diminished capacity can mean that an older individual is no longer able to perform essential self-care, and we see that very commonly with cognitive decline, dementia, et cetera. They may lack basic personal hygiene, appear dehydrated, malnourished, underweight, or what have you. This can be a sign of depression, grief, dementia, some other medical problem, and in many cases, the older person refuses to seek assistance. They, oftentimes, are in denial. They feel ashamed about needing help or feel worried about losing their independence. If you see this self-neglect, this could be indicative of some other larger systemic issue going on with the elder.

Signs of elder abuse can, unfortunately, be very difficult to recognize, mistaken for symptoms of dementia, the elder person's frailty, or again the caregivers may explain them to you in that way and just pass them off. In fact, many of the signs and symptoms of elder abuse do overlap with symptoms of mental deterioration, but that does not mean that we want to dismiss them on the caregiver's say-so.

Warning Signs

If you suspect abuse but you are not sure, look for the warning signs. We are going to go through these quickly as it relates to each of the types of abuse.

Physical Abuse Warning Signs

• Unexplained signs of injury, such as bruises, welts, or scars
• Broken bones, sprains, or dislocations
• A report of drug overdose or an apparent failure to take medication
• Broken eyeglasses or frames
• Signs of being restrained, such as rope marks on wrists
• Caregiver’s refusal to allow you to see the elder alone

These can include unexplained signs of injury such as bruises, welts, scars, especially if they appear symmetrically on both sides of the body, broken bones, sprains, or dislocations, or fractures that are unexplained. Another warning sign is a report of either a drug overdose or an apparent failure to take their medication. When you go in to do your visit, you may see that there is a lot more of that prescription remaining than should be. They may have broken eyeglasses, broken frames, signs of being restrained, like rope marks on their wrists, or things maybe that came from a zip tie. The caregiver may refuse to allow you to see the elder alone. There can also be signs of burns, internal injuries, and abrasions. These are injuries that are unexplained or somebody is giving you an explanation and that explanation is just really not plausible.

Emotional Abuse Warning Signs

• Threatening, belittling, or controlling caregiver behavior
• Behavior from the elder that mimics dementia
• Depression, sleep and appetite disturbances
• Decreased social contact
• Evasiveness, anxiety, hostility

When we look at emotional abuse warning signs, these are things like threatening, belittling, or controlling caregiver behavior. You may observe the caregiver and what they are saying may not ring true. Your "spidey sense" may be alerted. Behavior from the elder that mimics dementia such as rocking, sucking, or mumbling to themselves. Depression, sleep and appetite disturbances, decreased social contact, loss of interest in their own self, apathy, suicidal ideation, evasiveness, anxiety, hostility, or any of those changes can be potential warning signs. This person who has always wanted to go to activities and been very involved suddenly does not want to go and have isolated themselves would be a big red flag.

Sexual Abuse Warning Signs

• Bruises around breasts or genitals
• Unexplained vaginal or anal bleeding
• Torn, stained, or bloody underclothing
• Fear of being touched
• Inappropriate modesty on evaluation

You may notice some of these things while doing an ADL. Other issues would be unexplained vaginal or anal bleeding, torn, stained, bloody underclothing, fear of being touched, or an inappropriate modesty when you are delivering standard treatment or evaluation. You might have draped that person appropriately, but they still just do not want you to see them. 

Neglect Warning Signs

• Unusual weight loss, malnutrition, dehydration
• Untreated physical problems, such as bed sores
• Unsanitary living conditions
• Being left dirty or unbathed
• Unsuitable clothing or covering for the weather
• Unsafe living conditions
• Desertion of the elder at a public place
• Eccentric or idiosyncratic behavior, self-imposed isolation, marked indifference

Elder neglect or even self-neglect have some warning signs. These are things like unusual weight loss without a weight loss program, malnutrition, dehydration, untreated physical problems like bedsores or something else that should be treated, unsanitary living conditions, so dirt, bed bugs, or soiled bedding and clothing. They may be dirty or unbathed, or have unsuitable clothing or covering for the weather. For example, it could be cold outside yet the person has no coat. There may be no heat or running water, faulty electrical wiring, other fire hazards, or maybe they have been deserted at a public place. Another indication is the misuse or the absence of medication or an assistive device. You can also see things like eccentric or idiosyncratic behavior, self-imposed isolation, and a marked indifference to anything that is going on around them. All of those can be signs of neglect.

Financial Exploitation Warning Signs

• Significant withdrawals from the elder’s accounts
• Sudden changes in the elder’s financial condition
• Items or cash missing from the senior’s household
• Suspicious changes in wills, power of attorney, titles, and policies
• Addition of names to the senior’s signature card
• Financial activity the senior couldn’t have undertaken
• Unnecessary services, goods, or subscriptions
• The disparity between assets and appearance and general condition

Some of the warning signs here include significant withdrawals from that person's account, a sudden change in their financial condition, and items or cash missing from their household. Maybe, there have been changes in the will, in the power of attorney, and in titles and policies. They may have signed over these items to someone that just makes you scratch your head. There may be new additions of names to a signature card for the bank or other accounts. There may be financial activity that the person could not have possibly undertaken. For example, an ATM withdrawal when the account holder is bedridden or paying an account online when the person does not even have a computer. There could be unnecessary services, goods, or subscriptions. The client may also display fear, vague answers, or anxiety when asked about their personal finances. You may see a disparity between their assets and their appearance and their general condition. 

Healthcare Fraud/Abuse Warning Signs

• Duplicate billings for the same medical service or device
• Evidence of overmedication or under-medication
• Evidence of inadequate care when bills are paid in full
• Problems with the care facility

Duplicate billings for the same medical service or device, evidence of overmedication or under-medication, evidence of inadequate care when the bills are truly paid in full are some warning signs in this category. All of their medical bills are paid, but they do not look like they are cared for. This could also happen in an institution where there are problems with the care facility. The staff could be poorly trained, poorly paid, insufficient staff, or overcrowding.

Risk Factors

• Caregiver stress
• Depression in the caregiver
• Lack of support from other potential caregivers
• Substance abuse by the caregiver
• The intensity of the elderly person’s illness or dementia
• Social isolation
• The elder’s role, at an earlier time, as an abusive parent or spouse
• A history of domestic violence in the home
• The elder’s own tendency toward verbal or physical aggression

Taking care of a senior who has a lot of different care needs can be difficult. Both the demands of caregiving and the needs of that elder can create situations in which abuse is more likely to occur. Many nonprofessional caregivers, spouses, adult children, other relatives, and friends find taking care of an elder to be really satisfying and enriching, but the responsibilities and demands of caregiving can escalate and cause stress as that person's condition deteriorates. The stress of elder care can lead to mental and physical health problems that leave the caregiver burned out, impatient, and more susceptible to neglecting or lashing out at the elder in their care. Even caregivers in institutional settings can experience that stress that can lead to elder abuse. Nursing home staff particularly may be prone to elder abuse if they lack training, have too many responsibilities, are unsuited to caregiving, or they work under poor conditions. In addition to that caregiver's inability to manage stress, some other significant risk factors for elder abuse include depression in the caregiver and lack of support from other caregivers. The caregiver's perception that taking care of the elder is burdensome without any sort of emotional reward is another problem. Other risk factors include substance abuse by the caregiver, the intensity of the elderly person's illness or their dementia, social isolation, meaning that the elder and the caregiver are alone most of the time together, the elder may have been an abusive parent or a spouse, a history of domestic violence in the home, and the elder's own tendency toward verbal or physical aggression.

Federal Reporting Requirements

• Elder Justice Act (EJA): designed to address crimes committed against older persons, raise national awareness of elder justice issues and apply resources to the efforts of those confronting elder abuse and neglect on the front lines in healthcare settings

These reporting requirements come from the Elder Justice Act. The purpose of that act is to detect, prevent, and prosecute elder abuse, neglect, and exploitation. The Elder Justice Act is designed to address crimes committed against older persons, raise national awareness of elder justice issues, and then apply resources to the efforts of those confronting elder abuse and neglect on the front lines in our healthcare settings. The Elder Justice Act as well adds new elder justice provisions and very specific provider requirements particularly in long-term care by amending various sections of several titles of the Social Security Act.

• Section 1150B of the Social Security Act (the Act), as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), requires specific individuals in applicable long-term care facilities to report any reasonable suspicion of crimes committed against a resident of that facility
• Facilities are required to conspicuously post, in an appropriate location, a notice for its employees specifying the employees’ rights, including the right to file a complaint under this statute. The notice must include a statement that an employee may file a complaint with the SA against an LTC facility that retaliates against an employee.

Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act, requires that very specific individuals in applicable long-term care facilities report any reasonable suspicion of crimes committed against an individual of that facility. Now, this is required of any facility that receives at least $10,000 in federal funds under the act in the preceding year. That community is required to notify every covered individual of their obligation to report to the Secretary of Health and Human Services, known as the Secretary, and at least one local law enforcement entity, for any reasonable suspicion of a crime. A covered individual, in this case, is an owner, an operator, an employee, a manager, an agent, or a contractor. It includes pretty much everybody. Additionally, communities are required to post in a very conspicuous place a notice for employees specifying their rights including the right to file a complaint, and the notice also has to have a statement in it that an employee can file a complaint with the Secretary and they cannot be retaliated against. 

• You have a duty to report any suspected acts involving mistreatment, neglect, abuse, etc.
• Facilities must report any reasonable suspicion of a crime against a resident or patient to:
  • The Secretary of the U.S. Department of Health and Human Services (HHS), and
  • The law enforcement authorities in the political subdivision where the facility is located.

You do have a duty to report any suspected acts involving individual mistreatment, neglect, abuse, crimes, misappropriation of resident property, injuries of an unknown source, et cetera. Again, these are healthcare facilities again that are receiving federal aid. These facilities need to report any reasonable suspicion of a crime against an individual or a patient, number one, to the Secretary of the United States Department of Health and Human Services, and then also to the law enforcement authorities in the political subdivision where that facility is located. There are two specific federal reporting requirements, and most of these apply to the long-term care segment of the industry as that is where most of our elders reside.

• Two-time limits for the reporting of reasonable suspicion of a crime
  • Serious Bodily Injury – 2 Hour Limit
    • Shall report the suspicion immediately, but not later than 2 hours after forming the suspicion
  • All Others – Within 24 Hours
    • If no serious bodily injury shall report the suspicion not later than 24 hours after forming the suspicion
• “Serious bodily injury” is one involving extreme physical pain or substantial risk of death; or an injury involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or an injury requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.

There are two-time limits for reporting reasonable suspicions of crime depending on the seriousness of the event that leads to that suspicion. The first is whether or not there is a serious bodily injury. Now under the Elder Justice Act, serious bodily injury is one involving extreme physical pain, substantial risk of death, or an injury involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty. This is an injury requiring medical intervention such as surgery, hospitalization, or physical rehabilitation. If the events that cause a reasonable suspicion of harm or abuse and there is serious bodily injury, people are required to report immediately but no later than two hours after forming a suspicion to both local law enforcement and the Secretary of Health and Human Services. All others need to be reported within 24 hours. That is federal guidance. 

State Reporting Requirements

• Each state may have specific reporting requirements related to abuse
• It is important that you familiarize yourself with the requirements for the state in which you work/provide services
• Report as required by state law

This is where it gets tricky because every state is different. Each state may have specific reporting requirements related to the abuse. And for you, it is important that you familiarize yourself with the requirements for the state where you work and where you provide the services. If you feel or have a reason to believe that somebody is being abused, you need to report this. As every state is different and you need to report as required by your state law.

Resources

• State Adult Protection Statutes:
  • https://www.stetson.edu/law/academics/elder/home/adult-protection-statutes.php
• State Mandatory reporting Statutes:
  • https://www.stetson.edu/law/academics/elder/home/media/Mandatory-reporting-Statutes-for-elder-abuse-2016.pdf

Here are a couple of resources. One is the State Adult Protection Statutes, and the second link here is for State Mandatory Reporting Statutes. The second one specifically will tell you where to report, how to report, who is required to report, and what those timeframes are for your specific state. Hopefully, you can take the time to look those up as well. 

Child Abuse

Federal Definition of Child Abuse

• Federal Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C.A. § 5106g) defines child abuse and neglect as at minimum:
  • "Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation"; or
  • "An act or failure to act which presents an imminent risk of serious harm."

According to the United States Department of Health and Human Services, federal legislation provides guidance to states by identifying a minimum set of acts or behaviors that define child abuse and neglect. The Federal Child Abuse Prevention and Treatment Act or CAPTA, as amended by a Reauthorization Act in 2010, defines child abuse and neglect at a minimum to any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, and an act or failure to which presents an immediate or an imminent risk of serious harm.

Definitions

• A "child" generally means a person who is younger than age 18 or who is not an emancipated minor
• CAPTA does not provide specific definitions for types of maltreatment such as physical abuse, neglect, or emotional abuse
• Federal legislation sets minimum standards for States that accept CAPTA funding, each state provides its own definitions of maltreatment within civil and criminal statutes

Under these definitions, this definition refers very specifically to parents and other caregivers. A child under this definition generally means a person who is younger than the age of 18 or who is not an emancipated minor. And while CAPTA provides definitions for sexual abuse and the special cases of neglect related to withholding or failing to provide medically indicated treatment, it does not provide specific definitions for other types of maltreatment or things like physical abuse, neglect, or emotional abuse. While federal legislation sets those minimum standards for states that accept CAPTA funding, each state is going to go out on its own and provide its own definitions of maltreatment within civil and criminal statutes. 

State Statutes

• Definitions of child abuse and neglect are typically located in two places within each State's statutory code:
  • Civil statutes provide definitions of child maltreatment for mandated reporters
  • Criminal statutes define those forms of child maltreatment subject to arrest and prosecution

The federal definition is out there, but the state has to be accepting CAPTA funding for that federal definition to apply. More often than not, each state is going to have its own set of statutes related to child abuse. We will talk about this on another slide, but that is again where it is up to you to figure out the requirements in your specific state. Are you a mandatory reporter? What are your training requirements? I gave you some resources to do that, and we will talk about that in a minute. The definitions of child abuse are going to be located typically in two places within each state's statutory code. The first statutory code will be the civil statutes, and these will provide those definitions of what is child maltreatment. It also will help to guide the mandatory reporters and other individuals as well as to identify and report suspected child abuse and determine the grounds for intervention by the state child protection agencies and the civil courts. This is the overarching area of what is abuse, who reports, how do you report, and what do we do when you report. The criminal statutes, on the other hand, will define those forms of child maltreatment that can subject an offender to arrest and prosecution in criminal courts. Most of them will list out very specifically the types of things that are absolutely positively against the law and what would warrant an arrest, prosecution, jail time, community service, or whatever it would happen to be.

Types of Abuse

• Many states recognize four major types of maltreatment
  • Neglect
  • Physical abuse
  • Sexual abuse
  • Emotional abuse or neglect

Many states recognize four major types of maltreatment in their definitions and these include neglect, physical abuse, sexual abuse, and emotional abuse or neglect. Let's look at these in a little more detail. I think the first step in helping an abused or neglected child is learning those warning signs. The presence of a single sign does not prove that child abuse is occurring but it could be. But, when you look at the situation a little bit more closely, you may see signs appear repeatedly or in combination. When you see a pattern, that is when you want to take notice. If you do suspect at any time that a child is being harmed, you have to report your suspicions because that is going to help protect that child and get some help for the family. We will talk about reporting in a second, but any person can report suspicions of child abuse and neglect. Mandatory reporters need to report under very specific circumstances defined by the state. Healthcare providers with very few exceptions would be considered mandatory reporters in those states. 

Recognizing Child Abuse

• The Child:
  • Shows sudden changes in behavior or school performance
  • Has not received help for physical or medical problems
  • Has learning problems that cannot be attributed to specific causes
  • Is always watchful
  • Lacks adult supervision
  • Is overly compliant, passive, or withdrawn
  • Comes to school or other activities early, stays late, and does not want to go home

These are the signs in a child that may signal child abuse or neglect. They show sudden changes in behavior or school performance. They were a wonderful student and now they are not. They have not received help for a physical or a medical problem that has been brought to the parent's attention. They have learning problems or difficulty concentrating in the classroom that cannot be attributed to a very specific physical or psychological cause. Or, maybe that child is always watchful as though they are always preparing for something bad to happen. They are looking for that other shoe to drop or looking over their shoulder. They lack adult supervision when they are not of an age to be unsupervised. They are overly compliant or very passive or withdrawn. They say yes ma'am or no sir to all requests. They come to school or to other activities early, they stay late, and they do not really want to go home when it is time for dismissal.

• The Parent:
  • Shows little concern for the child
  • Denies the existence of—or blames the child for—the child’s problems in school or at home
  • Asks teachers to use harsh physical discipline
  • Sees the child as entirely bad, worthless, or burdensome
  • Demands a level of physical or academic performance the child cannot achieve
  • Looks primarily to the child for care, attention, and satisfaction of emotional needs

This parent shows little concern for the child. They pass off some of the things that are happening with their child as not being important. They deny the existence of or even blame the child for the child's own problems in school or at home. They ask a teacher or a caregiver to use harsh physical discipline if that child misbehaves. It is okay to do X, Y, and Z if the child misbehaves. "This is what we do at home." They see the child as bad, worthless, or burdensome. They demand a level of physical or academic performance that the child cannot possibly achieve. This is different from encouraging them to be a better student or athlete. This is forcing something that they could not possibly achieve or do not have the physical or mental capacity to do. They look at the child primarily for care, attention, and satisfaction of their own emotional needs rather than providing the care to the child for the child's needs.

• The Parent and Child:
  • Rarely touch or look at each other
  • Consider their relationship entirely negative
  • State that they do not like each other

We can also look at the parent and child dyad together. They rarely touch each other or look at each other. You do not see that bond or connection between the two of them. They consider their relationship entirely negative, and they may just flat out state that they do not like each other and truly mean that. We talked about the types of maltreatment that are generally defined in the state statute, and now, we are going to go through now some of the signs that are associated with the types of child abuse and neglect. It is important to note however that these types of abuse are typically found in combination rather than alone.

You will not typically just see physical abuse without also some sort of emotional or mental anguish as well. For example, a child who is sexually abused may also be neglected. You want to look for these in combination and look for some of those signs. And again, a lot of these are going to be very similar to what we just talked about with elder abuse. 

Physical Abuse

• Has unexplained burns, bites, bruises, broken bones, or black eyes
• Has fading bruises or other marks noticeable after an absence from school
• Seems frightened of the parents and protests or cries when it is time to go home
• Shrinks at the approach of adults
• Reports injury by a parent or another adult caregiver

They may have unexplained burns, bites, bruises, broken bones, and black eyes. They may be consistently in the emergency room for some sort of treatment. They have fading bruises or other marks that are noticeable after an absence from school. They seem frightened of the parents. They protest or they cry when it is time to go home. They shrink at the approach of an adult and are wary of adults who are around them. They report injuries by a parent or another adult caregiver, or they report an injury and the explanation of that injury is just not plausible. The proverbial "I fell down the stairs" type of excuse.

• Consider physical abuse when the adult:
  • Offers conflicting, unconvincing, or no explanation for the child’s injury
  • Describes the child as “evil,” or in some other very negative way
  • Uses harsh physical discipline with the child
  • Has a history of abuse as a child

We might want to consider physical abuse if they are offering conflicting, unconvincing, or no explanation for the child's injury. "have no idea how that happened." Or, "Don't worry about it. It's no big deal." They describe the child as evil in some way, or they are very negative in their description of the child. They use harsh physical discipline with the child even when it is not warranted. Another one is that they themselves may have a history of abuse as a child. 

Neglect

• The child is frequently absent from school
• Begs or steals food or money
• Lacks needed medical or dental care
• Is consistently dirty
• Lacks sufficient clothing for the weather
• Abuses alcohol/drugs
• States that there is no one at home to provide care

You want to consider the possibility of neglect when the child is frequently absent from school again without a reason. This is when they are not on vacation, not sick and at the physician, and not visiting their grandparents. They may beg or steal food in the cafeteria. They may lack the necessary medical or dental care that they should be having at their age. They may not have their immunizations not necessarily related to the opinions of the parent but because the parent refuses to give them. Maybe they need glasses, but they do not have glasses. They are consistently dirty and do not look well-kept. They have severe body odor or their hair is very dirty. They may have consistent issues with lice or other types of bugs. They may lack sufficient clothing for the weather, again very similar to elder abuse. It is cold outside but they do not have a coat. It is raining but they do not have anything to protect them from the elements. The child may be abusing alcohol, drugs, or other things more consistent in an older child. They may state that there is no one home to provide care for them. They may say, "I cook my own meals all the time." Another clue is, "I take care of a younger sibling." 

• Consider neglect when the adult:
  • Appears to be indifferent to the child
  • Seems apathetic or depressed
  • Behaves irrationally or in a bizarre manner
  • Is abusing alcohol or other drugs

You also want to consider the possibility of neglect again when we look at the parent or the adult caregiver and they are indifferent to that child. They are apathetic and do not seem to care. They themselves are depressed and not in a position to care appropriately for that child. They behave irrationally or in a bizarre type of manner. Or, they may be abusing alcohol or other drugs themselves.

Sexual Child Abuse

• Has difficulty walking or sitting
• Suddenly refuses to change for gym
• Reports nightmares or bedwetting
• Experiences a sudden change in appetite
• Demonstrates bizarre, sophisticated, or unusual sexual knowledge
• Becomes pregnant or contracts a venereal disease
• Runs away
• Reports sexual abuse by a parent or another adult caregiver

Consider the possibility of sexual child abuse when that child has difficulty walking or sitting. You see that they have pain in their genital area. It is observable that they are very uncomfortable. They suddenly refuse to change for the gym, participate in physical activities, or maybe participate in your treatment session. They may report having nightmares or bedwetting. Their appetite may have gone down or up, and they may also have sleep disturbances. They have bizarre, sophisticated, or even unusual sexual knowledge or behavior for their age. Things that they should not know but they do. They may become pregnant or have a sexually transmitted infection, particularly at younger ages. They run away or they report some sort of sexual abuse by a parent or another adult or caregiver. You have to take these comments very seriously. 

• Consider sexual abuse when the adult:
  • Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex
  • Is secretive and isolated
  • Is jealous or controlling with family members

We also want to consider the possibility of sexual abuse when the parent, adult caregiver, or older sibling is really protective of that child. This severely limits the child's contact with other children or other individuals, especially of the opposite sex. They are secretive and isolated. They look like they have an unhealthy type of family bond. They are very jealous and controlling with other family members.

Emotional Maltreatment

• Shows extremes in behavior
• Is either inappropriately adult or inappropriately infantile
• Is delayed in physical or emotional development
• Has attempted suicide
• Reports a lack of attachment to the parent

Signs of emotional maltreatment is when you see a child showing extremes in behavior. They may be overly demanding, extremely passive, or extremely aggressive. They are either inappropriately adult-like or infantile as examples. They may be delayed in their physical, emotional development, and cognitive development. Perhaps, they have attempted suicide or have even talked about suicide. They feel like their life is not worthy or unsatisfactory. They may report a lack of attachment to the parent. If we interact with that parent or caregiver, we may see that the adult constantly blames, belittles, or berates that child. They are really unconcerned about the child, their whereabouts, their well-being, and those sorts of things. They do not consider the offers of help for the child's problem. 

How to Report Suspicions

• Suspected Child Maltreatment
  • If in serious danger, call 911
  • National and local resources are available to provide assistance and information about reporting suspected maltreatment.
• Suspected child abuse or neglect?
  • Contact your local child protective services office or law enforcement agency
  • Know the statutes if you are a mandatory reporter

If you see suspicions, what do you do? If you or someone else is in immediate danger, call 911. That is the best thing to do because there are both national and local resources that are available to provide immediate assistance to that child and family. You would want to report that information about suspected maltreatment. Again this is very state-specific, but at a bare minimum, you would contact your local Child Protective Services office or law enforcement agency. If you are a mandatory reporter in your state, you are going to need to know what their requirements are. I can tell you that I am licensed in a couple of states, and I look at my licensing requirements. There are very specific rules that you need to follow about timeframes, phone calls, and specific people to contact. Unfortunately, in the scope of this presentation, we cannot go into that level of detail, but you need to know what the statutes are for your specific state. 

Who Can Report?

• Anyone can report suspected child abuse or neglect
• All U.S. States and territories have laws identifying mandatory reporters
• Mandatory reporters may include social workers, teachers, and other school personnel, childcare providers, physicians, and other health-care workers, mental health professionals, and law enforcement officers

Again all states have laws that identify persons who are mandatory reporters like social workers, teachers, school personnel, childcare providers, physicians, mental health professionals, and law enforcement officers. They are all identified in those state statutes, However, any person who suspects child abuse and neglect can and should report.

What Happens Next?

• Report a complete, honest account of what you observed that led you to your suspicion. Any reasonable suspicion is sufficient.
• Reports are sent to child protective services (CPS) for review
• If an investigation is deemed needed, CPS may talk with the family, the child, or others to help determine what is making the child unsafe
• For more information about where and how to file a report, contact your local child protective services agency or police department

You need to provide a completely honest account of what you observed that led you to suspect the occurrence of child abuse or neglect and any reasonable suspicion is sufficient. Do not make up details or leave out details - be clear, be honest about what you saw, what you heard, or what you observed. Do not base that on hearsay. It should only be based on your own report. This report is going to be sent over to Child Protective Services or CPS for review. Generally speaking, again for states, when they receive that report, the worker will review the information and determine if an investigation is necessary. That CPS worker may talk to the family, the child, or other individuals to help determine what possibly is making this child unsafe. They can also help parents and other caregivers get services, get an education, and get other assistance to help them through the situation. 

Resources

• Childhelp National Child Abuse
  • Call or text 1.800.4.A.CHILD (1.800.422.4453). Professional crisis counselors are available 24 hours a day, 7 days a week, in over 170 languages.
• National Center for Missing and Exploited Children’s CyberTipline
  • Report online sexual exploitation of a child or if you suspect that a child has been inappropriately contacted online at the CyberTipline.

There are national resources that are available. For the Childhelp National Child Abuse resource, there are professional crisis counselors there 24 hours a day, seven days a week available in 170 different languages. Every call that is placed is completely confidential, and the hotline offers things like crisis intervention, information, referrals out to other emergency services, social services, and other sorts of resources that are available in the community. There is also the National Center for Missing and Exploited Children's Cyber. This is an online reporting if you suspect any sort of sexual exploitation of a child, and that would include human trafficking. You can also report if you suspect that a child has been inappropriately contacted online. Information again is made available to law enforcement in order to conduct that investigation.

• State Statutes for Child Protective Services:
  • https://www.childwelfare.gov/topics/systemwide/laws-policies/state/
• State reporting Phone Numbers:
  • https://www.childwelfare.gov/organizations/?CWIGFunctionsaction=rols:main.dspList&rolType=custom&rs_id=5

Here are two resources for your states. The first one is the state statutes for Child Protective Services, and the second is the state reporting phone numbers. Now, these are not necessarily the end all be all. Again go back to your Practice Act, your licensure, etc. But, these are some good starting points so that you can start to read about what is required.

This text-based course is an edited transcript of the webinar, A Comprehensive Introduction to the Diagnosis and Treatment of Obsessive-Compulsive Disorder, presented by Johann D'Souza, PhD, LP, on January 5, 2026.

Course Overview

Obsessive-compulsive disorder (OCD) is a widely misunderstood condition, frequently reduced in popular culture to quirks of tidiness or orderliness. This course provides a clinically grounded introduction to the disorder, moving from common misconceptions through formal diagnostic criteria, symptom subtypes, and evidence-based assessment tools, before arriving at a thorough examination of the gold-standard treatment: Exposure and Response Prevention (ERP). Developed for mental health practitioners and other healthcare professionals seeking continuing education, the material draws on current DSM-5-TR criteria, published research, and clinical examples to build practical competence. By the end of this course, participants will understand what OCD is, how it differs from superficially similar conditions, and how to implement the fundamental stages of ERP with individuals across the lifespan.

This material is for educational purposes and does not replace clinical judgment or local policy.

Limitations/Risks

• OCD is a highly complex disorder that shares symptoms with several other disorders. This webinar is not a replacement for supervision, consultation, and specialized professional training for the diagnosis and treatment of OCD.
• This webinar does not constitute a clinical credential and does not include all OCD subtypes, comorbid conditions, treatment options, or treatment complexities.
• Treatment protocols and diagnostic criteria continue to evolve; this webinar represents current knowledge at the time of presentation.
• The stigma associated with mental health issues and specific beliefs about mental health and treatment vary widely across cultures. In some cultures, seeking mental health treatment is highly stigmatized, leading to reluctance in seeking treatment and/or participating fully in treatment. Therefore, practitioners should exercise cultural humility at all times with all clients.

Learning Outcomes

After this course, participants will be able to:

1. List the two primary symptoms of OCD.
2. Describe the differences between OCD, anxiety, and other disorders.
3. Explain three fundamental stages of Exposure & Response Prevention.

Common Myths

Before defining OCD precisely, it is useful to examine what OCD is not — because misunderstanding is widespread not only among the general public but within professional communities as well. Several persistent myths shape how people with OCD experience their disorder and the kind of help they seek.

One of the most pervasive myths is the idea that everyone is "a little OCD." There is a kernel of truth embedded here: many people experience recurring, intrusive thoughts from time to time. However, to receive a diagnosis of OCD, an individual must meet a clinical threshold of symptom severity and functional impairment that is uncommon for most people. The casual colloquial use of "OCD" to describe everyday preferences for order or cleanliness trivializes a condition that can be profoundly disabling.

A related and equally common myth is that OCD is always about hand washing, cleaning, or neatness. While contamination concerns and cleaning compulsions are among the more visible manifestations of OCD, they represent only one slice of the disorder's full range. OCD can present in ways that are entirely unrelated to cleanliness — for example, intrusive thoughts about harming a loved one, fears related to morality or religious transgression, or a vague but distressing sensation that something is "not quite right." Someone can meet full diagnostic criteria for OCD without ever engaging in cleaning behaviors at all.

Another myth holds that people with OCD are simply neurotic, eccentric, or beyond help. It is important to separate the person from the disorder: the unusual or distressing behaviors associated with OCD are products of the condition, not character flaws. With appropriate, evidence-based treatment, individuals with OCD can achieve substantial — often dramatic — symptom reduction and lead fulfilling, functional lives.

Perhaps the most clinically consequential myth is the belief that OCD can be treated by directly disputing or arguing against the dysfunctional beliefs driving it. Intuitively, it might seem that if a person is afraid of contamination, demonstrating that their fears are irrational should help. In practice, the act of counter-arguing, debating, or seeking logical reassurance tends to perpetuate OCD rather than relieve it. The obsessional cycle is not fundamentally a problem of faulty logic; it is a problem of avoidance and reinforcement — a distinction that becomes central to understanding why ERP is the treatment of choice.

Similarly, OCD is not simply a reflection of unresolved psychodynamic conflicts or childhood trauma. Stressful or traumatic experiences can certainly exacerbate symptoms or trigger their onset, but the current evidence base indicates a strong genetic predisposition that is primary to the disorder's development (American Psychiatric Association, 2022). Stressors can make it worse; they are not the root cause.

Finally, clinicians should be aware of how perfectionism can interact with OCD in treatment itself. Individuals with OCD tend to exhibit high rigidity and a low tolerance for uncertainty, and these traits can affect the treatment process. A patient may feel compelled to complete exposure homework "perfectly," inadvertently generating a new OCD cycle within the therapeutic work. Developing insight into this pattern — in both the patient and the clinician — is an important clinical competency.

Defining OCD

DSM-5 TR Definition

The formal definition of OCD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision is straightforward at its core (American Psychiatric Association, 2022). Three criteria must be met:

• The obsessions or compulsions are time-consuming and/or cause clinically significant distress or functional impairment.
• The obsessive-compulsive symptoms are not attributable to the effects of a substance or another medical condition.
• The disturbance is not better explained by the symptoms of another mental disorder.

What this definition leaves open is precisely what obsessions and compulsions are — and here the clinical literature departs significantly from everyday usage of these words.

Differentiating Disorders

Obsessions

In everyday speech, describing oneself as "obsessed" with a hobby or interest typically implies enthusiasm and pleasure. In the clinical context of OCD, the term means something nearly opposite. An obsession, as defined in the OCD literature, is a thought, image, or urge that is unwanted, intrusive, persistent, and irrational.

Each element of this definition carries diagnostic weight. The thought component refers to verbal content in one's mind — for example, the phrase "I am going to harm my child" entering awareness without the individual having invited it. An image refers to a mental picture, such as a vivid visualization of violence against a loved one. The third component, urge, is more nuanced and not universally experienced by people with OCD. It refers to a vague, uncomfortable somatic or perceptual sense that something is "not just right" — that a shirt sleeve is positioned incorrectly, that shoelaces are unevenly tightened, or that a symmetry has been disrupted. This phenomenon has been labeled "not just right OCD," and it is experientially distinct from cognitive worry.

The quality of being unwanted distinguishes OCD obsessions from ordinary preoccupations. The teenager who thinks about cars constantly is not experiencing obsessions in the clinical sense, because those thoughts are welcomed. Intrusive means the thought enters awareness without being sought; persistent means it returns repeatedly despite efforts to suppress or ignore it. The final criterion — irrational or unrealistic — is what most cleanly separates obsessions from the anxious worries seen in other disorders. Even exaggerated everyday worries bear some relationship to realistic events. OCD obsessions frequently carry a superstitious or magical quality that crosses into the clearly implausible: "If I do not wash my hands exactly five times, my grandmother will become ill and die." This irrational character is not a moral failing; it is the signature of the disorder.

The distinction between urge and fear of urge deserves particular attention for clinicians. A patient who reports "an urge to stab my spouse" when chopping vegetables is almost certainly not experiencing an actual drive to harm. What the patient experiences is an unwanted thought or image, accompanied by intense fear that they might act on it. The internal drive to harm is absent — that is precisely what makes the thought OCD rather than intent. Part of effective treatment involves helping patients develop insight into this distinction.

Compulsions

If obsessions are the internal, involuntary dimension of OCD, compulsions are the behavioral dimension — the things the person does in response. Compulsions are repetitive behaviors or mental acts that an individual feels compelled to perform in response to an obsession in order to reduce or prevent anxiety or distress, prevent a feared outcome, or make something feel "just right." Critically, they are either not connected in a realistic way to what they are intended to prevent or are clearly excessive in nature (American Psychiatric Association, 2022).

Compulsions may be overt and behavioral — hand washing, checking locks, arranging objects — or they may be entirely covert mental acts, such as silently counting, reviewing memories, or generating counter-thoughts. The compulsion is a choice, even when it feels automatic or overwhelming to resist. When working with children, clinicians should note that younger patients may be unable to articulate the connection between their obsession and their compulsive behavior. Helping these patients map the relationship between trigger, obsession, anxiety, compulsion, and temporary relief — the OCD cycle — is an important early phase of treatment.

The most universal category of compulsion is avoidance: any behavior the person engages in to steer clear of the feared thought, image, or situation. Reassurance-seeking is the next most common, in which the person repeatedly seeks confirmation from a spouse, parent, or clinician that the feared outcome has not occurred or is unlikely to occur. Providing reassurance, while immediately comforting, feeds the OCD cycle in exactly the same way a compulsion does. Confessing, checking, and rechecking, and mental reviewing are additional common compulsion types.

Insight

A critical clinical concept in OCD is the role of insight (Steinberg et al., 2025). Insight refers to the degree to which an individual recognizes that their obsessional fears are not realistic — that what they are experiencing is OCD, not an accurate perception of the world.

Image: The insight spectrum in OCD ranges from absent/delusional (firm belief that fears are real) through poor to good/fair (recognition that symptoms reflect OCD), with lower insight associated with poorer treatment outcomes (Steinberg et al., 2025).

At one extreme is good or fair insight: the person recognizes that feared thoughts are symptoms of a disorder and are not realistic, even if they still feel compelling. At the other extreme is absent or delusional insight: the individual is firmly convinced their fears are real. This rare but severe presentation — in which a person may be unable to leave the home because they are certain a harmed child is concealed somewhere in the building, despite living alone — begins to approximate a psychotic-spectrum disorder in its phenomenology.

More clinically common is poor insight, found in approximately one-fifth to one-third of individuals with OCD (Steinberg et al., 2025). These individuals oscillate: most of the time, they suspect they have OCD, but a persistent doubt remains — "maybe this time it really is true." Poor insight is more prevalent in OCD than in other anxiety-related conditions and carries significant treatment implications. Lower insight is one of the strongest predictors of poorer treatment response, making its assessment and its gradual improvement through treatment a clinical priority. One mechanism by which ERP improves insight is through repeated, successful fear-facing: when a person repeatedly confronts feared situations and observes that nothing catastrophic occurs, they accumulate experiential evidence that progressively weakens catastrophic beliefs.

Common OCD Subtypes

OCD can manifest in a remarkable variety of ways, and the specific content of obsessions is highly idiosyncratic. Nonetheless, research and clinical observation have identified common groupings or subtypes that help practitioners recognize and assess the full range of the disorder's presentations (Jalal et al., 2023).

Image: OCD subtypes mapped by obsession type and associated compulsions, illustrating the breadth of presentations beyond contamination and cleaning (Jalal et al., 2023).

Contamination OCD involves fears of germs, chemical contaminants, or substances with aversive sensory qualities, such as greasy or sticky textures. The corresponding compulsions typically center on washing, cleaning, or avoidance of perceived contaminants.

Scrupulosity involves an excessive fear of offending God, acting immorally, or being in a state of spiritual transgression. This subtype is of particular clinical importance because the symptom content intersects with the patient's deepest personal values. A patient with scrupulosity may engage in constant mental review of their words and actions, wondering whether an ambiguous statement was a lie or whether a momentary lapse placed them in spiritual jeopardy. Effective treatment requires a clinician who understands and respects the patient's religious and moral framework rather than pathologizing it wholesale.

Harm OCD involves recurrent, unwanted thoughts about causing harm to others or being harmed oneself. As noted in the section on obsessions, patients with harm OCD do not experience an internal drive to harm — they experience an overwhelming fear that they might. Taboo OCD is closely related, encompassing thoughts of a sexual nature, including fears of being attracted to children or committing sexual abuse. Because of the profound shame associated with these thoughts, patients are frequently reluctant to disclose them even to their therapist. Clinicians who do not directly and non-judgmentally inquire about this symptom domain may be treating a patient with significant taboo OCD without realizing it.

Just-right OCD involves the pervasive sense that things are not in their correct state — not perfectly symmetrical, not properly ordered, not adequately arranged. The discomfort is more somatic or aesthetic than cognitive; patients often struggle to articulate what specifically is wrong, only that something is not right.

On the compulsion side, avoidance is so universal that it can serve as a summary category for all compulsive behavior. Reassurance-seeking, confessing, checking and rechecking, repeating behaviors, and mental compulsions (internal reviews, counter-thoughts, neutralizations) round out the most common presentations (Jalal et al., 2023).

Other Related Disorders

OCD belongs to a broader family of conditions classified in the DSM-5-TR as obsessive-compulsive and related disorders, a grouping that reflects both phenomenological similarities and genetic relationships (Brierley et al., 2021). Understanding these related conditions helps clinicians think about comorbidity, differential diagnosis, and the broader context of a patient's presentation.

Image: OCD-related disorders sharing genetic and phenomenological features with OCD, including body dysmorphic disorder, tic disorders, illness anxiety disorder, body-focused repetitive behaviors, and hoarding (Brierley et al., 2021).

Tic disorders, including Tourette's syndrome, are among the most genetically proximate conditions to OCD. Vocal and motor tics — such as throat clearing or repetitive movements — are frequently comorbid with OCD, a pattern reflecting shared genetic architecture rather than coincidence.

Illness anxiety disorder (formerly hypochondriasis, often called health anxiety) involves excessive, disproportionate fear of having or developing a serious illness. This can present as a distinct disorder or as an OCD subtype, and careful assessment is needed to determine the most appropriate conceptualization.

Hoarding disorder may present as one symptom among many in a person with OCD or as a standalone condition. Similarly, body dysmorphic disorder — characterized by preoccupation with perceived flaws in physical appearance — shares important features with OCD and is treated with many of the same approaches.

Body-focused repetitive behaviors (BFRBs), including trichotillomania (hair pulling) and excoriation disorder (skin picking), are the most prevalent conditions in this category. They share a driven, repetitive behavioral quality with OCD compulsions and present similar treatment challenges.

OCD vs. Generalized Anxiety Disorder

The condition most frequently confused with OCD in clinical and general settings is generalized anxiety disorder (GAD). The two disorders share a surface-level quality — both involve excessive, unwanted mental activity that causes distress — but differ in several important ways (American Psychiatric Association, 2022).

The ego-dystonic nature of OCD obsessions is particularly diagnostic. A person with OCD is distressed by their thoughts precisely because those thoughts conflict with who they are and what they want. A person with harm OCD who fears harming their child is not someone who wishes to harm their child — the thought is alien to their identity. By contrast, GAD worries, while excessive, are connected to things the person genuinely cares about: finances, relationships, health, and performance. The person with GAD worries about things they wish would go well; the person with OCD is horrified by things they desperately wish would not happen.

Additionally, the behavioral responses differ. OCD generates highly specific, often ritualized compulsive patterns — particular sequences, numbers, or types of behaviors tied to the specific obsessional content. GAD generates more varied behavioral attempts to cope, primarily reassurance-seeking and preparation.

A note on perfectionism: Perfectionism itself is not a DSM diagnostic criterion, but individuals with OCD tend strongly toward rigidity, a high need for certainty, and discomfort with ambiguity. A person can be highly perfectionistic without having OCD and can have OCD without being a perfectionist, but the two frequently co-occur. This overlap has clinical relevance because perfectionism can become a vehicle through which OCD infiltrates the treatment itself, as patients attempt to perform their exposure homework "correctly" in a way that becomes its own compulsion.

Assessing OCD

When Does OCD Appear?

OCD can emerge at virtually any point across the lifespan, from preschool through adulthood. Research identifies two particularly common onset windows: between ages 8 and 12 and between late adolescence and early adulthood (Stein et al., 2025; Ziegler et al., 2021). The stress-diathesis model offers a useful framework for understanding this pattern: individuals with a genetic predisposition to OCD will typically not develop the full disorder until they encounter a meaningful life stressor. For most people, the physiological and psychosocial changes of puberty represent sufficient stress to trigger symptom onset, even without any specifically traumatic experience. Parents of children later diagnosed with OCD often report noticing precursor traits — rigidity, perfectionism, difficulty with transitions — from early in their child's development, long before those traits crystallized into clinically significant OCD.

The gap between symptom onset and formal diagnosis presents a significant public health challenge. On average, individuals wait approximately 13 years from the emergence of their first OCD symptoms to receiving a diagnosis (Ziegler et al., 2021). The interval from diagnosis to treatment is further extended, averaging approximately a year and a half (Ziegler et al., 2021). The combined effect is that individuals with OCD may spend a decade and a half or more living with a treatable condition before accessing an effective intervention. Contributing factors to this delay include the disorder's stigma, the private nature of obsessional content, and widespread lack of OCD-specific training even among mental health professionals.

Assessment

The gold-standard instrument for OCD assessment is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), a clinician-administered tool consisting of a detailed symptom checklist followed by a severity scale with established research-validated diagnostic cutoffs (Scahill et al., 1997). The Y-BOCS is broadly accepted within the field as the preferred assessment tool — a degree of consensus unusual in mental health assessment, where many comparable disorders have numerous competing instruments. Administering the full Y-BOCS takes between 30 and 60 minutes, depending on the clinical context.

Image: Standard OCD assessment framework including clinical interviews, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and its child version (CY-BOCS), the latter validated by Scahill et al. (1997).

The Y-BOCS serves two distinct functions. The symptom checklist component comprehensively surveys the full range of OCD symptom types, frequently helping patients recognize the breadth and interconnectedness of their symptoms — an exercise that is itself therapeutically valuable, since many patients have not previously understood their disparate experiences as manifestations of a single disorder. The severity scale component quantifies the impact of the obsessions and compulsions on the patient's daily life, providing a baseline against which treatment progress can be tracked. Re-administering the severity scale every few weeks allows clinicians and patients to monitor symptom reduction in a concrete, measurable way.

For younger patients, the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) provides a developmentally appropriate parallel instrument (Scahill et al., 1997). The CY-BOCS is child-assessed rather than purely clinician-administered, accommodating the developmental differences in how children report and understand their symptoms.

Comprehensive assessment goes beyond the Y-BOCS alone. Clinical interviews help identify comorbid diagnoses (which are common in OCD), assess the family environment (particularly important when working with children and adolescents), and develop a neuropsychological profile of the individual's cognitive and emotional functioning. For clinicians who need a briefer initial screen, shorter instruments such as the Florida Obsessive Compulsive Inventory (FOCI) can be administered quickly, though they do not replace the Y-BOCS for comprehensive assessment purposes.

Treatment

Research on OCD treatment is unusually well-organized and convergent. There is broad expert consensus that cognitive behavioral therapy (CBT) incorporating Exposure and Response Prevention (ERP) is the most effective treatment currently available (American Psychiatric Association, 2022). ERP alone produces symptom reductions of 60 to 80 percent. Pharmacotherapy, primarily using selective serotonin reuptake inhibitors (SSRIs), produces symptom reductions of approximately 40 to 60 percent. A third evidence-based option, particularly relevant for children, is Supportive Parenting for Anxious Childhood Emotions (SPACE), a parent-based approach found to be efficacious, comparable, and non-inferior to direct CBT (Lebowitz et al., 2020).

Image: Evidence-based OCD treatments including CBT with ERP (60-80% symptom reduction), SSRI pharmacotherapy (40-60% reduction), and the SPACE parent-based program (non-inferior to CBT; Lebowitz et al., 2020).

The relative advantages of ERP over pharmacotherapy deserve elaboration. While ERP and SSRIs are both effective, ERP yields benefits that persist beyond the treatment period, whereas pharmacotherapy produces benefits primarily while the medication is being taken. Withdrawal from medication typically results in symptom return. Additionally, SSRIs carry side effects and, in some cases, risks of physiological dependence. Clinical guidance generally favors initiating ERP as the first-line intervention. Medication is considered when: symptom severity significantly interferes with daily functioning; ERP alone has not produced an adequate response; symptoms are so severe that they prevent meaningful engagement with ERP; or the patient declines ERP.

The question of combined treatment has been examined in meta-analyses. The evidence suggests that ERP combined with SSRIs is marginally more effective than ERP alone, but the magnitude of the advantage is small and, in many studies, does not reach statistical significance. This evidence supports a stepwise approach: begin with ERP, add medication if needed, rather than defaulting to combination treatment from the outset.

The SPACE program merits particular mention because it inverts the conventional assumption that treating a child requires the child to be present in therapy. SPACE is a parent-based treatment in which the clinician works directly with parents — teaching them how to reduce accommodation of OCD symptoms and support the child's tolerance of anxiety — without necessarily seeing the child. Research has demonstrated that its effectiveness is comparable to direct CBT for childhood anxiety and OCD (Lebowitz et al., 2020).

ERP

Exposure + Response Prevention

Exposure and Response Prevention is a two-component protocol, and both components are essential. Removing either significantly reduces the intervention's effectiveness.

The exposure component involves deliberately and repeatedly confronting the thoughts, images, urges, situations, or stimuli that provoke obsessional distress. This is not passive or accidental contact with feared stimuli; it is intentional, purposeful, and structured. Exposures are most effective when designed to generate genuine discomfort, not a sterile or intellectualized approximation of it.

The response prevention component involves actively choosing not to perform the compulsion in response to the triggered anxiety. Rather than washing, checking, seeking reassurance, counting, or engaging in mental rituals, the person allows the anxiety to persist and observes that it naturally diminishes over time without any intervention. This process of riding the discomfort — commonly described as "riding the wave" — is the mechanism through which OCD loses its power. Performing the compulsion, even once, "spoils" the exposure by interrupting the anxiety's natural decline and reinforcing the false belief that the compulsion was necessary.

ERP Treatment

The ERP treatment protocol follows a structured, sequenced process (American Psychiatric Association, 2022):

• Psychoeducation about the diagnosis and treatment — helping the patient understand what OCD is, what ERP is, and why it works.
• Establishing treatment goals — clarifying what the patient wants their life to look like without OCD.
• Developing a treatment plan collaboratively — ensuring the patient has genuine ownership and investment in the process.
• Creating an exposure hierarchy or menu — listing the patient's fears in order from least to most anxiety-provoking, providing a structured roadmap for treatment.
• Practicing exposures in session — building the patient's confidence and correct technique before independent practice begins.
• Between-session practice (homework) — the primary driver of improvement, in which the patient independently conducts exposures in their daily life.
• Response prevention plans — developing specific strategies for managing compulsive urges when practicing independently.

Psychoeducation is not merely introductory. For patients who have never received an accurate conceptualization of their disorder, learning about OCD is itself a significant intervention. Clinicians often observe that patients experience relief simply from understanding that their seemingly bizarre or alarming experiences are recognized symptoms of a well-characterized disorder with effective treatment.

Establishing the exposure hierarchy is a collaborative process. The hierarchy typically begins with situations or stimuli that provoke only mild to moderate anxiety and progresses toward the most feared scenarios. This graduated approach (as opposed to flooding, which begins with the most difficult exposures) is the standard clinical recommendation. While flooding may produce faster results, most patients find a graduated approach more tolerable and are more likely to engage and persist in treatment.

The bulk of therapeutic change occurs outside the session, in the patient's independent practice. If the patient does not conduct exposures between sessions, symptom improvement will be minimal. This reality requires clinicians to invest significantly in building motivation, providing a clear homework structure, troubleshooting obstacles, and monitoring adherence.

The final stage — relapse prevention — is as important as the active treatment phase. Patients need a clear plan for responding when symptoms return, as they often do during periods of stress. A patient who understands that symptom recurrence does not mean treatment failure and who knows how to restart the exposure process independently has a fundamentally different prognosis than one who is discharged without this preparation.

Examples: Fear Learning and Safety Learning

The rationale for ERP rests on two contrasting models of how anxiety changes over time in response to feared triggers.

Image: Fear learning: repeated avoidance of a feared trigger causes the baseline anxiety level to rise over time, as each encounter-and-escape cycle reinforces the threat value of the stimulus.

Image: Safety learning: when feared triggers are faced without avoidance or compulsion, anxiety peaks and then naturally declines; with repeated exposures, each successive peak is lower, reflecting the acquisition of safety information.

When a feared trigger is encountered, and the response is avoidance or compulsion, anxiety spikes and then falls — but incompletely, returning to a baseline somewhat higher than before. Over time, repeated cycles of avoidance produce a gradual escalation of overall anxiety, so that the disorder becomes progressively more impairing. This is fear learning: the nervous system learns that the trigger is genuinely threatening because the person keeps running from it.

Safety learning is the alternative process, and it is the mechanism ERP is designed to cultivate. When a trigger is encountered, and the person does not avoid or engage in compulsion, anxiety spikes and may even increase briefly. But without escape, anxiety reaches its maximum and then declines naturally, following the physiological arc of an anxiety response. The next time the trigger is encountered, the anxiety peak is somewhat lower. Over many repeated exposures, the baseline anxiety associated with the trigger diminishes substantially. The nervous system has learned that the trigger is not genuinely dangerous — that the feared catastrophe did not occur. This is the informational foundation on which recovery is built.

ERP for OCD Hierarchy: Sample Case

The application of the exposure hierarchy is illustrated in the following example from a patient with harm OCD centered on the fear of poisoning a family member.

Image: Sample exposure hierarchy for harm OCD (fear of poisoning): steps progress from low-responsibility food contact (watching others cook) to high-responsibility direct cooking for family members, illustrating graduated exposure from least to most fear-provoking.

At the bottom of this hierarchy — the point of least anxiety — is watching a video of someone else cooking. This presents the feared context (food preparation) with minimal personal responsibility. As they progress upward through the hierarchy, the patient eventually reaches the highest level: cooking for their own family. At this level, the patient is directly responsible for the safety of loved ones — the maximal feared outcome. The hierarchy allows the clinician and patient to incrementally build evidence of safety, with each successful step reducing the overall threat valence of the feared scenario.

A critical clinical consideration is whether to use in-vivo (real-life) or imaginal exposures. In vivo exposures are more ecologically valid and closely replicate real-world conditions. However, some feared scenarios are impractical, impossible, or unethical to replicate in real life. A patient with a fear of harming a loved one cannot be asked to simulate that harm; a patient with a fear of jumping from a window cannot safely practice that fear literally. In these cases — which are common in harm OCD, taboo OCD, and other subtypes — imaginal exposures are used. In an imaginal exposure, the clinician guides the patient to vividly imagine the feared scenario in detail, using all five senses, sometimes incorporating a written script or trance techniques to deepen immersion. Imaginal exposures have several advantages: they can be conducted at any time, varied and extended beyond what real life allows, and adapted to feared scenarios that have no real-world analog. According to the presenter, imaginal exposures comprise the majority of exposures used in clinical practice.

Obstacles to Proper Diagnosis and Treatment

Despite the availability of highly effective treatment, many individuals with OCD go years or decades without receiving it. Multiple overlapping barriers account for this gap (Ziegler et al., 2021).

Stigma is a primary obstacle, especially when symptoms fall into taboo categories. A patient who is terrified that they might harm a child, commit incest, or act on a sexual thought they find abhorrent is profoundly unlikely to disclose that symptom without assurance of a non-judgmental clinical environment. The secrecy this engenders delays both diagnosis and treatment.

Lack of public awareness compounds stigma. Even when individuals suspect that their experiences might be symptoms of a diagnosable condition, they may not have access to accurate information about what OCD looks like, how it is diagnosed, or where to find help. Cultural context is relevant here as well: in communities where seeking mental health treatment is itself stigmatized, individuals may face significant social pressure against disclosure or help-seeking.

Lack of proper training among health professionals is a particularly consequential barrier. Research indicates that primary care physicians are no more likely than untrained laypersons to correctly identify OCD when it presents in their practice. This level of diagnostic miss among front-line healthcare providers means that many individuals who do seek care receive incorrect diagnoses or inappropriate treatment. Clinicians who work with OCD are encouraged to seek out specialty training rather than applying general anxiety treatment protocols, because the clinical presentation and the effective intervention differ meaningfully.

Difficulty finding specialists and financial constraints are interconnected practical barriers. OCD specialists with adequate training are not evenly distributed geographically, often have long waiting lists, typically charge higher fees, and frequently do not accept insurance. These structural factors disproportionately affect individuals with fewer resources, creating inequitable access to effective care.

Summary

OCD is a potentially debilitating mental health condition that affects approximately 2 to 3 million adults and approximately half a million children in the United States (Stein et al., 2025). Despite its severity and prevalence, it is highly treatable. CBT with ERP produces symptom reductions of 60 to 80 percent, making it one of the most effective interventions in all of mental health treatment. SSRIs and parent-based treatments offer additional evidence-based options that expand the range of patients who can benefit. At the same time, numerous barriers — stigma, limited professional training, geographic and financial constraints — prevent many individuals from accessing the care that could substantially relieve their suffering.

The goals of this course have been to provide participants with a foundation in what OCD is: its diagnostic definition, its two primary symptoms (obsessions and compulsions), its range of subtypes, and how it differs from related and superficially similar conditions. Participants have also been introduced to the fundamental stages of ERP, the mechanics of fear learning and safety learning, and the assessment tools used to characterize and track symptom severity. With this foundation, practitioners are better positioned to recognize OCD in their caseloads, to refer appropriately to specialists, and to begin building the specialized clinical skills that effective OCD treatment requires.

For additional resources, the International OCD Foundation (IOCDF) provides extensive educational material, clinician referral directories, and current research summaries at iocdf.org.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Brierley, M. E. E., Thompson, E. M., Albertella, L., & Fontenelle, L. F. (2021). Lifestyle interventions in the treatment of obsessive-compulsive and related disorders: A systematic review. Psychosomatic Medicine, 83(8), 817-833. https://doi.org/10.1097/PSY.0000000000000984

Jalal, B., Chamberlain, S. R., & Sahakian, B. J. (2023). Obsessive-compulsive disorder: Etiology, neuropathology, and cognitive dysfunction. Brain and Behavior, 13(6), e3000. https://doi.org/10.1002/brb3.3000

Lebowitz, E. R., Marin, C., Martino, A., Shimshoni, Y., & Silverman, W. K. (2020). Parent-based treatment as efficacious as cognitive behavioral therapy for childhood anxiety: A randomized noninferiority study of supportive parenting for anxious childhood emotions. Journal of the American Academy of Child & Adolescent Psychiatry, 59(3), 362-372. https://doi.org/10.1016/j.jaac.2019.02.014

Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S. I., King, R. A., Goodman, W. K., & Leckman, J. F. (1997). Children's Yale-Brown Obsessive Compulsive Scale: Reliability and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36(6), 844-852. https://doi.org/10.1097/00004583-199706000-00023

Stein, D. J., Ruscio, A. M., Altwaijri, Y., Chiu, W. T., Sampson, N. A., Aguilar-Gaxiola, S., ... Kessler, R. C. (2025). Obsessive-compulsive disorder in the World Mental Health surveys. BMC Medicine, 23(1), 416.

Steinberg, J. S., Morris, S. H., & Jaffee, S. R. (2025). 'Excessive and unreasonable': The relation between clinical insight and clinical correlates and treatment outcomes in obsessive-compulsive disorder across the life course. Child Psychiatry & Human Development, 56(1), 192-200.

Ziegler, S., Bednasch, K., Baldofski, S., & Rummel-Kluge, C. (2021). Long durations from symptom onset to diagnosis and from diagnosis to treatment in obsessive-compulsive disorder: A retrospective self-report study. PLOS ONE, 16(12), e0261169. https://doi.org/10.1371/journal.pone.0261169

This text-based course is an edited transcript of the webinar, Supporting Queer and Trans Clients in the Current Political Climate: Ethical Dilemmas and Interventions in Trying Times, presented by Giselle Levin, PsyD on October 6, 2025.

Course Overview

This course provides a comprehensive examination of the current sociopolitical landscape affecting queer and transgender clients in the United States. It explores the profound impact of anti-transgender legislation, media rhetoric, and healthcare bans on the mental health and psychosocial functioning of gender-diverse individuals. Through the lens of minority stress theory and clinical case studies, the course outlines specific ethical dilemmas mental health providers face, including issues related to detransition, "Do-It-Yourself" (DIY) hormone therapy, and documentation safety. Ultimately, it provides clinicians with actionable interventions and advocacy strategies to support client resilience and navigate these complex challenges.

Course Information

Giselle Levin, PsyD (they/she/he), is a licensed psychologist in the state of California specializing in transgender healthcare and sex therapy. Giselle completed their doctorate at Pace University in New York, NY, and trained as a postdoctoral resident in LGBT mental health at the San Francisco VA Medical Center. They currently work as a gender specialist at the University of California San Francisco - Child and Adolescent Gender Center. Giselle is a member of UCSF’s Mind the Gap consortium of gender-affirming providers for youth and is in the process of completing their AASECT sex therapy and WPATH transgender healthcare certifications.

Disclosures

• Presenter Disclosure:

  • Financial: Dr. Giselle Levin, PsyD received an honorarium for presenting this course. Giselle Levin has published articles on transgender healthcare, sex therapy, multiple minority stress, and adapting evidence-based interventions for marginalized populations.

  • Non-financial: Giselle Levin has no relevant non-financial relationships to disclose.

• Content Disclosure: This learning event does not focus exclusively on any specific product or service.

• Sponsor Disclosure: There is no external sponsor for this course.

Limitations/Risks

• Practitioners should cultivate cultural humility and cultural competence while committing to respect the diverse ethical and legal obligations associated with different regions and cultures.

• This course is geared toward mental health professionals who already possess fundamental knowledge and skills necessary to work with LGBT individuals.

• Ensure that you have adequate training prior to working with the above populations; consult or refer out as necessary.

• You are ethically required to refer out if you hold significant negative bias toward LGBT individuals.

• Reparative/conversion therapy is unethical and harmful.

Ethics Codes

Below are links to Ethics Codes for some of the major behavioral health professions. Please ensure you always refer to your own ethical code.

• AAMFT: https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx

• ACA: https://www.counseling.org/resources/aca-code-of-ethics.pdf

• APA: https://www.apa.org/ethics/code

• NBCC: https://nbcc.org/assets/ethics/nbcccodeofethics.pdf

• NAADAC: https://www.naadac.org/code-of-ethics

• NASW: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English

Learning Outcomes

After this course, participants will be able to:

• Explain at least three reasons for increased mental health concerns in queer and trans clients, including substance use, depression, suicidality, anxiety, self-harm, and disordered eating.

• Analyze ethical conflicts and considerations when working with queer and trans clients, including youth and their families.

• Identify two interventions that can be used with queer and trans clients to mitigate the impact of minority stress on mental health.

Current Climate

It's Going Down in History...

The current sociopolitical environment in the United States and globally is characterized by a significant intensification of rhetoric and policy directed against transgender and gender-diverse individuals. Providers and clients alike are navigating a period that some historical records may eventually classify as a time of persecution. For example, Wikipedia currently hosts an article titled "Persecution of transgender people under the second Trump administration," highlighting the severity with which these legislative and social shifts are being documented and perceived.

The rhetoric has shifted dangerously from pathologizing transgender individuals as "mentally ill" to framing them as "actively malicious" or as "terrorists." This progression—from stigmatization to dehumanization—is a known trajectory in the persecution of marginalized groups. This dehumanization manifests in several specific ways:

• Removal of Legal Rights: There are active efforts to strip transgender individuals of legal protections and recognition.

• Purge of Trans Government Employees: Reports indicate threats to the careers of transgender individuals working within the federal government and military sectors.

• Restriction on Passports and International Travel: New policies and proposals threaten the ability of transgender people to travel freely and safely.

• Promotion of Trans Healthcare Misinformation: Major news outlets, including those traditionally viewed as progressive, have published articles that question the validity and safety of gender-affirming care, causing confusion even among supportive allies.

• Attempts to Shut Down and Intimidate Providers: Clinics providing gender-affirming care (GAC) face threats to funding and legal intimidation, leading some to close or cease services.

• Portrayal of Trans People as Social Threats: The framing of transgender individuals, particularly trans women, as threats to women and children contributes to a hostile social environment.

Passport Updates

The ability to obtain accurate identification documents is a critical component of safety and social functioning for transgender individuals. Recent executive orders and legal challenges have centered on the inclusion of "biological sex" on passports, threatening to reverse progress made in allowing gender markers that align with an individual's identity (such as "X" markers or allowing self-selection of "M" or "F").

While lower courts have blocked some discriminatory policies, allowing some individuals to successfully update their documents, the threat of reversal remains. For example, a transgender man who passes as cisgender male may have a driver's license with an "M" marker. If his passport were forced to revert to an "F" marker based on birth assignment, international travel would become dangerous. Presenting a passport with a female marker while appearing phenotypically male in countries with strict gender laws or hostile climates could lead to harassment, detainment, or violence.

Furthermore, these restrictions impact families. Parents of transgender children express profound fear regarding travel. A parent of a six-year-old transgender girl, who has socially transitioned and lived as a girl for years, may fear that traveling internationally could result in accusations of child abuse or the removal of the child from their custody if documents do not align with the child's presentation. These fears effectively trap families within the country, limiting their freedom of movement.

State-by-State Map for GAC Youth Bans

The legal landscape regarding gender-affirming care for youth is a patchwork of bans, restrictions, and protections that varies significantly by state. It is crucial for providers to understand that the bans targeting gender-affirming care often prohibit treatments that are deemed medically necessary by every major medical association in the country.

A critical ethical and legal distinction exists regarding these bans: the medications being banned for gender-affirming care are often legal and routinely prescribed for other conditions. For instance, puberty blockers (GnRH analogues) are the standard treatment for precocious puberty (puberty occurring too early). A child with precocious puberty can access these medications with standard parental consent. However, in states with bans, a transgender child seeking the exact same medication to pause puberty for gender-affirming purposes—a fully reversible intervention—is denied access. This highlights the discriminatory nature of the legislation, which targets the identity of the patient rather than the safety of the medication.

Image Caption: As of 2025, over 25 states have enacted bans on best practice medical care for transgender youth, with some states making it a felony crime to provide such care (Movement Advancement Project, 2025).

As illustrated in the map above, the legal status of care is volatile:

• Felony Crime to Provide Care: Enacted in states such as North Dakota, Oklahoma, Idaho, Alabama, South Carolina, and Florida.

• Bans to Provide Care: Enacted in over 20 states including Texas, Utah, Georgia, and North Carolina.

• Protections: States like California, New York, and Minnesota have enacted "shield laws" or remain states where care is legal.

However, legality does not guarantee access. Even in "green" states, clinics may face immense pressure to stop providing care due to funding threats or harassment.

Other GAC Updates

Beyond state laws, other systemic threats are eroding access to care:

• Surgical Centers: Many surgical centers have voluntarily stopped providing care to youth under 19, even in states where it remains legal for those under 18 with parental consent. This age limit is often a reaction to executive orders or fear of litigation rather than clinical guidelines.

• Clinic Closures: Some major medical centers have shut down their gender health programs entirely due to political pressure, effectively abandoning patients who rely on them for hormone management and mental health support.

• Funding Threats: There are ongoing threats that the Centers for Medicare & Medicaid Services (CMS) could withdraw federal funding from hospitals that provide gender-affirming care. Because most major hospitals rely on CMS funding for their general operations, this threat endangers the financial viability of entire medical institutions, forcing them to choose between financial survival and providing specialized care.

Tracking Anti-Trans Legislation

Given the rapid changes in legislation, mental health providers must stay informed about the laws in their specific jurisdiction. Reliable resources for tracking this information include:

• Erin in the Morning: An independent journalist providing an "Anti-Trans Legislative Risk Assessment Map" and frequent updates.

• ACLU: Tracks anti-LGBT bills moving through state legislatures.

• Trans Legislation Tracker: A comprehensive database of bills impacting transgender rights.

Impact on Patients

Increase in DSM-5 Symptoms & Decrease in Psychosocial Functioning

The hostile political climate has a direct and measurable impact on the mental health of queer and transgender clients. Clinicians are observing a rise in clinical symptoms and a decline in psychosocial functioning across the lifespan, from young children to older adults.

Commonly observed symptoms include:

• Depression and Anxiety: Exacerbated by chronic uncertainty and fear.

• Suicidality and Self-Harm: Rates are rising as hope for a safe future diminishes.

• Disordered Eating: Often linked to attempts to control body shape or suppress secondary sex characteristics.

• Somatic Complaints: Many children present with gastrointestinal (GI) issues, often linked to anxiety or avoiding school bathrooms due to safety concerns.

• School Refusal: Children are increasingly refusing to attend school due to bullying and lack of safe facilities.

• Social and Family Conflict: The political climate has polarized families, leading to rejection or conflict where there may previously have been tolerance.

• Decreased Job Performance: The stress of potential job loss (e.g., for military or government employees) impacts professional functioning.

Research supports these clinical observations. A study by Lee et al. (2024) found statistically significant increases in suicide attempts among transgender youth aged 13-17 in the first year after state-level anti-transgender laws were enacted. Furthermore, exposure to news about anti-transgender legislation is associated with higher levels of depression, anxiety, and physiological stress responses (Dhanani & Totton, 2023). Restar et al. (2024) also found that transgender adults living in states with hostile policy environments reported significantly higher symptoms of depression and anxiety compared to those in more protective states.

Understanding Increase in Symptoms

The correlation between the political landscape and mental health symptoms is driven by several factors:

• Reduced Access to Care: Patients fear losing access to hormones or puberty blockers. For a young person who has socially transitioned, the prospect of undergoing an endogenous puberty that contradicts their gender identity is terrifying.

• Bullying and Harassment: School environments have become increasingly hostile, with reports of physical assaults and death threats against queer students becoming more common.

• Job Instability: Transgender individuals in the military or federal sectors face the potential erasure of their careers.

• Media Exposure: Constant exposure to dehumanizing media rhetoric acts as a chronic stressor. While some clients may try to disconnect, many feel a need to monitor the news to assess threats to their safety ("knowing the hunter is out there").

• Fears of Future Discrimination: Anxiety is often future-oriented, focused on the potential for forced detransition, family separation, or the need to flee the country.

Minority Stress Theory

Minority Stress Theory provides a framework for understanding how societal stigma translates into individual mental health outcomes. It posits that marginalized groups face chronic stress distinct from the general population.

Image Caption: The relationship between external stressors and internal psychological processes leading to adverse health outcomes (Testa et al., 2015).

As defined by Testa et al. (2015), the theory divides stressors into:

• Distal Stress Factors (External): These are objective events such as discrimination, rejection, victimization, and non-affirmation of identity.

• Proximal Stress Factors (Internal): These are the internal psychological processes resulting from the distal stressors, including internalized transphobia, expectations of rejection, and concealment of identity.

These factors combine to degrade mental and physical health, leading to higher rates of suicide and chronic illness.

Multiple Minority Stress

Clients often hold multiple marginalized identities, leading to compounded stress (intersectionality). Clinicians must consider the unique experiences of:

• BIPOC Communities: particularly Black, Indigenous, and Latinx transgender individuals who face racism alongside transphobia.

• Immigrant Communities: Undocumented families may fear that seeking gender-affirming care will draw attention to their immigration status.

• Religious Minorities: Jewish and Muslim transgender individuals may face rising antisemitism or Islamophobia in addition to transphobia.

• People with Disabilities: There is a high overlap between neurodivergence (specifically autism) and gender diversity. Attacks on disability rights and healthcare access further marginalize this population.

• Veterans: Those relying on the VA for care face specific anxieties regarding federal policy changes.

Increase in Disordered Eating

Disordered eating in the transgender population is often functionally different from that in cisgender populations. It can be a mechanism to manage gender dysphoria by altering the body. For example, starvation may be used to stop menstruation or reduce breast tissue development, while other behaviors might be used to reduce muscle mass or curves.

Research indicates that gender-affirming hormone therapy (GAHT) is protective against disordered eating. When individuals can access hormones that align their physical body with their gender identity, the need to use maladaptive eating behaviors to control their body often decreases. Conversely, losing access to GAHT may precipitate a relapse into disordered eating. Additionally, logistical barriers, such as the lack of safe bathrooms, can lead to restrictive behaviors (avoiding food and water) to prevent the need to use the restroom during the school or work day.

The Dangers of Conversion Therapy

With the restriction of affirmative care, some political factions promote "conversion" or "reparative" therapy as an alternative. This practice attempts to change a person’s sexual orientation or gender identity.

Data from the 2015 U.S. Transgender Survey highlights the extreme danger of this approach. Youth exposed to conversion therapy had a 55% increase in the risk of attempting suicide compared to those who were not. The risk of running away from home also doubled. These risks were highest for those exposed to the practice at a young age (between 11 and 14) (Campbell & van der Meulen Rodgers, 2023).

Mental health professionals have an ethical mandate to "Do No Harm." Engaging in or referring clients to conversion therapy violates this fundamental ethical principle.

Ethical Dilemmas

The current political climate creates complex ethical dilemmas where legal mandates, client safety, and clinical best practices may conflict.

Can You Support Detransition?

Case Study: Jay Jay is an 80-year-old transfeminine nonbinary veteran who, after a lifetime of suppressing their identity, began estrogen therapy. They experienced great joy in developing a feminine body. However, due to economic factors, Jay lost their housing in San Francisco and had to move to a rural area in Oregon to afford a home. In this new environment, Jay perceived a high threat of transphobia and physical violence. Consequently, Jay decided to stop taking hormones and "detransition" to ensure their physical safety.

Ethical Consideration: Clinicians may struggle with supporting a client in stopping a treatment that clearly benefits their mental health. However, in this case, the detransition is driven by external safety concerns rather than an internal shift in identity. Research indicates that over 82% of individuals who detransition do so because of external factors like family rejection or societal stigma, rather than a realization that they are not transgender.

In this scenario, the clinician’s role is to respect the client's self-determination and safety needs. Supporting Jay involves validating the unfairness of the situation, helping them grieve the loss of their authentic expression, and prioritizing their physical safety and housing stability.

When Clients Choose to Go DIY

Case Study: Jasper Jasper is a 23-year-old trans man who wishes to take testosterone. However, he distrusts the medical establishment, fearing that a formal prescription could be tracked or cut off by future legislation. Instead, he obtains testosterone from an unregulated source ("DIY"). He wants to continue therapy to process the changes but refuses to see a medical provider for the hormones.

Ethical Consideration: This presents a dilemma regarding scope of competence and safety. A therapist cannot prescribe or manage medication. However, refusing to treat Jasper could alienate him from his only source of mental health support.

The recommended approach is harm reduction. Similar to working with a client who uses substances or engages in self-harm, the clinician does not condone the risky behavior but works to minimize danger. This involves:

• Acknowledging the client's valid fears of the medical system.

• Educating the client on the risks of unmonitored hormone use (e.g., polycythemia, liver strain).

• Encouraging any possible safety steps (e.g., "If you won't see a doctor for a prescription, would you consider getting blood work done at a private lab to check your levels?").

• Discussing safe injection practices.

Documentation & Ethics

With the Department of Justice and other entities issuing subpoenas for medical records of transgender patients, documentation has become a safety issue.

Key Questions for Clinicians:

• Diagnosis: Do you include a diagnosis of Gender Dysphoria (F64.0)? While necessary for insurance coverage, it can also serve as a flag in medical records. If a client is paying out of pocket or seeking therapy for unrelated issues (e.g., anxiety), is the diagnosis necessary?

• Names and Pronouns: Do you document the client's chosen name and pronouns in the official chart, or keep them in a separate "shadow" file? Documenting them validates the client but could expose them if records are seized.

• Relationship Status: How are same-sex partners documented?

Intervention: Adopt a consent-forward approach. Have transparent conversations with clients about documentation. Ask: "I want to respect your identity, but I also want to protect your privacy. Here are the risks and benefits of documenting your chosen name in the official record. What do you prefer?"

Should We Delay GAC?

Case Study: Molly Molly is a 16-year-old trans girl who has socially transitioned and is desperate to start estrogen. Her therapist and doctors agree it is medically appropriate. However, her parents, while affirming of her identity, are terrified of the political climate. They want her to wait until she is 18 or until the political situation stabilizes to ensure her safety.

Ethical Consideration: This is a conflict of values: Safety vs. Authenticity. The parents prioritize physical safety; Molly prioritizes the quality of her life and her authentic development.

Intervention: The clinician's role is to facilitate a values-based conversation. For Molly, living as a boy might feel like a fate worse than the risk of discrimination. The therapist can help the family navigate this by validating the parents' fear while highlighting that denying care also carries severe risks (e.g., suicidality, worsening dysphoria). The goal is to help the family find a consensus that respects the adolescent's developing autonomy and the reality of their dysphoria.

Can Therapists Be Political?

Historically, mental health professions encouraged neutrality. However, the current context challenges this stance.

• The Personal is Political: The DSM-5 itself is a sociopolitical document, not just a scientific one. The laws governing practice are political. Conceptions of mental health are shaped by societal values.

• Ethical Obligation: Hope and Puckett (2024) argue that mental health providers are ethically required to engage in advocacy. Silence in the face of legislation that harms clients can be complicit.

• Scope of Advocacy: Advocacy can take many forms, from voting and calling legislators to attending protests or simply creating a safe, affirming space in the therapy room.

Image Caption: Engaging in public advocacy is one form of ethical action for mental health providers (Image: G. Levin).

Recommendations

General Recommendations for Providers

1. Consultation: Do not make decisions in isolation. Consult with legal experts regarding state laws and with colleagues regarding ethical gray areas.

2. Avoid Rash Decisions: Do not preemptively strip all charts of pronouns or cease care based on rumors. Base actions on verified legal and clinical information.

3. Communication: Clearly communicate your stance on privacy and advocacy to your clients. Knowing their therapist is "on their team" is a vital intervention in itself.

4. Advocacy: Engage in advocacy appropriate to your capacity. "Be loud" where you can.

5. Self-Care: Vicarious trauma is real. Find your own sources of resilience and joy.

Building Rapport

• Explicit Allyship: Do not assume clients know you are safe. State clearly that you are committed to LGBT rights.

• Proactive Inquiry: Do not wait for the client to bring up the news. Ask: "I know there has been a lot of heavy news regarding trans rights lately. How is that impacting you?"

• Knowledge: Do not place the burden of education on the client. Stay informed about major legislative updates so the client does not have to explain basic news events to you.

Recommendations for Patients: The Crash Pad

Clinicians can use the metaphor of a "Crash Pad" with clients. If the client feels they are climbing a dangerous cliff (navigating society), they cannot control whether they fall (legislation/discrimination), but they can build a crash pad to catch them.

Components of a Crash Pad:

• Community: Connection with other trans people.

• Supportive Individuals: A trusted cousin, friend, or therapist.

• Affirming Environments: A workplace or hobby group where they are respected.

• Practices: Meditation, exercise, or art that grounds them.

• T4T Relationships: "Trans for Trans" relationships, where partners share a mutual understanding of the gendered experience, can be a profound source of safety and intimacy.

Image Caption: The "Crash Pad" intervention helps clients visualize and strengthen their support network.

Queer/Trans Joy as Resistance

While it is necessary to discuss trauma and safety, it is equally important to center Queer and Trans Joy. Encouraging clients to access joy—through community events, pride celebrations, or personal expression—is a form of resistance against a system that seeks their misery

Recommendations for Parents

Parents often ask how much they should share with their children about the political climate.

• Assess Capacity: Consider the child's age and emotional maturity.

• Assume Knowledge: Children often know more than parents realize through social media and peers.

• The "Need to Know" Approach: A parent can ask, "Do you want to know what is going on in the news, or do you want me to handle it?"

  • Example: A father asked his 12-year-old daughter this question. She replied that she just wanted to be a kid. The father agreed to carry the burden of political awareness and advocacy so she could focus on her childhood. This is a model of protective parenting.

Using a Values-Based Approach

When clients or families feel stuck, a values clarification exercise can be powerful.

Image Caption: Mapping conflicting values helps clients understand their decision-making process in complex situations.

Clinicians can help clients identify their core values (e.g., Authenticity, Safety, Family Harmony) and acknowledge that these values may currently be in conflict. There is no single "right" answer; different clients will prioritize different values (like Jay choosing safety vs. Molly choosing authenticity).

Resources

Providing clients with concrete resources is an essential intervention.

• Relocation and Logistics:

  • Keshet Move to Thrive: Offers interest-free loans for relocation.

  • Project Open Arms: Resettlement project for trans families.

  • Elevated Access: Volunteer pilots providing free transportation to states with legal healthcare access.

• Legal and Support:

  • Trans Family SOS: Guiding families through legal and medical navigation.

  • Trevor Space: Online community for LGBTQ youth.

  • Human Rights Campaign: Emergency funds and resources.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425787

Campbell, T., & van der Meulen Rodgers, Y. (2023). Conversion therapy, suicidality, and running away: An analysis of transgender youth in the US. Journal of Health Economics, 89, 102750. https://doi.org/10.1016/j.jhealeco.2023.102750

Dhanani, L. Y., & Totton, R. R. (2023). Have you heard the news? The effects of exposure to news about recent transgender legislation on transgender youth and young adults. Sexuality Research and Social Policy, 20(4), 1345-1359. https://doi.org/10.1007/s13178-023-00869-7

Hope, D. A., & Puckett, J. A. (2024). Bans on evidence-based care for transgender and gender diverse people present risks for clients and dilemmas for mental health providers. Cognitive and Behavioral Practice, 31(1), 15-19. https://doi.org/10.1016/j.cbpra.2023.08.001

Lee, W. Y., Hobbs, J. N., Hobaica, S., DeChants, J. P., Price, M. N., & Nath, R. (2024). State-level anti-transgender laws increase past-year suicide attempts among transgender and non-binary young people in the USA. Nature Human Behaviour, 8(11), 2096-2106. https://doi.org/10.1038/s41562-024-01928-0

Movement Advancement Project. (2025). Healthcare laws and policies: Bans on best practice medical care for transgender youth [PDF]. Movement Advancement Project. https://www.lgbtmap.org/img/maps/citations-youth-medical-care-bans.pdf

Restar, A., Layland, E. K., Hughes, L., Dusic, E., Lucas, R., Bambilla, A. J., & Kershaw, T. (2024). Antitrans policy environment and depression and anxiety symptoms in transgender and nonbinary adults. JAMA Network Open, 7(8), e2431306. https://doi.org/10.1001/jamanetworkopen.2024.31306

Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65-77. https://doi.org/10.1037/sgd0000081

This text-based course is an edited transcript from a live webinar presented by Christina Marsack-Topolewski, PhD, MSW, LMSW.

Introduction

It is a pleasure to present this comprehensive overview of ADHD and its ethical and practical implications for clinical providers working with women. The number of women diagnosed with Attention-Deficit/Hyperactivity Disorder continues to increase, bringing to light a unique set of challenges and considerations. Women frequently manage a multitude of life responsibilities and demands, which can present significant daily hurdles when coupled with ADHD. Living with ADHD can affect nearly every aspect of life, including one's professional life, financial stability, educational pursuits, the experience of motherhood, and other interpersonal relationships.

Furthermore, for women navigating life with ADHD, these challenges can be compounded by the presence of co-occurring conditions. This article will provide a framework for understanding the distinct complexities and journeys that women with ADHD often encounter. It will also discuss various interventions, strategies, and resources designed to support women with ADHD and their loved ones, acknowledging that the impact of ADHD extends beyond the individual to their entire relational network.

Learning Outcomes

After engaging with this material, participants will be able to:

• Identify the characteristics, signs, and symptoms of ADHD in adulthood that are unique to women.
• Describe co-occurring conditions commonly experienced by women with ADHD.
• Explain practical and evidence-based strategies to support women with ADHD and their loved ones.

Limitations and Risks

Supporting women with ADHD can be complex, and their coinciding needs can be wide-ranging. This discussion will not cover every aspect of these topics. Therefore, continued and additional training and education on this topic are recommended. Treatment and approaches to support individuals with ADHD and other comorbid challenges do not coincide with a one-size-fits-all approach. Practitioners should engage in cultural humility at all times and acknowledge cultural variations in mental health and treatment. Adequate support often requires the use of a multi-disciplinary team to ensure comprehensive treatment.

What is ADHD?

According to the guidelines from the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), the criteria for individuals ages 17 and older include:

“Frequent inattention, seen through at least five of the following, for at least six months, in a way that is inappropriate developmentally”:

• Careless mistakes and lack of close attention to detail
• Difficulty paying attention on tasks
• Does not listen when addressed
• Gets too side-tracked to finish chores or workplace duties
• Loses materials or equipment necessary for tasks
• Forgetfulness in daily living
• Difficulty in organizing tasks
• Easily distracted; daydreaming
• Difficulty or dislike of work that requires sustained mental effort
• Procrastination

(American Psychiatric Association, 2022)

Continued - What is ADHD?

Per the guidelines from the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), the criteria for individuals ages 17 and older also include:

“Frequent hyperactivity and impulsivity, seen through at least five of the following, for at least six months, in a way that is inappropriate developmentally”:

• Fidgeting, squirming, tapping
• Leaves seat when expected to sit
• Running or climbing at inappropriate times, feelings of restlessness
• Inability to play quietly
• Is often “on the go” and/or “driven by a motor”
• Talks excessively
• Blurting out responses
• Trouble waiting for turn
• Interrupting, intruding in conversations

Note: Six or more symptoms of inattention and/or hyperactivity-impulsivity are required for children up to age 16.

(American Psychiatric Association, 2022)

These diagnostic criteria provide a foundational understanding of ADHD. However, it is crucial to recognize that the manifestation of these symptoms can differ significantly between genders, particularly in adulthood. For individuals over the age of 17, the presence of at least five symptoms in either the inattention or hyperactivity-impulsivity domain, persisting for at least six months in a developmentally inappropriate manner, is indicative of ADHD. The impact of these symptoms on daily functioning across multiple settings is also a key diagnostic consideration.

ADHD Symptoms

Other symptoms commonly observed include:

• Poor time management (e.g., trouble multitasking)
• Emotional dysregulation (e.g., frequent/chronic stress, constant state of worry)
• Low frustration tolerance
• Mood swings
• Challenges focusing on a task
• Difficulties coping with stress
• Temper

(Mayo Foundation for Medical Education and Research, 2024)

When considering ADHD symptoms in adulthood, particularly for women, the challenges often extend beyond the core diagnostic criteria. Poor time management, including difficulties with multitasking, can profoundly impact adult life, where demands are often high and varied. Emotional dysregulation, manifesting as frequent stress, constant worry, or mood swings, can significantly affect an individual’s well-being and relationships. A low frustration tolerance can lead to interpersonal difficulties, especially in demanding roles such as parenting. Many women with ADHD report feeling overwhelmed by the daily tasks required to manage a household and career, often leading to internal frustration and self-criticism. The inability to focus on tasks and difficulties in coping with stress further exacerbate these challenges, contributing to a sense of being perpetually behind or unable to meet expectations.

ADHD in Adults

These conditions are required, too:

• Before age 12, must experience several inattentive or hyperactive-impulsive symptoms
• The symptoms must impact the person in at least two settings
• Clear evidence that the symptoms “interfere with or reduce the quality of” the person’s social, school and work activities
• Another mental disorder doesn’t better account for the symptoms

(American Psychiatric Association, 2013)

For an adult diagnosis of ADHD, it is essential to establish a developmental history of symptoms appearing before age 12. This underscores the understanding of ADHD as a neurodevelopmental disorder. Furthermore, the symptoms must be pervasive, affecting the individual in at least two significant settings, such as home, school, work, or social environments. This criterion highlights the functional impairment caused by ADHD, distinguishing it from transient difficulties. The impact must be clearly evident in a reduction of quality in social, academic, or occupational functioning. Finally, it is crucial to rule out other mental disorders that might better explain the symptoms, although co-occurring conditions are common and will be discussed further.

Symptoms may be common in women

• Racing thoughts
• Talking excessively
• Difficulty maintaining relationships
• “A scarred and wounded self-esteem”
• Stigma associated with their condition

(Holthe & Langvik, 2017)

Research indicates that certain ADHD symptoms are more commonly observed in women. These include racing thoughts, which can contribute to anxiety and overwhelm, and talking excessively, which may be a manifestation of internal hyperactivity. Difficulty maintaining relationships is a significant concern, often stemming from challenges with consistency, emotional regulation, or perceived social missteps. Many women with ADHD report a "scarred and wounded self-esteem," resulting from years of struggling with undiagnosed or misunderstood symptoms, leading to feelings of inadequacy or failure. The stigma associated with their condition further compounds these emotional burdens, often leading to shame and a reluctance to seek help or disclose their diagnosis. These gender-specific manifestations are crucial for clinicians to recognize for accurate diagnosis and tailored intervention.

Struggles Associated with Dysexecutive Functioning & ADHD

Visible:

• Running late, not making deadlines
• Presenting as “scattered”
• Outward aggression, frustration

Invisible:

• Self-esteem and self-efficacy implications
• Loneliness and isolation
• Internal frustration
• Anxiety
• Depression

The challenges associated with dysexecutive functioning in ADHD can be categorized into visible and invisible struggles. Visible struggles are those observable by others, such as consistently running late, failing to meet deadlines, appearing disorganized or "scattered," and exhibiting outward aggression or frustration. These external manifestations often lead to negative feedback from colleagues, family members, and friends, reinforcing feelings of inadequacy.

Invisible struggles, though less apparent to others, are deeply impactful. These include significant implications for self-esteem and self-efficacy, as women with ADHD may internalize their difficulties as personal failings rather than symptoms of a neurological condition. This can lead to profound feelings of loneliness and isolation, as the effort to maintain relationships becomes overwhelming or as perceived failures lead to withdrawal. Internal frustration is a constant companion, a silent battle against one's own cognitive processes. Furthermore, anxiety and depression are frequently co-occurring invisible struggles, often stemming from the chronic stress of managing ADHD symptoms and the emotional toll of perceived failures and social misunderstandings. Recognizing both visible and invisible struggles is essential for a holistic understanding of the impact of ADHD on women.

Masking of Symptoms

May mask in the following ways:

• Avoid interrupting others (by being quiet)
• Compensatory strategies to support routines and organization
• Exhibit perfectionistic tendencies
• Mirror what others do (e.g., this is common to other conditions and masking)
• Try very hard to focus and be overly conscientious
• Engage in substance misuse (e.g., this may hide/manage their symptoms in social environments)
• Engage in socially appropriate sports and physical activities – which may also mask symptoms

Masking can diminish the adverse effects of ADHD. Masking can be exhausting.

Masking is a common coping mechanism for women with ADHD, where they consciously or unconsciously hide their symptoms to conform to social expectations or avoid negative judgment. This can manifest in various ways, such as deliberately avoiding interrupting others by remaining quiet, even when they have something to contribute. Many develop elaborate compensatory strategies to maintain routines and organization, which, while effective in presenting a semblance of order, can be incredibly draining. Exhibiting perfectionistic tendencies is another form of masking, as an intense focus on flawless execution can be an attempt to overcompensate for perceived deficits in attention or organization. Mirroring the behaviors of others in social situations is also common, allowing them to blend in and avoid drawing attention to their struggles.

The effort to try very hard to focus and be overly conscientious is a constant internal battle, leading to significant mental fatigue. In some cases, individuals may engage in substance misuse as a maladaptive coping mechanism to hide or manage their symptoms in social environments, seeking to calm racing thoughts or reduce anxiety. Furthermore, engaging in socially appropriate sports and physical activities can also serve as a form of masking, as these activities may provide an outlet for hyperactivity or a structured environment that temporarily alleviates symptoms. While masking can temporarily diminish the adverse effects of ADHD in social or professional settings, it is an incredibly exhausting process that can lead to burnout, increased anxiety, and a profound sense of inauthenticity.

Executive Functioning

Executive functioning refers to a set of cognitive processes that are crucial for controlling behavior and operating effectively in daily life. These functions act as the "orchestra conductor" of the mind, enabling individuals to plan, organize, reason, and problem-solve. For individuals with ADHD, particularly women, challenges in executive functioning can profoundly impact various aspects of their lives.

Consider the intricate process of planning a trip: it involves booking flights, coordinating layovers, checking luggage, navigating security, and arranging accommodation and transportation. For a woman with ADHD, these seemingly straightforward tasks can become overwhelming due to difficulties with planning, sequential thinking, and managing multiple steps. If children are involved, the complexity escalates further, requiring meticulous organization of their belongings, car seats, and schedules. The ability to foresee potential issues, prioritize tasks, and maintain focus throughout such a multi-step process relies heavily on intact executive functions.

When executive functions are impaired, even routine daily activities can become monumental challenges. This can lead to visible struggles, such as missed deadlines and disorganization, and invisible struggles, including low self-esteem, internal frustration, and social isolation. Understanding the specific executive functioning deficits a woman with ADHD experiences is paramount for tailoring effective interventions. The goal is to develop strategies and coping mechanisms that support these cognitive processes, enabling her to navigate daily demands more effectively and enhance her overall quality of life. This includes recognizing and capitalizing on her strengths, as many individuals with ADHD possess remarkable creativity, quick thinking, and the ability to generate novel ideas, which can be leveraged in various settings, particularly in the workplace.

Diagnosis

Women in adulthood are equally likely to be diagnosed with ADHD as men.

• Misdiagnosis
• Underdiagnosis
• Overdiagnosis
• Late-diagnosis (Long & Coats, 2022)

The diagnostic landscape for ADHD presents unique considerations for women. While childhood diagnoses show a significant male-to-female ratio (approximately 3:1, with 75% boys compared to 25% girls), this ratio tends to equalize in adulthood. This suggests a notable pattern of underdiagnosis in girls during childhood, potentially due to masking behaviors, differing symptom presentations, or societal expectations that often lead to girls’ symptoms being overlooked or misattributed. Consequently, many women receive a late diagnosis in adulthood, often after years of struggling with unexplained difficulties and accumulating negative self-perceptions.

The phenomenon of misdiagnosis is also prevalent, as ADHD symptoms in women can overlap with or be mistaken for other conditions like anxiety, depression, or bipolar disorder. Conversely, there is also a concern for overdiagnosis in some contexts. The implications of late diagnosis are significant; women may miss out on early interventions and the development of effective coping strategies, leading to a cumulative impact on their self-esteem, relationships, and professional lives. The elevated demands of adulthood, such as managing careers, households, and families, can make undiagnosed or unmanaged ADHD particularly challenging, with potentially severe consequences like job loss or financial instability. Therefore, increased awareness among clinicians about the unique presentation of ADHD in women is crucial for timely and accurate diagnosis.

Prevalence of ADHD

• Childhood prevalence: 7.8 to 9.5% of children in the United States (Polancyznk et al., 2014)
• Adulthood prevalence: 4.4% of adults in the United States (Kessler et al., 2006)
• Global estimates:

• Persistent adult ADHD (with a childhood onset) = 2.58% or 139.84M in 2020
• Symptomatic adult ADHD (regardless of childhood onset) = 6.76% or 366.33M in 2020 (Song et al., 2021)

The prevalence of ADHD varies across different age groups and global regions. In the United States, childhood prevalence ranges from 7.8% to 9.5%, encompassing both boys and girls. For adults in the United States, the prevalence is estimated at 4.4%. Global estimates provide a broader perspective: persistent adult ADHD, defined as having a childhood onset, was estimated at 2.58% or approximately 139.84 million individuals in 2020. Symptomatic adult ADHD, which includes individuals regardless of childhood onset, showed a higher global prevalence of 6.76%, affecting around 366.33 million people in 2020. These figures underscore the widespread nature of ADHD across the lifespan and globally, emphasizing the importance of understanding its impact on diverse populations, including women. The disparity between childhood and adult prevalence, particularly the equalization of gender ratios in adulthood, highlights the need for continued research and clinical attention to how ADHD manifests and is diagnosed in women.

Propensity of ADHD

• About 2.5% of adults have ADHD (Simon et al., 2009); keep in mind other estimates indicate adults with ADHD comprise 2-4% of the population.
• Men’s and women’s rates of ADHD
• Men’s and women’s rates of risky/impulsive behaviors are similar.
• Women with persistent ADHD tended to be less likely to have hyperactive symptoms and to drive recklessly, but women had more anxiety (Cortese et al., 2016).

While general estimates suggest that about 2.5% to 4% of adults have ADHD, the gender-specific nuances are particularly insightful. As previously noted, the rates of ADHD diagnoses tend to equalize between men and women in adulthood, a significant shift from the childhood prevalence. Interestingly, research indicates that men and women with ADHD exhibit similar rates of risky or impulsive behaviors. However, a study by Cortese and colleagues (2016) found that women with persistent ADHD were less likely to present with overt hyperactive symptoms and were less prone to reckless driving compared to their male counterparts. This subtle difference in symptom presentation further contributes to the underdiagnosis of ADHD in women, as their hyperactivity may manifest more internally as racing thoughts or excessive talking rather than overt physical restlessness. A notable finding from this research is that women with ADHD often experience higher levels of anxiety, which aligns with broader population trends where women are more frequently diagnosed with anxiety disorders. This increased anxiety can complicate the clinical picture, sometimes leading to ADHD symptoms being overshadowed or misattributed to anxiety alone. Understanding these gender-specific propensities is vital for accurate assessment and tailored therapeutic approaches.

Co-Occurring Conditions in Women with ADHD

Co-occurring conditions

Adults with ADHD have a greater likelihood to experience other co-occurring conditions.

• Anxiety
• Autism spectrum disorder
• Depression
• Bipolar disorder
• Substance use disorder

(Micai et al., 2023; Pehlivanidis et al., 2020)

The presence of co-occurring conditions is a significant aspect of ADHD in adulthood, particularly for women. Research consistently demonstrates that adults with ADHD have a substantially higher likelihood of experiencing other mental health conditions. Common co-occurring conditions include anxiety disorders, which often manifest as chronic worry, panic attacks, or generalized anxiety. Autism spectrum disorder (ASD) can also co-occur with ADHD, presenting a complex diagnostic picture where symptoms of both conditions may overlap or exacerbate each other. Depression, including major depressive disorder, is frequently observed, often stemming from the chronic stress, emotional dysregulation, and interpersonal difficulties associated with unmanaged ADHD. Bipolar disorder is another condition that can co-occur, making differential diagnosis and treatment planning particularly challenging due to the fluctuating mood states. Finally, substance use disorders are also more prevalent among adults with ADHD, sometimes used as a maladaptive coping mechanism to self-medicate or manage overwhelming symptoms. Clinicians must be vigilant in screening for these co-occurring conditions to provide comprehensive and integrated care. A recent meta-analysis by Micai et al. (2023) highlighted the elevated risks, noting that adults with ADHD face five times the risk of comorbid anxiety, 4.5 times the risk of major depression, 8.75 times the risk of bipolar disorder, and 4.6 times the risk of substance use disorder compared to individuals without ADHD. This underscores the critical need for a thorough assessment that considers the full spectrum of potential co-occurring challenges.

Many domains of life impacted

ADHD in women can profoundly impact numerous domains of life, often due to the elevated social, employment, financial, relational, and functional demands placed on adults. The expectation to juggle multiple roles and responsibilities can become immensely overwhelming when compounded by ADHD symptoms.

• School and Work Life: Challenges in academic and professional settings are common. This can include difficulties with organization, time management, focus, and meeting deadlines, leading to underperformance, job changes, or unemployment. A study by Biederman et al. (2021) found that adults with ADHD were less likely to be currently employed (52% vs. 72% of peers without ADHD) and experienced more job changes over a decade (5.4 vs. 3.4). They also reported less satisfaction with family, social, and professional lives.
• Social Challenges: Intimate relationships, friendships, and peer interactions can be strained. Difficulties with listening, impulsivity in conversation, or inconsistency in plans can lead to misunderstandings and relationship breakdowns. Morley and Tyrrell (2023) found that female university students diagnosed with ADHD in adulthood reported significant social, academic, and psychological difficulties, including stigmatization and social discrimination.
• Family and Parenting: For women who are mothers, the demands of parenting can be particularly challenging. Managing household tasks, children's schedules, and personal needs while contending with ADHD symptoms can lead to immense frustration and feelings of inadequacy. The constant juggle often results in a feeling of being "at the bare bones" in terms of daily functioning, as one client described it, struggling to keep even basic necessities like milk in the fridge.
• Sleep Quality: Poor sleep hygiene is frequently reported, which further exacerbates ADHD symptoms and negatively impacts overall functioning and well-being.

The cumulative effect of these impacts can significantly diminish a woman's quality of life, highlighting the urgent need for tailored support that addresses the multifaceted nature of ADHD in adult women.

Case Example #1

Married mother of 4 struggles with ADHD (diagnosed in childhood), OCD, and anxiety. Spouse does not “believe in” mental health conditions. A lot of shame surrounding challenges. Mother has developed many coping strategies – still difficult. Balancing work, house obligations, and child rearing is immensely overwhelming.

This case illustrates the profound complexities faced by women with ADHD, particularly when compounded by co-occurring conditions and unsupportive family dynamics. The client, a married mother of four, grapples with a childhood diagnosis of ADHD, alongside obsessive-compulsive disorder (OCD) and profound anxiety. A significant barrier to her well-being is her spouse's disbelief in mental health conditions, which creates an environment of shame and discourages her from seeking or utilizing necessary support, including medication or therapy. Despite having developed numerous coping strategies since her early diagnosis and achieving professional success, the immense demands of balancing work, household obligations, and child-rearing have become overwhelmingly challenging. The added pressures of children's illnesses, childcare issues, or school breaks further intensify her struggles, especially within a traditional household where domestic responsibilities are primarily hers. This scenario highlights the critical need for interventions that not only address the client's symptoms but also navigate complex family systems and societal expectations.

Case Example #2

Female in early 40s, twice exceptional. Has childhood diagnosis of ADHD, anxiety. History of an eating disorder. Recent divorce – now back to the workforce. Recently single (now single mother of 3 children). New work position acquired around the time of her divorce. Struggling with meeting and juggling the multi-faceted needs of work, motherhood, home life, food in fridge. FMLA.

This case exemplifies the compounding stressors that can overwhelm a woman with ADHD, particularly during significant life transitions. The client, a female in her early 40s, is "twice exceptional," indicating both giftedness and a neurodevelopmental diagnosis. She has a childhood diagnosis of ADHD and anxiety, coupled with a history of an eating disorder. Her recent divorce has thrust her back into the full-time workforce after a significant hiatus, adding immense financial and logistical pressure. Now a single mother of three children, she finds herself struggling to meet the multifaceted demands of her new work position, motherhood, and maintaining a functional home life, to the extent that even basic tasks like keeping food in the refrigerator become a struggle. Her anxiety is heightened, and she experiences daydreaming at work, impacting her ability to meet professional demands. The severity of her challenges has led her to explore options like the Family and Medical Leave Act (FMLA) to gain a temporary reprieve and re-stabilize. This case underscores the need for comprehensive, tailored support that considers the interplay of ADHD with past traumas, co-occurring conditions, and current life circumstances, emphasizing the importance of practical strategies and external supports to manage overwhelming daily responsibilities.

Shared Terminology

• Autonomy: Making informed, independent decisions. Having control over own actions, choices, and life.
• Self-determination: The ability to determine what is best for yourself without force or coercion.

In the context of ethical practice, understanding autonomy and self-determination is paramount when working with women with ADHD. Autonomy refers to an individual's capacity to make informed, independent decisions and to have control over their own actions, choices, and life. For women with ADHD, this can be particularly challenging due to the internal and external pressures they face, including societal expectations and the impact of their symptoms on decision-making processes. Clinical providers must work to nurture and foster a therapeutic relationship predicated on respect and empowerment, helping clients to understand their diagnosis and its implications within their multifaceted lives.

Self-determination is closely related, emphasizing an individual's ability to determine what is best for themselves without external force or coercion. In cases where a client's environment, such as a spouse who dismisses mental health conditions, undermines their ability to make choices about their care, clinicians must support the client in finding ways to exercise their self-determination, even if it means adopting more private or "close to the vest" coping strategies. The ethical imperative is to help clients recognize and build upon their strengths, providing hope and a framework that extends beyond the challenges of ADHD, while also acknowledging the gender-specific pressures that women with ADHD often navigate. This involves a delicate balance of validating their experiences, offering practical support, and advocating for their right to make choices that enhance their well-being.

Ethical Considerations & Complexities in Supporting Women with ADHD and their Families

• Balancing viewpoints and perspectives
• Self-determination and autonomy should be at the forefront of all conversations
• Strength-based approach
• Using the client at the forefront of planning and treatment
• Safety is key
• Dreams for now and the future
• What’s realistic and doable?
• Capitalizing on supports
• Using relevant formal supports
• Importance of support from informal support networks
• Robust social networks
• Community (reduction of social isolation and loneliness)
• Changing and evolving needs
• Women with ADHD
• Other supports and their capacity

Supporting women with ADHD and their families involves navigating a complex ethical landscape that requires careful consideration of multiple factors. A primary ethical consideration is the need to balance various viewpoints and perspectives, particularly when family members hold differing beliefs about mental health. The principles of self-determination and autonomy must remain at the forefront of all clinical conversations, ensuring that the woman's right to make informed decisions about her care is respected, even if those decisions diverge from external recommendations.

A strengths-based approach is crucial, focusing on identifying and leveraging the client's inherent abilities and resources. This involves placing the client at the forefront of planning and treatment, ensuring that interventions are tailored to her unique needs and aspirations. Safety is always a key consideration, especially when symptoms or co-occurring conditions might pose risks to the individual or others. Clinicians should also explore the client's dreams for both the present and the future, helping to establish goals that are realistic and doable within her current context.

Capitalizing on both formal and informal supports is vital. Formal supports include professional services, while informal support networks, such as friends, family, and community groups, play a critical role in reducing social isolation and loneliness. It is important to foster robust social networks, recognizing that the give-and-take dynamic of relationships is essential for long-term sustainability. The needs of women with ADHD and their support systems are constantly changing and evolving, requiring clinicians to remain flexible and adaptive in their approach. This includes assessing the capacity of other supports within the family unit to ensure that the burden of care is not unduly placed on any one individual.

Ethics & ADHD in Women

Code of Ethics – Ethical Principles

• Service
• Dignity and Worth of the Person

• Who decides?
• Right to decline treatment and other recommendations

• Importance of Human Relationships

(National Association of Social Workers, 2023)

The ethical principles guiding practice with women with ADHD are deeply rooted in core professional codes of ethics. The principle of Service emphasizes the clinician's commitment to helping people in need and addressing social problems. For women with ADHD, this means providing comprehensive support that extends beyond symptom management to address the broader impacts on their lives, including employment, relationships, and overall well-being.

The principle of Dignity and Worth of the Person is paramount. This involves recognizing and respecting the inherent value of each individual, regardless of their diagnosis. A critical aspect of this principle is acknowledging the client's autonomy and their right to self-determination. This raises questions such as "Who decides?" when it comes to treatment plans and life choices. It firmly establishes the client's right to decline treatment and other recommendations, even if the clinician believes they would be beneficial. This requires a delicate balance of providing informed guidance while respecting personal agency.

Finally, the Importance of Human Relationships underscores the significance of building strong, collaborative relationships with clients and their support networks. This principle recognizes that individuals are interconnected and that interventions are most effective when they consider the broader family and community context. For women with ADHD, fostering robust social networks and ensuring instrumental engagement with others can significantly enhance their quality of life and well-being. This also extends to the clinician-client relationship, which should be built on trust, empathy, and mutual respect.

Ethical Responsibilities to Clients

Social workers respect and promote clients' right to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.

(NASW Code of Ethics, 2023)

(Principle E): Respect for People's Rights and Dignity: Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making.

The ethical responsibility to clients, particularly those with ADHD, centers on upholding their right to self-determination. As outlined in the National Association of Social Workers (NASW) Code of Ethics, social workers are mandated to respect and promote clients' autonomy, actively assisting them in identifying and clarifying their personal goals. This means empowering women with ADHD to make choices about their lives and treatment, even when those choices may differ from professional recommendations. However, this right is not absolute; clinicians may ethically limit self-determination when a client's actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others. This requires careful professional judgment and a clear understanding of the boundaries of intervention.

Similarly, the American Psychological Association (APA) Code of Conduct, under Principle E, emphasizes "Respect for People's Rights and Dignity." Psychologists are expected to respect the inherent dignity and worth of all individuals, along with their rights to privacy, confidentiality, and self-determination. The APA code also acknowledges that special safeguards may be necessary to protect the rights and welfare of vulnerable individuals or communities whose vulnerabilities might impair their autonomous decision-making capacity. This is particularly relevant for women with ADHD, who may experience cognitive or emotional challenges that impact their ability to make fully autonomous decisions at all times. Therefore, clinicians must balance the promotion of self-determination with the responsibility to protect clients from harm, always striving to empower them while ensuring their safety and well-being.

Ethics & ADHD in Women

Code of Ethics – Ethical Responsibilities to Clients

1.02 Self-Determination

The principle of self-determination, as articulated in ethical codes such as the NASW Code of Ethics (Section 1.02), is a cornerstone of responsible clinical practice with women with ADHD. This principle mandates that clinicians respect and actively promote their clients' right to make their own choices and decisions. For women navigating life with ADHD, this means empowering them to identify their own goals and clarify what they want for their lives, rather than imposing external expectations or solutions.

In practice, this translates to collaborative treatment planning where the woman with ADHD is an active participant in setting her therapeutic objectives. It involves providing her with comprehensive information about her diagnosis, potential interventions, and available resources, allowing her to make informed choices. This also means respecting her right to decline certain treatments or recommendations, even if they are medically or clinically advised, provided her decision does not pose a serious, foreseeable, and imminent risk to herself or others. The clinician's role is to support her in exploring the implications of her choices, fostering her capacity for independent decision-making, and building her confidence in managing her condition. This ethical stance ensures that interventions are client-centered and uphold the dignity and autonomy of the individual.

Practical and Evidence-Based Strategies

Treatment Goals

• Ensure the recognition of strengths and use a strengths-based approach
• Start with the basics
• Develop effective strategies and coping mechanisms
• Support facets of life that are impacted
• Help clients move toward better physical and psychological functioning
• Provide support to address multi-faceted impacts of ADHD and other co-occurring conditions
• Seek pathways to elevate strengths and build self-esteem
• Enable clients to live full, meaningful, and rewarding lives

Effective treatment for women with ADHD is guided by several key goals, all centered on empowering the individual and enhancing her overall quality of life. A foundational goal is to ensure the recognition of strengths and consistently employ a strengths-based approach. This involves identifying and building upon the woman's unique talents, resilience, and positive attributes, fostering a sense of self-efficacy and hope.

Another crucial goal is to "start with the basics." This means addressing fundamental areas of functioning that may be impacted by ADHD, such as sleep hygiene, nutrition, and foundational organizational skills. By establishing a solid foundation, clients can build confidence and gradually integrate more complex strategies. The development of effective strategies and coping mechanisms is paramount, equipping women with practical tools to manage their symptoms and navigate daily challenges.

Treatment should also aim to support all facets of life that are impacted by ADHD, including employment, relationships, finances, and parenting. This holistic approach ensures that interventions are comprehensive and address the real-world difficulties clients face. A core objective is to help clients move toward better physical and psychological functioning, promoting overall health and well-being.

Furthermore, it is essential to provide support to address the multifaceted impacts of ADHD and any co-occurring conditions. This often requires an integrated approach that considers the interplay between various diagnoses. Ultimately, treatment goals should seek pathways to elevate strengths and build self-esteem, counteracting the years of negative self-perception that many women with ADHD experience. The overarching aim is to enable clients to live full, meaningful, and rewarding lives, recognizing their inherent worth and potential beyond their diagnosis.

Practical Solutions

• Understand unique needs, realities, and experiences of women and pair supports accordingly
• Help loved ones understand what ADHD is like and daily implications
• Focus on solving problems, being proactive
• Take breaks
• Exercise and physical activity
• Focus on strengths
• Family meetings – to help with communication and routines
• Establish and utilize routines
• Visual and auditory supports
• Maintain a healthy lifestyle
• Financial organization and money management
• Symptom management skills
• Prioritize sleep, self care, and well being
• Consider (when applicable) employment supports

Implementing practical solutions for women with ADHD requires a tailored approach that acknowledges their unique needs and experiences. Firstly, it is crucial to understand the specific realities and challenges women face and to pair supports accordingly. This might involve addressing the societal pressures of juggling multiple roles, such as career, motherhood, and household management.

Educating loved ones about what ADHD is like and its daily implications is vital. This can foster empathy and understanding, reducing blame and promoting a more supportive environment. Encouraging a focus on problem-solving and proactive strategies helps clients move beyond reactive responses to challenges. Incorporating regular breaks, exercise, and physical activity can significantly improve attention, mood, and overall well-being.

A consistent emphasis on strengths is essential, helping women with ADHD recognize and leverage their unique abilities, such as creativity, quick thinking, or hyperfocus in areas of interest. Implementing family meetings can improve communication and establish clear routines, which are highly beneficial for managing ADHD symptoms. Establishing and consistently utilizing routines, supported by visual and auditory aids, can provide much-needed structure and predictability.

Maintaining a healthy lifestyle, including prioritizing sleep, self-care, and overall well-being, is foundational for symptom management. Developing financial organization and money management skills is also critical, as ADHD can often impact financial stability. Specific symptom management skills, tailored to individual needs, should be taught and practiced. Finally, when applicable, exploring and implementing employment supports can help women with ADHD thrive in their professional lives, ensuring reasonable accommodations and strategies for workplace success. These practical solutions, when consistently applied, can significantly enhance a woman's ability to manage ADHD and improve her quality of life.

Consider Dynamics in Couples

NON-ADHD PARTNER:

• Feelings
• Behaviors
• Internal narrative

ADHD PARTNER:

• Feelings
• Behaviors
• Internal narrative

When ADHD is present in one partner, the dynamics within a couple can become particularly complex, impacting both the individual with ADHD and their non-ADHD partner. Understanding the distinct feelings, behaviors, and internal narratives of each partner is crucial for effective intervention.

For the non-ADHD partner, common feelings include anger, frustration, sadness, and disappointment. They may feel overwhelmed by the perceived disorganization, forgetfulness, or impulsivity of their ADHD partner, leading to resentment and a sense of carrying an unequal burden. Their behaviors might include nagging, micromanaging, or withdrawing emotionally. The internal narrative of the non-ADHD partner often revolves around themes of "I have to do everything," "I'm not being heard," or "Why can't they just try harder?" They may struggle to differentiate between intentional neglect and ADHD symptoms, leading to personalizing their partner's challenges.

For the ADHD partner, feelings often include shame, guilt, inadequacy, and frustration. They may feel misunderstood, criticized, or constantly "beaten down" by their partner's reactions. Their behaviors might include procrastination, avoidance, or defensiveness when confronted about symptoms. The internal narrative of the ADHD partner often involves self-criticism, such as "I'm not good enough," "I'm always letting people down," or "I'm trying my hardest, but it's never enough." They may struggle with emotional dysregulation, leading to mood swings or outbursts, which further strain the relationship.

Effective couples therapy for ADHD involves helping both partners understand ADHD as a neurological condition, not a character flaw. It focuses on developing communication strategies, establishing clear expectations, and implementing practical solutions for managing symptoms. The goal is to foster empathy, reduce blame, and create a supportive environment where both partners feel understood and valued, moving towards a more balanced and harmonious relationship dynamic.

Parenting with ADHD

Medications may not last long enough through the day so that moms can both work effectively at the office and do caregiving duties when they get home (Seay, 2022).

In the article, Terry Matlen, an ADHD consultant, recommended moms:

• Help their families understand what ADHD is like
• Focus on solving problems, not blaming
• Take breaks to cool down or re-energize
• Have family meetings and learn how to communicate
• Create routines

Parenting with ADHD presents a unique set of challenges for mothers, often exacerbated by the demanding nature of modern life. One significant issue is the duration of ADHD medication efficacy; many mothers find that their medication wears off before they finish their workday, leaving them unmedicated for the demanding caregiving duties upon returning home (Seay, 2022). This can lead to increased struggles with organization, patience, and executive functioning during critical evening hours.

Terry Matlen, a renowned ADHD consultant, offers valuable recommendations for mothers navigating these complexities. She emphasizes the importance of helping family members, including children and partners, understand what ADHD is like. This fosters empathy and reduces misunderstandings, shifting the focus from blame to collaborative problem-solving. Matlen also advises mothers to prioritize self-care by taking breaks to cool down or re-energize, acknowledging the immense mental and emotional toll of managing ADHD while parenting. Implementing family meetings can be instrumental in improving communication and establishing clear routines, which are vital for creating a predictable and supportive home environment. Routines provide structure that can significantly alleviate the organizational challenges inherent in ADHD, benefiting both the mother and her children. By adopting these strategies, mothers with ADHD can enhance their parenting effectiveness and improve overall family dynamics.

Potential Concerns for Women and their Families

• Shortage of medications and generic medication
• Are ADHD medications harmful? Role of medication
• Organizational challenges
• Listening skills
• Whether medication should be stopped during pregnancy

Several potential concerns can impact women with ADHD and their families, requiring careful consideration and clinical guidance. A significant issue that has emerged is the shortage of ADHD medications, particularly generic versions. This can lead to disruptions in treatment, increased stress, and difficulties in maintaining symptom control, profoundly affecting daily functioning and quality of life.

Another common concern revolves around the safety and role of ADHD medications, especially during sensitive periods like pregnancy. Women often grapple with questions such as "Are ADHD medications harmful?" and "Whether medication should be stopped during pregnancy." These are complex decisions that require thorough discussion with medical professionals, weighing the risks and benefits for both the mother and the developing fetus.

Beyond medication, organizational challenges are a pervasive concern. These can manifest in various aspects of home life, work, and personal management, leading to chronic stress, missed appointments, and a sense of being perpetually overwhelmed. Difficulties with listening skills, a common ADHD symptom, can impact communication within relationships, leading to misunderstandings and frustration for both the woman with ADHD and her family members. Addressing these concerns requires a multi-faceted approach that combines medication management (when appropriate), behavioral strategies, organizational tools, and open communication within the family unit.

Special Considerations for Motherhood while Navigating Life with ADHD

Motherhood, while profoundly rewarding, can be exceptionally challenging for women navigating life with ADHD. The inherent demands of raising children—from managing schedules and household tasks to providing consistent emotional support—can exacerbate ADHD symptoms and create significant stress.

• Organizational Structures, Routines: The need for robust organizational structures and consistent routines becomes paramount. ADHD can make it difficult to establish and maintain these, leading to chaos and overwhelm. Clinicians can help mothers develop practical systems for managing household chores, meal planning, and children's activities, often utilizing visual aids and reminders.
• Visual Supports: Visual supports, such as chore charts, visual schedules, and color-coded organizational systems, can be invaluable tools for both the mother and her children. These external aids reduce the reliance on working memory and executive functions, making daily tasks more manageable.
• Outside Supports: Leveraging outside supports is crucial. This can include formal supports like professional organizers, ADHD coaches, or childcare assistance, as well as informal supports from family, friends, or community groups. Delegating tasks and accepting help can significantly alleviate the burden.
• Divisions of Duties in the Household: Equitable divisions of duties within the household are essential, especially if a partner is present. Open communication about responsibilities, acknowledging the impact of ADHD on certain tasks, can prevent resentment and foster a more collaborative environment. For single mothers with ADHD, this might involve creative solutions for outsourcing tasks or building a strong support network.

Ultimately, supporting mothers with ADHD involves a holistic approach that acknowledges the unique interplay between ADHD symptoms and the demands of parenting, providing tailored strategies to promote both the mother's well-being and a stable, nurturing environment for her children.

Tips for Clinicians Supporting Moms with ADHD

• Support use of routines
• Make problem solving a focus
• Help client avoid blame
• Support efforts to accept the reality of living with ADHD
• Support home structure to benefit all family members, including children

(Agnew-Blais et al., 2022)

Clinicians supporting mothers with ADHD can employ several effective strategies to enhance their clients' well-being and family functioning. Firstly, consistently supporting the use of routines is paramount. Routines provide predictability and structure, which are incredibly beneficial for individuals with ADHD in managing their daily lives and reducing cognitive load. Helping mothers establish and adhere to consistent schedules for themselves and their children can significantly alleviate stress and disorganization.

Secondly, making problem-solving a central focus of therapy is crucial. Instead of dwelling on past mistakes or perceived failures, guide clients to identify specific challenges and collaboratively develop practical, actionable solutions. This empowers mothers to feel more in control and capable of navigating difficulties.

Thirdly, it is vital to help clients avoid blame, both self-blame and external blame. Many mothers with ADHD internalize their struggles as personal failings, leading to shame and guilt. Clinicians can reframe these challenges as symptoms of a neurodevelopmental condition, fostering self-compassion and reducing the emotional burden. Similarly, addressing any blame from family members and facilitating understanding can create a more supportive home environment.

Fourth, supporting efforts to accept the reality of living with ADHD is a significant therapeutic step. Acceptance does not mean resignation but rather a realistic understanding of the condition's impact and a commitment to developing effective coping mechanisms. This can lead to greater self-awareness and a more adaptive approach to daily life.

Finally, clinicians should actively support the development of a home structure that benefits all family members, including children. This might involve strategies for decluttering, creating designated spaces for belongings, and implementing consistent household rules. By creating an organized and predictable home environment, clinicians can help reduce chaos, improve family dynamics, and enhance the overall quality of life for everyone involved. Resources from organizations like CHADD on coaching, organization, time management, and Cognitive Behavioral Therapy (CBT) can be invaluable tools for both clinicians and clients.

Care Techniques

• Awareness
• Medication (stimulants, nonstimulants, off-label use of anti-depressants)
• Cognitive-behavioral therapy, relaxation training, stress management, couples or family therapy
• Job mentoring, job/behavioral coaching in executive functioning skills
• Sleep hygiene
• Focus on strengths
• Digital detox and limits
• Exercise
• The power of…

• Laughter
• Knowledge
• Influence over ADHD

A comprehensive approach to caring for women with ADHD involves a combination of techniques tailored to individual needs. Awareness is the foundational step; understanding ADHD as a neurodevelopmental condition, rather than a character flaw, is crucial for both the individual and their support system.

Medication often plays a significant role in managing ADHD symptoms. This includes stimulants, nonstimulants, and sometimes off-label use of antidepressants, all of which should be carefully considered and managed by a medical professional.

Therapeutic interventions are equally important. Cognitive-behavioral therapy (CBT) helps individuals identify and change negative thought patterns and behaviors associated with ADHD. Relaxation training and stress management techniques equip clients with tools to cope with the chronic stress and emotional dysregulation that often accompany ADHD. Couples or family therapy can address relational dynamics strained by ADHD, fostering better communication and understanding.

For professional life, job mentoring and job/behavioral coaching in executive functioning skills can provide targeted support for workplace challenges, such as time management, organization, and task completion.

Prioritizing sleep hygiene is essential, as poor sleep can exacerbate ADHD symptoms. Strategies to improve sleep quality, such as consistent sleep schedules and a conducive sleep environment, are vital.

A consistent focus on strengths helps to build self-esteem and confidence, allowing women with ADHD to leverage their unique talents and abilities. Implementing digital detox and limits can reduce distractions and improve focus in an increasingly connected world. Regular exercise is a powerful tool for managing symptoms, improving mood, and reducing anxiety.

Finally, recognizing the power of laughter, knowledge, and influence over ADHD can be transformative. Laughter provides emotional release and perspective. Knowledge empowers individuals to understand their condition and advocate for their needs. And fostering a sense of influence over ADHD, rather than being controlled by it, cultivates agency and resilience. These care techniques, when integrated thoughtfully, can significantly improve the quality of life for women with ADHD.

Strategies and Supports

• Balancing expectations, roles, and responsibilities
• Pomodoro technique
• Task decomposition/breaking down of tasks
• Reminders
• Section 504 - Access, Reasonable accommodations

Effective strategies and supports are essential for women with ADHD to navigate their daily lives successfully. A key area of focus is balancing expectations, roles, and responsibilities. Women often face immense pressure to excel in multiple domains, and ADHD can make this balance particularly challenging. Clinicians can help clients identify realistic expectations, prioritize tasks, and delegate responsibilities where possible, fostering a more sustainable lifestyle.

Practical techniques can significantly aid in managing attention and productivity. The Pomodoro Technique, for instance, involves working in focused intervals (e.g., 25 minutes) followed by short breaks, which can help maintain concentration and prevent burnout. Task decomposition, or breaking down large tasks into smaller, more manageable steps, reduces overwhelm and makes daunting projects feel more achievable. Utilizing various reminders, such as digital alarms, sticky notes, or visual cues, can compensate for forgetfulness and aid in task initiation and completion.

In educational and employment settings, understanding and advocating for Section 504 access and reasonable accommodations is crucial. Section 504 of the Rehabilitation Act of 1973 prohibits discrimination based on disability and ensures that individuals with disabilities have equal access to programs and activities. For women with ADHD, this might translate to accommodations such as extended time on assignments, a quiet workspace, flexible scheduling, or access to assistive technology. By implementing these strategies and leveraging available supports, women with ADHD can enhance their executive functioning, improve productivity, and experience greater success and well-being in all aspects of their lives.

Practical Tips for Women with ADHD

• Practice wellness
• Stay active and connected with others
• Connect with others and find community
• Develop a support system
• Check out community resources and events
• Consider being a part of a faith-based community
• Recognize internal signs and symptoms that may co-occur/be associated with ADHD
• Support co-occurring conditions

For women living with ADHD, integrating practical tips into daily life can significantly enhance well-being and symptom management. A fundamental tip is to practice wellness holistically, encompassing physical, mental, and emotional health. This includes prioritizing adequate sleep, nutritious eating, and stress-reduction techniques.

It is crucial to stay active and connected with others. Regular physical activity can help manage hyperactivity and improve focus, while social engagement combats feelings of isolation. Actively seeking to connect with others and find community is vital. This might involve joining support groups, clubs, or shared interest groups where individuals can relate to similar experiences, fostering a sense of belonging and reducing loneliness.

Developing a robust support system—including friends, family, and professionals—provides a safety net and a source of encouragement. Additionally, exploring community resources and events can open doors to new opportunities for learning, social interaction, and practical assistance. For some, considering involvement in a faith-based community can offer spiritual support, a sense of purpose, and a structured social environment.

Finally, it is important to recognize internal signs and symptoms that may co-occur or be associated with ADHD, such as anxiety, depression, or emotional dysregulation. Being attuned to these internal cues allows for proactive management and seeking appropriate support for co-occurring conditions. By integrating these practical tips, women with ADHD can build resilience, enhance their coping skills, and cultivate a more fulfilling and balanced life.

Keep in mind…

Supports can be put in place to manage and alleviate the symptoms of ADHD. In the family and other contexts, striving for interdependence is key. Use the strengths to balance the needs of the total unit.

It is crucial to remember that while ADHD presents significant challenges, effective supports can be implemented to manage and alleviate its symptoms. The goal is not to eliminate ADHD, but to empower individuals to thrive despite its presence. In family and other relational contexts, striving for interdependence is key. This means fostering an environment where individuals can rely on each other's strengths and support each other in areas of weakness, rather than expecting complete self-sufficiency from every member. By recognizing and utilizing the unique strengths of each individual, the needs of the entire unit can be balanced, leading to greater harmony and collective well-being. This collaborative approach ensures that the burden of ADHD is shared, and that everyone contributes to creating a supportive and functional environment.

Remember

There is always something that can be done to help women living with ADHD improve their quality of life (which also helps the overall family quality of life). Consider helping individuals develop routines, strategies, coping mechanisms, and opportunities to build on strengths, augment social supports, and build self-esteem.

It is a fundamental truth that interventions and support can always be provided to help women living with ADHD enhance their quality of life. This improvement extends beyond the individual, positively impacting the overall family quality of life. Clinical providers should focus on empowering these women by assisting them in developing practical routines, effective strategies, and adaptive coping mechanisms. Creating opportunities to build on their inherent strengths is paramount, fostering a sense of self-efficacy and competence. Furthermore, actively working to augment their social supports—both formal and informal—can combat isolation and provide a vital network of assistance and understanding. Ultimately, the consistent effort to build self-esteem is crucial, helping women with ADHD to recognize their inherent worth and capabilities, leading to a more fulfilling and meaningful life.

Additional Information & Resources

DSM-5 Diagnostic Criteria in ADHD

See link for DSM-5-TR diagnostic criteria (pages 2-7): https://www.pbm.va.gov/PBM/AcademicDetailingService/Documents/508/10-1659_ADHD_QRG_P97097.pdf

https://www.aafp.org/dam/AAFP/documents/patient_care/adhd_toolkit/adhd19-assessment-table1.pdf?ref=clarityxdna.com

Resources

Resources for Adults with ADHD (copy and paste links into a new browser window):

• ADHD Fact Sheets (Note: there is a whole section of resources for adults with ADHD and parents)

• https://chadd.org/understanding-adhd/adhd-fact-sheets/

• Attention Deficit Disorder Association (ADDA)

• https://add.org/resources/

• CHADD

• https://chadd.org/for-adults/overview/

• National Institute of Mental Health

• https://www.nimh.nih.gov/health/publications/adhd-listing

Resources - Books

• ADHD & Marriage, where “The ADHD Effect on Marriage” author Melissa Orlov and psychiatrist and author Dr. Ned Hallowell blog about marriages when at least one spouse has ADHD. Hallowell, his wife (Sue Hallowell), and Orlov wrote “Married to Distraction.”
• “Executive Functioning Skills for Adult ADHD: Proven Techniques and Exercises to Learn Time Management, Increase Focus, and Stop Procrastinating,” by Catherina Kaylie
• “FAST MINDS: How to Thrive If You Have ADHD (Or Think You Might),” by Craig Surman, Karen Weintraub, and Tim Bilkey
• “Faster Than Normal: Turbocharge Your Focus, Productivity, and Success with the Secrets of the ADHD Brain” by Peter Shankman, who was diagnosed with ADHD in his 30s
• “Smart But Stuck: Emotions in Teens and Adults with ADHD,” by Thomas E. Brown, PhD
• “Taking Charge of Adult ADHD,” by Russell A. Barkley, PhD
• The New York Times 6 Books for adults living with ADHD (March 24, 2024): https://www.nytimes.com/2024/03/25/well/mind/adult-adhd-books.html

How to Engage in Consistency in Parenting as a Parent with ADHD

Resource: https://www.youtube.com/watch?v=1XvM9WSHgZI

Workplace Accommodations

Video: https://www.youtube.com/watch?v=-Cfatp1gy-8

Employees in the Workplace

Video: https://www.youtube.com/watch?v=_HXV2doQVlM

Supports and Resources - Websites for women with ADHD:

Website: https://www.qbtech.com/blog/top-6-must-visit-websites-for-women-with-adhd/

Books for Women with ADHD:

Website: https://www.additudemag.com/slideshows/adhd-books-for-women/#:~:text="The Queen of Distraction"&text=Written by a psychologist, this,and respected psychologist Sari Solden.

Information regarding Women and ADHD

Website: https://www.understood.org/en/topics/adhd-women

Kaleidoscope Society

Website: https://www.kaleidoscopesociety.com/

Duke Center for Girls & Women with ADHD

Website: https://adhdgirlsandwomen.org/

Verywell Mind

Website: https://www.verywellmind.com/add-symptoms-in-women-20394

ADDitude

Website: https://www.additudemag.com/category/adhd-add/adhd-in-adults/add-women/?srsltid=AfmBOorsazRsrqhshU8sI3xhryVJpBhtfxgnZY18IGNpQ0-g_t58f0yT

ADDA – Attention Deficit Disorder Association

Website: https://add.org/women-with-adhd/

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Pehlivanidis, A., Papanikolaou, Κ., Mantas, V., Kalantzi, E., Korobili, K., Xenaki, L. A., Vassiliou, G., & Papageorgiou, C. (2020). Lifetime co-occurring psychiatric disorders in newly diagnosed adults with attention deficit hyperactivity disorder (ADHD) or/and autism spectrum disorder (ASD). BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-02828-1

Polanczyk, G. V., Willcutt, E. G., Salum, G. A., Kieling, C., & Rohde, L. A. (2014). Psychiatric comorbidities in children and adolescents with ADHD: A meta-analysis of clinical and community samples. European Child & Adolescent Psychiatry, 23(9), 833–848.

Rivas-Vazquez, R. A., Rivas-Vazquez, A. R., & Rivas-Vazquez, A. M. (2023). Masking in ADHD: A systematic review. Journal of Attention Disorders, 27(10), 1083–1094.

Seay, B. (2022, April 14). SuperMom is overrated! ADDitude. https://www.additudemag.com/parenting-moms-with-adhd-advice-help/

Simon, V., Czobor, J., Bálint, S., Mészáros, Á., & Bitter, I. (2009). Prevalence and correlates of adult attention-deficit hyperactivity disorder: A systematic review and meta-analysis. Psychological Medicine, 39(2), 195–208.

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Additional Current References

Baggio, S., da Cunha Gonçalves, L., Heller, P., Wolff, H., & Gétaz, L. (2025). Informed Consent in Vulnerable Populations: The Case of Detained Persons with Attention Deficit Hyperactivity Disorder. Journal of Empirical Research on Human Research Ethics, 1. https://doi-org.ezproxy.uu.edu/10.1177/15562646251340474

Giray, L. (2025). Cases of Using ChatGPT as a Mental Health and Psychological Support Tool. Journal of Consumer Health on the Internet, 29(1), 29–48. https://doi-org.ezproxy.uu.edu/10.1080/15398285.2024.2442374

Harkness, K., Bray, S., Durber, C. M., Dewey, D., & Murias, K. (2025). Assessing the Contribution of Measures of Attention and Executive Function to Diagnosis of ADHD or Autism. Journal of Autism & Developmental Disorders, 55(4), 1353–1364. https://doi-org.ezproxy.uu.edu/10.1007/s10803-024-06275-9

Maffly-Kipp, J., & Morey, L. C. (2025). Detecting Attention Deficit Hyperactivity Disorder and its feigning using the Personality Assessment Inventory. Applied Neuropsychology: Adult, 32(3), 730–739. https://doi-org.ezproxy.uu.edu/10.1080/23279095.2023.2207215

Pehlivanidis, A., Kouklari, E.-C., Kalantzi, E., Korobili, K., Tagkouli, E., & Papanikolaou, K. (2025). Self-reported symptoms of attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and affective lability in discriminating adult ADHD, ASD and their co-occurrence. BMC Psychiatry, 25(1), 1–14. https://doi-org.ezproxy.uu.edu/10.1186/s12888-025-06841-0

This text-based course is an edited transcript of a live webinar presented by Ryan Kirk, PsyD.

This material is for educational purposes and does not replace clinical judgment or local policy.

Risks/Limitations

• This course provides foundational training but does not certify clinicians in EMDR or specialized trauma interventions.
• Clinicians are encouraged to seek further supervised training specific to EMDR protocols and advanced telehealth competencies.
• Due to diverse client populations, cultural competence strategies discussed may require tailored adaptations in unique clinical contexts.
• Participants are advised to consult state-specific telehealth guidelines for complete compliance.

Learning Outcomes

After this course, participants will be able to:

• Identify ethical considerations, diversity, equity, and inclusion (DEI) strategies, and best practices for culturally competent telehealth services.
• Describe strategies for effectively adapting trauma interventions, EMDR, and child and play therapy techniques for telehealth settings.
• Explain methods to establish and maintain human connection and therapeutic rapport during virtual sessions.

Introduction

Telehealth has undergone a profound transformation, particularly since 2020, becoming an indispensable modality in behavioral health. This shift, largely accelerated by global events such as the COVID-19 pandemic, has necessitated that clinicians across various disciplines, including those in primary care and behavioral health, integrate some form of telehealth intervention into their practice. This article aims to explore key insights for mastering telehealth in behavioral health, focusing on ethical guidelines, diversity, equity, and inclusion (DEI) considerations, and the adaptation of clinical interventions. Specific attention will be given to trauma treatments, EMDR, and play therapy, alongside a discussion of various virtual platforms and, crucially, techniques for fostering rapport and human connection in teletherapy.

The growth of telehealth has been exponential, offering unprecedented access to mental health services for individuals who might otherwise face significant barriers. These barriers can include geographical distance, transportation challenges, physical limitations, or privacy concerns. The ability to deliver care remotely has not only expanded the reach of behavioral health professionals but has also introduced a new set of complexities and considerations that demand careful navigation. This article will delve into these aspects, providing a comprehensive overview for clinicians seeking to enhance their telehealth practice.

Telehealth Behavioral Health Case Study

To provide a practical framework for applying the concepts discussed, we will follow a case study involving Daniel, an 8-year-old Latino male. Daniel's primary concern is increased anxiety and behavioral disruptions at school following witnessing domestic violence in his home. He was recently referred by his school counselor due to noticeable anxiety, a decrease in school performance, and aggressive behaviors towards his classmates.

Daniel's mother, Sofia, scheduled a telehealth session due to transportation barriers and privacy concerns that prevented in-person visits. The family resides in a rural community with limited access to mental health services, highlighting the critical role telehealth can play in bridging service gaps. As we proceed through the various sections of this article, we will revisit Daniel's case to illustrate how ethical considerations, DEI strategies, and adapted clinical interventions can be effectively applied in a real-world telehealth scenario.

Ethics Codes

Ethical practice forms the cornerstone of all clinical work, and its importance is amplified in the context of telehealth. Every major behavioral health profession has, to our knowledge, addressed telehealth within its ethics code. Clinicians are strongly advised to consult their specific ethical guidelines to ensure compliance and best practice. Resources for various professional organizations include:

• American Association for Marriage and Family Therapy (AAMFT)
• American Counseling Association (ACA)
• American Psychological Association (APA)
• National Board for Certified Counselors (NBCC)
• National Association of Addiction Professionals (NAADAC)
• National Association of Social Workers (NASW)

Additionally, clinicians must be aware of and adhere to their state-specific laws and administrative rules governing telehealth practice. These guidelines provide the foundational framework for ensuring ethical and responsible service delivery in the virtual environment.

Ethical and DEI Considerations – Brief Review

Ethical practice is foundational, particularly in telehealth. It is paramount to ensure privacy and confidentiality, which encompasses not only the use of secure video platforms but also safeguarding the virtual workspace. Clinicians must clearly communicate informed consent, detailing telehealth-specific risks and limitations. Proper documentation is essential to meet compliance standards and ensure quality care within one's organization or practice.

Diversity, Equity, and Inclusion (DEI) are equally important. Clinicians must be mindful of cultural differences and language barriers, which can be even more challenging to detect in an online platform. Strategies such as culturally sensitive communication and providing resources in the client's preferred language are crucial. Awareness of digital literacy levels is also vital. While some older individuals may need assistance with computer technology, younger generations, though comfortable with cell phones or tablets, may find these devices less ideal for telehealth interventions. The goal is to meet the patient where they are, understanding their typical interaction with technology.

Accessibility challenges related to disability or limited technological resources must also be considered. In Daniel's case, residing in a rural community with limited access to technology underscores the need for tailored approaches. Clinicians must always adapt their approach on a case-by-case basis, even when working with a general population, to ensure that telehealth services are accessible and effective for all clients.

Case Study: Diversity, Equity, and Inclusion (DEI) in Telehealth

Daniel and Sofia represent a diverse cultural and socioeconomic background, making the application of DEI principles in telehealth particularly relevant. Practicing diversity, equity, and inclusion in telehealth necessitates culturally sensitive communication, ensuring that language is both accessible and inclusive. It also requires understanding cultural views on mental health. How do Daniel and his mother generally perceive mental health practitioners or accessing therapy services? This understanding is crucial, as it adds another layer to how they might interact with technology and how these two aspects converge.

Acknowledging barriers to service access, such as their rural location, is vital. Openly addressing any cultural stigma related to counseling can foster greater engagement and trust. Several questions arise when considering cultural considerations in telehealth sessions with Daniel and Sofia. One might consider potential stigma surrounding mental health discussions and familial dynamics. Who is involved in the treatment, and who might wish to be involved? In a brick-and-mortar setting, one might anticipate meeting only the mother and child, but in a digital format, several additional relatives might wish to participate. How does this dynamic translate to a virtual environment?

Culturally appropriate methods of emotional expression also warrant attention. To what extent are nonverbal cues captured on screen? If the clinician is only visible from the shoulders up, how might this limit the observation of whole-body dynamics or nonverbal communication beyond traditional talk therapy? These discussions are essential for ensuring a comprehensive understanding of the client's emotional world.

Socioeconomic factors significantly influence Daniel's engagement and access to telehealth. Internet access limitations, including the speed required to sustain a video conference, and device availability are critical considerations. Clinicians must assess what devices the family possesses and how they interact with the clinician's chosen platforms. Offering practical solutions, such as phone check-ins or leveraging community resources, is paramount if reliable telehealth connectivity becomes an issue. For instance, an organization might set up a room with a computer in a different location within a rural community, allowing clients to access telehealth services even without home internet. This creative problem-solving is vital, while also being mindful of limiting solutions that involve public spaces, such as libraries, where full privacy may not be guaranteed.

Informed Consent and Client Autonomy

Informed consent and client autonomy are fundamental to building a strong therapeutic alliance, whether in traditional or virtual therapy settings. It is imperative for the patient to clearly understand telehealth procedures. This includes detailing the session structure, such as the expectation of using a virtual waiting room or preparing microphones and video before the session begins. Confidentiality measures must be thoroughly explained; patients may not fully grasp the security protocols simply by seeing a portion of the clinician's screen. Transparency about the measures the clinician personally takes to safeguard privacy is invaluable.

Data privacy is another critical aspect. Patients should be informed about whether sessions are recorded (typically they are not without explicit consent) and that data is generally not retained. A thorough discussion of the risks and benefits of telehealth compared to in-person therapy is also essential. If a clinician has reservations about telehealth ultimately benefiting a patient, it is best not to proceed with this modality.

When working with minors, as in play therapy or trauma therapies, obtaining informed consent from parents or legal guardians and assent from the child is crucial. The comprehension level must be appropriate for each developmental stage. For example, when conducting sand tray therapy, the clinician should explain how the virtual experience might differ from an in-person session where direct guidance or coaching is possible.

Best practices for informed consent include providing written documents that clearly detail telehealth-specific concerns, as recommended by APA guidelines. Ample time should be allocated for questions, not just at the intake or the beginning of treatment, but throughout the therapeutic process. This ongoing dialogue allows patients to express their comfort levels and helps gauge whether telehealth remains a suitable fit. Ultimately, ensuring that the client and caregiver clearly understand their rights and roles in telehealth services is paramount.

Confidentiality and Privacy

Confidentiality and privacy are paramount in telehealth. Practitioners must utilize secure, encrypted communication platforms that comply with HIPAA regulations. The era of using platforms like FaceTime for therapy is long past; secure options such as Zoom for business and healthcare, and other specialized platforms, are now standard. A list of hyperlinked resources will be provided at the end of this article, offering various platforms, some specifically designed for interventions like EMDR, bilateral stimulation aids, or group therapy modalities.

It is crucial to clearly communicate potential limitations of confidentiality in telehealth. This includes addressing accidental disclosures if someone enters the client's private space during a session. Clinicians should prepare for scenarios such as a patient attempting to find privacy in a public restroom, as this highlights the need for continuous assessment of the confidentiality of the client's environment. If a client is interrupted, any sensitive discussions should be paused to ensure no one overhears the private conversation. Particular attention must be paid to privacy issues in child and trauma-focused therapies, as sensitive disclosures may raise additional confidentiality concerns.

Best practices involve confirming that the client has a confidential and secure environment, free from disruptions, for each session. This might involve a virtual tour of the space. Regular reminders about the importance and limitations of confidentiality are essential, especially for minors and trauma survivors, ensuring they understand who has access to session content. Just as in traditional therapy, minors must understand that parents will be contacted in certain situations where confidentiality must be breached, clarifying that this does not mean parents will be brought into the video session without the child's knowledge.

Competence and Professional Boundaries

Ensuring professional competence in using telehealth technology and platforms is vital. This includes proficiency in technical troubleshooting and ethical decision-making within a virtual environment. It is advisable to conduct some of this troubleshooting during the initial intake to establish a safe environment, confirm good internet speeds, and ensure the patient is comfortable interacting on screen.

Clinicians must also recognize the limitations of telehealth in accurately assessing nonverbal cues, particularly in child therapy or trauma work, and adjust their practice accordingly. Patients do not need to be so close to the screen that only their head is visible. If an intervention involves bilateral stimulation or "butterfly hugs," a conversation should occur at the outset to determine the best setup for the technology, allowing the patient or parent to arrange it before the session. This proactive approach prevents the patient from feeling pressure to perform correctly while simultaneously discussing sensitive information. The goal is to avoid creating anticipatory anxiety related to the technology.

Maintaining clear professional boundaries in virtual interactions, especially regarding out-of-session communications, is equally important. Best practices include pursuing ongoing training and certification specific to telehealth best practices and ethical standards. For those engaging in specialty interventions, consulting the accrediting bodies or developers of those interventions for telehealth guidance is highly encouraged, as most now offer relevant literature. Establishing clear communication guidelines and protocols for session scheduling, rescheduling, and after-hours contact is also crucial. While the virtual format may make it seem easier for patients to text, email, or call, clinicians must clearly define these limitations, just as they would in standard therapy.

Trauma-Informed Ethical Practices

Applying trauma-informed care principles to telehealth practice is essential, prioritizing safety, transparency, and client empowerment. This guidance, derived from SAMHSA, emphasizes that patients must feel comfortable engaging in this modality, a comfort that may take several sessions to achieve. The aim is to ensure forward progress in the therapeutic journey.

It is crucial to acknowledge that trauma work via telehealth carries a risk of re-traumatization if not carefully managed. Clinicians must consider potential technological breakdowns, lag, or loss of connection during deep meditative states. These possibilities warrant upfront discussions with patients. A backup plan, such as a phone call to continue the session, should always be in place to prevent patients from feeling stranded during critical moments of trauma processing.

Best practices involve utilizing virtual grounding and containment strategies specifically designed for telehealth settings. These adaptations help patients remain grounded during sessions. Regular monitoring for emotional safety is also vital, requiring clinicians to adjust their therapeutic approach to reduce client distress and ensure supportive follow-up care.

Ethical Considerations for Child Therapy and Play Therapy

Child therapy and play therapy in a telehealth format often require significant adaptation. Direct physical interaction, as in traditional in-person sessions, is typically not possible. The primary goal is to maintain therapeutic effectiveness while upholding ethical standards. The Association for Play Therapy, in 2020, released recommendations for such adaptations, which clinicians are encouraged to consult.

Considering developmental appropriateness and age-specific confidentiality is paramount. Working with a 10-year-old differs significantly from working with a 3- or 4-year-old. The role of the parent or caregiver in facilitating the session may also increase, potentially involving more interaction between them and the child than would typically occur in an office setting.

Best practices include selecting age-appropriate virtual play interventions and ensuring caregiver involvement in creating a therapeutic space conducive to online play therapy. Clear communication of expectations and boundaries for both caregivers and child clients regarding interactions within teletherapy sessions is essential. For instance, clinicians might advise parents that while they can assist with setting up the digital format, they should not simply "pop in and out" of the session to maintain child confidentiality. A brief 5-minute start or close with parents, with the middle of the session dedicated solely to the clinician and child, can help maintain this boundary.

Ethics, Diversity, Equity, and Inclusion (DEI)

Ethically sound telehealth practice must actively consider diversity, equity, and inclusion by recognizing the multifaceted barriers clients face. These barriers can include language differences, which may necessitate a translator, similar to in-office settings. Cultural stigma surrounding mental health is another significant factor; clinicians must understand how patients perceive accessing therapy in general, and then layer on how they feel about accessing telehealth specifically. Socioeconomic constraints, such as the cost of devices and internet access, also impact access to telehealth. Clinicians should strive to level the playing field as much as possible, exploring creative approaches such as directing clients to community resources or designated office spaces where technology can be accessed.

Addressing potential implicit biases in telehealth interactions is crucial, as these can influence the therapeutic alliance or clinical judgment. For example, if a clinician expects a patient to maintain direct eye contact with the camera, but the patient's cultural background dictates a more deferential interaction style, the clinician must be well-versed in these nuances. Understanding that this is not a lack of respect but a cultural norm allows for appropriate adjustment of expectations.

Best practices involve actively engaging in cultural humility and seeking education on culturally responsive telehealth strategies. The growing body of research in this area provides valuable insights into interaction strategies for specific populations in telehealth. Providing equitable services is also paramount, which includes accommodating client needs through language assistance, culturally appropriate interventions, and flexible scheduling to address access barriers. This might mean adjusting session times to align with when community resources for technology are available.

Crisis Management and Ethical Decision-Making

Telehealth practitioners must anticipate and proactively prepare for crisis situations during virtual therapy sessions, especially when working with trauma and high-risk client populations. This guidance is reinforced by APA articles from 2017. It is crucial to clarify protocols for managing crises remotely, including suicidal ideation, threats of harm, or disclosures of ongoing abuse. When geographical distance is a factor, safety plans with nearby support systems may need to be established to assist at-risk patients.

Best practices involve creating and clearly communicating telehealth-specific crisis response plans. These plans should include immediate contact numbers, such as suicide hotlines or other interventions typically provided in face-to-face settings. Procedures for emergency intervention must be clearly outlined, including agreements to remain online beyond the scheduled therapeutic hour if necessary, to ensure the patient's safety and stabilization, and potentially arranging for a safe person to join them. Detailed, written crisis protocols outlining exact steps for both the client and clinician to follow in urgent situations are also essential.

Ethics Summary

Ethical practice within telehealth is critical for ensuring the delivery of effective, safe, and culturally responsive behavioral health services. By diligently adhering to established ethical guidelines, behavioral health clinicians can successfully provide trauma-informed care, implement child-focused interventions, and offer diversity-inclusive therapy services remotely. It is imperative for clinicians to engage in continuous professional development through regular training and to maintain familiarity with current ethical codes. This ongoing commitment provides the necessary foundation for sound ethical decision-making within the evolving landscape of telehealth practice.

Case Study: Best Practices and Ethical Considerations in Telehealth

Returning to our case study, as we meet with Daniel and his mother for their initial telehealth appointment, it is critical to integrate ethical guidelines and best practices. The first step involves obtaining clear and specific informed consent from Sofia regarding the nuances of telehealth sessions. This conversation must ensure she thoroughly understands the potential risks, the privacy safeguards we will implement, and the privacy measures she should also take. Additionally, a plan for addressing emergencies or technological interruptions must be established. Utilizing an encrypted, HIPAA-compliant telehealth platform and clearly outlining data security measures will enhance trust in the telehealth process.

To handle informed consent with Daniel's mother and ensure her understanding, a clear, age-appropriate explanation of telehealth, its functionality, and what to expect should be provided. Verification of understanding can be achieved by asking Sofia to paraphrase or recite her understanding of how the telehealth sessions will work, with this consent thoroughly documented.

To confirm confidentiality and data security with Daniel's family, it is essential to clarify that the platform is encrypted and to discuss privacy settings so they understand that session content is not shared with others. The clinician's unwavering commitment to confidentiality should be emphasized. Furthermore, providing a written detailed explanation or a frequently asked questions (FAQ) document can be a valuable resource, particularly if telehealth is a regular component of the clinician's practice.

Telehealth for Trauma Treatment and EMDR

We now turn our attention to Eye Movement Desensitization and Reprocessing (EMDR), specifically examining how this powerful, evidence-based trauma intervention can be adapted for telehealth settings. While early research and interventions for EMDR were primarily conducted face-to-face, telehealth has significantly broadened its accessibility, providing essential trauma treatment to clients who might otherwise face limited access due to geographic, physical, or logistical barriers. Shapiro's 2017 article, referenced at the end of this document, provides valuable insights into this expansion. Successfully translating EMDR to virtual environments necessitates thoughtful modifications, specialized tools, and careful ethical considerations to ensure both effectiveness and client safety.

EMDR Brief Summary

EMDR is an evidence-based therapeutic modality primarily used for addressing trauma and distressing experiences. Developed by Francine Shapiro, EMDR integrates bilateral stimulation, such as guided eye movements across the midsection, to facilitate the brain's natural processing mechanisms. This approach enables clients to reprocess traumatic memories, thereby reducing their emotional intensity and associated distress. EMDR has demonstrated high effectiveness as an evidence-based intervention for post-traumatic stress disorder (PTSD), anxiety disorders, and depression, often leading to a more rapid alleviation of symptoms compared to some traditional therapies. Its incorporation expands the therapeutic toolbox, offering a powerful resource for supporting clients on their healing journey.

How to Obtain Training

EMDR training is typically available to licensed behavioral health professionals, including psychologists, social workers, counselors, marriage and family therapists, and psychiatric nurses. The training process generally involves completing an EMDR International Association (EMDRIA) approved course. These courses consist of intensive workshops that combine didactic learning, live demonstrations, supervised practice, and consultation sessions. Training usually spans several weekends or a week-long intensive program, followed by substantial supervised clinical practice sessions to ensure competency. After initial training, ongoing supervision and consultation are crucial for therapists to refine their skills. Completing this comprehensive training equips clinicians with a robust, evidence-based therapeutic tool that significantly enhances their ability to work with patients experiencing trauma and anxiety.

Virtual Bilateral Stimulation Methods

Bilateral stimulation is at the core of EMDR treatment. Traditionally, this involves eye movements guided by a therapist in person. In telehealth, several virtual methods are utilized. Visual methods may include following a therapist's finger across the webcam or using digital platforms specifically designed for EMDR, some of which feature tools that facilitate back-and-forth eye tracking, such as RemotEMDR or BilateralStimulation.io. These resources are listed in the references section. Another common method involves auditory bilateral stimulation, where clients use headphones to listen to alternating audio tones, facilitated by specialized EMDR platforms. Clinicians may need to provide additional coaching to patients on setting up their virtual environment, including the use of headphones, to achieve this.

Tactile stimulation offers another avenue, involving methods clients can perform themselves, such as alternately tapping on their shoulders or legs, often referred to as a "butterfly hug" technique. All these methods aim to activate bilateral brain activity, which is essential for EMDR processing, while maintaining client comfort and engagement in a virtual format. It is crucial to clearly demonstrate and practice virtual bilateral techniques with clients before starting treatment. This proactive approach prevents the first exposure to these techniques from coinciding with the discussion of a traumatic experience, thereby reducing anticipatory anxiety. The goal is to ensure clients feel comfortable and competent with the technology before engaging in sensitive processing.

These methods have proven effective when clearly demonstrated, practiced, and discussed with clients prior to therapy sessions, as highlighted in Parnell's research. The therapist's role is to select the bilateral stimulation method most suitable for the client's comfort, preference, and technological capabilities.

Telehealth Adapted EMDR Protocol

Adapting the standard EMDR protocol, which typically includes eight phases—history taking, preparation, assessment, desensitization, installation, body scan, closure, and reevaluation—to a teletherapy format requires maintaining fidelity to the original methodology. While adaptations are necessary, the fundamental phases must still be followed, just as they would be with an in-person patient. Telehealth adaptations primarily focus on utilizing secure virtual environments to ensure privacy and compliance with HIPAA regulations. It is crucial to adequately prepare clients for what to expect during remote sessions.

Reinforcing the structure of EMDR virtually and thoroughly explaining each phase is critical. Adjusting the pacing of the session and transparently communicating these adjustments to the patient empowers them with information about the pros and cons of the virtual format. If a patient ultimately decides that an in-person approach is preferable, that wish should be respected.

Remote Resourcing and Stabilization

A critical component of EMDR therapy, especially when addressing severe trauma, is ensuring clients possess effective emotional regulation tools. In telehealth settings, this may involve guiding clients through virtual mindfulness exercises, grounding techniques, or guided imagery. Helping the client create a "calm place" and "safe place" virtually can significantly enhance their resilience. This is particularly important when discussing sensitive, trauma-related issues, as it helps reduce emotional flooding during processing and ultimately reinforces the client's sense of agency.

This process requires regular practice and consistent reinforcement of these resources at the beginning and end of sessions to help clients manage distress. When considering adaptations, it may be necessary to dedicate more time to ensuring the initial starting point or location is quiet and confidential, fostering a calm environment conducive to entering a meditative headspace.

Trauma-Focused Telehealth EMDR

When utilizing EMDR specifically for trauma-focused therapy via telehealth, special attention must be given to remote containment strategies, crisis planning, and any immediate safety measures that might be necessary if the patient experiences emotional flooding during the session. A clear plan must be in place to manage such situations and guide the patient back to a calm state.

During trauma-focused sessions, emotional activation is expected. As clinicians, we must carefully assess a client's readiness and stability before initiating EMDR online. Clear emergency protocols and crisis planning must be firmly established, and clients should be provided with explicit guidelines or frequently asked questions (FAQs) regarding crisis procedures. This might include providing resources such as the National Suicide Hotline (988) and establishing a specific telehealth safety plan to ensure immediate access to crisis interventions if needed.

Virtual EMDR Group Protocols

Virtual EMDR group therapy is an emerging and increasingly beneficial approach, particularly in scenarios involving shared trauma, such as natural disasters, community violence, or supporting healthcare workers during events like the COVID-19 pandemic. Much of the research in this area originated from the need to provide an outlet for highly fatigued and overtaxed healthcare workers to process shared experiences with peers.

Group EMDR protocols necessitate special attention to informed consent regarding confidentiality and group safety. It is crucial to ensure that the virtual environment is private, meaning that individuals in the background of one participant do not have access to the confidential information of other participants. This mirrors the in-person imperative to prevent information from leaving the group. Facilitators must ensure a secure environment, clarify boundaries, roles, and expectations prior to initiation, and continuously reinforce confidentiality, especially given the increased number of linked devices in a group format.

EMDR Telehealth Ethics Reminder, Resources and References

For further guidance on EMDR telehealth ethics, several key resources are available. The EMDR International Association (EMDRIA) provides specific guidelines on virtual EMDR, accessible through their website. Additionally, the American Psychological Association (APA) offers comprehensive telepsychology guidelines that are highly relevant.

In terms of specific EMDR telehealth platforms and tools, several options exist. RemotEMDR is a dedicated online EMDR therapy platform. BilateralStimulation.io offers a free virtual bilateral stimulation tool, and Easy EMDR provides an online platform for visual and auditory bilateral stimulation.

For client safety and crisis resources, the National Suicide Prevention Lifeline (988) offers 24/7 crisis support. The Crisis Text Line provides text-based crisis support by texting HOME to 741741.

Recommended literature for clinicians seeking to deepen their understanding and training in EMDR includes:

• Shapiro, F. (2017). Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures (3rd ed.). Guilford Press.
• Leeds, A. (2016). A Guide to the Standard EMDR Therapy Protocols for Clinicians, Supervisors, and Consultants (2nd ed.). Springer Publishing Company.
• Parnell, L. (2013). Attachment-Focused EMDR: Healing Relational Trauma. W.W. Norton & Company.

These resources provide comprehensive information for those looking to pursue more training or enhance their EMDR practice in a telehealth context.

Case Study: Effective Rapport-Building via Telehealth

Returning to Daniel and Sophia's case, building rapport through telehealth requires very intentional efforts. Sessions can begin with engaging, age-appropriate icebreakers. For instance, asking Daniel about his favorite hobbies or inviting him to a "virtual show and tell" where he can share objects or activities from his home that he wouldn't typically bring to an in-person session can be highly effective. This might include introducing pets, which can be a powerful way to build rapport and bond with the patient.

Consistently maintaining direct eye contact, assuming it is culturally appropriate, involves looking into the camera and modeling how to interact on screen. This clearly demonstrates to Daniel that the clinician is focused and attentive, serving as positive modeling not only for children but also for adults, showing a high comfort level with the technology and a genuine presence.

To modify communication style for building trust and rapport online with a child client, clinicians should adjust their voice tone, utilize visual gestures, and employ expressive facial expressions. Incorporating interactive elements that foster emotional connection is also crucial.

Regarding virtual tools or activities that might engage Daniel effectively, the internet offers numerous possibilities. Shared online games, such as chess, checkers, or word games, can be beneficial, provided they are compatible with a HIPAA-compliant platform. Digital drawing tools and storytelling applications, akin to a journaling practice, can also enhance engagement and make sessions more enjoyable for Daniel.

Case Study: Trauma Therapy via Telehealth

In addressing Daniel's trauma from witnessing domestic violence, a trauma-informed care approach specifically adapted for telehealth is essential, guided by best practice guidelines. Before delving into traumatic memories, it is paramount to ensure Daniel is in a safe, comfortable, and confidential space at home. Virtual grounding exercises should be employed, teaching Daniel breathing or sensory grounding skills to manage distress. This foundational work and coaching, which might be more extensive than in face-to-face therapy, are crucial to ensure that if Daniel becomes overwhelmed by the additional element of technology, he can utilize techniques like deep breathing to regain presence in the session.

To adapt trauma-focused interventions for Daniel via telehealth, clinicians might use visual aids, such as a breathing exercise, and virtual grounding techniques like counting backward from 10. Each step should be clearly demonstrated over video to eliminate any ambiguity, ensuring Daniel does not have to guess how to perform the technique.

Telehealth-specific safety measures must also be considered. Working collaboratively with Sofia, Daniel's mother, to establish a clear safety plan is vital. This plan should ensure Daniel has access to supportive resources and emergency contacts in case of any distress he might experience during sessions, particularly given the potential for traumatic events related to domestic violence to arise.

Adapting Child and Play Therapy for Virtual Care

Child and play therapy necessitate creativity when transitioning to an online format. The integration of engaging, interactive virtual activities that align with the child's developmental stage is crucial. Encouraging caregiver involvement when appropriate facilitates meaningful therapeutic interaction, even in a remote setting. Examples of such activities include guided drawing, where a child might draw their family and describe its members, or a more specific prompt like drawing how they wish to be perceived by peers. Interactive storytelling or bibliotherapy can also be employed, perhaps through shared digital storybooks or collaborative drawing platforms. Virtual sand tray therapy, using digital tools that allow children to select and place symbolic objects, helps externalize internal experiences. Emotion-focused games, virtual puppet therapy, and mindfulness or virtual yoga sessions are also valuable options. Clinicians must guide parents in setting up a conducive therapy space at home to maximize effectiveness and ensure safety, potentially sending FAQs or emails in advance.

Modifying Therapy Techniques for Virtual Sessions

When transitioning play therapy to a virtual platform, careful selection of methods that are engaging, interactive, and developmentally appropriate is essential. Virtual interventions must be clearly structured and easy for the child to follow remotely. The principle of "less is more" often applies; steps should be easily digestible. It is important to anticipate and resolve any technology challenges. If additional interactions involving hyperlinks or navigation to other areas are incorporated, their number should be limited to avoid overwhelming the child or parent. Selecting virtual tools such as digital drawing platforms, online stories, and interactive games can significantly enhance engagement and outcomes, offering age-appropriate alternatives to standard talk therapies.

Integrating Caregivers Effectively

Caregivers, especially for children, play a crucial role in virtual therapy. Their involvement in teleplay therapy sessions is paramount, as virtual therapy takes place within the home environment, making caregiver support central to therapeutic activities. Clinicians can engage parents through phone calls or virtual video calls to outline session intentions and specific timestamps for their involvement. Gil's 2015 article provides good examples of how to prepare and converse with family members or caregivers. For instance, caregivers might set up a safe, comfortable therapy environment, assist with technology setup, and reinforce session activities. In a virtual sand tray therapy scenario, extensive coaching with the parent might enable them to facilitate the physical interaction that would otherwise occur in a face-to-face setting, with the practice extending as homework.

Tele-Play Therapy Examples

Several tele-play therapy examples can be effectively adapted for virtual settings. Guided drawing and expressive arts encourage children to express emotions through interactive drawing tasks. Clinicians might prompt a child to create a safe space or draw their feelings, then discuss these creations to gain insights into their emotional world. Interactive storytelling and bibliotherapy can involve digital storybooks or shared screens, allowing for collaborative drawing or storytelling. Virtual sand tray therapy, utilizing digital platforms, enables children to select and place symbolic objects, helping them externalize internal experiences safely. Emotion-focused games, such as feeling charades or emotion matching, promote emotional identification and expression. Virtual puppet therapy offers a unique dramatic element, leveraging the unseen space to facilitate safe emotional expression through puppets. Finally, mindfulness and virtual yoga, through simple exercises or brief child-friendly sessions, can help reduce anxiety and improve emotional regulation. Clinical judgment is always essential to determine the best fit for the child, their family's comfort, and their overall interaction and growth.

Family and Parent-Child Interactive Teletherapy

Family involvement through structured interactive teletherapy can be a powerful tool, particularly in addressing relationship dynamics. This approach can help strengthen attachment bonds and reinforce session outcomes within the home environment. Various methods can facilitate family interaction on screen, including joint art projects, collaborative storytelling, or structured emotion-sharing tasks. Anything that promotes effective communication and supports family wellness can be beneficial.

Trauma-Focused Approaches and EMDR Adaptations

Shapiro's 2017 article highlights the significant therapeutic value of integrating trauma-informed strategies, such as virtual EMDR or trauma-focused Cognitive Behavioral Therapy (TF-CBT), adapted for telehealth. The article specifically discusses carefully adapted trauma processing techniques, including virtual bilateral stimulation through guided tapping activities or "butterfly hugs," which support children in safely exploring and processing traumatic memories remotely. Clinicians engaging in these trauma-related processing techniques via telehealth are strongly encouraged to consult this article for comprehensive guidance.

Considerations for Diversity, Equity, and Inclusion (DEI)

Adapting child and play therapy techniques virtually also requires careful attention to cultural sensitivity, diversity, equity, and inclusion. It is paramount to ensure that all activities are culturally relevant, inclusive, and sensitive to the family's background. This necessitates an open discussion at the outset of therapy, prompting clinicians to thoughtfully consider the cultural differences that may exist based on the patient in front of them.

Ethical Considerations in Virtual Child Therapy

Several ethical considerations are paramount in virtual child therapy. Confidentiality and privacy are critical, requiring the exclusive use of HIPAA-compliant telehealth platforms. Informed consent is equally crucial; caregivers must be fully informed about telehealth specifics, potential risks, and their responsibilities during sessions. They need to understand the pros and cons of engaging in this format, as convenience alone does not guarantee suitability for their presenting problems or symptoms. Competence is another key ethical pillar; clinicians must continuously develop their skills related to virtual care delivery, ensuring familiarity with technological platforms and the utilization of age-appropriate virtual therapy methods. Finally, safety protocols are essential. Clinicians must have a clear safety plan and established procedures for implementation should a crisis arise during a session.

Adapting Child/Play Therapy to Telehealth Wrap-up

As we conclude this section, it is evident that teleplay therapy offers innovative, accessible, and highly effective avenues for delivering therapeutic services remotely. Clinicians are strongly encouraged to continuously expand their telehealth toolkit through ongoing professional education, consulting with experienced colleagues, and seeking guidance from professional associations that have developed specific guidelines, such as the Association for Play Therapy and the National Child Traumatic Stress Network (NCTSN), which are excellent resources for ongoing training.

For Daniel's case, to facilitate play-based emotional expression, specific virtual interventions could include utilizing virtual sand tray tools, guided storytelling, and drawing platforms. In this scenario, such approaches could encourage Daniel to open up more emotionally and be more willing to explore his experiences, thereby building stronger rapport. To monitor and maintain engagement and emotional safety during virtual child therapy, clinicians should regularly observe Daniel's emotional reactions, frequently check his comfort level, and use rating scales or check-ins and check-outs. This continuous assessment, not just at the start of treatment but at each subsequent visit, helps gauge his comfort and the effectiveness of the therapeutic relationship.

Building Human Connection Virtually

Establishing a strong therapeutic alliance remains paramount in a virtual setting, just as it is in person. This involves building trust and rapport, increasing emotional attunement remotely, and effectively managing any virtual crises. When patients know that their clinician has a plan for managing emergencies, it fosters a sense of security and trust.

Telehealth Best Practices: Key Takeaways

To recap the essential elements for mastering telehealth in behavioral health:

• Quick review of ethical guidelines: Clinicians must regularly consult their specific ethical guidelines and state regulations to ensure compliant and responsible practice.
• Cultural responsiveness in telehealth: Understanding and adapting to diverse cultural backgrounds, language barriers, and digital literacy levels is crucial for providing equitable and effective care.
• Effective virtual therapeutic techniques: Employing creative, engaging, and age-appropriate interventions, especially for trauma and child therapies, is key to maintaining clinical effectiveness in a remote environment.

Ultimately, the aim is to create compassionate, effective, and ethical care remotely. The resources discussed throughout this article, including specific platforms for trauma-based interventions like EMDR and general ethical guidelines from organizations such as the APA, ACA, and NASW, provide invaluable support for clinicians in achieving this goal (NASW, 2021).

Telehealth Course Resources

Copy and paste the links into a new browser window.

Child and Play Therapy via Telehealth

• Virtual Sandtray Therapy: https://www.sandtrayplay.com
• Interactive Storytelling and Bibliotherapy: https://www.storybird.com
• Virtual Puppet Therapy: https://puppetools.com
• Online Playrooms and Interactive Games: https://toytheater.com
• Virtual Mindfulness and Yoga Activities: https://www.cosmickids.com

EMDR and Trauma-focused Telehealth Resources

• EMDR International Association (EMDRIA): https://www.emdria.org
• Virtual EMDR Platform: https://virtualemdr.com
• Trauma-focused Cognitive Behavioral Therapy (TF-CBT): https://www.nctsn.org/interventions/trauma-focused-cognitive-behavioral-therapy
• PTSD Telehealth Toolkit (Veterans Affairs): https://telehealth.va.gov

Telehealth Ethical Guidelines and Resources

• American Psychological Association (APA) Guidelines for Telepsychology: https://www.apa.org/practice/guidelines/telepsychology
• American Counseling Association (ACA) Code of Ethics (Telehealth): https://www.counseling.org
• National Association of Social Workers (NASW) Standards for Technology: https://www.socialworkers.org

References

American Counseling Association. (2014). ACA code of ethics. Retrieved from https://www.counseling.org/Resources/aca-code-of-ethics.pdf

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. Retrieved from https://www.apa.org/ethics/code

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000

American Psychological Association. (2021). Guidelines for the practice of telepsychology. Retrieved from https://www.apa.org/practice/guidelines/telepsychology

Association for Play Therapy. (2020). Play therapy best practices. Retrieved from https://www.a4pt.org/page/PTBestPractices

EMDR International Association. (2020). EMDR therapy and telehealth guidelines. Retrieved from https://www.emdria.org

Gil, E. (2015). Play in family therapy (2nd ed.). Guilford Press.

Landreth, G. L. (2021). Play therapy: The art of the relationship (4th ed.). Routledge.

Leeds, A. (2016). A guide to the standard EMDR therapy protocols for clinicians, supervisors, and consultants (2nd ed.). Springer Publishing Company.

National Association of Social Workers. (2017). NASW standards for technology in social work practice. Retrieved from https://www.socialworkers.org

National Association of Social Workers. (2021). NASW code of ethics. Retrieved from https://www.socialworkers.org/About/Ethics/Code-of-Ethics

National Child Traumatic Stress Network. (2021). Trauma-focused cognitive behavioral therapy. Retrieved from https://www.nctsn.org/interventions/trauma-focused-cognitive-behavioral-therapy

Norwood, C., Moghaddam, N. G., Malins, S., & Sabin‐Farrell, R. (2020). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta‐analysis. Clinical Psychology & Psychotherapy, 27(6), 797–808. https://doi.org/10.1002/cpp.2456

Parnell, L. (2013). Attachment-focused EMDR: Healing relational trauma. W.W. Norton & Company.

Perry, B. D., & Hambrick, E. P. (2008). The neurosequential model of therapeutics. Child Trauma Academy. Retrieved from https://childtrauma.org

Shapiro, F. (2017). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). Guilford Press.

Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Retrieved from https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf

Veterans Affairs Telehealth Services. (2021). PTSD and trauma telehealth toolkit. U.S. Department of Veterans Affairs. Retrieved from https://telehealth.va.gov

Additional Current References

These references were added as additional information on the topic for course participants; the presenter did not use them in developing the course.

Adedoyin, A. C., Wynn, S., Adunlin, G., Adegboyega, A., Holly, H., Makanjuola, D. I., Adedoyin, O. O., Bolaji, O., Olawoyin, E., & Makanjuola, O. E. (2025). Telehealth access inequality for african americans in rural areas: Interventions from an interprofessional education perspective. Journal of Human Behavior in the Social Environment. Advance online publication. https://doi.org/10.1080/10911359.2025.2470901

Choi, S., Hussain, S., Wang, Y., D'Aunno, T., Mijanovich, T., & Neighbors, C. J. (2025). Telehealth disparities in outpatient substance use disorder (sud) treatment among medicaid beneficiaries during covid-19. Substance Use & Misuse. Advance online publication. https://doi.org/10.1080/10826084.2025.2478603

Palfai, T. P., Kratzer, M. P. L., Taylor, J. L., Otis, J. D., & Winter, M. R. (2025). Addressing pain and heavy drinking among patients in hiv-care: A pilot study of an integrated telehealth intervention. AIDS and Behavior. Advance online publication. https://doi.org/10.1007/s10461-025-04660-8

Torres, V. A., Coe, E., Jackson, J., Leonard, K., Rostockyj, J., Swensen, K., Meyer, E., Gulliver, S. B., & Jones, S. (2025). Data‐informed selection of evidence‐based treatments for posttraumatic stress disorder and co‐occurring symptoms. Journal of Traumatic Stress. Advance online publication. https://doi.org/10.1002/jts.23133

Young, J. F., Jones, J. D., Schwartz, K. T. G., So, A., Dysart, G. C., Kanine, R. M., Gillham, J. E., Gallop, R., & Davis, M. (2025). Telehealth-delivered depression prevention: Short-term outcomes from a school-based randomized controlled trial. Journal of Consulting and Clinical Psychology, 93(4), 213–225. https://doi.org/10.1037/ccp0000913

This text-based course format is a transcript of a live webinar that was created by Continued and edited with AI assistance.

Learning Outcomes

After this course, participants will be able to:

1. Describe the characteristics and variance in the manifestation of autism.
2. Identify common co-occurring mental health conditions among individuals with autism.
3. Explain substance use and abuse realities relevant to individuals with autism.

Introduction

As the prevalence and diagnosis of autism spectrum disorder continues to increase, it is relevant to have an understanding of the multi-faceted nature of this condition. Individuals with autism have a high propensity to develop other co-occurring conditions that impact their lives and their overall quality of life. High rates of mental health conditions and substance use disorders have been found among individuals with autism. This course will provide a foundation of autism, discuss common co-occurring conditions, and explore substance use and abuse realities.

Substance Use Disorder

To set the stage for our discussion, it is important to understand Substance Use Disorder (SUD) from a diagnostic perspective. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) provides comprehensive criteria for SUD. It recognizes 10 separate classes of drugs and outlines 11 diagnostic criteria. The DSM-5-TR integrates the historical categories of substance abuse and dependence into a single disorder, Substance Use Disorder, with varying severity levels: mild, moderate, and severe.

The four main categories of criteria for SUD include:

1. Physical dependence
2. Risky use
3. Social problems
4. Impaired control

Examples of the 11 diagnostic criteria include: taking the substance in larger amounts or for longer than intended; not managing to do what one should at work, home, or school because of substance use; and needing more of the substance to achieve the desired effect, indicating tolerance. It is crucial to differentiate whether observed behaviors are primarily due to SUD, autism, or a combination of both, as this has significant implications for accurate diagnosis and tailored intervention.

Overview of Autism

Characteristics, Variance in the Manifestation, and Prevalence

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by specific diagnostic criteria outlined in the DSM-5-TR. It is essential to note that these challenges are not better explained by an intellectual disability or global developmental delay.

Autism Spectrum Disorder Characteristics

The diagnostic criteria for ASD, according to the DSM-5-TR, include:

1. Social communication and social interaction deficits. These encompass challenges in expressive, receptive, and social language, making everyday communication and social nuances particularly confusing.
2. Restricted, repetitive behaviors, interests, or activities. This can manifest in various ways, from repetitive movements to intense, narrow interests, and adherence to routines.
3. Symptoms must be present in the early developmental period. Even if a diagnosis is received later in life, the symptoms must have been evident during early development, though they may have been masked or camouflaged.
4. Impairment in social, occupational, or other domains impacting current functioning. The symptoms must cause significant impairment across multiple contexts, such as school, work, relationships, and other functional areas of life.

The concept of "social camouflaging" or "masking" is particularly relevant. Individuals with autism may learn to blend in or hide their autistic traits in social situations, which can be incredibly exhausting and may lead to delayed or missed diagnoses. This ability to mask can make it difficult for others to recognize the underlying challenges, leading to a lack of appropriate support.

Points of Consideration

Understanding the variance in the manifestation of autism is paramount. As the saying goes, "If you've met one person with autism, you've met one person with autism." This highlights the unique ways ASD can present in individuals, making a one-size-fits-all approach to support and intervention ineffective.

Prevalence

The prevalence of autism has seen a significant increase over the past few decades. According to the Centers for Disease Control and Prevention (CDC), as of April 15, 2025, approximately 1 in 31 children in the United States are diagnosed with ASD. This marks a notable rise from previous estimates, such as 1 in 36 children in 2022 and 1 in 44 prior to that. While data on adults with autism is still developing, emerging literature suggests that the prevalence among adults may be even higher.

Broadening of Diagnostic Criteria, Greater Awareness, Screening in Part, Greater Identification

Several factors contribute to this increasing prevalence. The broadening of diagnostic criteria in the DSM, coupled with greater public awareness and increased screening efforts, has led to greater identification of individuals with ASD. Many individuals who historically went undiagnosed or were misdiagnosed with other conditions, such as depression or anxiety, are now receiving accurate autism diagnoses. Early and accurate diagnosis is crucial for accessing specialized treatment and support. Increased survival rates for preterm babies and various environmental factors also play a role in the rising numbers.

Diagnosis Ratio

Historically, findings exhibit a 3:1 male-to-female ratio, with many studies indicating a 4:1 ratio. However, it is important to consider that females with autism may be more adept at social camouflaging, leading to underdiagnosis in this population.

Autism and Co-Occurring Conditions

The presence of co-occurring conditions, or comorbidities, is a significant aspect of the autistic experience. Individuals with ASD often experience a higher likelihood of developing other mental and physical health challenges compared to the general population.

Common Co-Morbidities

Common co-occurring mental health conditions among individuals with autism include:

• Attention-deficit/Hyperactivity disorder (ADHD)
• Executive functioning challenges
• Anxiety disorders
• Depression
• Eating disorders, such as Anorexia and Avoidant/Restrictive Food Intake Disorder (ARFID). ARFID is a newer eating disorder characterized by highly selective eating or a general lack of interest in food, which can lead to poor growth and nutrition.

It is crucial to note that misdiagnosis with other conditions can be common, highlighting the need for thorough assessment and a nuanced understanding of how ASD presents alongside other challenges.

Possible Reasons for Co-morbidities

Several factors contribute to the high rates of comorbidities in individuals with ASD:

• Social isolation: A significant challenge, with recent reports indicating high rates of loneliness in the general population, which is often amplified for individuals with autism.
• Need to control one's own environment: This can manifest in behaviors resembling obsessive-compulsive disorder or various anxieties.
• Craving social inclusion, but challenges with obtaining it: Many individuals with autism desire social connection but struggle with the nuances of forming and maintaining friendships.
• Sensory challenges: Difficulties processing sensory input (e.g., tactile experiences, smells) can lead to distress and contribute to maladaptive coping mechanisms.
• Challenges across all settings: If daily life feels consistently difficult across work, school, and relationships, the likelihood of developing co-occurring conditions increases.
• Disrupted plans and routines: Unexpected changes can lead to significant distress and emotional dysregulation.

Other Considerations

Beyond mental health conditions, individuals with autism may face additional challenges throughout their lives, from childhood to adulthood, across various settings such as school, work, and relationships. These include:

• Bullying: Individuals with ASD are often targets of bullying due to their social differences.
• Safety issues: They are at an increased risk for abuse, exploitation, and neglect, partly due to challenges with social language, naivety, and trusting nature.

Autism and Substances

Substance Use and Abuse Realities

The intersection of autism and substance use is a critical area of study, revealing unique vulnerabilities and patterns of misuse within the autistic population.

Prevalence of Substance Misuse in Autism

The prevalence of Substance Use Disorder (SUD) in people with Autism Spectrum Disorder (ASD) appears to be higher than once considered. While previous data may have underestimated this, current research suggests a greater extent of use and misuse. Studies indicate a ranging prevalence of substance abuse in samples with ASD, from 1.3% to 36% (Ressel et al., 2020). Some research even suggests a double risk for individuals with ASD to develop an SUD compared to those without autism (Kunreuther, 2021). The variability in prevalence rates can be attributed to differences in sample characteristics and diagnostic measures across studies. It is important to note that assessment measures specifically designed to screen for substance abuse in individuals with ASD are often lacking, leading to limitations in establishing a general prevalence.

Common Substances Used

When data is collected regarding specific types of substances used, the following are commonly reported:

• Tobacco
• Alcohol
• Cannabis

A systematic review by Ressel et al. (2020) highlighted that while these substances are commonly used, studies often report varying rates of associated substance abuse. For instance, rates of alcohol use disorder (AUD) range from 1.3% to 16%, and cannabis use disorder rates are reported between 6.5% and 8% among ASD samples.

Considerations

Individuals with ASD might be less likely to self-report substance misuse, making accurate data collection challenging. Drug use is often reported as a means of self-medication. Studies indicate that individuals with ASD are nine times more likely to use recreational substances to manage behavior and are also more likely to use them to manage mental health symptoms (Weir et al., 2021). This suggests that substance use can be a maladaptive coping mechanism for the unique challenges faced by autistic individuals, such as social difficulties, sensory overload, and emotional dysregulation. The visual of a backpack, for instance, can symbolize the hidden struggles and the search for relief that individuals might undertake, sometimes leading to the exploration of substances. The image of a solitary figure contemplating a landscape can evoke feelings of disconnection, while a group of individuals embracing at sunset can represent the crucial need for community and belonging, especially in the context of recovery.

Risk and Protective Factors

Understanding the specific risk and protective factors for individuals with ASD is crucial, as they may differ from those in the general population.

Risk and Protective Factors for General Population May Differ for Those with ASD

Factors that may be more common among those with ASD and contribute to increased risk include:

• Fewer social resources: This can encompass a lack of belonging, diminished social networks, and lower social capital.
• Less/lack of appropriate support and services: Inadequate access to tailored interventions can exacerbate vulnerabilities.
• Greater likelihood to experience physical and mental health conditions: The high comorbidity rates increase the overall burden on individuals.
• Difficulties with emotional regulation: Challenges in managing emotions can lead to maladaptive coping strategies, including substance use.
• Challenges with behavior management: Difficulties in self-regulation can contribute to impulsive behaviors related to substance use.

The image of a building with the question "HOW ARE YOU, REALLY?" painted on its side powerfully conveys the often-unseen struggles and the importance of truly understanding the internal experiences of individuals, particularly those with ASD who may mask their difficulties.

Risk Factors for SUD in ASD Population

Several factors specifically increase the risk of SUD in the ASD population:

• Comorbid externalizing disorders.
• Perceived social deficits.
• Psychological distress.

While some studies have found these factors to be statistically non-significant in isolation, the cumulative effect and the interplay of these elements are important. High autistic traits have been found in some studies to increase the risk for "high drug use" in adolescent populations with autism. However, conclusions regarding the direct association between substance abuse and autistic traits require cautious interpretation due to variations in study methodologies and sample sizes.

Environmental Risk Factors for Substance Use or Abuse

Ressel et al. (2020) identified six key environmental risk factors that increase the likelihood of developing substance abuse among individuals with ASD and ADHD:

1. Late ASD diagnosis: A delayed diagnosis can mean a prolonged period without appropriate support and understanding, increasing vulnerability.
2. Few social resources: Limited social connections and support networks can lead to isolation and a greater propensity for maladaptive coping.
3. Lack of structure: Unstructured environments can be particularly challenging for individuals with ASD who often thrive on routine and predictability.
4. Family history of SUD: This is a common risk factor across populations, but its impact can be amplified for individuals with ASD.
5. Early smoking onset: Initiating smoking at a young age is a known predictor of future substance use.
6. Family history of adversity: Adverse childhood experiences and other traumatic events within the family environment can significantly increase the risk for SUD.

Other Considerations for Possible Elevated Risk of SUD in ASD

Beyond environmental factors, several individual characteristics contribute to an elevated risk of SUD in individuals with ASD:

• Sensory challenges: Individuals with autism may engage in substance use to mitigate the impact of adverse sensory experiences, such as difficulties processing tactile input, under-responsiveness to sensory input, or challenges with processing smells. The image of headphones on a yellow background can symbolize the need for sensory regulation and the potential use of substances to achieve it.
• ADHD: The comorbidity of ADHD with ASD is common, and the associated challenges with executive functioning can increase vulnerability to SUD.
• Mood and/or anxiety disorders: These co-occurring mental health conditions are frequently self-medicated with substances.
• Individual cognitive characteristics:

• Perceived social deficits: Some individuals with autism report that substance use increases their confidence in social environments and eases communication, leading them to use substances to reduce social anxiety.
• High social motivation: Paradoxically, individuals with ASD who have a high desire for social interaction and high social interest (high reward dependence) may be more prone to SUDs if they struggle to achieve meaningful social connections naturally.
• Psychological distress: High levels of psychological distress are a significant precipitating factor for substance use and abuse in individuals with autism. The blurred image of the word "FOCUS" can represent the cognitive challenges and psychological distress that individuals with ASD may experience, leading them to seek relief through substances.
• Weak executive functioning: Deficits in executive functioning (e.g., planning, reasoning, problem-solving, self-management) can contribute to difficulties with self-management and increase the likelihood of using substances as a maladaptive coping mechanism. The prefrontal cortex, responsible for executive functions, is the last part of the brain to develop, and developmental delays in this area can be particularly challenging for individuals with ASD, especially when compounded by other comorbidities.

Other Vulnerability Factors

Additional factors that increase the risk of substance use among people with autism include:

• Childhood use of drugs: Early initiation of drug use is a strong predictor of future SUD.
• Being coerced or tricked into drug use: Individuals with developmental disabilities may be more susceptible to coercion due to traits such as naivety, trusting nature, and difficulties in discerning intentions. Augmenting skills to reduce this vulnerability is crucial.
• Trauma: Adverse childhood experiences and other traumatic events can significantly increase the risk for SUD. The impact of trauma on individuals with autism can be unique and requires specialized understanding and intervention.

Demographics to Consider

Research on the intersection of disability, opioid misuse, and suicidality provides important demographic considerations. A study by Marsack-Topolewski and Chan (2024) on a sample of people with disabilities (not exclusively autism) revealed:

"Results indicated NMPOU [non-medical prescription opioid misuse] was associated with higher odds for serious thoughts of suicide. Having a disability was associated with higher odds for having a plan for suicide and having a suicide attempt. Adolescents with disabilities who engaged in NMPOU had over three times the likelihood for serious thoughts of suicide. Social work services can be tailored for adolescents with disabilities within the context of the family unit to address the impact of the opioid epidemic using a disability-oriented framework." (Marsack-Topolewski & Chan, p. 1, 2024).

Further analysis using the National Survey for Drug Use and Health (NSDUH) by Chan and Marsack-Topolewski (2023) examined the effect of opioid misuse and disability on serious thoughts of suicide, having a suicide plan, and making a suicide attempt. The findings indicated that NMPOU was associated with 37% higher odds for having a suicide plan and 73% higher odds for having a suicide plan over the last year. Opioid misuse is suggested to be a significant risk factor for suicide, and individuals with disabilities are found to be at greater risk. These studies underscore the critical need for targeted interventions and support for adolescents with disabilities, including those with ASD, who are at heightened risk for both substance misuse and suicidality.

Protective Factors

While the risks are significant, it is equally important to identify and leverage protective factors that can decrease the risk of substance use and abuse among individuals with ASD.

• Individual personality: Traits such as low sensation-seeking tendencies can serve as a protective factor.
• Environmental factors: Limited access to drugs significantly reduces the opportunity for substance use.
• Specialized interventions: Tailored support and treatment approaches can build resilience and reduce vulnerabilities.

However, it is also noted that among a clinical sample of adolescents with ASD, there was a higher prevalence of smoking and over four times the risk of illicit drug use, highlighting the complexities in this population.

Clinical Implications: Assessment, Diagnosis, Treatment

Targeted Screening and Diagnosis

A critical clinical implication is the need for targeted screening and diagnosis for both SUD and mental health conditions, particularly in adolescents with ASD. Current screening methods and tools may not be adequately geared to capture these phenomena in the autistic population, leading to undiagnosed cases. Screening should be provided and meticulously aligned with the unique needs and presentation of individuals with ASD. Many individuals with co-occurring ASD and SUD remain undiagnosed, underscoring the urgency for improved assessment practices.

Treatment (SUD and Mental Health Conditions)

• Targeted prevention: Proactive measures are essential to prevent the onset of SUD in individuals with ASD.
• Tailored approach for treatment: A "one-size-fits-all" approach is ineffective. Cognitive Behavioral Therapy (CBT), when tailored to the needs of individuals with ASD, has shown promising results.
• Group CBT: Studies have indicated that group CBT, specifically designed for patients with ASD and co-occurring SUD, yielded positive outcomes (Walhout et al., 2022). This intervention led to lower levels of alcohol use, less passive coping styles, reduced depression, decreased anxiety, and less stress. Notably, a three-month follow-up after the group intervention showed even stronger effects, suggesting the benefit of sustained support. This highlights the potential for specialized and tailored interventions to be highly efficacious for this specific population.

Considerations for Substance-Use Services

Substance use services must be designed to account for the unique needs of individuals with ASD and their co-occurring substance use challenges. Many individuals with ASD who seek substance use services also experience high rates of anxiety (87%), depression (75%), and ADHD, with chronic pain also being commonly reported (Munday et al., 2025). The reasons for substance use vary, often including self-medication for anxiety, depression, sensory challenges, or to enhance social confidence and communication.

Therefore, there is a clear need for personalized, inclusive, and neuro-affirming care. This involves:

• Trauma-informed approaches: Recognizing and addressing the impact of past traumas, which are prevalent in the ASD population.
• Neuro-affirming environments: Providing quiet spaces free of sensory stressors, which can be highly beneficial for individuals with sensory sensitivities.
• Individualized and tailored communication: Adapting communication styles to suit the specific needs of the individual, recognizing that social masking can be exhausting and may hide underlying difficulties.
• Understanding social masking: Professionals must be aware that individuals with ASD may acutely blend in or mask their characteristics in social situations, leading to exhaustion and withdrawal afterward. This masking can contribute to delayed diagnoses and a lack of understanding of their true needs.
• Managing co-occurring conditions: Treatment plans must integrate support for all co-occurring mental and physical health conditions, as they are often intertwined with substance use.

Studies by Marsack-Topolewski and Weiss (2020) and Munday et al. (2025) have highlighted significant access issues and barriers to substance use services for adults with autism, including challenges related to accommodation, acceptability, availability, and affordability. These findings underscore the importance of professional development for practitioners in substance use supportive spaces to ensure that services are trauma-informed, neuro-affirming, tailored, and specific to individuals with ASD who are dealing with SUDs.

Complexities in Supporting Care Recipients, their Families, and Providers

Supporting individuals with ASD who are experiencing substance misuse challenges involves navigating significant complexities, balancing multiple viewpoints and perspectives. This includes:

• Balancing viewpoints and perspectives: Ensuring that all voices are heard, including those of the person with SUD, their family, and care providers.
• Safety is key: Prioritizing the safety and well-being of the individual throughout the treatment and recovery process.
• Dreams for now and the future: Helping individuals and their families envision realistic and achievable goals for their present and future.
• Limited supports: Acknowledging that formal and informal supports can be limited due to factors such as waitlists and costs. Leveraging relevant formal supports and emphasizing the importance of robust informal support networks and community engagement (to reduce social isolation and loneliness) is crucial.
• Changing and evolving needs: Recognizing that the needs of the person with SUD, as well as paid and unpaid care providers, will change over time, requiring flexible and adaptive support strategies.

Multi-pronged Approach

Moving forward, a multi-pronged approach is necessary to address the complex interplay of autism, co-occurring challenges, and substance misuse. Key areas of focus include:

• Awareness: Increasing understanding among the general public, healthcare professionals, educators, and families about the unique vulnerabilities and needs of individuals with ASD regarding substance use.
• Prevention: Developing and implementing targeted prevention strategies that consider the specific risk factors and protective factors for the autistic population.
• Treatment: Enhancing access to and the quality of specialized, neuro-affirming treatment options for SUDs in individuals with ASD. This includes leveraging interventions like group CBT and ensuring services are trauma-informed and individualized.
• Support for the person with SUD: Providing comprehensive support that addresses not only substance use but also underlying mental health conditions, sensory challenges, and social difficulties.
• Support for family and caregivers: Recognizing the vital role of families and caregivers and providing them with resources, education, and emotional support.
• Professional development: Ensuring that professionals across various disciplines receive ongoing training and education to understand the intricate relationships among autism, co-occurring challenges, and substance misuse.
• Understanding the relationship: Continuing research to deepen our understanding of these complex interconnections to inform evidence-based practices.

The image depicting Naloxone (Narcan) nasal spray and Zimhi (naloxone HCl injection) serves as a stark reminder of the opioid crisis and the importance of overdose prevention and response, highlighting a critical aspect of substance misuse realities.

Treatment and Services

Effective treatment and services for individuals with ASD and SUD require a comprehensive and integrated approach. Key components include:

• Hotline support: Providing immediate access to crisis lines and helplines for guidance and support.
• Recovery support: Offering ongoing support systems to aid in long-term recovery, including peer support groups and community-based programs.
• Treatment options: Ensuring a range of evidence-based treatment modalities are available, tailored to the individual's needs and preferences.
• Education, advocacy, community, family support: Empowering individuals and their families through education, advocating for their rights and needs, fostering a sense of community, and strengthening family support systems.

Treatment Directions

The direction of treatment should prioritize personalized, inclusive, and neuro-affirming care, recognizing the unique presentation of ASD and its comorbidities.

Supporting Clients in Building and Maintaining Relationships

Community and social connection are often missing pieces for individuals with ASD, yet they are vital for well-being and recovery. Supporting clients in building and maintaining relationships involves:

• Connecting with local support groups (e.g., through SAMHSA's Find Support services).
• Seeking out local activities, events, and faith communities that align with their interests.
• Connecting with online informational groups for peer support and shared experiences.
• Making time for existing friendships and relationships.
• Reinforcing the message: "Remember – you are not alone!"

The image of multiple hands reaching out to touch a tree trunk powerfully symbolizes the importance of connection, support, and the collective strength found in community.

Remind and Help Clients and Consumers Know that They are Not Alone

Emphasizing that individuals are not alone in their struggles is a powerful message that can foster hope and encourage help-seeking behaviors. Resources such as SAMHSA's support group locator and information on group therapy for substance abuse can be invaluable tools for clients and their families.

Resources

A wealth of organizational resources is available to support individuals, families, and professionals in addressing autism, mental health, and substance misuse.

Organizational Resources – Opioid Prevention and Misuse

• Centers for Disease Control (CDC) Opioid Overdose: Offers an overdose prevention and response toolkit.
• CDC – Overdose Prevention Resources: Provides a variety of communication resources for overdose prevention.
• CDC – Health Care Provider Toolkits: Includes toolkits specifically for healthcare providers, such as the Naloxone Toolkit.
• Rural Community Toolbox: A valuable resource for rural communities, particularly concerning opioid prevention and misuse.
• SAMHSA Opioid Prevention Toolkit: Another comprehensive toolkit for overdose prevention and response.
• State of Michigan Opioid Resources: Provides diverse resources, including access to the "Michigan Safer Opioid Prescribing Toolkit."
• Wyoming Prevention Depot: Offers resources on opioid risk and protective factors.
• National Helplines: Many states offer helplines, in addition to the national helpline: 1-800-662-4357.

Organizational Resources – Support

• Mental Health America: A leading community-based nonprofit dedicated to addressing the needs of those living with mental illness.
• NAADAC: The Association for Addiction Professionals: Provides education, clinical training, and advocacy for addiction professionals.
• National Institute on Alcohol Abuse and Alcoholism (NIAAA): Offers publications and resources on treatment for alcohol problems.
• National Institute on Drug Abuse (NIDA): Provides scientific information on drug abuse and addiction.
• National Institute on Mental Health (NIMH): The lead federal agency for research on mental disorders.

Resources

• SAMHSA Buprenorphine Practitioner Locator: Helps locate practitioners who can provide buprenorphine for opioid use disorder.
• SAMHSA Find Help: A comprehensive tool to find treatment services.
• SAMHSA Opioid Treatment Program Directory: Provides a directory of opioid treatment programs.

Organizational Resources

Note - Links are subject to change.

• Substance Abuse and Mental Health Services Administration (SAMHSA):
• Website: https://www.samhsa.gov/
• SAMHSA’s National Hotline: 1-800-662-HELP (4357)
• Substance Abuse and Mental Health Services Administration (SAMHSA) – Find Treatment:
• Website: https://findtreatment.gov/

Supports

• 988 Lifeline:
  • 988 Suicide & Crisis Lifeline Website: https://988lifeline.org/
• National Helpline:
  • Treatment referral and information, 24/7
  • Website: https://findtreatment.gov/
  • 1-800-662-HELP

Online resources are available for practitioners working with specific populations, such as the Deaf and hard of hearing, to ensure that information and support are accessible and aligned with their unique needs.

Limitations and Risks

Substance use and abuse are complex and the coinciding needs for individuals with autism can be wide ranging. This webinar will not cover every aspect of these topics. Therefore, continued and additional training and education on this topic are recommended. Treatment and approaches to support individuals with autism experiencing substance misuse challenges do not coincide with a one-size-fits-all approach. Practitioners should engage in cultural humility at all times and acknowledge cultural variations regarding substance use and abuse, as well as treatment. Adequate support often require a multi-disciplinary team to ensure comprehensive treatment.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Anderson, S. A. R., & Catallozzi, M. (2021). Autism spectrum disorder and the risk of substance use disorder: A call for targeted screening and prevention in adolescents. JAMA Pediatrics, 175(2), e205376. https://doi.org/10.1001/jamapediatrics.2020.5376

Barber, W., Aslan, B., Meynen, T., Marsden, J., Chamberlain, S. R., Paleri, V., & Sinclair, J. M. A. (2025). Alcohol use among populations with autism spectrum disorder: narrative systematic review. BJPsych Open, 11(1), 1–15. https://doi-org.ezproxy.uu.edu/10.1192/bjo.2024.824

Beck, J. S., Lundwall, R. A., Gabrielsen, T., Cox, J. C., & South, M. (2020). Looking good but feeling bad: “Camouflaging” behaviors and mental health in women with autistic traits. Autism, 24(4), 809–821. https://doi.org/10.1177/1362361320912147

Brede, J., Babb, C., Jones, C., Elliott, M., Zanker, C., Tchanturia, K., ... & Mandy, W. (2020). “For me, the anorexia is just a symptom, and the cause is the autism”: Investigating restrictive eating disorders in autistic women. Journal of Autism and Developmental Disorders, 50, 4280–4296. https://doi.org/10.1007/s10803-020-04479-3

Centers for Disease Control and Prevention. (2025). Data and statistics on autism spectrum disorder. https://www.cdc.gov/autism/data-research/index.html

Chan, K. T., & Marsack-Topolewski, C. N. (2023). The association of opioid misuse and suicidality among people with disabilities. Substance Use & Misuse, 58(1), 1–10. https://doi.org/10.1080/10826084.2022.2125271

Çi̇çek, A. U., Arslan, S. C., Bozok, B. K., Çolak, S. A. S. M., Abanoz, E., & Ucuz, İ. (2025). The Prevalence of Comorbid Psychiatric Disorders in Children and Adolescents with Asperger Syndrome. Journal of Harran University Medical Faculty / Harran Üniversitesi Tıp Fakültesi Dergisi, 22(1), 132–140. https://doi-org.ezproxy.uu.edu/10.35440/hutfd.1564572

Dickter, C. L., Chang, I., Burk, J. A., & Bravo, A. J. (2025). Autistic traits, emotion regulation, social anxiety, drinking to cope, and problematic alcohol use: A cross-cultural examination among young adults from seven countries. Substance Use & Misuse, 60(5), 766–774. https://doi.org/10.1080/10826084.2024.2447435

Haasbroek, H., & Morojele, N. (2022). A systematic literature review on the relationship between autism spectrum disorder and substance use among adults and adolescents. Review Journal of Autism and Developmental Disorders, 9(1), 1–20. https://doi.org/10.1007/s40489-021-00242-1

Hrycko, A. J., & Sinderbrand, M. (2025). Inpatient hospitalization of adolescents diagnosed with autism spectrum disorder: An ethical analysis. American Journal of Bioethics, 1–7. https://doi-org.ezproxy.uu.edu/10.1080/15265161.2025.2497989

Jadav, N., & Bal, V. H. (2022). Associations between co‐occurring conditions and age of autism diagnosis: Implications for mental health training and adult autism research. Autism Research, 15(11), 2112–2125. https://doi.org/10.1002/aur.2808

Kunreuther, E. (2021). Autism spectrum disorder and substance use disorder: A dual diagnosis hiding in plain sight. Psychiatric Clinics, 44(1), 35–49. https://doi.org/10.1016/j.psc.2020.11.004

Latif, F., Bajwa, S., Ashraf, R., Malik, S., Dogar, F. A., & Anjum, A. (2025). Unveiling the impact of neurodevelopmental disabilities on intra-family dynamics: A phenomenological exploration. Professional Medical Journal, 32(1), 84–93. https://doi-org.ezproxy.uu.edu/10.29309/TPMJ/2025.32.01.8342

Loomes, R., Hull, L., & Mandy, W. P. L. (2017). What is the male-to-female ratio in autism spectrum disorder? A systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 56(6), 466–474. https://doi.org/10.1016/j.jaac.2017.03.013

Marsack-Topolewski, C. N., & Chan, K. T. (2024). The relationship of opioid misuse and suicidality among adolescents with disabilities. Families in Society, Advance online publication. https://doi.org/10.1177/1044389424122916

Munday, K., Papadopoulos, C., Adkin, T., & Gray-Hammond, D. (2025). Improving substance-use services for autistic adults: Insights and recommendations from autistic adults. Autism in Adulthood. Advance online publication. https://doi.org/10.1089/aut.2024.0213

Ressel, M., Thompson, B., Poulin, M. H., Normand, C. L., Fisher, M. H., Couture, G., & Iarocci, G. (2020). Systematic review of risk and protective factors associated with substance use and abuse in individuals with autism spectrum disorders. Autism, 24(4), 899–918. https://doi.org/10.1177/1362361320910963

Walhout, S. J., Zanten, J. V., DeFuentes-Merillas, L., Sonneborn, C. K., & Bosma, M. (2022). Patients with autism spectrum disorder and co-occurring substance use disorder: A clinical intervention study. Substance Abuse: Research and Treatment, 16. https://doi.org/10.1177/11782218221085599

Weir, E., Allison, C., & Baron-Cohen, S. (2021). Understanding the substance use of autistic adolescents and adults: A mixed-methods approach. The Lancet Psychiatry, 8(8), 673–685. https://doi.org/10.1016/S2215-0366(21)00160-7

This text-based course is an edited transcript of a live webinar presented by Giselle Levin, PsyD.

This material is for educational purposes and does not replace clinical judgment or local policy.

Course Overview

In this course, we will undertake a thorough and critical examination of the current classification of paraphilias and paraphilic disorders within the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). We will move beyond a simple recitation of diagnostic criteria to explore the historical evolution of these classifications, the ethical and legal implications of diagnosis, and the complexities of distinguishing between non-pathological sexual diversity and genuine psychological distress. Our analysis will be guided by central questions we must consider as clinicians, including the fundamental difference between a paraphilia and a paraphilic disorder and the role of classifications in the context of consent and criminal behavior. This discussion underscores the need for a nuanced, ethically-informed, and culturally competent approach to understanding paraphilic interests and behaviors.

Limitations/Risks

This presentation focuses on the fundamentals of DSM-5 Paraphilic Disorders. We discuss distinguishing paraphilias and paraphilic disorders, DSM-5 criteria, and an overview of treatment. This presentation does not provide in-depth training related to diagnosing and treating paraphilic disorders. Seek consultation or refer as needed.

This presentation provides a general overview of DSM-5 Paraphilic Disorders, but does not explore the cultural variations in how these disorders may be perceived, expressed, or diagnosed across different communities. Clinicians should apply culturally competent approaches and consider how societal norms, stigma, and access to care may influence assessment and treatment. Seeking culturally informed consultation or resources is recommended when working with diverse populations.
​​

Learning Outcomes

After this course, participants will be able to:

• Differentiate between non-disordered sexuality and DSM-5 paraphilias in two case studies.
• Describe ethical concerns related to the pathologizing of normal human sexual diversity within the DSM-5.
• Identify situations in which clients could benefit from diagnosis and treatment for DSM-5 paraphilias.

FAQs

• Are there guidelines for documentation that you recommend around paraphilic disorders?
• How do you treat patients who are invested in the idea that they have a paraphilia when there are no issues of nonconsensual behavior?
• Given that the DSM-5's paraphilic disorders have so many problems, what are your thoughts about what ideally DSM-6 should do with the chapter?
• How do we recommend we combat stigma among our coworkers about paraphilic disorders?
• Sexual offending is such a huge problem. Do you have different views on paraphilic disorders that involve sexual offenses compared with those that don't?

Guiding Questions:

• What is the difference between a paraphilia and a paraphilic disorder?
• How do we distinguish "normal" variations in human sexuality from a paraphilic disorder?
• Should psychological disorders be used as a mechanism for understanding criminal behavior and/or non-consensual sexual behavior?

Notice!

• What surprises you?
• What seems to be clinically relevant or irrelevant to your work?
• Which criteria feel helpful or unhelpful with regard to distinguishing "normal" sexual diversity and pathology?

History & DSM-5 Changes

The history of nosology—the way in which we classify diseases and disorders—is a journey that reveals as much about societal values and political landscapes as it does about scientific understanding. The evolution of the paraphilic disorders chapter within the DSM is a prime example of this.

When the first edition of the DSM was released in 1952, it included a category for "sexual deviation" under the broader heading of sociopathic personality disorder. This category was incredibly broad and encompassed a wide spectrum of behaviors that were not explicitly linked to procreation. This included homosexuality and what was then termed "transvestism," as well as other interests like pedophilia, fetishism, and sexual sadism.

The inclusion of these behaviors under a psychiatric label marked a significant shift from the previous view that these acts were sinful or evil. The perspective moved from one of morality to one of medicine, from seeing individuals as "bad" to seeing them as "mad". While some might argue that this medicalization was a step toward a more empathetic view, it also had severe negative consequences. The classification provided a seemingly scientific justification for the institutionalization of queer individuals, castration, and widespread discrimination. It gave society a scientific sanction to fire people from their jobs, to expel them from their families, and to deny them citizenship on the basis of their sexual orientation or gender expression. This period, therefore, highlights a crucial question that still resonates today: to what extent is the DSM a truly scientific document, and to what extent is it a reflection of social and political pressures? The scientific rigor behind the paraphilic disorders chapter has, in fact, been heavily questioned, and this lack of a strong evidence base has led to continued debate.

The landscape changed dramatically in 1973 with the removal of homosexuality from the DSM, an action driven largely by the tireless work of queer rights activists. This change was not without controversy and was met with strong resistance from many clinicians. The introduction of "paraphilias" in the DSM-III in 1980 was, in many ways, a compromise between these opposing factions. It also introduced a new, now-removed category of "ego dystonic homosexuality," which pathologized individuals who were distressed by their same-sex attractions, allowing a continued space for classification of same-sex attraction as a disorder under a new guise. This was a clear example of the DSM adapting to social pressures while still maintaining a degree of what some would consider a pathologizing stance.

The DSM-IV introduced a key element that is still central today: the "distress criterion". This meant that an individual could be diagnosed with a paraphilic disorder based on the presence of distressing urges or fantasies, even without having acted on them or having any functional impairment. This was a significant development because it shifted the focus from behavior alone to the individual's internal experience.

The DSM-5, released in 2013, further refined this by making a crucial distinction between a paraphilia and a paraphilic disorder. The emphasis was placed on either personal distress, functional impairment, or the causing of harm or risk of harm to others. This distinction was a major step toward acknowledging that not all unusual sexual interests are pathological.

Paraphilias vs. Paraphilic Disorders

The distinction between a paraphilia and a paraphilic disorder is a cornerstone of the DSM-5's approach to this topic.

A paraphilia is defined by the DSM-5 as an "intense and persistent sexual interest other than genital stimulation or preparatory fondling with normal, physically mature, and consenting human partners" (American Psychiatric Association, 2022). This definition is complex and contains several key components that require careful unpacking. First, the sexual interest must be for a specific act or target, one that is outside of what the manual considers "normal" or "preparatory" sexual activity. The term "normal" itself is highly problematic and subjective. Second, the interest must be "intense and persistent," a qualitative measure that lacks a clear, research-supported definition, making it difficult to apply consistently. Finally, the "erotic target" must be other than what is considered a "normal, physically mature, and consenting human partner". This raises questions about what constitutes a "normal" partner and whether certain sexual interests, such as those for a particular body type, could technically be considered a paraphilia. The DSM-5 acknowledges that there are a vast number of potential paraphilias, many of which do not have a specific diagnosis in the manual.

The shift from the term "paraphilia" to "paraphilic disorder" in the DSM-5 was meant to clarify that not all paraphilic interests are pathological. For a paraphilia to become a paraphilic disorder, it must meet specific criteria. The individual's paraphilic interest, urges, or behaviors must either cause "distress or functional impairment to the individual" (Criterion B) OR have "caused harm or risk of harm to others" (Criterion B). This distinction is absolutely critical because it means that a person could have a paraphilia (meeting Criterion A) but not have a diagnosable disorder (by not meeting Criterion B). For example, a person with an intense and persistent fetishistic interest in feet would only be diagnosed with Fetishistic Disorder if that interest was causing them significant distress in their life or interfering with their daily functioning.

The distress and impairment criterion, however, is a point of significant contention. It is often challenging to determine whether an individual's distress stems from their sexual interest itself or from the societal stigma and internalized shame associated with that interest. We will explore this ethical dilemma further in later sections, but it is a fundamental problem with the current diagnostic framework.

Voyeuristic Disorder (F65.3)

Voyeuristic Disorder is defined as having "recurrent and intense sexual arousal from observing an unsuspecting person who is naked, disrobing, or engaging in sexual activity" (American Psychiatric Association, 2022). The fantasies, urges, or behaviors must have been present for at least six months.

The diagnostic criteria (Criterion B) further specify that for a diagnosis to be made, the individual must have either acted on these urges with a non-consenting person, OR their urges or fantasies must cause them significant distress or functional impairment (American Psychiatric Association, 2022). This is a vital point to remember as it distinguishes a momentary impulse from a diagnosable disorder.

The criteria also include an age requirement (Criterion C), stating that the individual must be at least 18 years old (American Psychiatric Association, 2022). This is an attempt to avoid pathologizing what the DSM-5 considers to be "normative sexual exploration" in adolescence.

The manual provides specifiers for individuals "in a controlled environment" (e.g., a prison or psychiatric hospital) and for those "in full remission". To be in full remission, an individual must have not acted on the urges and must have experienced no distress or impairment for at least five years while in an uncontrolled environment (American Psychiatric Association, 2022). The long duration of the remission period is notably longer than for many other mental health conditions.

It is important to note that consensual voyeuristic behavior, such as a partner watching another undress with their knowledge and agreement, would not meet the diagnostic criteria unless the individual experienced significant distress or functional impairment that was not related to societal stigma.

Exhibitionistic Disorder (F65.2)

Exhibitionistic Disorder shares a similar structure to Voyeuristic Disorder. It is characterized by "recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person" (Criterion A) (American Psychiatric Association, 2022). The fantasies, urges, or behaviors must persist for a period of at least six months.

As with other disorders, the individual must have (Criterion B) either acted on these urges with a non-consenting person, OR their fantasies and urges must cause them marked distress or functional impairment (American Psychiatric Association, 2022). Acts of exhibitionism are common, but the key to a diagnosis lies in the intensity and recurrence of the interest, which is much less common.

The specifiers for this disorder include whether the exposure is directed toward prepubertal children, physically mature individuals, or both. Additional specifiers exist for "in a controlled environment" and "in full remission" (American Psychiatric Association, 2022). Again, the element of a "non-consenting person" is central to the behavior, but the distress and impairment criteria can be met even in the absence of a non-consenting act, which is a point of confusion for some clinicians.

Frotteuristic Disorder (F65.81)

Frotteuristic Disorder is defined by (Criterion A) a "recurrent and intense sexual arousal from touching or rubbing against a non-consenting person" (American Psychiatric Association, 2022). This must be present for a period of six months. The diagnostic criteria (Criterion B) require that the individual has acted on these urges OR that the fantasies and urges cause them significant distress or functional impairment (American Psychiatric Association, 2022).

This is an important distinction to make because frotteuristic acts—unwanted touching or rubbing against another person—are surprisingly common, occurring in up to 30 percent of adult men in the United States and Canada. However, a diagnosis of Frotteuristic Disorder is only made when there is a recurrent and intense sexual interest driving the behavior, which is a far less common occurrence. Statistics show that only 10 to 14 percent of men in outpatient settings with paraphilic disorders and hypersexuality meet the criteria for this disorder. Therefore, a single act of frotteurism would not warrant a diagnosis, as it does not meet the "recurrent and intense" criteria. The disorder, like others, also has specifiers for "in a controlled environment" and "in full remission" (American Psychiatric Association, 2022).

Sexual Masochism Disorder (F65.51)

Sexual Masochism Disorder stands apart from the previous disorders because it does not inherently involve a non-consenting partner. This disorder is defined as having (Criterion A) "recurrent and intense sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer" (American Psychiatric Association, 2022). The fantasies, urges, or behaviors must have been present for at least six months.

The diagnostic criteria (Criterion B) state that these behaviors, urges, or fantasies must be causing the individual significant distress or functional impairment (American Psychiatric Association, 2022). A diagnosis would not be made for a person who engages in consensual sexual masochism without experiencing distress. This distinction is critical because it separates consensual BDSM activities from a diagnosable disorder. Many people engage in consensual activities that fall under this umbrella, such as rope play or degradation, without any negative psychological consequences.

The disorder includes a specifier for "with asphyxiophilia," which is defined as deriving sexual arousal from choking (American Psychiatric Association, 2022). This is noted for its inherent dangers and the higher risk of death associated with such behavior. As with other disorders, there are specifiers for "in a controlled environment" and "in full remission".

The case study of Michael, an 80-year-old gay man who was distressed by his consensual masochistic interests due to his Mormon upbringing, perfectly illustrates the complexity of the "distress" criterion. While he technically meets the criteria for the disorder because he has distress, the root of his distress is not the behavior itself but the internalized shame from societal stigma.

Sexual Sadism Disorder (F65.51)

Sexual Sadism Disorder is the counterpart to masochism, defined as having (Criterion A) "recurrent and intense sexual arousal from the physical or psychological suffering of another person" (American Psychiatric Association, 2022). This must also be present for a period of six months.

The diagnostic criteria (Criterion B) require that the individual has either acted on these urges with a non-consenting person OR that their urges and fantasies cause them significant distress or functional impairment (American Psychiatric Association, 2022). A key point from the DSM-5 is that individuals who sadistically assault others but deny any sexual arousal or distress can still be diagnosed with this disorder. This is because the act itself, which has caused harm to another, is sufficient for the diagnosis. This is an important distinction, as it shows that harm to others can trump the individual's self-reported experience of distress or arousal.

It's also worth noting a striking statistic: less than 10 percent of sexual offenders in the United States meet the criteria for Sexual Sadism Disorder, which suggests that the vast majority of sexual offenders are not motivated by this specific type of paraphilic interest. This disorder, like the others, has specifiers for "in a controlled environment" and "in full remission" (American Psychiatric Association, 2022).

Pedophilic Disorder (F65.4)

Pedophilic Disorder is defined as having (Criterion A) "recurrent and intense sexual arousal from sexual activity with a prepubescent child (under the age of 13)" (American Psychiatric Association, 2022). The fantasies, urges, or behaviors must have been present for at least six months. The diagnostic criteria (Criterion B) require that the individual has either acted on these urges OR that their urges and fantasies cause them significant distress or functional impairment (American Psychiatric Association, 2022).

A critical diagnostic criterion to emphasize is (Criterion C): the individual must be at least 16 years old AND at least five years older than the child (American Psychiatric Association, 2022). Therefore, a 13-year-old and a 17-year-old would not meet the criteria, as the five-year age gap is not met.

The DSM-5 also notes that individuals who repeatedly approach children can be diagnosed even if they deny sexual intent or distress, as their behavior itself is sufficient for the diagnosis (American Psychiatric Association, 2022).

Specifiers for this disorder include whether the attraction is "exclusive" or "non-exclusive" to prepubescent children, the gender of the children of interest ("attracted to males/females/both"), and whether the interest is "limited to incest" (American Psychiatric Association, 2022). It is also important to note that while pedophilia (the paraphilia) is often considered a lifelong condition, pedophilic disorder is not. An individual could stop meeting the criteria for the disorder if their urges no longer cause distress or functional impairment, though they would still be considered to have the paraphilia of pedophilia.

Let's consider a quiz question: According to the DSM-5, which of the following individuals would meet criteria for pedophilic disorder? a) A 23-year-old man who has sexually arousing fantasies about young children but has never acted upon any urges and denies distress or interpersonal difficulty. b) An 18-year-old boy who is in a sexual relationship with a 13-year-old girl. c) A 16-year-old boy who has highly distressing sexual fantasies about a 9-year-old cousin. d) A 45-year-old woman who is sexually involved with a 16-year-old girl.

The correct answer is (c). The 16-year-old meets the age requirement (Criterion C) of being at least 16 and at least five years older than the nine-year-old. He is experiencing highly distressing fantasies, which meet the criteria for the disorder (Criterion B). The other options fail to meet the criteria: (a) lacks distress or action (Criterion B); (b) has an insufficient age gap (Criterion C); and (d) involves a child outside of the prepubescent definition (Criterion A).

Fetishistic Disorder (F65.0)

Fetishistic Disorder is defined as having (Criterion A) "recurrent and intense sexual arousal from either non-living objects or a highly specific focus on non-genital body parts" (American Psychiatric Association, 2022). This must be present for at least six months. The diagnostic criteria (Criterion B) require that these behaviors, urges, or fantasies cause the individual significant distress or functional impairment (American Psychiatric Association, 2022).

It is important to note (Criterion C) that this diagnosis is not given if the interest is limited to cross-dressing or to sex toys that are designed to stimulate the genitals (American Psychiatric Association, 2022). An example would be an intense sexual interest in shoes, feet, or armpits, where these objects or body parts become the primary focus of sexual arousal.

While many people might enjoy incorporating a fetishized object or body part into their sexual activity, a person with this disorder would often have a preference for the fetishized object over traditional sexual acts. They would feel more sexually satisfied with the fetishized object present. Only a small number of people with this disorder would feel that they absolutely need the fetishized object to be present to experience sexual arousal. The disorder has specifiers for the type of fetish (body parts, nonliving objects, other), "in a controlled environment," and "in full remission" (American Psychiatric Association, 2022).

Transvestic Disorder (F65.1)

Transvestic Disorder is defined as having (Criterion A) "recurrent and intense sexual arousal from cross-dressing" (American Psychiatric Association, 2022). The fantasies, urges, or behaviors must have been present for at least six months. The diagnostic criteria (Criterion B) require that these behaviors, urges, or fantasies cause the individual significant distress or functional impairment (American Psychiatric Association, 2022).

A key point to emphasize is that this diagnosis is not for people who cross-dress for reasons of gender affirmation, as in the case of a trans person. It is specifically tied to sexual excitement. The disorder is noted to be more prevalent in men than women and can be specified as "with fetishism," meaning the individual is aroused by specific garments or fabrics, or "with autogynephilia," which is defined by the DSM-5 as being aroused by the thought or image of oneself as a woman (American Psychiatric Association, 2022).

I want to highlight a troubling statement from the DSM-5 that suggests this behavior can "interfere with or detract from heterosexual relationships," implying a bias toward "conventional marriages" and a potential pathologization of behavior that is simply a departure from a narrow definition of normalcy (American Psychiatric Association, 2022). This phrasing in the manual itself underscores the ethical and political dimensions of these classifications.

Differential Diagnosis

When a person presents with symptoms or behaviors that may be related to a paraphilic disorder, it is crucial for a clinician to consider a differential diagnosis. Certain conditions can mimic or present with similar behaviors, but the underlying cause is different.

For example, if a sexual interest or behavior only occurs during a manic episode, a period of acute psychosis, while under the influence of substances, or in the context of a neurocognitive disorder, a paraphilic disorder diagnosis is not appropriate. The behavior is considered a symptom of the primary condition, not a stand-alone disorder. The case study of Robert, a 25-year-old man whose new and erratic behaviors, including assault, coincided with symptoms of a potential manic episode or substance use, illustrates this.

Similarly, a person with Conduct Disorder or Antisocial Personality Disorder might engage in norm-breaking behaviors, including assaultive behavior, but if there is no specific, recurrent, and intense sexual interest driving the behavior, a paraphilic disorder diagnosis is not warranted. I want to specifically mention that general sexual assault is not included as a paraphilic disorder.

Obsessive-Compulsive Disorder (OCD) is another important differential to consider. The case study of Mary, a 19-year-old with intense and distressing thoughts about touching a young child, perfectly illustrates this. Her thoughts are "ego-dystonic," meaning they are inconsistent with her self-concept and she finds them highly distressing. There are no positive feelings or sexual arousal associated with the thoughts, and she has no desire to act on them. The anxiety and rumination about being a pedophile are classic signs of OCD, not a paraphilic disorder. The DSM-5's distress criterion can be particularly challenging in such cases, as the distress may be a result of the intrusive thoughts rather than a paraphilic interest.

Finally, let's touch on the difference between Transvestic Disorder and Gender Dysphoria. While the DSM-5 suggests that a person with Transvestic Disorder does not have gender incongruence, it also confusingly states that a person can have both (American Psychiatric Association, 2022). This ambiguity highlights the need for clinicians to rely on a thorough assessment of the individual's full experience, rather than a superficial checklist of symptoms.

BDSM vs. Paraphilic Disorders?

The relationship between BDSM and the paraphilic disorders chapter in the DSM-5 is a contentious and often misunderstood topic. Drawing on my personal and professional experience, I want to emphasize that the fundamental distinction between consensual BDSM and a paraphilic disorder is the presence or absence of consent.

In BDSM, consent is not just assumed but is an active, ongoing, and fundamental part of the practice (Dunkley & Brotto, 2020). It involves detailed pre-scene negotiation, clear communication of desires and boundaries, and the use of safety mechanisms like safe words. Without consent, BDSM activities would be considered abuse or assault, not a consensual sexual practice.

Which Paraphilic Disorders Could Overlap with BDSM Behaviors?

Certain paraphilic disorders, specifically Sexual Sadism Disorder and Sexual Masochism Disorder, could potentially overlap with behaviors found in BDSM. However, the disorders that involve a non-consenting person, such as Voyeuristic Disorder, Exhibitionistic Disorder, and Frotteuristic Disorder, cannot be considered consensual BDSM. The very nature of the act is predicated on the lack of consent.

Can Overlap:

• Sexual Sadism Disorder
• Sexual Masochism Disorder

Cannot Overlap:

• Pedophilic Disorder
• Frotteuristic Disorder
• Voyeuristic Disorder
• Exhibitionistic Disorder

The case study of Michael, the 80-year-old gay man who was distressed by his consensual masochistic interests due to his religious upbringing, demonstrates the problematic nature of the distress criterion. While he technically meets the criteria for Sexual Masochism Disorder (due to distress), his distress is not about the behavior itself but the societal stigma and internalized shame associated with it. This is a powerful argument for the ethical concerns surrounding the DSM-5's classification.

ICD-11 Diagnoses

In contrast to the DSM-5's approach, the ICD-11, published in 2019, has taken a different path (World Health Organization, 2019). It has removed several diagnoses related to consensual behavior, including Fetishism, Fetishistic Transvestism, and Sadomasochism. Any consensual BDSM was removed.

The ICD-11 has shifted its focus to disorders that involve non-consensual behavior. For example, Sexual Sadism was changed to "Coercive Sexual Sadism Disorder" to focus specifically on non-consensual acts of sadism. What remains are disorders such as Exhibitionistic Disorder, Voyeuristic Disorder, Pedophilic Disorder, Coercive Sexual Sadism Disorder, and Frotteuristic Disorder. This move reflects a global effort to destigmatize consensual sexual interests and to concentrate diagnostic efforts on behaviors that cause genuine harm. This contrast between the DSM and ICD highlights the ongoing debate about the proper role of these diagnostic manuals in a diverse and evolving world.

Prevalence

Understanding the prevalence of various sexual interests and behaviors is essential for a clinician attempting to distinguish between a common variation in human sexuality and a statistically abnormal one.

A 2017 study found a surprisingly high prevalence of BDSM fantasies or practices, with almost 70 percent of people reporting at least one such fantasy or practice (Herbenick et al., 2017). However, a much smaller percentage, around 7 percent, actually identified as BDSM practitioners (Brown et al., 2020). This shows that a wide range of sexual interests exists, but most people do not organize their sexual identity around them.

Image Caption: Prevalence of BDSM fantasies versus BDSM practitioner identity in the general population. While nearly 70% of people report BDSM fantasies (Herbenick et al., 2017), only about 7% identify as practitioners (Brown et al., 2020). Data notes: Left Chart (BDSM Fantasies): Yes (red, ~69%), No (grey, ~31%) . Right Chart (BDSM Practitioners): Yes (red, ~7%), No (grey, ~93%).

Image Caption: Prevalence of various sexual interests in the general population (Herbenick et al., 2017). Rates include Public sex (43%), Spanking (30%), Role play (22%), Bondage (20%), Whipping (13%), and BDSM parties (8%). Data notes: Diagram shows six boxes with percentages: Public sex: 43%; Spanking: 30%; Role play: 22%; Bondage: 20%; Whipping: 13%; BDSM parties: 8%.

Another study found that 45 percent of people had a desire to engage in a paraphilia, and nearly 34 percent had actually engaged in a paraphilic behavior (Joyal & Carpentier, 2017). It's important to emphasize that many of the interests considered paraphilic by the DSM-5—such as voyeurism, fetishism, frotteurism, and masochism—are not, in fact, "statistically unusual" because they occur in more than 16 percent of the population (Joyal & Carpentier, 2017). The key difference between a common interest and a paraphilic disorder lies in the "recurrent or intense" nature of the interest, which is much less common, endorsed by less than 10 percent of people. This distinction is vital for clinicians to consider, as they must not mistake a common, if unconventional, sexual interest for a diagnosable disorder.

Criticisms of Paraphilic Disorders

The DSM-5's chapter on paraphilic disorders has been the subject of significant criticism from a number of experts in the field. I want to highlight an article by Moser (2019), who argued that the chapter would likely not pass a peer review process for publication in an academic journal. This scathing critique points to a number of fundamental problems with the chapter.

First, Moser (2019) noted a lack of transparency surrounding the development of the chapter, with committee members reportedly signing a confidentiality pledge and a lack of evidence that expert feedback was genuinely incorporated. The DSM-5 is a "consensus document," not a comprehensive literature review, and critics argue that this approach led to a chapter that is not rooted in quality research. No field trials were conducted to support the validity and reliability of the new diagnoses and criteria (Moser, 2019).

Other criticisms include the ambiguity of key terms. For instance, the manual lacks a clear definition for what constitutes an "intense" sexual interest, making it difficult to distinguish between a paraphilic and a "normophilic" interest (Moser, 2019). The term "preference," used by the APA, is also seen as problematic, as it can evoke the same kind of stigma that was historically used to pathologize homosexuality (Moser, 2019). This raises the question of whether a strong preference for a particular body type, such as redheads or curvy people, could technically be considered a paraphilia, a line of reasoning that, while absurd, highlights the flaws in the manual's language. For non-consensual disorders, Moser (2019) notes that "the crime is the disorder," questioning why this logic isn't applied to other crimes like embezzlement or even general sexual assault.

A major ethical and clinical criticism is the "distress criterion". I repeatedly voice a strong dislike for this criterion, noting that it is nearly impossible to distinguish between personal distress and distress that is a result of societal stigma and internalized shame. The APA's guidance that the distress should be personal, not from societal stigma, is seen as impractical and naive, as every individual is impacted by the society and culture in which they live. As Moser (2019) argues, it's unclear how a clinician could know where the distress truly originated, and most clinicians may not even be aware of this fine distinction from an APA fact sheet. This can lead to the pathologizing of people who are simply struggling with the shame and guilt of having a non-normative sexual interest, rather than a genuine psychological disorder. I argue that a psychiatric diagnosis should not be a reflection of what is "culturally or morally abhorrent" but should instead be based on a clear and evidence-based understanding of psychopathology.

How Do YOU Define Psychopathology?

Our discussion of the criticisms of the DSM-5's paraphilic disorders chapter culminates in a thought-provoking question about the very definition of psychopathology. This question forces clinicians to reflect on the foundations of their practice and the ethical implications of diagnosis.

Image Caption: Defining psychopathology is complex. It is often considered an intersection of what is statistically abnormal, culturally or morally abhorrent, and what causes clinical distress or functional impairment. Data notes: Central term: Psychopathology. Four surrounding terms: Statistically Abnormal, Culturally/Morally Abhorrent, Clinical Distress, Functional Impairment.

A diagnosis should not be made simply because a behavior is statistically abnormal, as many paraphilic interests are not. It should not be made simply because a behavior is culturally or morally abhorrent, as this opens the door to pathologizing any behavior that falls outside of a narrow societal norm. Diagnosis should also not be based solely on functional impairment or clinical distress without careful consideration of the source of that distress. As discussed in the case study of Michael, the source of distress was not his consensual BDSM activities but the internalized shame from his religious upbringing. A proper definition of psychopathology must be robust enough to withstand these challenges and must be rooted in a clear understanding of the individual's psychological experience, not just their behavior or the judgments of society.

Ethical Considerations

The diagnosis of a paraphilic disorder is not a neutral clinical act; it carries with it significant and potentially devastating ethical and legal consequences. It is important to highlight the fact that these diagnoses can be used in court to invoke sexually violent predator (SVP) statutes. This can lead to the involuntary commitment of individuals for life, sometimes preventatively, based on the presence of a diagnosis. This means that a person could be institutionalized without having committed a sexual crime, simply because they have a specific paraphilic disorder. This underscores the power and responsibility inherent in a diagnostic manual like the DSM-5.

Moser (2019) is quoted as saying that the APA should be held accountable for the harm its classifications cause, arguing that the DSM is a "policy and social document" as much as it is a scientific one, and that the APA should be clear when the science does not support its position.

The stigma associated with these diagnoses is immense and can lead to serious psychological harm. The DSM-5 itself acknowledges that suicidality is associated with the stigma-related shame and guilt experienced by some BDSM practitioners (American Psychiatric Association, 2022). This is a tragic consequence of a diagnostic system that has, in some cases, failed to adequately distinguish between unconventional sexual interests and genuine psychological pathology. The ethical obligation of clinicians is, therefore, to be extremely cautious and thoughtful in their application of these diagnoses, always considering the potential for harm to the individual.

Treatment: An Overview

Treatment for paraphilic disorders is a complex and multifaceted undertaking that typically involves a combination of pharmacological and behavioral therapies. The goal of treatment is not to change a person's sexual interest but to address the behaviors that are causing harm or distress.

Image Caption: An overview of common treatment modalities for paraphilic disorders includes pharmacological, behavioral, and cognitive-behavioral therapies.

Pharmacological treatments are often used to reduce sexual arousal and libido and are most commonly used with individuals who have a history of sexual offending. Behavioral therapies, such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Schema-Focused Therapy (SFT), are also used to treat paraphilic disorders. These therapies are designed to address the cognitive distortions that maintain the behaviors, to help the individual recognize and correct maladaptive behaviors, and to address affective components such as a lack of empathy, which are often present in individuals with psychopathy or Antisocial Personality Disorder. The ultimate goal of these therapies, particularly in forensic settings, is to reduce recidivism. It is important to note that these treatments are most often used with sexual offenders.

Pharmacological Treatments

The use of pharmacological interventions for paraphilic disorders is a testament to the serious nature of the behaviors they are meant to address. The most common medications used are Selective Serotonin Reuptake Inhibitors (SSRIs), which can help to improve impulse control and reduce "deviant thoughts" in some individuals.

More aggressive treatments include anti-androgens and GnRH agonists, which work to reduce sexual arousal and libido by blocking testosterone. I use the stark phrase "akin to castration levels" to describe the effect of these medications. This highlights the severity of the treatment and the potentially life-altering side effects. The impact on bone health can be severe, with some individuals developing osteoporosis. Other side effects can include diabetes and high blood pressure. These medications are not a cure for the paraphilia itself but are intended to manage the intense urges and reduce the risk of re-offending. They are a tool used in a broader treatment plan that includes therapy and other behavioral interventions.

CBT & Other Therapies

Behavioral therapies are a cornerstone of treatment for paraphilic disorders, particularly for sexual offenders. Cognitive Behavioral Therapy (CBT) is a key modality used to identify and address the cognitive distortions that may maintain a person's paraphilic behaviors. The focus is on helping the individual recognize and correct maladaptive thoughts and behaviors.

I also want to mention the use of Dialectical Behavior Therapy (DBT) and Schema-Focused Therapy (SFT), which can be used to address broader psychological issues that may be present, such as psychopathy, Antisocial Personality Disorder, or a lack of empathy.

A comprehensive treatment plan might include psychoeducation about behavioral change, a functional behavioral analysis to understand what is perpetuating the behaviors, impulse control training, and the development of risk cards to help the individual identify situations that might lead to re-offending. Communication skills training and relapse prevention are also crucial components. Ultimately, the goal of these therapies is to reduce recidivism and to help individuals live a life that is in line with their values, even if they continue to have paraphilic interests. The discussion of an Internet-administered CBT protocol provides a detailed example of what such a treatment might look like, with a clear focus on education, skill-building, and relapse prevention.

Clinical Utility

A central question that must be asked of any psychiatric diagnosis is whether it has "clinical utility," a standard that the APA itself endorses. Citing Moser (2019), I would argue that the clinical utility for paraphilic disorders is questionable. While there may be a general link between paraphilias and other psychological disorders (Renaud, 2019), this does not automatically mean that all paraphilias should be pathologized.

The clinical utility of these diagnoses is most clear in forensic settings. Citing Shumate et al. (2023), I would argue that the focus of diagnosis and treatment should be on those who have a paraphilic disorder and have sexually offended, with the primary objective being to reduce recidivism.

For individuals who have paraphilic interests but have not acted on them and are not causing harm to others, the clinical utility of a diagnosis is far less clear. For people who engage in consensual BDSM or who have fantasies and arousal without a risk of offending, the focus of treatment should not be on eliminating their sexual interest. Instead, the focus should be on helping them manage any distress or functional impairment that they are experiencing, particularly if that distress is a result of societal stigma and internalized shame.

The case study of Michael perfectly illustrates this point. He was distressed by his consensual masochistic interests because of his religious upbringing, not because the interests themselves were inherently pathological. In such a case, the goal of therapy would be to help him process and manage his internalized shame, not to diagnose him with Sexual Masochism Disorder and attempt to "cure" his sexual interest. I also want to mention that there is very little data on what is considered "normal" sexual behavior, which further complicates the clinical utility of these diagnoses.

Who is the best candidate for treatment?

Our final question is a poll, designed to test the understanding of the key concepts discussed throughout this course.

Who is the best candidate for treatment for paraphilic disorders? a) A patient who is practicing sexual sadism with a consenting adult partner. b) A patient who is experiencing significant distress due to their addiction to pornography. c) A patient who crossdresses and experiences arousal while doing so. d) A patient who has exposed his genitals to a nonconsenting person.

The correct answer is (d). The rationale is that treatment for paraphilic disorders, particularly the forensic-focused treatments discussed, is most appropriate for individuals who have caused harm to others through non-consensual behavior.

Options (a) and (c) involve consensual behaviors and would not be the primary focus of treatment. While these individuals may be experiencing distress, the treatment would be focused on managing the effects of societal stigma and internalized shame, not on eliminating the paraphilic interest itself. Option (b) is not considered a paraphilic disorder in the DSM-5. I want to reiterate the central theme of this presentation: the diagnosis and treatment of paraphilic disorders should be reserved for those who are causing harm to others, with the goal of reducing recidivism, and should not be used to pathologize consensual sexual diversity.

Conclusion

I urge clinicians to think carefully and critically about when to diagnose and when to treat paraphilic disorders. I would like to reiterate that the "consequences can be huge" when it comes to the potential for legal ramifications like involuntary commitment and the profound psychological burden of stigma. It is important to underscore the inherent complexities of distinguishing between sexual diversity and genuine pathology, and careful consideration should be taken when reviewing the ethical concerns surrounding the DSM's role in potentially pathologizing consensual behaviors. The core message here is to prioritize treatment for individuals who have caused harm to others through non-consensual acts, with the primary goal of reducing recidivism. For individuals experiencing distress related to consensual sexual interests, the focus should shift to addressing the impact of societal stigma and internalized shame, rather than pathologizing their sexual preferences. I hope that the "crash course" has "changed the way you think about paraphilic disorders" and how to diagnose or treat, and when to diagnose or treat, if at all. Thank you for your time.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Brown, A., Barker, E. D., & Rahman, Q. (2020). A systematic scoping review of the prevalence, etiological, psychological, and interpersonal factors associated with BDSM. The Journal of Sex Research, 57(6), 781–811.

Herbenick, D., Bowling, J., Fu, T. C., Dodge, B., Guerra-Reyes, L., & Sanders, S. (2017). Sexual diversity in the United States: Results from a nationally representative probability sample of adult women and men. PloS one, 12(7), e0181198.

Dunkley, C. R., & Brotto, L. A. (2020). The role of consent in the context of BDSM. Sexual Abuse, 32(6), 657–678.

Joyal, C. C., & Carpentier, J. (2017). The prevalence of paraphilic interests and behaviors in the general population: A provincial survey. The Journal of Sex Research, 54(2), 161-171.

Moser, C. (2019). DSM-5, paraphilias, and the paraphilic disorders: Confusion reigns. Archives of Sexual Behavior, 48(3), 681-689.

Renaud, M. (2019). An examination of the relationship between the paraphilias and anxiety (Doctoral dissertation, Université d'Ottawa/University of Ottawa).

Sahoo, S., Pandiyan, S., & Chakravarty, R. (2023). Paraphilias: an update on nosology and diagnostic challenges. The Journal of Forensic Psychiatry & Psychology, 34(3-4), 371-385.

Shumate, J., Song, S. H., & Saleh, F. M. (2023). Paraphilic disorders, psychopathy, and those who sexually offend: a narrative review of treatment modalities. International Journal of Impotence Research, 1-7.

World Health Organization. (2019). International classification of diseases (11th ed.). https://icd.who.int/

Additional Current References

Please Note: The following resources have been included for members to view additional resources associated with this topic area. These resources were not used by the presenter when creating this course.

Abreu, R. L., Barrita, A. M., Sostre, J. P., Parmenter, J. G., & Watson, R. J. (2025). Interest in preexposure prophylaxis, cyberbullying, internalized stigma, and parental acceptance among Latinx sexual and gender diverse youth. Health Psychology, 44(3), 266–274. https://doi.org/10.1037/hea0001455

Hsu, K. J., Morandini, J. S., & Rudd, S. (2025). Cut from the same cloth? Comparing the sexuality of male cross-dressers and transfeminine individuals through the conceptual framework of autogynephilia. Archives of Sexual Behavior. Advance online publication. https://doi.org/10.1007/s10508-024-03053-7

Jabbour, J. (2025). Interest in BDSM: Structural, sexual, and personality factors. Dissertation Abstracts International: Section B: The Sciences and Engineering, 86(6-B).

Kirgios, E. L., Silver, I., & Chang, E. H. (2025). Does communicating measurable diversity goals attract or repel historically marginalized job applicants? Evidence from the lab and field. Journal of Experimental Psychology: General, 154(3), 624–643. https://doi.org/10.1037/xge0001699

McCauley, P. S., Eaton, L. A., Puhl, R. M., & Watson, R. J. (2025). Support from school personnel and in-school resources jointly moderate the association between identity-based harassment and depressive symptoms among sexual and gender diverse youth. Journal of Educational Psychology. Advance online publication. https://doi.org/10.1037/edu0000945

Editor's Note: This text-based course is an edited transcript of the webinar, Eco-anxiety: Symptoms and Solutions, presented by Karen Magruder
MSW LCSW-S.

Learning Outcomes

After this course, participants will be able to:

• Explain key symptoms of eco-anxiety.
• Describe the prevalence of eco-anxiety among diverse populations.
• List evidence-based treatments for eco-anxiety.

Introduction

Hello, everyone. Thank you for joining me today as we explore the topic of eco-anxiety, how it manifests, and what we, as clinicians, can do about it. Before we dive into the heart of the discussion, let’s take a moment to cover some housekeeping details.

Limitations/Risks

Eco-anxiety is a highly complex topic, and this webinar is designed to provide an introduction to eco-anxiety and some treatment options. It’s important to note that this presentation is not intended to be an exhaustive or all-encompassing exploration of the subject. Eco-anxiety can manifest differently across various cultures and communities, so as practitioners, it’s crucial to exercise cultural humility and acknowledge diverse perspectives. This ensures that we avoid a one-size-fits-all approach and provide care that is sensitive to individual and community needs.

Session Overview

By the end of this session, I hope to achieve the outlined learning outcomes. To set the stage, I’d like to share a bit of my story—how, as a social worker, my professional identity intersected with environmental issues, and how I came to care deeply about and gain knowledge on these topics within a social work context. After that, we’ll explore eco-anxiety by examining its causes, symptoms, and prevalence, particularly among diverse populations. Finally, we’ll delve into clinical interventions that are either evidence-based or show promise in treating and addressing eco-anxiety, with the goal of helping individuals develop effective coping strategies.

What Are Your Burning Questions? (Live Webinar)

Before we get started, I’d like to get a general sense of your questions about eco-anxiety. I see someone caught the intentional use of “burning questions” there—yes, that’s exactly the point. Our house is on fire, after all. I’ve noted a few points to address along the way, and we’ll revisit the rest later. Let’s dive in!

My Story

As promised, I want to provide some context for today’s presentation by sharing my personal and professional journey, particularly how ecological and environmental issues intersect with my work in social services and mental health. I’ve always appreciated the benefits of spending time in nature—the awe, wonder, and mental health boost that comes with being outdoors. Growing up, I valued the beauty of the natural world and tried to be as environmentally responsible as I could, doing things like recycling, reducing waste, turning off lights, and conserving water. These were all small steps to reduce my carbon footprint, but I never really considered the physical environment as an integral part of social work or social service practice.

In my education and early career, we focused on the political, economic, and social environments, but the literal environment wasn’t emphasized in the same way. That began to shift for me as I started seeing not only the benefits I enjoyed from nature but also the challenges and disruptions that environmental issues caused in daily life. For example, living in Phoenix, Arizona, where the heat can be extreme—it’s 110 degrees today as I speak!—I’ve seen firsthand how these conditions can range from small inconveniences, like recycling bins warping in the heat, to major disruptions in daily life.

The turning point for me came during Hurricane Harvey in Texas. At the time, I was living in Dallas and working with older adults in assisted living and nursing facilities. I witnessed the disproportionate impact of the hurricane on this vulnerable population. Many older adults had mobility or health issues, limited support networks, fixed incomes, and a physiological susceptibility to environmental challenges. These factors made them particularly vulnerable during and after the storm. I volunteered at a shelter providing crisis intervention and saw how unprepared the system was to meet their needs. The nonprofit I worked for, The Senior Source, stepped in to provide walkers, adult incontinence supplies, and assistance with continuity of care for home healthcare and medications.

That experience was a wake-up call for me. I realized that social and environmental issues aren’t siloed, with social workers addressing one and environmentalists tackling the other. They’re deeply connected. For instance, as I continued working with older adults, I saw how heat waves strained nonprofits that were trying to bridge gaps in resources, such as installing or repairing air conditioning or providing cooling centers. Older adults, who are less physiologically adaptable to extreme heat, were especially at risk, and it became clear how environmental issues exacerbate social vulnerabilities.

After that lightbulb moment, I pursued more education to deepen my understanding. I earned a certificate in Climate Change and Health from Yale and became involved in the Climate Reality Project through Al Gore’s activism. These experiences helped me educate others about the connections between climate issues and social justice. Now, as a social worker and educator, I focus on treating eco-anxiety, which we’ll discuss more in-depth shortly, while also raising awareness about how clinicians and social service professionals have a critical role to play. Environmental scientists aren’t the only ones who can contribute to solutions. We, too, have skills and expertise that are vital in addressing these intertwined challenges.

Earth Has a Fever

All of that is to say that, in my studies and efforts to better understand these issues and how I could contribute, I’ve come to see it this way: the Earth has a fever. While it’s beyond the scope of this lecture to delve into all the environmental issues we’re facing, I find this simplified analogy helpful. Just as a small increase in my body temperature—from 98.6 to, say, 101 degrees—might seem minor, it makes a big difference in how I feel and function. The same is true for the Earth. Even a few degrees of warming can have profound effects on ecosystems, intensifying disruptions and rippling through the planet’s systems.

While climate change is a major challenge, it’s not the only ecological issue we face. Unfortunately, vulnerable and historically marginalized populations often feel the impacts of these crises first and worst. For example, as I shared earlier, the disproportionate effects of Hurricane Harvey and extreme heat waves in Texas highlighted how environmental challenges exacerbate existing inequities. These realities underscore the need for us to address both the ecological and social dimensions of these problems.

Today's Environmental Injustices

Figure 1 shows some of today's environmental injustices.

Figure 1. Today's environmental injustices.

While it’s beyond the scope of my talk today to provide an exhaustive list of the environmental injustices we face, some key examples include increasing heat waves, the rising intensity of hurricanes, climate-forced migration, and various forms of pollution—whether air pollution, plastic waste, litter, or other contaminants. Other issues include food deserts, where low-income urban communities lack access to fresh and affordable food, and the disposal of toxic waste, such as chemical or nuclear waste. Access to clean and safe water is another critical issue.

These environmental injustices affect not just our clients but many of us as well. They remind us of the interconnectedness of these challenges and the urgent need to address them on both systemic and personal levels.

How Does That Make You Feel?

Given the brief overview I’ve just shared about some of the challenges our Earth is facing, how does that make you feel? Even after just a short discussion of these pressing issues, I’d love to hear your thoughts. If you’re comfortable, please share in the chat how you’re feeling, and I’ll read some of your responses aloud.

I’m seeing a range of emotions here: frightened, anxious, depressed, frustrated, devastated, concerned, helpless, overwhelmed, powerless, worried. Someone mentioned, "The tornado is here," and others shared feelings of anxiety and being uninformed. Thank you so much for sharing. These are powerful and honest responses, and I want to validate and honor these experiences.

It’s certainly not my intention to scare you or ruin your day with this talk. We will absolutely get to solutions and ways to cope. But I think this crowdsourced list of emotions beautifully illustrates the very essence of eco-anxiety. The feelings you’ve shared—anxiety, helplessness, overwhelm, concern—are classic symptoms of eco-anxiety.

For those of you who wanted a clear definition of eco-anxiety, you’ve just captured it in your own words. Eco-anxiety is this collective experience of emotional distress in response to the environmental crises we face. It’s a very real and growing phenomenon, and it impacts not only our clients but also us as professionals. Let’s explore it further.

Eco-anxiety

What is eco-anxiety, exactly? Let’s take a closer look at what this really means. It’s described as a pervasive fear of environmental damage or ecological disaster, largely rooted in the current state of the environment and predictions about the future. While I’ll go into more detail about symptoms in the next slide, this definition captures the core of what eco-anxiety entails.

Importantly, eco-anxiety is increasingly recognized as a distinct area of clinical focus—it’s a real and valid concern. However, I want to clarify that it is not currently defined as a distinct diagnosis in the DSM. When I describe it as a topic that clinicians are focusing on, it’s to emphasize the growing interest in understanding and addressing this issue in a sensitive and appropriate way, even though it doesn’t yet have formal diagnostic criteria.

Common Symptoms

How eco-anxiety is defined and its common symptoms are an amalgamation of insights from recent literature, publications, trainings, and other resources on the topic. Since eco-anxiety isn’t codified in the DSM, it’s a bit fuzzier than conditions with formal diagnostic criteria. However, the way I’ll describe it should help you better recognize some of these symptoms or presentations, whether you see them in clients, loved ones, or even yourself.

Some of the common symptoms include pervasive worry. This isn’t just, "Oh, I went to Karen’s lecture, now I’m briefly worried about the Earth having a fever, and then I move on with my day." Instead, it’s a more enduring sense of worry that doesn’t pass quickly. Anxiety, as the term suggests, can present in familiar ways—physiological responses, rumination, and other manifestations typical of anxiety disorders.

A particularly key and unique aspect of eco-anxiety, which many of you touched on earlier, is the feeling of helplessness, powerlessness, or impotence. That overwhelming sense of having little or no control is a common feature. Frustration and anger are also often present, reflecting the emotional toll of witnessing environmental challenges without feeling equipped to make a significant impact. Additionally, we often see symptoms like sleeplessness and changes in eating patterns, both of which are common when stress or anxiety is heightened.

These symptoms paint a picture of how eco-anxiety manifests and how deeply it can affect people, far beyond a fleeting concern. Recognizing these signs is the first step toward addressing and supporting those experiencing eco-anxiety.

Climate Anxiety

Now, to discuss a few different terms, I’m using the term eco-anxiety. Eco-anxiety is kind of middle-level. In Figure 2, I’ve used this graphic to show that we have anxiety in the largest sphere.

Figure 2. Levels of anxiety.

Of course, you can have targets of anxiety related to a number of different issues. Eco-anxiety is a specific subtype of anxiety where you might feel worried, frustrated, helpless, or concerned about issues related to the environment—anything from pollution and toxic waste to climate change and other environmental injustices or problems, like those shown on the previous slide.

Climate anxiety, in turn, is a specific subtype of eco-anxiety, focused specifically on climate change. Given the scope and urgency of climate change, it’s no surprise that climate anxiety is a very common subtype of eco-anxiety. This type of anxiety often centers on what individuals see in the news about the climate crisis and the overwhelming challenge of processing and dealing with it all.

One of the questions I’ve already seen come in is how eco-anxiety differs from general existential dread. In my clinical and professional opinion, they are certainly related. Eco-anxiety and climate anxiety can spur broader existential questions, and having existential conversations can be an effective way to address them. However, eco-anxiety and climate anxiety are more specific than general existential malaise. Hopefully, that helps clarify the distinction.

There was also a question about discussing the evidence of climate change with clients. I’ll touch on that a bit later, as it fits better with what’s coming up next, but I’ll definitely circle back to it.

To summarize, eco-anxiety differs from climate anxiety in that eco-anxiety is broader, encompassing environmental issues beyond climate change, such as toxic waste or pollution, while climate anxiety focuses specifically on the challenges and threats posed by climate change.

Eco-Grief

Another differential diagnosis worth noting is the distinction between eco-anxiety and eco-grief. Eco-anxiety is very future-oriented—it's about worrying over what is to come. In contrast, eco-grief is more past-oriented, involving mourning the loss of what used to be. People might present with both, and they are certainly interconnected and intertwined. However, identifying which one is the more prominent presenting factor can shape the treatment approach. Just as we treat grief differently from anxiety, we also approach eco-anxiety differently than eco-grief.

This talk focuses on eco-anxiety, so we’ll concentrate on addressing future-oriented worries and how to help individuals cope with them effectively.

Other Related Conditions

A final note on related conditions you might encounter: specific phobias are included in the DSM, and you can reference the diagnostic criteria for those. It’s possible for someone to reach the threshold for a diagnosis of a specific phobia, such as one related to climate change. However, eco-anxiety in the general public tends to be less intense than a phobia. Phobias are often perceived as excessive or irrational—not that this perception is necessarily accurate—but eco-anxiety usually falls on a spectrum from realistic concern to potentially more apocalyptic views. For example, as someone mentioned in a question, how do we address individuals with an apocalyptic perspective that may not be rooted in reality? This highlights the spectrum of eco-anxiety, with phobias existing on the more intense end. However, most eco-anxiety doesn’t rise to the level of a diagnosable phobia.

Seasonal Affective Disorder (SAD) is another condition to distinguish from eco-anxiety. SAD is often tied to limited sunlight during certain seasons and affects individuals in a predictable, cyclical pattern. Eco-anxiety, by contrast, is not seasonal and is related to ongoing concerns about the natural environment.

Generalized Anxiety Disorder (GAD) encompasses a broader range of worries, while eco-anxiety is more specific and targeted. Unlike phobias, which may be perceived as irrational, many fears tied to eco-anxiety are well-founded. Concerns about environmental crises—such as animal depopulation, melting glaciers, sea-level rise, extreme weather, and coral bleaching—are grounded in real and observable phenomena. Climate change coverage has shifted from distant "doom-and-gloom" warnings to the unsettling reality that it is already unfolding before our eyes.

One key takeaway, and a spoiler for a treatment strategy, is that validating these concerns is essential. To some degree, eco-anxiety reflects real challenges, and it’s important to acknowledge that it’s not excessive or irrational to feel worried about the climate and the state of our environment. However, the lack of formal inclusion in the DSM can lead to eco-anxiety being underrepresented or misdiagnosed, making it harder to address in clinical settings. This underrepresentation underscores the need for clinicians to approach eco-anxiety with sensitivity and understanding.

Prevalence

Here’s what we know about the prevalence of eco-anxiety. Since it’s not a distinct disorder in the DSM, it’s challenging to measure consistently. However, if eco-anxiety were taken into account with more intentionality in clinical or healthcare settings, scholars and clinicians could gather more reliable statistics. Even with these limitations, reports indicate that eco-anxiety is a growing concern, especially among younger populations.

For instance, "climate emergency" was Oxford Dictionary’s word of the year not long ago, reflecting how pressing this issue has become. In 2021, there was a staggering 4000% increase in Google searches for "climate anxiety," illustrating how awareness and concern are rising. Large-scale surveys, like those conducted by Yale’s Institute for Climate Change, offer additional insights. A recent global survey of over 10,000 young people aged 16 to 25 found that 84% were moderately or extremely worried about climate change. Similarly, a study of the adult U.S. population revealed that 43% of Americans were alarmed or concerned about climate change, and another report indicated that two-thirds of the U.S. population were somewhat or very worried about it.

These figures show that eco-anxiety is not only gaining attention but becoming increasingly relevant in people’s lives. Greta Thunberg’s iconic statement, “Our house is on fire,” resonates deeply, as the concern spans generations. For example, parents may become preoccupied with fears about the future their children or grandchildren will inherit.

Although eco-anxiety isn’t easily measured—there’s no standardized question in the census or in most clinical assessments—estimates suggest that anywhere from 40% to 80% of the U.S. population experiences some level of worry about environmental issues. This means it could reasonably surface in therapeutic contexts, warranting awareness and preparedness among clinicians.

Impacted Populations

Environmental issues affect many, if not all, of us. However, as I mentioned earlier, the impact tends to fall disproportionately on vulnerable and marginalized populations. Eco-anxiety is not just a U.S. phenomenon; it has been documented across the world, including in Canada, Europe, Australia, the Pacific Islands, and Asia. I would venture to say that some degree of eco-anxiety exists everywhere there is concern about environmental issues. Unfortunately, those who have contributed the least to problems like climate change or pollution often suffer the most severe and earliest consequences. These populations face greater exposure to environmental issues, heightened vulnerability, and lower adaptive capacity—the ability to cope and recover from these impacts.

That being said, eco-anxiety is commonly observed among younger people, as reflected in the literature. Youth are often exposed earlier to dire messages about climate change and other environmental injustices, and they arguably have the most at stake. Since they will live to see the long-term effects of environmental crises, they may feel a heightened sense of urgency and responsibility, making them particularly vulnerable to developing eco-anxiety. That said, anyone can experience eco-anxiety, regardless of age or background.

Overview of Interventions

Let’s talk about solutions and interventions for eco-anxiety. This is still an emerging area of focus, with much of the literature having been published since 2020. In my work through a DSW program and other research efforts, I’ve systematically reviewed what scholars and clinicians are identifying as effective ways to address eco-anxiety in therapy. Here’s what I’ve found:

The first and most important step is validation. Recognizing a client’s concern about environmental issues as legitimate is essential. It’s not about labeling someone as an alarmist or dismissing them as a “fragile snowflake.” Often, these concerns are rooted in real evidence of current and worsening environmental issues. Expressing empathy and maintaining a non-judgmental attitude allows clients to feel heard and supported. While eco-anxiety can sometimes involve cognitive distortions that may need to be addressed, most of the time, it’s a natural and valid reaction. Think about Maslow’s hierarchy of needs—food, water, and shelter are fundamental, and when these are threatened, anxiety is a normal response. Validating that anxiety aligns with this reality.

Returning to a pre-submitted question about discussing evidence of climate change with clients: as with any issue, this should be client-led. Meeting clients where they are is crucial. If the topic arises organically, sharing sound, evidence-based knowledge can help validate their concerns or potentially support cognitive reframing. However, this should always be done without imposing an agenda or overwhelming the client with facts unless it feels helpful and appropriate at the moment.

Taking action is another powerful intervention. A hallmark of eco-anxiety is the sense of helplessness. Helping clients regain a sense of control—whether through small, meaningful actions like cultivating a garden, volunteering, or engaging in political activism—can alleviate this feeling. It’s not about solving all the world’s problems as one individual but identifying ways to act in alignment with personal values and passions. For some, this might be through education, art, writing, or science. The key is allowing clients to choose how they engage, rather than prescribing specific actions.

Social support is also invaluable. A strong support network, whether through friends, family, or community groups, can provide understanding, encouragement, and connection. Beyond individual relationships, there are emerging resources like climate cafés—similar to death cafés—where people gather to share their experiences and feelings about environmental issues. These kinds of specific support groups are growing in cities across the U.S. and can offer spaces to process eco-anxiety collectively.

Ecotherapy, or nature-based interventions, is another effective approach. For individuals who associate nature with danger due to experiences like hurricanes or tornadoes, reestablishing a positive connection with the natural world can help. This could involve spending time in parks, hiking, or even incorporating greenery into indoor spaces, such as filling an office with plants. Restoring a balanced relationship with nature can shift perceptions from fear to appreciation and healing.

Mindfulness is a well-established, evidence-based intervention that applies here as well. Eco-grief tends to focus on the past, while eco-anxiety is future-oriented. Mindfulness, with its emphasis on non-judgmental awareness of the present moment, can help clients ground themselves, recenter, and break out of cycles of rumination.

Cognitive reframing is another promising intervention. If a client’s worries are disproportionate or unrealistic, reframing can help create a more balanced perspective. For instance, addressing "should" statements tied to eco-guilt—like “I should be doing more to reduce my carbon footprint”—can encourage clients to acknowledge the efforts they are already making and focus on what is within their control. This technique can foster healthier, more adaptive thought patterns.

Finally, I want to emphasize again the importance of validation. While identifying cognitive distortions is important, it’s equally critical not to shame someone for their response to what is, in many cases, a valid and natural reaction to a real threat. Validation should remain the foundation of any intervention.

Acceptance & Commitment Therapy (ACT)

I see a lot of value and promise in Acceptance and Commitment Therapy (ACT) for treating eco-anxiety. I’ll be presenting at a conference about this in October with a former student of mine. ACT is a well-established, empirically supported psychotherapy that focuses on helping clients accept their current thoughts and feelings rather than getting stuck in past events or excessively worrying about the future.

One of ACT's key strengths is its emphasis on mindfulness. ACT encourages clients to live in the present moment and engage fully with their current experiences, helping them step back from rumination and anxiety while fostering psychological flexibility. ACT also promotes committed action, encouraging clients to take meaningful steps aligned with their values, even in the face of difficult emotions or circumstances.

I find ACT’s hexaflex model for psychological flexibility (as shown in Figure 3) particularly useful when addressing eco-anxiety. It provides a framework for helping clients navigate distressing emotions, build resilience, and make choices that align with their values in a way that feels purposeful and empowering. This combination of acceptance, mindfulness, and committed action makes ACT an especially promising approach for addressing the unique challenges of eco-anxiety.

Figure 3. ACT's hexaflex model of psychological flexibility.

As I’ve already mentioned, mindfulness is a valuable tool, and it’s a key component of ACT. Identifying values is another excellent activity in the context of eco-anxiety. ACT encourages a degree of acceptance around distressing thoughts and emotions, allowing clients to acknowledge their feelings without becoming overwhelmed by them.

What I particularly appreciate about ACT is how it helps align values with committed action. It’s not just about being present, accepting feelings, and defusing unhelpful thoughts—it’s about using that clarity to take meaningful action in alignment with one’s values. This process can be incredibly empowering and is especially effective in addressing the feelings of helplessness that are so often a hallmark of eco-anxiety. By connecting values to action, ACT provides a pathway to move forward with purpose and resilience.

Cognitive Behavioral Therapy (CBT)

As I mentioned earlier when discussing cognitive reframing, Cognitive Behavioral Therapy (CBT) has also been applied to eco-anxiety. One of its strengths is that it’s an evidence-based approach for generalized anxiety and specific phobias, which, as we’ve discussed, share some overlap with eco-anxiety. Cognitive reframing can be a helpful tool for addressing unhelpful thought patterns, but behavioral activation stands out as particularly effective.

Behavioral activation focuses on engaging clients in specific, tangible activities that can improve their mood and help them feel more grounded. These activities might include self-care practices, spending time in nature, or other actions that promote a sense of well-being and resilience. By helping clients identify and engage in meaningful activities, CBT can support them in getting into a better headspace.

That said, it’s important to approach eco-anxiety with care and avoid giving the impression that we are being judgmental or invalidating legitimate concerns. Balancing validation with encouragement toward adaptive behaviors is key to providing effective support.

Self-Care: The UP STREAM Model

I also want to share the UPSTREAM model, a framework I developed to encapsulate best practices for supporting ourselves and our clients who might be experiencing eco-anxiety. As an educator, I love snappy mnemonics and acronyms to make these concepts easier to remember. This model is designed to summarize strategies for addressing eco-anxiety effectively:

• U – Understanding and Self-Compassion: This reflects the importance of validation and recognizing that it’s okay to experience distress. Practicing self-compassion helps us acknowledge and manage these feelings without judgment.

• P – Participating in the Solution: Taking action is empowering. Encourage clients to decide what this looks like for them based on their own interests, skills, and comfort levels. For example, instead of suggesting specific actions like voting for a particular candidate, ask what resonates with them and aligns with their values.

• S – Self-Talk: Addressing and limiting negative self-talk or cognitive distortions that can amplify valid concerns is key. Helping clients identify and reframe these patterns can reduce the intensity of their anxiety.

• T – Trauma Healing: While this talk focuses on anxiety, eco-anxiety and eco-grief are interconnected. Many individuals have experienced environmental injustices or personal trauma related to these issues. Supporting clients in processing and healing from these experiences can be essential.

• R – Reducing Isolation: Building and maintaining social support is critical. Whether through relationships or participation in community or support groups, reducing isolation can foster resilience and emotional well-being.

• E – Ecotherapy: Nature-based interventions help restore a positive relationship with the natural world. Activities like spending time in parks or incorporating greenery into daily spaces can counteract the fear and disconnection that eco-anxiety often brings.

• A – Acts of Self-Care: Self-care practices are crucial for maintaining emotional balance and keeping one’s “cup full.” Encouraging clients to prioritize activities that nurture them helps sustain their mental health.

• M - Mindfulness: Engaging in present-focused, nonjudgmental awareness is a powerful tool for managing eco-anxiety. Mindfulness helps ground clients and prevents them from becoming overwhelmed by past traumas or future fears.

This model provides a comprehensive and easy way to remember actionable steps for addressing eco-anxiety. We’ve now covered the symptoms of eco-anxiety, described its prevalence, and explored various potential treatments, including this model, to help guide effective intervention.

Summary

To wrap up, let me summarize the key points we’ve discussed.

Eco-anxiety involves feelings of worry, fear, and helplessness related to climate change and other environmental degradation. It is often accompanied by stress, insomnia, a sense of loss, and other related challenges. While eco-anxiety is not officially included in the DSM, tools are being developed to screen for and better understand it. However, it remains less defined compared to other mental health conditions. Even so, a significant portion of people—anywhere from 40% to 80% of Americans—express some level of concern about environmental issues. Among these, a smaller but meaningful subset may need clinical intervention, though it’s likely more prevalent than we might initially assume.

Eco-anxiety is not limited to the United States; it is a global phenomenon, with higher prevalence among younger generations and communities directly impacted by climate change. Indigenous populations and residents of vulnerable regions often experience greater levels of eco-anxiety. This is linked to three elements of vulnerability: exposure, sensitivity, and adaptive capacity. For example, people living in coastal areas are more exposed to rising sea levels, while certain groups, such as children and older adults, are more biologically sensitive to specific environmental issues like air pollution or extreme heat. Additionally, those with limited social, economic, or political resources often have reduced adaptive capacity, making it harder to cope with environmental challenges. These compounded vulnerabilities contribute to higher levels of eco-anxiety in disenfranchised populations.

Younger generations are particularly affected, having grown up with ongoing messages about climate change and environmental degradation. They also face a significant personal stake in how these issues will unfold over the coming decades, adding to the emotional burden they carry.

Eco-anxiety is still an emerging area of focus, offering clinicians opportunities to conduct further research and develop tailored interventions. While many traditional approaches to anxiety are effective, there are specific strategies that show promise for addressing eco-anxiety. Validation is key, providing compassion and reassurance that these feelings are a normal and natural response to real threats. Brief psychoeducation about the validity of their concerns can also help. Encouraging clients to take meaningful action within their circles of influence can help address feelings of helplessness, while social support reduces isolation and fosters a sense of community. Mindfulness practices can assist clients in staying present and managing anxiety that is often future-oriented. Evidence-based therapies like Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT) are particularly helpful, using interventions such as cognitive reframing, behavioral activation, and values-aligned action.

While the exploration of other modalities, such as existential therapy and narrative therapy, is ongoing, many tools designed for anxiety, in general, are effective starting points. Ultimately, addressing eco-anxiety involves a mix of validation, action, support, and mindfulness to help individuals navigate these complex and deeply felt concerns.

Questions and Answers

How do you deal with an apocalyptic stance from young people?
It’s important to think of this as a spectrum. Some individuals might not be concerned at all, and perhaps they should be, as increased awareness could lead to meaningful action. On the other end of the spectrum, some may adopt an overly apocalyptic view that might not align with reality and may require gentle balancing. A certain level of anxiety is valid and expected given the circumstances. Accepting and processing these feelings is essential, followed by coping strategies to help manage and minimize distress. For individuals with unrealistic views, sensitive and balanced cognitive reframing can be helpful in addressing distortions without invalidating their concerns.

Why are environmental conditions labeled as injustices?
Environmental conditions are often considered injustices because vulnerable and historically marginalized communities tend to suffer first and worst from these issues. For example, environmental racism is a well-documented phenomenon where communities of color are more likely to have undesirable environmental conditions, such as toxic waste disposal sites, in their neighborhoods compared to affluent communities. Urban heat islands provide another example—lower-income residents living in city centers often experience higher temperatures due to reduced tree cover and increased concrete and emissions, unlike residents in wealthier suburbs. While some environmental problems affect everyone, these justice-related elements disproportionately impact marginalized groups.

Can environmental issues be coded as a focus of clinical attention?
Yes. In the DSM-IV, environmental problems were often addressed under Axis IV. While the multiaxial system is no longer part of the DSM-5, there is a section in the back for "Other Conditions That May Be a Focus of Clinical Attention," which includes a code for environmental issues. While not a formal diagnosis, this allows clinicians to note eco-anxiety as a relevant factor in therapy. For billing purposes, some clinicians use codes for unspecified anxiety disorders if eco-anxiety is a prominent issue requiring clinical attention.

How should clinicians handle eco-anxiety that ranges in severity?
Eco-anxiety can vary significantly. Some clients may only bring it up occasionally, perhaps after reading a distressing news article, requiring brief validation and coping strategies like behavioral activation or limiting news intake. Others may experience more pervasive and severe eco-anxiety that needs ongoing attention. Tailoring the approach to the individual’s needs is essential.

What about Gus Speth’s quote on environmental problems and human attitudes?
Speth’s quote highlights that many of the world's top environmental problems—biodiversity loss, ecosystem collapse, and climate change—are human-caused and rooted in attitudes like selfishness, greed, and apathy. Addressing these issues requires not just scientific and technological solutions but also cultural and spiritual transformation. For those interested in actionable solutions, the book and website Drawdown provide a comprehensive list of top solutions for climate and environmental issues. These solutions are multifaceted, involving science, technology, education, and awareness to address the complexity of the problem.

What are the limitations of CBT when addressing eco-anxiety?
While CBT can be very effective, there’s a risk that cognitive reframing might be perceived as invalidating by clients if their concerns are dismissed as "irrational." Eco-anxiety often stems from real and pressing environmental threats, so it’s critical to use clinical judgment to balance reframing with validation. Avoiding judgment ensures the intervention remains compassionate and effective.

How can clinicians help clients with perfectionism around their environmental impact?
This is often referred to as "eco-guilt." Clients may struggle with the idea that they can’t completely mitigate their environmental impact, or they may find that some actions are not feasible in their lives. Encouraging clients to explore their values, as suggested in Acceptance and Commitment Therapy, can be a good starting point. Helping them balance their values of sustainability with a reasonable and achievable lifestyle is essential. Acknowledge their efforts, emphasize that they’re doing the best they can, and remind them that individual actions are part of a larger collective effort. Encourage grace and self-compassion, as no single individual can solve the issue alone.

Can eco-anxiety show up as an OCD theme or other compulsive disorder?
Yes, eco-anxiety can manifest as an OCD theme. Documented cases include obsessions and compulsions related to environmental impact, such as compulsively checking light switches or faucets to save energy or water. In such cases, traditional OCD interventions remain effective, even if there’s an environmental element involved. Similarly, eco-guilt can sometimes be a factor in hoarding disorder, where individuals feel conflicted about discarding items due to concerns about waste. Talking through the impacts of their choices—whether recycling, donating, or discarding—is a compassionate way to address these concerns.

I encourage you to reach out if you have more questions. You can find me on LinkedIn or email me at karenmagruder@uta.edu. Thank you so much for your thoughtful questions and participation, and I hope this session provided useful insights.

References

Please refer to the additional handout.