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. 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, at its core, straightforward (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).

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).

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 the 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 Sophie Nathenson, PhD.

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

Course Overview

This course provides health professionals with a comprehensive framework for understanding and identifying human trafficking in the United States. Grounded in a sociological perspective, the material examines the complex definitions, scope, and societal factors that contribute to trafficking. Participants will learn to recognize the physical, behavioral, and psychological indicators of trafficking in both adult and minor victims, with a specific focus on signs that may present in healthcare settings. The course offers practical guidance on trauma-informed communication, clinical assessment, and the use of national resources to report suspected cases and support vulnerable individuals.

Learning Outcomes

After this course, participants will be able to:

• Describe the different types and venues of human trafficking prevalent in the United States.​

• Explain at least two risk factors and warning signs, including social and systemic factors, of human trafficking for both adult and minor victims.

• Identify five specific indicators of trafficking that can be identified in healthcare settings and appropriate resources and protocols for reporting suspected cases.

Risks/Limitations

• Generalization of Trends: Trends presented change over time and population.

• Limited Cultural Representation: The course may not fully encompass the diversity of experiences with human trafficking or the regional or global scope and differences.

• Research Scope: This course does not contain an exhaustive review of research conducted on these topics.

Definitions of Human Trafficking

Understanding the formal definitions of human trafficking is the first step in distinguishing it from other related criminal activities. These definitions provide the legal framework for identification, reporting, and prosecution, establishing clear boundaries for what constitutes this severe violation of human rights.

Federal Definitions

The primary federal legislation governing human trafficking in the United States is the Trafficking Victims Protection Act (TVPA). First enacted in 2000, this act establishes clear definitions for the main forms of trafficking and provides a framework for prosecution, protection, and prevention (U.S. Department of Justice, 2024).

• Sex Trafficking: This is defined as the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a commercial sex act, where the commercial sex act is induced by force, fraud, or coercion.

• Labor Trafficking: This involves the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

A critical provision of the TVPA relates to minors. Any individual under the age of 18 who is engaged in commercial sex is legally considered a trafficking victim, regardless of whether force, fraud, or coercion can be proven (U.S. Department of Justice, 2024). This removes the burden of proving manipulation in cases involving children, acknowledging their inherent vulnerability. Beyond these two primary categories, other forms of trafficking exist, including child trafficking for non-sexual labor, bonded labor (debt peonage), forced marriage, and organ trafficking.

Michigan State Law

State laws often provide additional specificity that reflects local priorities and legal structures. For example, the Michigan Penal Code defines human trafficking as the knowing exploitation of an individual, with a particular focus on vulnerable populations (State of Michigan, 1931). The key element in this definition is the concept of "knowingly." A person is not culpable if they are caught in a situation without awareness of the context or details of the exploitation.

The Michigan statute includes specific actions, such as:

• Benefitting financially from the exploitation.

• Controlling an individual's access to controlled substances as a means of coercion (State of Michigan, 1931). This tactic is a common method used to maintain control over a victim, creating a physiological dependency that compounds psychological manipulation.

Distinctions from Other Crimes

Human trafficking is often confused with other serious crimes, but its methods and motivations are distinct. It is not always a violent crime, and the signs of abuse may not be physically visible. While violence can be a component, psychological control is often the primary and most powerful tool.

• Smuggling: This crime involves providing transportation across a border, typically with the consent of the individual being transported. While dangerous and illegal, it is not trafficking unless the relationship transitions into a situation of force, fraud, or coercion after the transport is complete. Smuggling is a crime against a nation's border, whereas trafficking is a crime against a person.

• Kidnapping: This typically involves taking someone against their will for a specific purpose, such as a ransom. The motivation is often a one-time event or payment, whereas trafficking is an ongoing form of exploitation for labor or commercial sex.

Trafficking is far more likely to rely on psychological means of control rather than physical restraint. These tactics include manipulation, defrauding individuals with false promises, and making threats against the victim or their loved ones (Eryarsoy et al., 2024). This sustained psychological pressure paralyzes individuals, preventing them from seeking help even when physical escape appears possible.

Tactics

The methods used by traffickers are often subtle and designed to break down a person's autonomy over time. Psychological means are more common than physical confinement, particularly when a family member is the trafficker, as the pre-existing emotional ties can be powerfully exploited (Eryarsoy et al., 2024).

Common tactics include:

• Fraud: This involves making false promises to lure a victim into a situation of dependency. Examples include offering a good job with a specific salary, a safe place to live, a marriage proposal, or support for their family. Once the victim is isolated, these promises are broken, and the exploitation begins.

• Threats: Traffickers frequently use threats to maintain control. This can include threats of physical violence against the victim, threats of harm to their family members and loved ones, or threats of deportation for undocumented individuals. The fear these threats generate can be a more effective restraint than any physical barrier.

• Debt and Intimidation: Many victims are trapped through debt bondage. A trafficker might withhold pay, create a fraudulent debt for transportation or lodging, hold personal documents like passports or identification as collateral, and use various forms of intimidation to ensure the "debt" can never be repaid (Eryarsoy et al., 2024).

Sociological Perspective

To effectively identify and prevent human trafficking, it is essential to look beyond individual cases and examine the broader societal conditions that allow it to flourish. A sociological perspective focuses on the "upstream" factors—the social and systemic issues that create vulnerability in the first place. This approach studies group differences rather than individual pathologies to understand how belonging to certain demographic groups can increase risk. This view shifts the focus from asking "What is wrong with this person?" to "What is happening in our society that allows this to occur?"

This perspective emphasizes several key areas:

• Social Factors: These include a person's demographics, such as race, gender, sexuality, marital status, and employment status. Analysis of these factors can reveal patterns of vulnerability within a population.

• Prevention Focus: By examining upstream factors, the focus shifts from intervention to prevention. Addressing the root causes of vulnerability—such as poverty, lack of education, and discrimination—can reduce the pool of potential victims.

• Systemic Factors: These are issues embedded within our societal systems, such as healthcare, education, and justice. A lack of access to resources, for example, is a systemic factor that can increase an individual's risk of being trafficked.

• Role of Institutions: This involves analyzing how institutions like schools and hospitals can either contribute to a person's vulnerability or serve as critical points for identification and support.

• Social Environment: A person's environment—including their family, neighborhood, and experiences with discrimination—profoundly affects their psychological and even physiological well-being. A hostile or unstable social environment creates the fertile ground in which traffickers operate.

Role of Behavioral Health Professionals

Behavioral health professionals are uniquely positioned to identify and support victims of human trafficking. The growing awareness of this issue has highlighted the critical role clinicians play in the response system, serving as a potential lifeline for individuals who may not encounter other service providers.

Key responsibilities include:

• Mandatory Reporting: Professionals must be aware of and comply with their state's mandatory reporting laws regarding suspected abuse and trafficking, particularly concerning minors.

• Identifying and Supporting Victims: This involves recognizing the subtle signs of trafficking and understanding the resources available to help victims.

• Addressing Consequences: Clinicians must be prepared to address the specific and severe mental, physical, and emotional consequences of trafficking, which often manifest as complex trauma.

• Providing Trauma-Informed Care: It is crucial to use a trauma-informed approach to avoid re-traumatizing victims during assessment and treatment.

• Collaboration and Coordination: Effective support requires collaboration with specialized organizations, law enforcement, and social services that are equipped to handle trafficking cases. No single provider can meet all of a survivor's needs.

• Empowering Vulnerable Individuals: A key prevention strategy is to empower at-risk individuals by providing them with the support and resources needed to reduce their vulnerabilities before a trafficker can exploit them.

Identification

Identifying victims is a challenging but critical task. Traffickers are skilled at manipulation, and victims often do not self-identify due to fear, shame, or psychological control. It is a misconception that trafficking only occurs in other countries; it is a significant problem within the United States.

Victims who are not believed or are met with inadequate responses from institutions can experience re-victimization, which reinforces their sense of helplessness and distrust of authority. A major barrier to identification is the stigma associated with the circumstances of trafficking. Labeling a victim as a "criminal," "delinquent," or "prostitute" prevents professionals from seeing the underlying coercion and exploitation. Overcoming this stigma is essential for effective identification (Toney-Butler et al., 2017).

Policy

Several key policies have been enacted to address human trafficking at both the national and international levels, creating tools for both law enforcement and victim support services.

• The Trafficking Victims Protection Act (TVPA) of 2000 was a landmark piece of federal legislation. It allows trafficked foreign nationals to be eligible for federally funded benefits, including healthcare and immigration assistance.

• The T Visa is a specific provision that offers immigration relief to victims of human trafficking. It prohibits deportation and provides a pathway to potential permanent residency, which encourages victims to come forward and cooperate with law enforcement without fear of being removed from the country.

• The United Nations Sustainable Development Goals also address this issue, with Goal 8 aiming to promote "decent work and economic growth," directly targeting the exploitative labor conditions that trafficking creates.

Scope of Trafficking

Human trafficking, including domestic servitude, occurs in every region of the world. However, measuring its true prevalence is difficult due to the hidden nature of the crime.

• Global Estimates: The estimated number of people in modern slavery varies widely, with figures ranging from 12.3 million to over 45.8 million worldwide. This vast range reflects the significant challenges in data collection.

• Types of Trafficking: According to the United Nations Office on Drugs and Crime, sex trafficking accounts for approximately 50% of all trafficking cases. The International Labour Organization provides a more conservative estimate of 23%.

• Victim Demographics: Children constitute a large portion of victims, making up around 46% of cases. In high-income countries, child trafficking is often for sexual exploitation, forced criminality, or begging, whereas globally it is more often for forced labor (Trafficking, n.d.). Traffickers disproportionately target the extremely poor, those from dysfunctional homes, and individuals who have been abandoned. Approximately 61% of all victims are women and girls.

• Runaways: In the U.S., the link between running away and trafficking is strong. The National Center for Missing and Exploited Children estimates that one in six endangered runaways is likely a victim of child sex trafficking.

• Trafficker Profiles: Trafficking is not typically perpetrated by lone individuals. The majority of cases (57%) are run by organized criminal enterprises. Other structures include "governance-type" organized crime (18%), opportunistic associations (14%), and individual traffickers (11%). This highlights that trafficking is often a business, and identifying one victim may lead to a much larger network.

National Prevalence

In the United States, several organizations work to track the scope of the problem, providing the best available data on this clandestine activity.

• The Polaris Project: This is a leading research and advocacy organization that has handled over 400,000 contacts related to trafficking since its inception.

• National Human Trafficking Hotline: In 2023 alone, the hotline received over 30,000 "signals"—including calls, texts, emails, and web chats. These signals led to the identification of over 9,600 potential cases involving nearly 17,000 victims.

• Michigan Data: In 2023, Michigan accounted for 779 of these tips, which resulted in 254 confirmed cases and 506 victims. The running total of data for Michigan reflects nearly 10,000 tips, over 3,000 confirmed cases, and more than 6,200 victims since the hotline began collecting data.

Across the U.S., victims of both sex and child trafficking are disproportionately women and girls, with women and girls of color being impacted at even higher rates.

Data Limitations

Despite these numbers, there are major gaps in the research on trafficking prevalence and identification (Barrick & Pfeffer, 2024). The data we have likely represents only a fraction of the true scope of the problem.

Key limitations include:

• Hidden Population: Trafficking is a clandestine crime. Victims are difficult to reach and may not self-identify, making accurate counts nearly impossible (Barrick & Pfeffer, 2024).

• Varied Definitions: Different agencies and jurisdictions may use slightly different definitions of trafficking, leading to inconsistencies in data collection.

• Multiple Data Sources: Data is collected by various entities, including social services, healthcare systems, and the criminal justice system, but these sources are often not integrated.

• Difficulty of Proof: Proving trafficking, especially when it involves psychological manipulation rather than physical confinement, is much harder than proving other crimes. This leads to a significant drop-off between potential cases and official prosecutions. For instance, of 11,500 potential situations identified by the National Human Trafficking Hotline in 2019, federal law enforcement opened only 1,830 cases (U.S. Department of State, 2020).

Social Factors

Certain social factors create and exacerbate the vulnerabilities that traffickers exploit. These factors often relate to instability and a lack of a protective social network.

• Unstable or Insecure Housing: Individuals who are homeless or at risk of homelessness are prime targets. This includes youth aging out of the foster care system, who often lack the support services needed to transition to stable independence.

• Displacement: Displaced populations, such as undocumented migrant workers and refugees, are particularly vulnerable. Language barriers can prevent them from understanding the true nature of a fraudulent offer, and the fear of deportation is a powerful tool of coercion.

• Minority or Disability Status: Individuals belonging to minority groups or those with disabilities often face discrimination and marginalization, which increases their risk.

• Poverty and Marginalization: Poverty creates a desperation that traffickers prey on. When people lack access to basic resources, a false promise of a job or a safe home can be incredibly alluring.

These vulnerable populations are disproportionately impacted because their life circumstances align perfectly with the manipulative tactics used by traffickers.

Systemic Contributors

Beyond individual social factors, broader systemic issues within a society contribute to an environment where trafficking can thrive. These are large-scale problems that increase risk for entire communities.

Systemic contributors include:

• Lack of access to quality healthcare

• Inadequate educational opportunities

• Limited access to stable, living-wage employment

• Shortages of safe, affordable housing

• Harmful cultural norms and attitudes around sex, gender, and labor

These systemic failures create a constant state of precarity for many people, making them more susceptible to the false promises of exploiters.

Previous Trauma as a Risk Factor

A history of trauma is one of the most significant risk factors for becoming a victim of human trafficking. Traffickers specifically target individuals who have already been victimized, as they are often more easily manipulated and controlled.

Key trauma-related risk factors include:

• Adverse Childhood Experiences (ACEs): A high ACE score, which measures experiences like abuse, neglect, and household dysfunction before the age of 17, is strongly correlated with a wide range of negative life outcomes, including vulnerability to trafficking (De Vries & Goggin, 2020).

• Neglect from Caretakers: A history of neglect can leave individuals with a profound need for safety and affection, which traffickers exploit through "loverboy" tactics of feigned love and security.

• Intimate Partner Violence (IPV) and Sexual Abuse: Prior experiences with IPV or sexual abuse can normalize exploitation and make it harder for a victim to recognize and resist a trafficking situation.

• Gender Identity: Transgender individuals face high rates of discrimination, family rejection, and homelessness, leading to increased vulnerability. According to a 2015 survey by the National Center for Transgender Equality, 1 in 25 transgender individuals had engaged in sex work, and 19% had participated in "survival sex" to meet basic needs.

In Hospitals

Healthcare settings are a critical, and often missed, opportunity for intervention. Research indicates that as many as 87% of trafficking victims in captivity seek medical treatment at some point during their exploitation but do not receive assistance (Toney-Butler et al., 2017).

Healthcare professionals should be aware of the following dynamics:

• Use of Translators: If a translator is needed for a suspected victim, it should never be a family member or the person who accompanied them to the appointment. This person could be the trafficker. An independent, professional interpreter is essential (Hachey & Phillippi, 2017).

• Trafficker Behavior: Traffickers often seek the fastest possible care to minimize exposure. They may become aggressive or agitated over long wait times in an emergency department and may "hospital shop" to get in and out quickly.

• Victims from All Backgrounds: While it is important to be aware of risk factors, professionals must remember that victims can come from any social group or economic background. A person who appears to come from a stable home can still be a victim.

In Child Welfare & Juvenile Justice Systems

The child welfare and juvenile justice systems are high-risk environments for trafficking. Youth in these systems are often dealing with the exact vulnerabilities—such as a history of trauma, instability, and lack of a protective family—that traffickers seek out.

Although research in this area is limited, existing studies show a strong overlap. A study in Florida of over 12,000 allegations found that half of the children with a human trafficking abuse allegation were already involved in the child welfare system at the time (Scaggs et al., 2024).

Further findings from this study include:

• Females were more likely than males to be involved in the child welfare system.

• Black children were more likely than white children to be involved in both the child welfare and juvenile justice systems.

• Victims of sex trafficking were more likely than victims of labor trafficking to be involved in both systems (Scaggs et al., 2024).

This data underscores the need for professionals in these systems to shift their perspective. An adolescent who appears to be a "perpetrator" of a crime may, in fact, be a victim of trafficking. Adopting a mindset that views these youth as potential victims first is crucial for breaking the cycle of exploitation.

Signs of Human Trafficking

Recognizing the signs of human trafficking requires a multi-faceted approach that looks at physical, behavioral, and psychological indicators. It is also important to understand the common venues where trafficking occurs and the characteristics of potential victims. However, it is essential to remember that many victims may fall outside of a typical profile (Rambhatla et al., 2021).

Physical Indicators

Physical signs are often the most direct evidence of abuse, though they are not always present.

• Injuries and Neglect: Look for unexplained injuries, signs of physical abuse or neglect, poor hygiene, and signs of malnutrition or dehydration (Rambhatla et al., 2021).

• Specific Wounds: Certain types of injuries are highly suggestive of trafficking, such as abrasions from ropes or belts, scratches, road rash, and small, circular cigarette burns.

• Branding and Tattoos: Research has shown that brandings, tattoos (especially those indicating ownership), and rashes are more common in sex trafficking. In contrast, victims of labor trafficking are more likely to present with burns and deep cuts related to hazardous working conditions (Rambhatla et al., 2021).

Behavioral Indicators

Behavioral indicators often reflect the fear and control that define a victim's experience.

• Demeanor: A victim may appear fearful, anxious, submissive, or hyper-vigilant.

• Reluctance to Share Information: Evasiveness or reluctance to share personal information is a major red flag.

• Detachment: The person may speak about their experiences in the third person, a form of mind-body separation common in trauma survivors.

• Physical State: They may appear sleep-deprived or impaired by substances.

• Inconsistent Stories: Pay close attention to inconsistencies in their stories about their home life, job, or relationships.

• Unexplained Absences: For minors, this can manifest as unexplained absences from school, poor attendance, or runaway behavior.

• Pride in Travel: Paradoxically, a young person might boast about travel, which could be a red flag if the details are vague or do not add up.

Psychological Indicators

The psychological toll of trafficking is immense and often presents with symptoms that overlap with other mental health conditions.

• Trauma Symptoms: Victims frequently exhibit symptoms of Post-Traumatic Stress Disorder (PTSD), such as nightmares, flashbacks, irrational fears, and irritability (Hopper & Gonzalez, 2018; Okech et al., 2018).

• Mood and Anxiety Disorders: Depression and anxiety are extremely common (Hopper & Gonzalez, 2018).

• Other Conditions: Substance abuse and suicidal ideation are also prevalent among survivors (Sidun, 2025).

• Trauma Bonding: Victims may show a strong, seemingly loyal attachment to a controlling or abusive individual. This phenomenon, known as trauma bonding, is a survival mechanism that can be mistaken for a consensual relationship.

• Social Isolation: Traffickers work to isolate their victims from friends and family to maintain control. This isolation becomes a significant psychological indicator (Okech et al., 2018).

Identifying Venues

Trafficking can happen anywhere, but certain venues and industries are known hotspots for recruitment and exploitation.

• Online and Youth-Centered Venues: Recruitment often happens online through social media and chat rooms. After-school programs can also be venues, with traffickers sometimes being other students.

• Advertisements: Job advertisements may contain red flags, such as obscured phone numbers, language over-emphasizing trustworthiness ("this is a safe job"), or specifications about ethnicity or youth.

• High-Risk Activities: Activities such as stripping, pornography, forced begging, and drug sales are often linked to or serve as entry points into trafficking.

• Common Labor Venues: Labor trafficking is common in restaurants, hair and nail salons, domestic work (as nannies or au pairs), and agricultural settings.

• Common Sex Trafficking Venues: Sex trafficking frequently occurs in hotels and motels, on the street, in brothels (which may be disguised as homes or legitimate businesses), through escort services, and at truck stops, bars, and strip clubs.

Clinical Red Flags

In a clinical setting, several red flags can indicate that a patient may be a victim of trafficking.

• Controlling Companion: The person is accompanied by a dominant individual who speaks for them, refuses to let them be alone, or becomes agitated when the patient is addressed directly.

• Lack of Documents: The patient lacks identification documents, such as a driver's license or passport, or is not in control of them.

• Inability to Keep Appointments: They are unable to schedule or attend appointments independently.

• Signs of Control: There are signs that the person is working excessively long hours, is being constantly monitored, or has their movements restricted.

• Health Indicators: Recurrent sexually transmitted infections (STIs), especially in a minor, are a major red flag. Other signs can include signs of addiction and injuries that the patient claims are self-inflicted (Hachey & Phillippi, 2017).

Questions to Ask: Identifying Trafficking Red Flags

Because victims may be afraid to disclose their situation directly, asking indirect questions can help gather information and identify red flags. These questions should be asked in a private, safe setting without anyone else present.

Work and Finances

• Are you being paid the wages that were part of the initial agreement?

• Can you change jobs if you want to? Would anything happen to you if you quit your job?

• Did you pay a fee to get your job? Do you owe a debt to your employer?

• Do you have access to your money and your identification?

Freedom of Movement

• Can you come and go as you please, take bathroom breaks, and eat when you want?

• Have you moved around a lot? Do you know your current address?

• Are there locks on the doors or bars on the windows where you live? Can you leave freely?

Living and Working Conditions

• What are your home conditions like? Do you have your own bed?

• Is it too cold or too hot where you live or work?

• Are you provided with safety equipment for your job, like masks, gloves, or a safety harness?

• Does your employer provide your housing?

Safety and Threats

• Has your employer or anyone else ever threatened you?

• Are you concerned about your safety? What about your family's safety?

(Adapted from the National Human Trafficking Resource Center) 

Trauma-Informed Care

A trauma-informed care approach is essential when working with potential victims of trafficking. This approach is designed to create an environment of safety and trust and to minimize the risk of re-traumatization.

Key principles include:

• Recognize Trauma Signs: Be aware of the signs of trauma, including nonverbal cues, and make appropriate referrals.

• Create a Safe Environment: Use slow, calm speech, maintain respectful eye contact, and position oneself at the same physical level as the client. The physical layout of the room, including the location of the door, should be considered to enhance feelings of safety.

• Empower the Client: The goal is to restore a sense of power and control to the client. Allow them to make choices and lead the conversation where possible. Avoid creating a dynamic where the professional is an authority figure to be feared. It is not enough to say "this is a safe space"; the professional must earn that trust through their actions.

Communicating

The language used with a potential victim is critical for building trust. Communication should be supportive, non-judgmental, and clear.

Here are some suggested phrases:

• "We are here to help you, and our priority is your safety. We can help keep you safe."

• "Everyone has the right to live without being abused or hurt, and that includes you."

• "You deserve to be independent and make your own choices. We can help you with that."

• "We can get you help to protect your family and your children."

• "You have rights, and I will do everything in my power to help you."

• "You can decide what is best for you, but let me give you a number you can call for help 24 hours a day. You don’t even have to tell them your name."

Crucially, do not make false promises. Only offer assistance that can realistically be provided. Offering help and failing to deliver can be deeply re-traumatizing.

(Adapted from the Department of Health and Human Services) 

Cultural Competency

Cultural competency is the ability to work effectively with diverse populations. In the context of human trafficking, it involves understanding how cultural factors can influence a victim's experience and disclosure.

• Avoid Assumptions: Do not write off potential signs of trafficking as mere "cultural differences."

• Recognize Language Barriers: Language barriers can obscure discrepancies in a person's story, causing professionals to miss red flags. As stated previously, always use a professional, independent interpreter.

• Understand Cultural Stigma: A victim's immigration status or cultural stigmas around sex and abuse can be powerful barriers to disclosure.

• Examine Personal Biases: All professionals have biases. It is critical to reflect on these biases and prevent them from interfering with identification and care. For example, a bias that a person "should have known better" can completely shut down a provider's ability to see the coercion involved.

Barriers to Identification

Several factors can prevent the successful identification of trafficking victims.

• Lack of Protocols or Resources: Many organizations lack clear protocols for how to respond to a suspected case of trafficking.

• Stigma, Myths, and Stereotypes: Preconceived notions about what trafficking is and who it affects can blind professionals to the reality in front of them (e.g., the myth that it only happens in other countries).

• Lack of Privacy: It can be difficult to separate a potential victim from their trafficker, both physically and psychologically, due to the strong trauma bond that may exist.

• Incomplete History: A client may not give a full or accurate history, making it impossible to identify them as a victim.

Clinical Applications

To apply this knowledge in a clinical setting, professionals should focus on several key actions:

• Establish Trust: Work actively to identify potential victims by establishing trust and consistently practicing trauma-informed care.

• Know Local Resources: Become familiar with the National Human Trafficking Hotline as well as local shelters, advocacy groups, and other support services. Being able to provide a direct, local referral can make all the difference.

• Understand Reporting Laws: Learn the specifics of the mandatory reporting laws in the applicable state or jurisdiction.

• Pursue Further Education: Take advantage of further training opportunities, such as simulations or role-playing exercises, to build skills and confidence in identifying and responding to trafficking.

Head-to-Toe Assessment, 1

A systematic physical assessment can reveal numerous indicators of human trafficking. The following is a comprehensive guide to potential findings from a head-to-toe evaluation.

• Head/Face: Look for bruising (old, new, or healing), lacerations, hematomas, and signs of acute or chronic head trauma or headache. Check for missing hair or bald spots from hair-pulling.

• Ears/Mouth: Assess for hearing trouble, damage to the auditory canal or eardrum, and trauma to the oropharynx (e.g., lacerations, burns, ulcerations). Note any broken teeth, tooth decay, or gum irritation. The oral mucosa can also show signs of anemia or dehydration.

• Eyes/Neck: Note any visual defects, tattoos or brands hidden in the hairline or on the neck, and any signs of strangulation, such as bruising.

• Chest/Cardiovascular: Check for signs of chest trauma, heart murmurs, cigarette burns, and tattoos that imply ownership. Be aware of stress-related cardiovascular issues like arrhythmias or high blood pressure.

• Respiratory/Environmental: Inhalation injuries may be present from exposure to chemicals, toxic fumes, asbestos, or mold. Meth lab exposure can cause burning to the eyes, nose, and mouth, chest pain, and dizziness. Look for signs of tuberculosis (night sweats, coughing up blood, fever, weight loss) or signs of hypothermia/hyperthermia from poor working conditions.

• Gastrointestinal: Assess for chronic GI issues like nausea, vomiting, or abdominal pain. Check for rectal trauma, bleeding, or parasites.

Head-to-Toe Assessment, 2

The assessment should continue through the rest of the body systems, paying close attention to signs of sexual and physical abuse.

• Back/Genitourinary: Look for bruising or scarring on the back. Sexually explicit tattoos or tattoos implying advertisement in the pubic area are a major red flag.

• Obstetrical/Gynecological: Note any OB/GYN complaints, especially recurrent STIs. An STI in a minor is a powerful indicator of sexual abuse. Other signs include repeated unwanted pregnancies, forced abortions, anogenital trauma, and evidence of retained foreign bodies in the vagina. Inquire about the number of sexual partners and condom use.

• Musculoskeletal: Look for signs of repetitive trauma, work-related injuries, or injuries from forced acts (e.g., back problems from wearing heels for long hours, jaw problems from forced oral sex). Note any fractures (old or new) and contractures.

• Extremities/Skin: Check for cigarette or scald burns. Ligature marks or scars around the wrists and ankles are highly indicative of bondage. Look for skin conditions like scabies, infestations, impetigo, or fungal infections.

• Nutritional: Signs of nutritional deficits can include Vitamin D deficiency (from lack of sunlight), anemia, fine or brittle hair, signs of anorexia or bulimia, and severe electrolyte abnormalities. In children, look for growth abnormalities and poor dental health.

• Neurological: Neurological issues can include unexplained memory loss, inability to concentrate, migraines, vertigo, numbness or tingling, and seizures or pseudo-seizures. Insomnia and nightmares are also common.

Key Resource: National Human Trafficking Hotline

The single most important resource for professionals and victims is the National Human Trafficking Hotline.

• Phone: Call 1-888-373-7888.

• Text: Text "HELP" to 233733.

• Emergency: Call 911 for immediate danger.

• Live Chat: humantraffickinghotline.org

• Email: help@humantraffickinghotline.org

This confidential service does more than take tips. It connects victims and survivors to services in their local area and provides training and technical assistance to professionals. Support is available in English, Spanish, and over 200 other languages through interpreters.

Take-Home Messages

Human trafficking is a complex issue, but awareness and diligence can save lives.

• Be aware of the upstream social factors and community characteristics that make certain groups more susceptible to exploitation.

• Remember that trafficking affects people from all walks of life; do not let stereotypes prevent identification.

• Identification can happen before or during confinement. Recognizing early warning signs is a key part of prevention.

• Do not be afraid to ask direct, non-judgmental questions in a safe and private setting.

• Understand that many victims may not have the capacity or willingness to leave their situation immediately due to intense psychological manipulation and fear. Be patient and persistent in offering support.

References

Barrick, K., & Pfeffer, R. (2024). Advances in measurement: A scoping review of prior human trafficking prevalence studies and recommendations for future research. Journal of Human Trafficking, 10(1), 1–19.

Eryarsoy, E., Topuz, K., & Demiroglu, C. (2024). Disentangling human trafficking types and the identification of pathways to forced labor and sex: An explainable analytics approach. Annals of Operations Research, 335(2), 761–795.

Hopper, E. K., & Gonzalez, L. D. (2018). A comparison of psychological symptoms in survivors of sex and labor trafficking. Behavioral Medicine, 44(3), 177–188.

Okech, D., Hansen, N., Howard, W., Anarfi, J. K., & Burns, A. C. (2018). Social support, dysfunctional coping, and community reintegration as predictors of PTSD among human trafficking survivors. Behavioral Medicine, 44(3), 209–218.

Rambhatla, R., Jamgochian, M., Ricco, C., Shah, R., Ghani, H., Silence, C., ... & Kourosh, A. S. (2021). Identification of skin signs in human-trafficking survivors. International Journal of Women’s Dermatology, 7(5), 677–682.

Scaggs, S. J., Starseed, S. C., Kluckman, M., Tueller, S., & Yu, L. (2024). A state-wide analysis of characteristics and predictors of dual system involvement among child victims of human trafficking. Child Abuse & Neglect, 147, 106530.

Sidun, N. M. (2025). Understanding and combating human trafficking: A psychological perspective. American Psychologist.

State of Michigan. (1931). The Michigan Penal Code (Excerpt), Act 328 of 1931, Chapter LXVIIA: Human Trafficking.https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-328-1931-LXVIIA

Trafficking, W. I. H. (n.d.). Human trafficking of children in the United States: A fact sheet for schools. Retrieved July 1, 2025.

Editor's Note: This text-based course is an edited transcript of the webinar, Recognizing and Identifying Teen Dating Violence, presented by Kaytlyn Gillis, MSW, LCSW-BACS.

Learning Outcomes

After this course, participants will be able to:

• Identify the various ways IPV takes place in teen relationships.
• Explain unhealthy vs healthy teen relationships.
• Identify best practices for developing a safety plan for teen victims of IPV and understanding when to report and/or involve parents.

Risks and Limitations

This course includes information about relationship abuse, addressing various forms, including those specific to the LGBTQ+ community. Given the wide range of abusive and traumatic experiences in relationships, this is not an exhaustive overview. Some experiences may differ from those described here. Participants are encouraged to analyze this material within the context of their professional climate and practice. The roles and practices of individuals who support survivors vary greatly, so these experiences may also appear differently depending on your specific role.

Presenter Positionality

Before we begin, I’d like to share a bit about my positionality to provide context for my perspective. I am a white woman, which affords me the privilege of presenting as white and benefiting from the societal advantages that come with that. I am also a member of the queer and LGBTQ+ community.

I have personal experience as a queer teen navigating the challenges of coming out. While I faced bias and discrimination related to my identity, I also carried the privilege associated with being white. Additionally, I am a survivor of intimate partner violence and relationship trauma. When I speak on these topics, I draw from both firsthand experience and professional expertise.

As a therapist, I work with survivors of family and relationship trauma across a broad spectrum, including those who have experienced domestic violence within their families or relationships. My clients span all ages, from young people to older adults. I regularly provide training on recognizing intimate partner violence and have worked extensively with the legal system, offering education and raising awareness about IPV, which is often overlooked in that context.

In terms of education, I earned my bachelor’s degree from Clark University, a master’s degree in social work from Tulane University, and am a current Ph.D. student at Michigan State University, focusing on domestic violence.

What is IPV?

Intimate partner violence (IPV) is defined by the CDC as abuse or aggression occurring within a romantic relationship. Broadly, it includes any intentional behavior in a relationship that causes emotional or physical harm. While this definition may seem vague, the flexibility is intentional to encompass the diverse ways IPV manifests.

Different behaviors qualify as abusive depending on the individual and the context. What one person considers harmful might not be perceived the same way by someone else. That said, there are clear criteria for identifying and categorizing domestic violence.

IPV can happen to anyone, regardless of gender, race, nationality, sexuality, faith, socioeconomic status, or age. It’s important to emphasize this point because certain groups—such as teens and older adults—are often excluded from discussions about IPV. These populations are frequently overlooked in IPV assessments and broader conversations, even within clinical settings. Ensuring inclusivity in these discussions is crucial to addressing IPV for all age groups.

Why is it Important to Learn About IPV in Teens?

Understanding IPV in teens is essential because healthcare workers are often the first point of contact for individuals experiencing abuse. Our work spans a variety of settings—healthcare facilities, clinics, schools, and policymaking spaces, among others. While I can’t list every role represented here today, it’s safe to say we work in diverse environments.

Most, if not all, of us will encounter a client who has been a victim of IPV at some point in our careers. However, many of us might not recognize that this has occurred. This isn’t necessarily a fault of the clinician; not every client will disclose their experiences, especially if it doesn’t feel relevant to the situation at hand.

Still, given the prevalence and relevance of IPV, it’s vital to understand our unique role. We are often the first professionals to identify abuse simply because of the nature of our interactions with clients. Whether in emergency rooms, social services, or other settings, we’re often the initial point of contact. By creating safe spaces for teens to disclose their experiences, we increase the likelihood that they’ll feel comfortable coming forward. Equally important is knowing how to respond and take appropriate next steps when they do.

Terminology

Before diving deeper, let’s review some key terms for this training:

• Victim and Survivor: I use these terms interchangeably, depending on the context. I recognize that people have strong preferences for one term over the other, and I aim to use both respectfully.
• Perpetrator: Refers to the individual committing the abusive act. This person is often the partner but not always.
• Intimate Partner Violence (IPV), Domestic Violence (DV), and Teen Dating Violence: These are related but distinct terms that I will use throughout the session, with context provided as needed.

Understanding and respecting these terms is critical as we navigate discussions about IPV.

2-Minute Reflection Exercise

The purpose of this quick reflection exercise is to help us, as clinicians, reflect on our biases—because we all have them. Consider this question: Is intimate partner violence (IPV) in teen relationships the same as in adult relationships? Why or why not?

There is no right or wrong answer. Experiences vary widely, and your response will be shaped by your own knowledge and perspective. Whether this is your first time learning about IPV or you’ve had personal or professional exposure, reflect on what you’re bringing into this discussion. Keep this in mind as we move forward, as this reflection will frame how you engage with the material.

Forms of Dating Violence in Teen Relationships

When discussing forms of dating violence in teen relationships, it’s essential to consider the context. Many terms will be familiar, either from working with adults or encountering them in social media discussions. However, teens often experience these behaviors in unique ways. Let’s explore some of these forms and how they may present in teen relationships.

Physical Abuse

Physical abuse is often the first form that comes to mind when people think of domestic violence. It includes actions like hitting, slapping, throwing objects, or using physical force to harm someone. Unfortunately, this type of abuse is frequently prioritized in legal assessments, sometimes overshadowing other forms of IPV. While physical abuse remains a critical concern, we now understand that IPV encompasses many other harmful behaviors.

Coercive Control

Coercive control involves behaviors aimed at dominating or manipulating a partner through threats, punishment, or retaliation. For teens, this might look like a partner threatening to break up, exposing private information, or sharing intimate photos on social media. Other examples include refusing to use—or lying about using—birth control, or pressuring a partner to do the same. These behaviors often exploit vulnerabilities unique to adolescents, such as social reputation or family dynamics.

Emotional Abuse

Emotional abuse includes actions like name-calling, intentional humiliation, and stonewalling (e.g., ignoring or giving the silent treatment). Teens may report partners calling them names or refusing to engage in communication as forms of punishment. It’s worth noting that these behaviors often overlap with other forms of abuse, compounding their impact.

Sexual Abuse

Sexual abuse can involve forced sexual contact, sharing intimate content without consent, or lying about sexually transmitted infections (STIs). Among teens, sharing explicit photos or videos on social media without permission has become an alarming trend. These violations of trust and privacy can have lasting emotional consequences and are increasingly prevalent among young people.

Psychological Abuse

Psychological abuse often includes manipulative behaviors like gaslighting, stalking, or spiritual abuse. While teens might describe their experiences using terms like "narcissistic abuse," it’s important to approach these statements with curiosity rather than judgment. For example, when a teen claims their ex is a "narcissist," it provides an opportunity to explore what they’re experiencing and how it’s affecting them. The goal is not to define or label but to understand and support.

Case Studies

Case Vignette 1: Jesse

Jesse, a 13-year-old student, was referred after being caught skipping class. She shares that her relationship stress has made school feel unimportant. Initially, her truancy appears to be the main issue, but through active listening, it becomes clear that her relationship is the root cause.

When Jesse describes her partner as “not in school anymore,” it raises a red flag. This vague detail prompts further exploration into her concerns and discomforts. By providing education on healthy versus unhealthy relationships and information about consent laws, clinicians can empower teens like Jesse without making them feel judged or pressured. Avoiding direct confrontation about her partner’s age helps maintain trust, ensuring she feels safe to share more when ready.

Case Vignette 2: Braden

Braden, a 15-year-old, seeks help, describing his relationship as “toxic.” Rather than imposing definitions, the focus is on understanding his perspective: What feels toxic? What’s happening? This allows Braden to define his experience in his own terms.

It’s crucial not to assume the gender of Braden’s partner. Using neutral pronouns like “they” creates a more inclusive environment, especially for queer teens who may fear disclosing their identity. Braden expresses concerns about being outed—a common fear among LGBTQ+ youth—and receives education on healthy versus unhealthy relationships, tailored to his situation.

Unique Factors of IPV in Teens

Intimate partner violence (IPV) among teens presents unique challenges, often making it difficult to recognize and address. Teens are frequently overlooked in IPV assessments, and many don’t realize they are experiencing abuse. This lack of awareness can stem from various factors, including behaviors being normalized, excused, or influenced by harmful trends on social media. Some teens may not understand what constitutes abuse because they come from family environments where abusive behavior is common. For these teens, what they experience in their relationships may feel normal, making recognition even harder.

Fear of getting into trouble can also deter teens from seeking help. Some may face restrictions about dating altogether or may worry about dating someone their parents disapprove of—whether that person is of the same gender, a different race, or a different faith. These fears can lead them to hide their relationships, further complicating their ability to address IPV.

How is Dating Violence Different with Teens?

Dating violence among teens differs significantly from that experienced by adults, and context is key to understanding these differences. While no age excuses bad or unhealthy behavior, it’s important to approach young relationships with an awareness of developmental factors. Teens are still learning about boundaries, emotions, and relationships. Labeling certain behaviors as abusive without considering context can sometimes complicate the conversation.

Take, for example, the term “gaslighting.” It was named Word of the Year recently, largely due to its prevalence on social media. While the concept holds merit in many situations, social media often dilutes its meaning, applying it broadly to any form of conflict or miscommunication. This highlights the importance of carefully assessing what teens are describing without immediately assigning labels.

How is Dating Violence Different with LGBTQ+ Teens?

Approximately 26% of female teens and 15% of male teens experience dating violence. While comprehensive statistics for LGBTQ+ teens are limited, it’s clear that teens of all genders face these challenges. For LGBTQ+ teens, the experience can be uniquely complex.

Take Braden’s story as an example. LGBTQ+ teens often fear being outed. Their families, schools, or communities may not be accepting of their sexuality or gender identity. Sharing their experiences of abuse or dysfunction can risk exposing their identities, creating a dangerous situation. For many, the potential consequences of being outed—such as rejection, hostility, or homelessness—are so severe that they choose to remain silent about the abuse.

Social environments often compound these difficulties. Teens may grow up hearing negative messages about LGBTQ+ people, internalizing fear and shame. Recent legal changes in some regions have only heightened this fear, discouraging teens from disclosing information that might reveal their identities.

For healthcare workers, it’s crucial to validate these fears. Disclosure for LGBTQ+ teens isn’t just a conversation—it can feel like a life-or-death decision. Some teens I’ve worked with have been kicked out of their homes at young ages, while others live in constant fear of such an outcome. The stakes are incredibly high for these individuals.

Abuse within LGBTQ+ relationships can also take specific forms. A partner may threaten to out the teen to their family or community if they attempt to leave or report the abuse. This coercion forces many teens to remain in harmful relationships, reasoning that enduring the abuse is safer than the potential fallout of being outed. Additionally, queer teens may experience unique forms of sexual abuse, such as being forced to have unprotected sex under the assumption that pregnancy is not a risk.

These layered complexities demand a nuanced and compassionate approach from those working with LGBTQ+ teens experiencing IPV.

Common Ways Teens May Excuse Abuse

Teens often rationalize or excuse abusive behavior in ways that reflect their environment, developmental stage, or lack of awareness. Some common examples include:

• Intellectualizing: Teens may justify their partner’s actions, saying, “He was just angry; he’s not normally like this.”

• Desensitization: Teens who grow up in abusive families or violent communities may have a diminished emotional response to abuse. They’ve been exposed to so much violence or trauma that they fail to recognize abusive behaviors as abnormal.

• Excusing: Teens might downplay harmful behavior by attributing it to external stressors. For example, they might say, “She was just stressed about finals; it’s not usually like this.”

• Beliefs About Gender Roles: Some teens internalize harmful societal norms. A boy might say, “Men just act like this sometimes. I shouldn’t get upset.”

• Reasoning or Bargaining: Teens may try to negotiate with their abuser, saying things like, “Please don’t out me. I’ll stay with you, just stop doing this.”

• Self-Blame: Like survivors of all ages, teens often blame themselves for the abuse. Developmentally, they are particularly prone to internalizing guilt for negative events, believing, “If something bad happened, it must be my fault.”

• Denial: Many teens mimic the justifications they’ve heard in their families. A teen might say, “My boyfriend wasn’t angry, he was just tired,” echoing what they’ve heard parents say, such as, “Dad wasn’t angry, he was just tired,” or, “Mom wasn’t loud, she was just frustrated.”

This cycle of denial and minimization is deeply ingrained in many young people. It reflects a learned tendency to downplay bad behavior and compare it to others, often concluding, “It’s not that bad. Other people have it worse.”

By recognizing these patterns, we can better support teens in identifying unhealthy relationships and breaking free from harmful cycles.

“Toxic” Relationships

Let’s take a moment to talk about the buzzword “toxic.” If you’ve been on social media over the past couple of years or if you work with kids, you’ve likely encountered this term. It’s everywhere right now, and while it’s a useful descriptor in some cases, it’s important to understand how its meaning varies.

As clinicians, we know that not all toxic relationships are abusive. Toxicity exists on a spectrum. When I hear the term in a clinical setting, I associate it with specific behaviors—those that are abusive, extremely unhealthy, or even dangerous. However, teens often use the word differently.

For many young people, “toxic” might simply describe a personality conflict or an ongoing disagreement. There’s also a generational difference in how these terms are applied, which can create a gap in understanding between adults and teens. My goal is not to label their usage as right or wrong but rather to gain insight into their perspective.

I’ve worked with clinicians who, upon hearing a teen describe their relationship as “toxic,” immediately assume the teen is experiencing abuse. While that could be the case, it’s essential to pause and explore further. Jumping to conclusions—either to dismiss or validate their claim—can overlook the nuances of their experience. Treatment is most effective when it centers the teen’s perspective and meets them where they are.

What is “Normal” in Teen Relationships?

What qualifies as “normal” in teen relationships? It’s a complicated question, as adolescence is a time of exploration and growth. Here are some behaviors that often fall within the realm of normal:

• Occasional name-calling
• Arguments and disagreements
• Competition or jealousy
• Frequent changes in romantic interests
• Online arguments or drama
• Curiosity about sexuality

While these behaviors might not always be healthy, they are common developmental milestones for teens. Many of us can likely relate to some of these experiences from our own younger years.

On the other hand, certain behaviors cross the line and are decidedly not normal. These include:

• Physical violence (hitting, punching, etc.)
• Sexual violence
• Excessive name-calling
• Bullying or cruelty

Occasional name-calling, for instance, can fall into the realm of normal depending on the context. Teens often refer to it as “josing” or playful banter, and it’s important to assess whether the behavior is mutual or intended to cause harm. Bullying or intentionally cruel behavior, however, is never acceptable.

When discussing intimate partner violence (IPV) or teen dating violence, it’s vital to stress that bad behavior is never excusable. However, I encourage viewing each situation as an opportunity to educate teens about healthy relationships. By considering the context of their behavior, we can guide them toward better understanding and healthier interactions.

Younger teens, for example, might react with more extreme emotions due to their developmental stage. While it’s not acceptable for someone to endure this, understanding that they are still learning what is and isn’t okay can help frame conversations. Cultural differences may also influence what is considered typical behavior.

Ultimately, “normal” doesn’t always mean healthy, and it doesn’t mean acceptable. Everything—good or bad—becomes an opportunity to explore, educate, and guide teens toward healthier relationships while reinforcing that dating violence is never excusable.

IPV in Modern Times

Intimate partner violence (IPV) among teens has evolved in modern times, introducing challenges that are often overlooked in traditional IPV assessments. Technology plays a significant role, with issues such as tracking devices, stalking, and surveillance through social media becoming increasingly common. Social media, in particular, has become a powerful tool for perpetuating teen dating violence.

Teens often underestimate the permanence and impact of online activity. Many believe that platforms like Snapchat or Instagram stories are fleeting, thinking, “It’s only on my story, so no one will see it later.” They don’t always realize that content shared online rarely disappears entirely. As clinicians, our role includes educating teens about these risks, even if the information doesn’t seem to resonate immediately.

I recognize that when I bring up these topics with teens, it might go in one ear and out the other. That’s part of the challenge of working with this age group. If someone had tried to explain these concepts to me as a teenager, I might have dismissed it too. But our responsibility is to educate, persistently and patiently, and provide tools for navigating these modern risks. Small things like tagging locations or sharing check-ins might seem harmless to them, but they’re often used by others to monitor their movements or activities.

Why Teens May Seek Support

Teens come to us for a variety of reasons, and it’s not always obvious at first that IPV is involved. For example, as I mentioned earlier with Braden, a teen might openly say, “My relationship isn’t going well,” or use the word “toxic.” But more often, they come to us for unrelated issues, and only later do we uncover dating violence beneath the surface.

There are certain signs that may point to underlying IPV, such as:

• Poor self-esteem
• Mental health concerns like depression or anxiety
• Sleep difficulties
• Appetite changes
• Personality shifts
• Academic or behavioral changes

For instance, imagine a straight-A student who sits at the front of the class every day. Suddenly, they start failing their classes, sleeping through lectures, or showing no interest in school. Such drastic changes should prompt us to ask, “What’s going on here?”

Teens may also get into legal trouble or face disciplinary action at school, which can sometimes be connected to relationship stress or abuse. Parents often play a key role in these situations. Some will approach us saying, “Here’s my teen. Fix them. They’re the problem.” Others will be more supportive, expressing a desire to help their child navigate their struggles.

Supportive parents can make a significant difference. When a parent encourages their teen to engage in therapy or conversations about their challenges, it often creates a productive environment. However, in cases where the teen feels forced into counseling, it can backfire. For example, you might start a session by saying, “Well, since you’re here anyway, let’s play Uno while we talk.” This relaxed approach can help ease the tension and make the teen feel less pushed.

Whether a teen feels supported or pressured, the goal is to meet them where they are, gradually building trust and creating space for honest conversations about what they’re experiencing.

How Can We Support Teen Clients During this Time?

Supporting teen clients during this time involves many of the same principles we use with all clients, but with added sensitivity to their unique developmental needs. Listening empathetically and allowing them to share their story without interruption is critical. Often, clinicians worry about the smaller details, like exact times or dates, but those specifics aren’t our priority. If a teen says something happened on Friday night but isn’t sure if it was at 10:00 or 11:00, that’s okay. Our role isn’t to be detectives—it’s to help them process and heal. The healing begins when they feel heard.

Encouraging documentation can also be empowering. For example, if reporting is necessary, I model transparency by showing them what I’m writing. I explain, “This is the information I have, and here’s how it might be shared—whether that’s with a parent, school staff, or law enforcement.” This practice ensures they’re informed and minimizes surprises, helping build trust.

Having open conversations is equally important. For anyone working with young people, one crucial reminder is to avoid taking their anger or frustration personally. Teens often react with extreme emotions; it’s part of their developmental stage. While this doesn’t mean we should tolerate inappropriate behavior, it helps to remember that their reactions are rarely about us.

Avoid instructing them to leave their relationship. Saying, “You need to end it,” can alienate them, making them less likely to trust or confide in us. Similarly, trying to explain or reason with teens often backfires. They’re likely to push back even harder—sometimes just for the sake of arguing. I’ve had teens argue with me about the color of the sky simply because they wanted to challenge something.

Instead, take a nonjudgmental approach. If a teen says something like, “I have to stay in this relationship because I’m keeping them alive,” respond with curiosity rather than judgment. Say, “Tell me more about that.” Avoid insisting they report their situation unless legally required, as forcing this step can strip away their sense of autonomy.

Finally, avoid making assumptions about their gender, sexuality, or faith. Comments like, “This is God’s plan,” or suggesting they pray can be alienating unless you know their faith aligns with such sentiments. Instead, meet them where they are and let them guide the conversation.

Who is at Risk?

Which teens are most at risk for dating violence? Certain factors increase vulnerability. Teens who experience abuse or dysfunction at home are particularly susceptible. Those with poor self-esteem, depression, or other mental health struggles are also at higher risk.

Living in violent environments or witnessing domestic violence at home is another significant factor. In my work, I often see connections between unhealthy family dynamics and later relationship patterns. For example, a teen who grows up watching their father abuse their mother—or a grandfather mistreat an aunt—may come to view gender-based violence as normal. This normalization increases their likelihood of experiencing or perpetrating dating violence.

Research also highlights a link between early sexual or dating behaviors and higher risks of teen dating violence. While there are many theories about why this happens, it’s a pattern worth considering. Additionally, having friends who experience dating violence can normalize the behavior within social circles, further perpetuating the cycle.

How Will I Know if a Teen is Experiencing Dating Violence?

Identifying dating violence in teens isn’t always straightforward. Some teens will self-report, as in Braden’s case, directly telling you about their situation. Others might display visible signs, such as body language, physical injuries, or behavioral changes.

In some cases, external factors bring teens to your attention. Schools might mandate sessions with a counselor due to legal troubles, disciplinary issues, or behavioral concerns. For instance, a teen caught fighting might reveal they were defending themselves from a violent partner. Similarly, substance use or self-medication could indicate an underlying issue like dating violence.

Mandated sessions can go either way. Sometimes, they create an opportunity to connect with a teen, while other times, the teen resents being forced into therapy. When a teen is resistant, a low-pressure approach can help. For example, start with something casual like, “Since you’re here anyway, let’s play a quick game of Uno.”

Listen carefully to what teens say. Phrases like, “I’m afraid to break up with them,” or “My partner controls me,” can be red flags. Teens might also blame themselves, saying, “Maybe it’s my fault,” or express fear of retaliation, such as, “They’ll out me if I tell anyone.”

Social media complicates these situations. Sharing passwords is, for some reason, a current trend among teens, and it often enables controlling behaviors. A teen might say, “I can’t tell you what happened because they have my Snapchat password.”

Keep in mind that many teens won’t disclose their experiences immediately, or at all. You might work with a teen for weeks or months before uncovering signs of dating violence. Maintaining an open mind and a judgment-free environment is crucial to creating a space where they feel safe to share.

Assessing and Screening

When assessing and screening, the first step is ensuring confidentiality while being transparent about exceptions. When I work with teens, I start by reassuring them: “I’m not going to tell your parents what we talk about.” Most teens are deeply concerned about confidentiality, and for good reason. I explain that everything they share stays private unless it falls under specific exceptions, which I review with them to avoid surprises later.

Always conduct assessments alone—especially without parents present. This ensures the teen feels safe to speak openly. If a parent insists on being involved, I adapt my approach depending on the situation. Sometimes, I’ll explain that it’s policy to meet with the teen individually. Other times, I’ll agree to a joint meeting first, followed by private sessions with the teen going forward. In certain cases, I meet with the teen privately before bringing in the parent. There’s no one-size-fits-all approach, so flexibility is key.

Referrals and ongoing safety assessments are crucial. For instance, if a teen comes in with visible bruises or scrapes, they may need a referral to their primary care doctor. It’s important to provide clear, actionable resources so they know where to turn for additional help.

One critical reminder: never include information about dating violence on discharge paperwork. Teens often toss these papers into their backpack, where a parent, friend, or partner might find them. A discovery like that could put the teen in an unsafe situation. Instead, provide education verbally and create a safe space for them to process their experiences. Avoid trying to convince them they’re in an abusive situation—they’ll resist. Instead, focus on education and let them come to their own conclusions in a supportive environment.

Always ask about other forms of abuse, not just physical violence. While this is starting to change, many assessments still focus heavily on physical abuse. Stay gender-neutral and avoid assuming sexuality or gender. Use open-ended questions like, “What’s your relationship like with your partner?” or “How do they treat you?” rather than asking directly if they’ve been emotionally abused.

Teens may not immediately recognize or acknowledge their social supports. When creating safety plans, I’ve had kids suddenly remember a coach or teacher who has been a source of encouragement. These moments can be empowering and remind teens that they’re not alone.

Lastly, don’t rush to report unless there’s an immediate safety issue. Reporting is sometimes necessary, but it should never be done impulsively. I’ll address this in more detail later.

Documenting and Reporting

When documenting and reporting, accuracy and clarity are essential. Always record as much detail as possible in the teen’s own words, including the date, time, location, and specific events they describe. If they say something happened “Friday night after the football game,” write exactly that. It’s not our role to investigate whether it was 10:00 p.m. or sunset or who was present—we document what the teen shares, not what we suspect or assume.

Safety assessments, referrals, and resource recommendations should all be part of your notes. Always seek consultation or support when needed. No matter how experienced we are, it’s helpful to bounce ideas off a colleague, whether it’s to determine if something is reportable or to gain a fresh perspective on a safety concern.

It’s also important to remember that clinical notes are not the same as police reports. While this distinction may be familiar to many, it’s worth emphasizing. Police reports are investigative and involve gathering evidence, whereas clinical notes reflect the client’s narrative and our professional observations.

In summary, thoughtful documentation and collaborative consultation are key to providing effective support while maintaining ethical standards.

Legal Issues and Reporting

I’ve encountered situations where clinicians mistakenly shared their clinical notes with the police. It’s important to clarify that our documentation serves a different purpose. Clinical notes are for therapeutic and professional use, not for investigation. Legal requirements, however, vary depending on your state and professional license.

Each license comes with specific mandates. Some states require healthcare practitioners to report certain situations, while others do not. These laws are changing frequently, making it crucial to stay updated on current regulations.

Here are common examples of reportable scenarios:

• Sexual abuse or assault
• Threats of harm to oneself or others
• Dating violence involving a partner over 18

However, the specifics depend on your jurisdiction, license, and agency policies. For instance, some agencies may require reporting a sexual assault to a supervisor, even if it doesn’t meet state-mandated thresholds. Similarly, in schools, if a student discloses suicidal ideation with a plan, that may need to be escalated to administrators, parents, or law enforcement.

Confidentiality is critical when working with any client, especially protected populations. For example, if a teen has a younger sibling exposed to abuse or neglect, or if the teen is a parent themselves, reporting laws may apply differently. These considerations make it essential to understand both the specifics of the law and the unique circumstances of each case.

Different Types of Reporting Laws

There are four primary categories of reporting laws, though these can vary by jurisdiction:

1. Injuries caused by weapons
2. Abuse, neglect, or exploitation of children
3. Abuse, neglect, or exploitation of vulnerable adults or elders
4. Situations involving other exposed individuals, such as younger siblings or dependents

For example, if a teen comes to you with a baby, your reporting obligations may extend to the child’s safety as well. Similarly, you may need to report if the teen’s younger sibling is in harm’s way, even if the teen themselves isn’t the primary focus. Each situation requires a careful assessment of who is at risk and the context surrounding the abuse or neglect.

Unintended Consequences of Reporting

While reporting is sometimes necessary, it’s important to be mindful of unintended consequences. I’m not suggesting we avoid reporting, but we need to consider the potential risks.

For LGBTQ+ teens, reporting can unintentionally out them to their family or school, potentially placing them in a life-threatening situation. Forced outing may make them feel unsafe, isolated, or at greater risk of harm. Similarly, teens of color face disproportionate representation in the child welfare system. Historically, children of color have been removed from their families at much higher rates than their white peers, creating additional trauma and systemic inequities.

Other fears teens express include:

• Fear of Child Protective Services (CPS) involvement
• Fear of police or legal action
• Fear of retaliation from their family or abuser

Some teens, especially those from undocumented families, worry about the implications for their family’s immigration status. Others might have had negative past experiences with authority figures, healthcare workers, or law enforcement, further compounding their fears.

For many, the idea of involving parents can feel worse than the abuse itself. I’ve had teens tell me, “If you tell my dad, it’ll be so much worse than what I’m already dealing with.” In such cases, family violence or abuse may already be present, adding layers of complexity to the reporting decision.

Shame and embarrassment are also common barriers to disclosure, particularly for teens who feel they’re at the mercy of adults making decisions about their lives. These factors highlight the importance of balancing legal obligations with compassion and careful judgment.

Things to Be Mindful of When Reporting

When reporting, consider the following:

• Impact: Who will be affected, and how?
• Biases: Are implicit biases influencing your decision?
• HarmReduction: Assess the risks and benefits of reporting to ensure you minimize harm.

Consultation is invaluable. When I worked in a school, I often relied on colleagues to bounce ideas off of. Talking through a case can help you avoid rushing into a decision or missing something important.

When you must report, be honest with the teen. For older teens, I model transparency by saying, “Here’s what you told me. This is the information I’m required to share, and here’s who I’ll share it with.” For example: “You said it happened Saturday night after the football game, and you were sexually assaulted. That’s the information I’ll need to report.”

This approach ensures they’re not blindsided by a visit from CPS or law enforcement. It empowers them to understand the process and feel less helpless.

Should You Report?

Most situations aren’t clear-cut yes or no decisions. Some are obvious, but many require careful consideration. Here are a few examples to reflect on:

1. A gay teen discloses an abusive relationship with an older female partner, involving physical fights and name-calling.
   Questions to consider: How much older is the partner? Does the behavior meet the threshold for abuse or reporting in your jurisdiction?

2. A young teen reports living in a violent household with physical abuse, substance use, and a three-year-old sibling present.
   Here, the risks extend beyond the teen to their younger sibling. Assessing the safety of everyone in the household is critical.

3. A young male discloses that his female partner yells at him and makes him feel bad.
   This might not warrant reporting, but it’s worth exploring further to determine whether there’s a pattern of abuse or harm.

In each scenario, the key is to weigh the risks, consult when necessary, and prioritize the teen’s safety and well-being.

Safety Planning

When working with teens on safety planning, the process is similar to working with adults but requires adjustments to suit their developmental stage and unique needs. Safety plans should always be personalized and tailored to the individual. They can be handwritten, saved in their phone, or even verbalized. What’s most important is that the plan is memorable.

In high-stress or crisis situations, teens are unlikely to pull out a written safety plan. Instead, the conversations we’ve had and the tools we’ve discussed stay in their minds, helping them recall where to go or who to contact. For instance, a teen might suddenly remember they can go to Coach Johnson’s office because we talked about it during safety planning. This process lights up those mental connections and reinforces their support network.

Start by identifying priorities. Protect living things first, and create a list of people they can call. Review their support system, including friends, school staff, or trusted adults. Having a point of contact at school is often crucial since that’s where teens spend most of their time. This could be a teacher, coach, school counselor, or social worker.

If applicable, explore their faith or social communities. Teens may find support through a youth pastor, a trusted neighbor, or older relatives like cousins or siblings. While parents are often the first line of support, extended family members can also play a vital role in providing safety and guidance.

Safe spaces are equally important. Ask where they feel secure. While many teens say their room, encourage them to think of other places as well. I’ve had teens say they feel safe in the choir room or other familiar spaces at school. Knowing where they can retreat during difficult times is an essential part of the plan.

Ongoing safety assessments are critical. In addition to evaluating risks related to dating violence, assess for suicidal or homicidal ideations, as these risks often escalate in crisis situations.

Crisis Resources

It’s also important to prepare teens to access crisis resources quickly. Go over how to call 911, as even simple actions like locating the emergency button on a phone can feel overwhelming during a crisis. Some teens freeze, unsure whether to press the red button, type “911,” or use the emergency lock screen. Reviewing these steps in advance can make a big difference.

Provide additional resources like the 988 Suicide & Crisis Lifeline and the teen-specific crisis text line (741741). For privacy, teens can save the number under a nondescript name like “Chris from Math Class” to avoid questions if someone looks through their phone.

Discuss online safety as well. Teens should change passwords if they’ve shared them with a partner or anyone else who might misuse them. While messages about not checking in or minimizing social media posts often go in one ear and out the other, repeating these points over time can help them sink in.

Finally, provide psychoeducation on laws and safety around sharing photos. This issue is prevalent, and while teens may not want to disclose whether it applies to them, giving them the information empowers them to make safer choices.

Examples of Safety Plans

Here’s an example of a safety plan for Braden. He identified his older cousin Erica as a key support, which is great, along with her mom. He also mentioned his favorite teacher, Miss Terry, as someone he could turn to for help.

We reviewed how to pull up emergency numbers on his phone. While this might seem basic, in a crisis, having practiced it can make all the difference. For crisis support, we identified his safe place: the teen LGBTQ+ center. Braden loves painting and playing Dungeons & Dragons, so we talked about how engaging with his D&D group chat could provide a positive distraction. Sending silly memes or connecting with the group is a small but meaningful way to cope.

We also addressed online safety. Braden changed the passwords for his Instagram and Snapchat accounts, which his boyfriend had previously accessed. Additionally, we discussed strategies for staying safe online, emphasizing the importance of privacy and protection.

Jessie’s safety plan followed a similar approach. Her support network included her mom, close friends, youth pastor, and volleyball coach. She saved crisis numbers like 911, the 988 lifeline, and the teen crisis text line (741741) on her phone.

For her safe place, Jessie chose her room, but we also explored other options. She listed coping skills that work for her, and we incorporated the same psychoeducation we provided to Braden. This included discussions on online safety and maintaining her privacy.

Why Safety Plans Matter

As you may notice, these safety plans include similar steps:

• Building a social support system
• Ensuring access to crisis numbers
• Identifying safe spaces
• Listing effective coping strategies
• Providing ongoing psychoeducation

The repetition is intentional. These steps reinforce critical tools and resources that teens might rely on during difficult moments. Most kids won’t pull out a written safety plan during a crisis. Instead, these conversations jog their memory when it matters most.

For example, if it’s a Saturday night and Jessie can’t reach her teacher or school counselor, she remembers she can text the crisis line or call a trusted friend. Similarly, Braden might think of his D&D group chat or the LGBTQ+ center when he’s feeling overwhelmed. Safety plans don’t just serve as lists—they create mental roadmaps, empowering teens to take action and access support when they need it.

Frequent Questions and Summary

One of the most common questions I receive during these trainings—especially over the past couple of years—is about how changes in laws or societal shifts are affecting clinicians, and whether these changes are relevant to teen dating violence.

This is a complex question, and the answer often depends on the state you’re in. It’s clear that many of us are grappling with this issue in various ways. The challenge lies in holding space for clients experiencing feelings of powerlessness. For example, when teens express frustration or fear about things beyond their control, it’s important to acknowledge their struggles without pretending we can solve them.

Sometimes, safety plans will need to be adapted to these circumstances. I may adjust how much I document or carefully consider the wording I use, always keeping the teen’s safety and privacy in mind. My focus in these situations often shifts to being present—holding space for their fear, uncertainty, and vulnerability. As clinicians, it can be difficult to sit with the reality that we can’t always provide immediate solutions, but the act of being there is powerful in itself.

Another frequent question I get is how therapists or clinicians with personal experiences of intimate partner violence (IPV) or family violence can use their history to help teens. This is an important topic, and I want to emphasize a few key points.

First, maintaining boundaries is essential. Each of us will have different relationships with the teens we serve, and it’s crucial to know what aspects of our history are relevant to the session. For instance, I once worked in a small town outside New Orleans, where everyone seemed to know everyone else. Many of the teens I saw were connected to teachers or counselors at their school. While I wasn’t from that area and didn’t share a history with them, some of my colleagues did. In those cases, maintaining professional boundaries became even more critical to avoid overstepping or bringing personal history into the session unnecessarily.

Second, use personal insight wisely. Remembering yourself as a young person can provide valuable perspective. For example, when discussing social media, I often reflect on how invincible I felt as a teen. If someone had warned me not to overshare on MySpace or similar platforms, I probably wouldn’t have listened. Now, with hindsight, I can frame my advice in a way that feels relatable rather than preachy.

Third, model resilience and recovery. Teens often assume that adults in helping roles have perfect lives and have never faced challenges. By normalizing the human experience, we show them that growth and healing are possible. For instance, acknowledging that everyone makes mistakes or faces struggles helps break down unrealistic expectations and creates a space for openness and connection.

As we close, I want to leave you with this: Continuous growth is a lifelong journey, both as individuals and as clinicians. Whether it’s examining our biases, reflecting on how our personal history shapes us, or finding ways to strengthen our practice, growth is about more than avoiding blame or shame. It’s about striving to be better for ourselves and the people we serve.

Ask yourself:

• How does my history impact who I am?
• How does it shape me as a clinician, a healthcare worker, a partner, or a member of society?

These reflections help us stay grounded in our work and support our ongoing evolution as professionals. By embracing growth, we can better serve our clients and make a meaningful difference in their lives.

References

Centers for Disease Control and Prevention. (2019). Understanding teen dating violence: Fact sheet. Retrieved from https://www.cdc.gov/violenceprevention/pdf/tdv-factsheet.pdf

Font, S. A., Berger, L. M., & Slack, K. S. (2012). Examining racial disproportionality in child protective services case decisions. Children and Youth Services Review, 34(11), 2188–2200. https://doi.org/10.1016/j.childyouth.2012.07.012

Foshee, V., McNaughton Reyes, H., Chen, M., Ennett, S., Basile, K., DeGue, S., Vivolo Kantor, A., Moracco, K., & Bowling, J. (2016). Shared risk factors for the perpetration of physical dating violence, bullying, and sexual harassment among adolescents exposed to domestic violence. Journal of Youth and Adolescence, 45(4), 672–686. https://doi.org/10.1007/s10964-015-0404-z 

Gillis, K. (2021). Invisible bruises: Understanding and breaking the patterns of domestic violence. Lisa Nicole Publishing.

Harland, K. K., Vakkalanka, J. P., Peek-Asa, C., & Saftlas, A. F. (2021). State-level teen dating violence education laws and teen dating violence victimization in the USA: A cross-sectional analysis of 36 states. Injury Prevention, 27(3), 257–263. https://doi.org/10.1136/injuryprev-2020-043960

Pastor-Bravo, M. D. M., Vargas, E., & Medina-Maldonado, V. (2023). Strategies to prevent and cope with adolescent dating violence: A qualitative study. International Journal of Environmental Research and Public Health, 20(3), 2355. https://doi.org/10.3390/ijerph20032355

Rochford, H. I., Peek-Asa, C., Abbott, A., Estin, A., & Harland, K. (2022). United States' teen dating violence policies: Summary of policy element variation. Journal of Public Health Policy, 43(4), 503–514. https://doi.org/10.1057/s41271-022-00365-7

Taquette, S. R., & Monteiro, D. L. M. (2019). Causes and consequences of adolescent dating violence: A systematic review. Journal of Injury & Violence Research, 11(2), 137–147. https://doi.org/10.5249/jivr.v11i2.1061

The Trevor Project. (2021, February 12). Physical dating violence and suicide risk among LGBTQ youth. The Trevor Project. Retrieved from https://www.thetrevorproject.org/research-briefs/physical-dating-violence-and-suicide-risk-among-lgbtq-youth/

Zaza, S., Kann, L., & Barrios, L. C. (2016). Lesbian, gay, and bisexual adolescents: Population estimate and prevalence of health behaviors. JAMA, 316(22), 2355–2356. https://doi.org/10.1001/jama.2016.14741

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.

Ackard, D. M., & Eisenberg, M. E. (2024). Verbal, physical, and sexual dating violence among a population-based sample of teens: Does exposure to intimate partner violence in the home account for the association between dating violence and mental health? Child Abuse & Neglect, 147, Article 106581. https://doi.org/10.1016/j.chiabu.2023.106581

Brewer, N. Q., Thomas, K. A., & Guadalupe-Diaz, X. (2024). “It’s their consent you have to wait for”: Intimate partner violence and BDSM among gender and sexual minority youth. Journal of Interpersonal Violence, 39(1–2), 35–58. https://doi.org/10.1177/08862605231193445

Dasgupta, S., & Melvin, E. (2024). Technology-based intimate partner violence intervention services for Generation Z victims of violence. Social Sciences, 13(3), Article 169. https://doi.org/10.3390/socsci13030169

Hubbell, J. T. (2024). Elucidating intimate partner violence rate disparities between same- and opposite-sex couples: A demographic approach. Journal of Interpersonal Violence, 39(3–4), 651–675. https://doi.org/10.1177/08862605231197781

Nydegger, L. A., Blanco, L., Marti, C. N., & Kreitzberg, D. (2024). Moderation effects of gender on the association between intimate partner violence and suicidal ideation or attempt among adolescents: A secondary analysis of the 2017 YRBS. Archives of Suicide Research, 28(1), 310–323. https://doi.org/10.1080/13811118.2023.2173112

Editor’s note: This text-based course is an edited transcript of the webinar, Working with Transgender and Gender Diverse Youth: Navigating the Current Political Climate, Clinical Practice Guidelines, and Ethical Considerations, presented by Giselle Levin, PsyD.

Learning Outcomes

After this course, participants will be able to:

• Describe current mental health challenges facing transgender and gender-diverse youth.
• Identify standards and clinical practice guidelines for provision of gender-affirming care of youth.
• Apply clinical interventions to support transgender and gender-diverse youth coping with minority stress and other mental health challenges.

Limitations/Risks

• This presentation presents the fundamentals of working with trans and gender-diverse youth. Further training, supervision, and/or consultation may be required before working with specific patients. 
• Information in the presentation is generalized and may not apply to specific patients. Refer or consult as needed.
• Ethical and legal standards may differ from state to state. Ensure that you are familiar with the laws and ethics specific to your state. 
• Individual and cultural considerations should be explored prior to pursuing treatment and interventions.

Introduction

Today, we will explore how mental health professionals like you can support transgender and gender-diverse youth and their families in your practice. We will focus on the impact of minority stress, discussing its significance and associated mental health challenges. As a fundamental course, we'll introduce the standards of care, though we will not delve deeply into complex topics.

Assessing gender-diverse youth for readiness to begin puberty blockers, hormones, or surgeries requires a nuanced approach. Such medical gender-affirming care demands additional training, supervision, and consultation. You may encounter patients with complex needs that necessitate specialized attention. In these cases, always refer or consult based on your training level and comfort with the patient's specific situation.

We'll also cover some general information useful when dealing with particular cases. Understanding ethical and legal standards is crucial, which vary significantly from state to state. I will show a detailed map highlighting the various pieces of legislation proposed and passed across different states. Being aware of the laws in your state is essential, as is understanding the ethical codes specific to your professional field. For instance, as a psychologist, my guidelines might differ from those for Licensed Marriage and Family Therapists (LMFTs) or social workers. Lastly, we must consider individual and cultural factors before pursuing treatment or interventions. These preliminary considerations are vital in providing effective and sensitive care to your patients.

The Political Climate: Events, Legislation, and Articles

Let's examine the current political climate, focusing on recent events, legislation, and related articles. We'll start with anti-transgender bills in 2024. Remarkably, even though it's only April of 2024, there have already been 539 bills proposed across 41 states this year. This widespread legislative activity has affected nearly every state in the U.S. Of these bills, 21 have passed, 92 have failed, and the majority, 426, remain active. This volume of legislation underscores the significant attention and contention surrounding this issue.

What exactly do these bills entail? These bills target:

• Re-definition of sex
• Curriculum censorship
• School facilities bans (bathrooms, lockers)
• School sports bans
• Forced outing in schools

The redefinition of sex often stipulates sex as strictly binary—male or female—and identical to the sex assigned at birth. This conflation of sex and gender precludes any later changes in gender identity if it doesn't match the sex assigned at birth.

Another significant area is curriculum censorship. This includes bills that prevent discussions about LGBTQ+ individuals, particularly transgender and gender-diverse topics, within schools. It restricts teachers from using books with non-binary or transgender characters and limits educational resources and opportunities. Such bills also aim to censor or ban LGBTQ+ groups in schools and impose facility bans that restrict students from accessing certain facilities, like bathrooms, that do not align with their gender assigned at birth. 

For example, a transgender girl who fully presents as female would be compelled to use the boys’ bathroom or locker room. School sports bans are also prevalent, prohibiting transgender students from joining teams that align with their gender identity rather than their assigned sex at birth.

Forced outing is another concerning issue. This practice requires that transgender students be outed at school, making their transgender status known to teachers and peers, which can lead to bullying and create a hostile environment.

Healthcare restrictions are also widespread. These include age limits on accessing gender-affirming care and could even carry criminal penalties for providers who offer such care to transgender youth. Interestingly, these restrictions often exempt similar treatments for cisgender youth or mandatory treatments for intersex infants.

Speaking of intersex individuals—those whose biological characteristics do not fit typical binary notions of male or female bodies—it’s estimated that approximately 1.7% of the population is intersex. This might involve chromosomal differences or ambiguous genitalia. Many intersex infants undergo surgery without their consent, yet such procedures are generally not subject to the same restrictions as gender-affirming surgeries for older youth.

Additionally, there are prison restrictions that disproportionately affect transgender individuals in incarceration, often denying them access to essential gender-affirming treatments. Funding restrictions also play a role, blocking programs like Medicaid from covering necessary treatments for transgender individuals.

Religious exemptions are another barrier, allowing healthcare providers and others in the community to deny care or services to LGBTQ+ individuals based on religious beliefs. Lastly, there are significant hurdles regarding accurate IDs. Restrictive bills limit the ability to update gender information on official documents like birth certificates and driver's licenses, which can lead to discrimination and violence, as well as practical challenges in employment, housing, and travel.

In addition to the types of bills previously discussed, there are other anti-LGBTQ+ legislative actions that don't necessarily fit neatly into those categories. These include bans on marriage equality and bills that preempt or override local non-discrimination protections, stripping back established rights and safeguards for LGBTQ+ individuals.

Bills Passed in 2024

AL SB129: “Each public institution of higher education shall ensure that every multiple occupancy restroom be designated for use by individuals based on their biological sex.”

In higher education, policies now mandate that individuals use restrooms based on their biological sex, not their gender, gender identity, or presentation. This requirement overlooks the complexities of gender expression and identity.

ID H0421: “In human beings, there are two, and only two, sexes: male and female; (2) Every individual is either male or female; (3) An individual's sex can be observed or clinically verified at or before birth”

This is scientifically incorrect. As previously mentioned, an estimated 1.7% of people are intersex, meaning they possess sex traits that do not conform to the traditional binary. For example, someone with androgen insensitivity syndrome, a common intersex condition, is genetically male with XY chromosomes but is resistant to male hormones like testosterone. Consequently, they do not develop male characteristics and typically appear female at birth, often being designated as female despite lacking internal female reproductive organs and being infertile.

Another intersex condition, congenital adrenal hyperplasia, occurs in individuals with XX chromosomes who produce high levels of androgens. This can lead to ambiguous genitalia, where external genitalia may appear male, yet internal genitalia include a uterus. Therefore, the sex of someone with congenital adrenal hyperplasia cannot be definitively observed or clinically verified at birth.

These examples illustrate that such legislation is not grounded in science and is, in fact, scientifically inaccurate. It can be especially harmful not only to transgender individuals but also to those who are intersex.

WI AB377: “The three designations are 1) males, 2) females, and 3) males and females. The bill defines “sex” as the sex determined at birth by a physician and reflected on the birth certificate. The bill also requires an educational institution to prohibit a male pupil from participating on an athletic team or in an athletic sport designated for females. Finally, the bill requires the educational institution to notify pupils and parents if an educational institution intends to change a designation for an athletic team or sport.”       VETOED

This bill was vetoed, but it aimed to define sex strictly as male and female, the only designations deemed valid, a scientifically incorrect concept. Additionally, it stipulated that these designations be determined at birth. Under this bill, a male pupil—including a transgender girl—would not be allowed to participate on an athletic team or in a sport designated for females. Furthermore, the bill mandated that educational institutions notify students and parents if a transgender child was to join a sports team that aligned with their gender identity.

ID H0455: “Requiring students to share restrooms and changing facilities with members of the opposite biological sex generates potential embarrassment, shame, and psychological injury to students, as well as increasing the likelihood of sexual assault, molestation, rape, voyeurism, and exhibitionism; every public school restroom or changing facility accessible by multiple persons at the same time must be: (a) Designated for use by male persons only or female persons only; and (b) Used only by members of that sex.”

You can see that many of these rules deeply affect students, which is particularly concerning given that schools are already challenging environments for youth. Under these regulations, students would not be able to use restrooms that align with their gender identity. Interestingly, the rationale provided states that allowing students to share restrooms and changing facilities could lead to potential embarrassment, shame, and psychological injury. However, this concern appears to focus solely on cisgender students. The statement further suggests that this mixing increases the likelihood of sexual assault, molestation, rape, voyeurism, and exhibitionism.

Yet, there is no research supporting the claim that transgender individuals using bathrooms that align with their gender identity are more likely to perpetrate any form of sexual misconduct in those settings. Thus, these assertions are not backed by empirical evidence. Moreover, the policy mandates that public school restrooms and changing facilities, like locker rooms, be designated strictly for male or female use based on the sex assigned at birth.

WY SF0099: “No physician or health care provider shall: [...] Provide, administer, prescribe or dispense [...] prescription drugs that induce [...] puberty suppression or blocking prescription drugs to stop or delay normal puberty; [...] Supraphysiologic doses of testosterone to females [...] Supraphysiologic doses of estrogen to males.”

Here, we examine another bill that was passed, which prohibits physicians and healthcare providers from offering medical gender-affirming care to youth. This includes prescribing or dispensing drugs that induce, block, or delay puberty.

We'll discuss puberty blockers in more detail shortly. These medications are completely reversible and provide transgender youth with additional time to explore their gender identity and consider their options before making any irreversible decisions. Importantly, puberty blockers also spare them from undergoing puberty, which might be dysphoric and distressing. Once these blockers are discontinued, the individual will experience their natural puberty.

The bill also addresses testosterone and estrogen, which are used in hormone therapy. We will delve into the distinctions between puberty blockers and hormone therapy later. While the effects of hormone therapy are partially reversible, some aspects are irreversible. This bill bans both treatments, impacting the ability of transgender youth to receive care that could significantly ease their gender dysphoria.

ID S1352: “No person engaged in the practice of professional counseling or marriage and family therapy in the state of Idaho shall be required to provide counseling to or facilitate the counseling of a client in support of goals, outcomes, or behaviors that conflict with the sincerely held religious, moral, or ethical principles of the counselor or therapist.”

We're seeing that therapists who do not support transgender youth are not required to provide services, which, in a way, aligns with ethical obligations to refer patients when there is significant negative bias. Ethically, it is crucial that patients are treated by professionals who can support them without prejudice.

However, the situation is nuanced. While it is understandable that a transgender youth would not benefit from working with a therapist who harbors strong anti-trans sentiments, the legislation also allows therapists to refuse to facilitate counseling that supports the client's goals if these goals conflict with the therapist's moral principles. This aspect of the law can lead to a lack of support for transgender youth, as it permits professionals to decline to provide essential therapeutic services based on personal beliefs, potentially leaving vulnerable clients without necessary care.

I must emphasize that the ramifications of these bills extend beyond transgender individuals, affecting cisgender people as well. This is particularly evident in policies like bathroom bans or facility restrictions.

Consider, for instance, the impact on intersex individuals, who make up an estimated 1.7% of the population and do not fit neatly into the binary categories of male or female. They are directly affected by such legislation. But the implications also reach cisgender individuals. For example, women with polycystic ovarian syndrome (PCOS), a condition that can cause facial hair growth, may face discrimination in female restrooms despite being cisgender.

Moreover, societal assumptions about gender appearance can lead to accusations and challenges for cisgender individuals as well. Online and in public spaces, cisgender women and men are sometimes mistakenly identified as transgender, leading to harassment and discrimination. This can occur even with individuals who exhibit traditionally feminine or masculine traits—demonstrating that appearance alone is not a reliable indicator of someone's gender identity.

These legislative measures also affect children and youth, who may be subjected to similar forms of discrimination and misunderstanding. The scope of harm from such bills is wide, impacting not only those who are transgender but also many who are not, including those with certain medical conditions and the broader cisgender population.

Tracking Anti-Trans Legislation 

If you're interested in staying informed about anti-trans legislation, several excellent resources are available. "Erin In The Morning" offers a comprehensive Anti-Trans Legislative Risk Assessment Map, which details the status of proposed and passed bills in each state. This map is particularly useful for understanding the legislative risks and includes separate sections for adults and youth. Initially, much of this legislation targeted youth, but there is now also a significant amount aimed at adults.

Additionally, the ACLU is tracking 484 anti-LGBT bills. Their website provides updates on their progress, whether they have just been proposed or have already been passed. It’s a valuable resource for those looking to understand the broader scope of legislation affecting the LGBTQ+ community.

There is also a trans legislation tracker available online. This tool is specifically designed to follow legislation that directly impacts transgender individuals. Using these resources can provide a clearer picture of the legislative landscape and help you stay informed about changes that might affect your community.

In The News

Recently, there has been a noticeable increase in media coverage concerning gender-affirming care, particularly for youth. A prominent New York Times article raised concerns about the adequacy of mental health assessments for youth receiving such care. It suggested that co-occurring mental health issues were not adequately addressed, leading some individuals to ultimately detransition or express regret.

The World Professional Association for Transgender Health (WPATH), a key global organization in transgender healthcare similar to the American Psychological Association (APA), provides evidence-based standards of care. WPATH's latest manual, the Standards of Care 8, is accessible online at no cost and extensively cites the supporting research. WPATH also maintains a confidential forum for medical and mental health experts to discuss complex cases. Unfortunately, this forum was recently compromised by anti-trans activists, resulting in the unauthorized release and misrepresentation of confidential information in what became known as the "WPATH Files." 

Erin In The Morning responded with a detailed rebuttal, highlighting the misinterpretations and distortions of the leaked information, which seemed designed to fuel anti-trans rhetoric. This incident is just one example of the challenges facing medical and mental health providers working with transgender individuals, particularly youth. There have been cases of individuals posing as patients to expose providers, a form of healthcare fraud that adds to the already tense environment.

There are numerous anti-trans articles circulating. We'll discuss further how this affects transgender youth and explore ways you, as a provider, can take a supportive stance. It's crucial to understand that transgender healthcare, particularly for trans youth, is currently at the center of intense political controversy. This group has been singled out as a focal point for debate and conflict. Consequently, there is a significant amount of anti-trans rhetoric specifically targeting this vulnerable population. As healthcare providers, recognizing this context is essential for effectively supporting and advocating for transgender youth.

Trans and Gender-Diverse (TGD) Youth

Let's shift our focus to understanding trans and gender-diverse youth. First, it's important to clarify terminology. We often use the terms "trans and gender-diverse" or "trans and gender-expansive" because not all youth under this umbrella identify strictly as transgender. Additionally, some children who identify as gender-diverse in their youth may not retain these identities into adulthood. Gender diversity can be fluid and subject to change, which we'll explore further.

To provide some context on the broader spectrum of LGBT identification, let’s consider recent data. According to a Gallup Poll, which has been tracking LGBT identification since 2012, with the latest poll conducted in 2024, there are notable generational differences in how people identify. Among Boomers, only 5% identify as part of the LGBT community, compared to 10% of Millennials and a significant 25% of Gen Z—reflecting a substantial generational shift.

Specifically focusing on transgender identification, the numbers are smaller but still indicative of a generational change: 0.2% of Boomers, 1.1% of Millennials, and 2.8% of Gen Z identify as transgender. Most of the LGBT Gen Zers are bisexual, with about 15% identifying as such, which is a stark contrast to those identifying as gay or lesbian. Other identities within the LGBT spectrum, including transgender, represent smaller percentages but are crucial for understanding the full diversity within these communities.

Figure 1. Graph showing the percentage of people identifying as LGBTQ+.

Since the initiation of the Gallup Poll in 2012, which tracks LGBT identification among those aged 18 and older, there has been a noticeable increase in the percentage of individuals identifying as LGBT. Figure 1  provides a visual display of this information. In 2012, approximately 3.5% of the population identified as LGBT, a figure that rose to 5.6% four years ago and stands at 7.6% today. This significant increase suggests a changing landscape in societal acceptance and self-recognition of diverse sexual orientations and gender identities.

The rise in LGBT identification, particularly among Gen Z, where a large portion identifies as bisexual, may reflect greater societal acceptance and visibility. Older generations, like Boomers, who identify as LGBT are more likely to describe themselves as lesbian or gay, which may indicate a previous era's more restrictive understanding of sexuality. The broader acceptance of bisexuality today suggests that individuals who might not have previously explored or accepted this aspect of their identity now feel more comfortable doing so.

Moreover, the acceptance of non-binary identities within the transgender community has also grown. Historically, societal acceptance was generally extended only to those who presented themselves fully as either female or male—transgender women or men. There is increasing recognition and support for individuals who identify outside these binary categories, acknowledging those who feel they lie somewhere in the middle, embody elements of both, or do not fit into the binary at all. This shift is critical in understanding the increase in individuals identifying as transgender or non-binary.

Gender Diversity in Children

Gender diversity in children is a normal aspect of developmental progression. From as early as two or three years old, children begin to recognize and interact with the concept of gender, understanding its social elements. In preschool, it's common to see children gravitating toward certain toys or clothing traditionally associated with a particular gender—boys opting for dolls or wearing tutus and girls preferring boys' attire and rejecting the color pink.

It's crucial to recognize that such expressions of gender diversity in young children are not indicative of a pathological condition. Nor do they necessarily predict a future transgender identity or gender incongruence. For example, a boy who enjoys wearing tutus might grow up to identify as a man, possibly as a more feminine man or as a gay man, reflecting variations in sexual orientation rather than gender identity. Similarly, femininity in cisgender gay men or masculinity in straight women are expressions of gender diversity that don't strictly align with transgender or non-binary identities.

Gender expression in children is fluid and cannot reliably predict future gender identity. A child showing gender-diverse traits may grow up to identify within a range of possibilities—from continuing to embrace a gender-diverse identity, to identifying as a feminine man or masculine woman, or not aligning with any of these categories permanently. Essentially, there is no fixed path or clear predictor for how a child's gender identity will evolve.

Understanding this fluidity is vital in supporting gender-diverse children. We recognize gender diversity not as an anomaly but as a part of the broader spectrum of human development that occurs naturally alongside the emergence of gender awareness in children. This perspective is fundamental when discussing what gender diversity means for children and how to support their growth in a nurturing and affirming environment.

Gender Diversity in Adolescence

Gender diversity in adolescence presents unique considerations. In discussions about adolescence, including those within WPATH (World Professional Association for Transgender Health), we typically consider this period as extending from puberty to the age of maturity. However, the exact parameters of adolescence aren't strictly defined, as puberty can start very early in some children, and cognitive development, particularly executive control neural systems, continues into the mid-twenties. This development challenges the notion that turning 18 automatically signifies the transition from adolescence to adulthood, as cognitive development continues well past this age.

In the United States, the age of majority is 18, but it's important to recognize that this age can range from 15 to 21 in other countries. Moreover, turning 18 doesn't necessarily equate with immediate independence or adult responsibilities. Many individuals continue to depend on their parents well into their mid-twenties, which is why considerations relevant to adolescents often apply to transitional-age youth—those from the age of majority up to about 25. These young adults are navigating the complex journey from adolescence to full adulthood, dealing with both social and psychosocial challenges.

Legally, the standards of care for adolescents apply up until the age of 18. After this, adult standards of care take precedence. It's also crucial to acknowledge that some adolescents may experience gender incongruence from childhood, while others only encounter these feelings during puberty—a time of significant physical and gender development that can trigger the onset of gender dysphoria or incongruence.

Regarding terminology, "dysphoria" and "incongruence" are often used interchangeably, though they represent a diagnostic distinction between DSM-5 and ICD-11 frameworks. These terms describe a mismatch between an individual's gender assigned at birth and their experienced gender.

Adolescence is a pivotal time for gender identity development, which often begins in childhood but intensifies during puberty. Influences such as social media and peer interactions play significant roles in shaping gender expectations and identities during this time. As adolescents learn and navigate these influences, their understanding of gender and identity continues to evolve, making adolescence a critical period for support and guidance in gender identity development.

A comprehensive clinical approach is crucial when working with transgender adolescents. This approach is necessary partly because adolescents must be able to understand hypothetical situations to give informed consent for treatments that might have long-term effects. Children often struggle with this concept, but adolescents are generally developing the cognitive awareness needed to think about future consequences and cause-and-effect relationships. However, it's also common for adolescents to display risk-taking behaviors and experience a sense of urgency, perceiving time differently than adults.

Those of you who have worked with teenagers, especially those in distress like depression, might notice that they have difficulty envisioning a life different from their current situation. They often feel an immediate need for change, driven by a heightened sensitivity to rewards, which focuses their attention on short-term outcomes rather than long-term implications. Additionally, adolescents place significant importance on peer relationships, which can be a source of support or a risk factor, depending on the health of those relationships. As they seek more autonomy from their parents, the influence of their peers can become even more pivotal.

The variability in maturity among teenagers is notable. For example, a 17 or 18-year-old might exhibit less self-awareness and insight than a 14-year-old. This individuality means that when making decisions about gender-affirming medical treatments—which can have lifelong consequences—it's essential to consider a range of developmental factors.

This nuanced understanding of adolescent development informs our approach to their care. In my presentations on hormone therapy or surgery for adults, the focus on these developmental considerations is less intense, reflecting adults' greater maturity and decision-making capacity. However, with adolescents, we exercise heightened diligence during the assessment process to ensure that decisions about their care are made with a full understanding of the potentially irreversible effects. This careful approach is vital in supporting adolescents as they navigate these critical decisions.

Minority Stress & Mental Health in Trans and Gender-Diverse Youth

Minority Stress Theory

Let's delve into the topic of minority stress and its impact on the mental health of youth. Minority stress theory, developed by Meyer and seen in Figure 2, is a foundational framework for understanding the mental and physical health disparities observed in LGBT individuals, particularly transgender people.

Figure 2. Minority Stress Theory.

Research strongly supports the minority stress theory, suggesting that LGBT people face higher rates of mental and physical health issues. The question arises: Why does this disparity exist? The theory identifies two primary types of stress factors: distal and proximal.

Distal stress factors represent external stressors that significantly affect the well-being of transgender individuals. These include discrimination, rejection by family, peers, or institutions, victimization through physical or verbal abuse, and non-affirmation, such as being deliberately misgendered or called by incorrect pronouns.

The impact of these distal stress factors is profound, directly correlating with severe outcomes. They contribute to a heightened incidence of mental and physical health problems within the transgender community, particularly among transgender youth. Furthermore, these factors are strongly associated with the tragically high rates of suicide observed among transgender individuals.

The direct link between these external stressors and negative health outcomes underscores the critical need for supportive interventions and policies to mitigate these stressors and provide transgender individuals, especially youth, with safer, more affirming environments.

Proximal stress factors involve the internalization of the external stressors described as distal factors. These internal stressors include internalized homophobia or transphobia, where a transgender individual may feel there is something inherently wrong with them due to their identity, leading to feelings of shame, disgust, or severe self-criticism.

Additionally, negative expectations can heavily impact transgender individuals, especially youth. Many feel their future prospects are bleak—believing they will never succeed in personal relationships, career ambitions, or broader societal acceptance. This often results in low self-esteem and confidence, which may not always be directly linked to their gender identity in their own minds but stems from the ongoing internalization of societal rejection and stigma.

Concealment is another significant proximal stress factor. Many transgender individuals may hide their identity by engaging in activities like secretly trying on clothes that affirm their gender identity or purchasing and hiding such items to avoid detection and potential conflict. This behavior is a direct response to the fear and anxiety produced by societal judgment and lack of acceptance.

These proximal stress factors mediate the relationship between external pressures and the negative outcomes they cause, establishing a complex interaction where external abuses become internal struggles that further exacerbate health and well-being issues. This mediation illustrates how distal factors impact individuals directly and indirectly by fostering harmful internal narratives and behaviors.

Furthermore, the concept of multiple minority stress must be considered. This occurs when individuals identify with more than one marginalized group, compounding their experiences of stress and adversity. For example, a transgender person of color may face intersecting prejudices related to both their gender identity and race, intensifying their experience of minority stress and its associated impacts. Understanding and addressing these layered stresses is crucial for supporting the mental and physical health of transgender individuals, particularly those who are navigating multiple marginalized identities.

ADDRESSING Framework

The ADDRESSING framework, developed by Pamela Hayes (2008), is an essential tool for understanding the complexities of individual identity, particularly concerning marginalization, power, and privilege. This framework breaks down various categories contributing to an individual's identity, each linked to potential marginalization. Here's a brief overview of each component within the ADDRESSING acronym:

• Age: Young people and older adults often possess less societal power than adults aged 18 to 65, who typically have more influence.
• Disability (Developmental): Autism is a common example. Individuals with developmental disabilities may experience increased minority stress. Notably, there is a significant overlap between individuals who are autistic and those who are transgender, with higher incidences of autism among transgender populations and vice versa.
• Disability (Acquired): Conditions like traumatic brain injury or spinal cord injuries that occur later in life. Like developmental disabilities, these also lead to increased minority stress and can profoundly impact an individual’s life and identity.
• Religion: Religions other than Christianity often face more marginalization in predominantly Christian societies.
• Ethnicity: Ethnic minorities, or kids of color, generally experience greater marginalization compared to their white peers.
• Socioeconomic Status (SES): Individuals from lower socioeconomic backgrounds have less privilege than those from higher income brackets.
• Sexual Orientation: Within the transgender community, those who are heterosexual typically experience less discrimination compared to transgender individuals who are gay, lesbian, bisexual, or otherwise non-straight. For example, a transgender girl attracted to men is considered straight and may face fewer challenges than a transgender girl attracted to women or both genders. Transgender individuals who are straight have better mental health care. They have more privileges than transgender individuals who are also lesbian, gay, or bisexual.
• Indigenous Heritage: Individuals with indigenous backgrounds can face unique challenges and discrimination, adding another layer to their identity and experiences of marginalization.
• National Origin: The citizenship status of an individual, particularly when they are transgender, can significantly impact their mental health and well-being. Non-U.S. citizens, especially from countries with limited LGBT rights, face ongoing stress due to potential instability in their residency status. For example, I currently have a patient who is a transgender woman from India, sponsored by her company to work in the tech industry, which is notably volatile at the moment, especially in the Bay Area. She lives with the constant fear of losing her job, and if that were to happen, she believes she would have only about 30 to 60 days to find new employment or face deportation to India, where she would have far fewer protections.
• Gender: It's also crucial to acknowledge how gender affects experiences of privilege and marginalization. Transgender individuals and women typically have less privilege compared to cisgender men, facing numerous systemic barriers that impact their social, professional, and personal lives.

Understanding these dimensions of identity through the ADDRESSING framework helps to highlight the intersecting challenges faced by individuals, emphasizing the need for targeted support and inclusive policies to mitigate these pressures.

Impact of Minority Stress

The impact of minority stress on mental health disparities among transgender and gender-diverse youth is significantly influenced by their experiences of discrimination and rejection. Research confirms that support and acceptance from family, friends, and educational institutions play a critical role in the well-being of these youths. When their social environments embrace them, transgender and gender-diverse youth often show good psychological adjustment and resilience.

Conversely, when they lack support, the consequences can be severe. Distal stressors such as discrimination and rejection can lead to these youths feeling ostracized from their school life, exacerbating feelings of isolation. This external rejection often fosters internalized transphobia and low expectations, which can further deepen their sense of isolation and alienation.

Effective coping strategies involve proactive advocacy for inclusion, particularly within educational settings. Working directly with teachers to promote understanding and acceptance and fostering peer support networks are essential actions. Addressing the mental health needs of transgender youth thus requires a holistic approach that involves their families, peers, and schools. These elements are not just supportive aspects of their lives; they are pivotal determinants of a transgender youth's mental health outcomes.

Have You Heard the News? 

The impact of anti-trans legislation is a significant source of minority stress for transgender youth and young adults, manifesting as a profound distal stress factor. A study conducted between September and November of 2021 explored the implications of exposure to news about newly proposed anti-trans legislation and how perceptions of support for this legislation within one's social network—such as from parents or friends—affect these individuals.

The findings were concerning: news consumption related to this legislation was directly associated with increased rumination and physical health symptoms among trans youth and young adults. Furthermore, if these individuals perceived that their social network supported the legislation, they experienced even greater rumination, depressive symptoms, physical health symptoms, and an intensified fear of disclosing their identity.

The study also included open-ended questions, which revealed that this legislation not only affects access to gender-affirming healthcare but also impedes their ability to seek general healthcare services. Many avoid medical settings altogether due to fear of discrimination or past negative experiences. Additionally, the legislative climate has led to an increase in discrimination during medical treatment and prompted unhealthy coping responses among these individuals. These findings highlight a crucial message for policymakers: the laws they propose and enact have real and damaging effects on the mental and physical well-being of trans youth. 

Gender-Affirming Interventions for Trans and Gender-Diverse Youth

Gender-Affirming Care: Social Transition

Gender-affirming interventions for trans and gender-diverse youth are crucial for their well-being and are often misunderstood. Here’s an overview of what these interventions entail and the standards of care involved.

• Name change;
• Pronoun change;
• Change in sex/gender markers (e.g., birth certificate, identification cards, passport, school and medical documentation, etc.);
• Participation in gender-segregated programs (e.g., sports teams, recreational clubs and camps, schools, etc.);
• Bathroom and locker room use;
• Personal expression (e.g., hairstyle, clothing choice, etc.);
• Communication of affirmed gender to others (e.g., social media, classroom or school announcements, letters to extended families or social contacts, etc.). (Coleman et al., 2022)

Social transition is the primary approach for children who are prepubertal, typically younger than 10 or not yet at Tanner stage 2 of puberty. Medical interventions like hormones, puberty blockers, or surgeries are not considered for children who have not reached these developmental milestones. Social transition involves several reversible changes designed to affirm a child's experienced gender. This includes updating their name across various settings to reflect their gender identity, adopting pronouns that align with the child’s gender identity, and changing gender markers on official documents such as birth certificates, school records, and medical documents to reflect the child's affirmed gender. Children are also allowed to participate in activities and programs, such as sports teams, that align with their gender identity.

For prepubertal children, hormonal differences are not yet a factor, which supports their inclusion based on their affirmed gender rather than their sex assigned at birth. Facilitating access to bathrooms and locker rooms that correspond with the child’s gender identity is another aspect of social transition. Supporting the child in expressing themselves through clothing, hairstyle, and other forms of personal presentation that reflect their identity is also key. Additionally, helping to communicate the child’s gender identity to others, which might include social media announcements or letters to extended family members, is part of this process.

These elements of social transition are entirely non-medical and reversible. They are aimed at supporting the child in a way that affirms their identity, which is critical for their psychological and emotional health. 

Gender-Affirming Care: Prosthetics

In addition to social transition, other non-medical, gender-affirming interventions involve prosthetics or specific training to help individuals express their gender identity. These interventions, which do not involve medication or surgery, play a crucial role in aligning one’s external appearance with one's gender identity.

For masculinizing purposes, binders are often used. These compression garments are designed to flatten the chest, creating a more masculine appearance, and are suitable for individuals who have experienced breast development but are not seeking medical treatment. Packers, another form of prosthetic, are utilized to create the appearance of a bulge in the genital area, simulating the presence of a penis. STP (stand-to-pee) devices enable individuals who do not have a penis to urinate while standing. These devices are shaped to function as prosthetics and urinary aids.

For feminizing effects, gaffs and tucking are common practices. Tucking involves repositioning the penis and testicles to achieve a smoother appearance in tight clothing, while gaffs are specialized undergarments designed to hold these parts securely. Breast forms, worn to simulate the appearance of breasts, enhance the feminine silhouette. Wigs also play an essential role, particularly for individuals who desire longer hair or face challenges with hair loss.

Additionally, aesthetic procedures like laser hair removal aid in achieving a more consistent appearance with one’s gender identity, though their reversibility varies. Voice training is another critical aspect, helping individuals modify their vocal pitch and resonance to better match their gender presentation. While some may seek professional guidance for voice training, others might use self-guided methods.

These gender-affirming interventions, while non-medical, are vital components of the support system for transgender and gender-diverse individuals, offering additional ways to safely and comfortably express their identities.

Gender-Affirming Care

The final piece of gender-affirming care involves medical transition, which consists of three primary categories. The first category includes puberty blockers, also known as GnRH analogs. These blockers prevent the development of endogenous secondary sex characteristics, effectively pausing puberty. This intervention is fully reversible, with no impact on fertility or other puberty-related changes once the treatment is discontinued. Puberty blockers provide adolescents with additional time to explore their gender identity without the distress often associated with puberty. For instance, a 12-year-old at Tanner stage 2 might use puberty blockers to halt puberty, allowing time for further cognitive development and exploration before making decisions about hormones, which are only partially reversible.

Tanner stage 2 marks the onset of visible changes. For those designated female at birth, this stage typically starts between ages 9 and 11 and is characterized by the development of breast buds under the nipples, which may become itchy or tender. The areola, the darker area around the nipple, expands, and the uterus begins to grow. A small amount of pubic hair starts to appear. Tanner stage 2 generally begins around age 11 for those designated male at birth. Changes include enlargement of the testicles and the scrotum, with some pubic hair forming at the base of the penis. It is at this stage that puberty blockers are deemed appropriate, not earlier.

The second category of medical transition involves hormones. For individuals assigned male at birth, the regimen can include estrogen and testosterone blockers, while those assigned female at birth may receive testosterone. The effects of hormone therapy are partially reversible. For example, breast growth induced by estrogen does not recede when hormone treatment is stopped and would require surgical removal if desired. Prolonged hormone use can also impact fertility. Testosterone administration can lead to irreversible changes such as voice deepening and facial and body hair growth. Hair loss, another effect of testosterone, is also irreversible. Fertility effects are generally more reversible for those assigned female at birth taking testosterone compared to those assigned male at birth on estrogen and testosterone blockers.

The third category is surgeries, which are entirely irreversible. While reconstructive surgeries are possible, they do not fully reverse the original alterations. Masculinizing top surgery, or double mastectomy, is the most common procedure performed under age 18, typically starting at age 16. This procedure achieves a flatter chest appearance. Most other surgeries are recommended after age 18.

WPATH Standards of Care 8: Children

Continuing with the Standards of Care 8, we focus now on children, particularly those who are pre-puberty. It is crucial to emphasize that the standards of care do not involve any medical interventions for these children. Instead, the focus is on providing support through knowledge and understanding.

• 7.1 - We recommend health care professionals working with gender-diverse children receive training and have expertise in gender development and gender diversity in children and possess a general knowledge of gender diversity across the life span. 
• 7.2 - We recommend health care professionals working with gender-diverse children receive theoretical and evidenced-based training and develop expertise in general child and family mental health across the developmental spectrum. 
• 7.3 - We recommend health care professionals working with gender-diverse children receive training and develop expertise in autism spectrum disorders and other neurodiversity or collaborate with an expert with relevant expertise when working with autistic/neurodivergent, gender-diverse children
• 7.4 - We recommend health care professionals working with gender-diverse children engage in continuing education related to gender-diverse children and families. 
• 7.5 - We recommend health care professionals conducting an assessment with gender-diverse children access and integrate information from multiple sources as part of the assessment. 
• 7.6 - We recommend health care professionals conducting an assessment with gender-diverse children consider relevant developmental factors, neurocognitive functioning, and language skills. 
• 7.7 - We recommend health care professionals conducting an assessment with gender-diverse children consider factors that may constrain accurate reporting of gender identity/gender expression by the child and/or family/caregiver(s).
• 7.8 - We recommend health care professionals consider consultation, psychotherapy, or both for a gender-diverse child and family/ caregivers when families and health care professionals believe this would benefit the well-being and development of a child and/or family.
• 7.9 - We recommend health care professionals offering consultation, psychotherapy, or both to gender-diverse children and families/caregivers work with other settings and individuals important to the child to promote the child's resilience and emotional well-being.
• 7.10 - We recommend health care professionals offering consultation, psychotherapy, or both to gender-diverse children and families/caregivers provide both parties with age-appropriate psychoeducation about gender development.
• 7.11 - We recommend that health care professionals provide information to gender-diverse children and their families/caregivers as the child approaches puberty about potential gender-affirming medical interventions, the effects of these treatments on future fertility, and options for fertility preservation. 
• 7.12 - We recommend parents/caregivers and health care professionals respond supportively to children who desire to be acknowledged as the gender that matches their internal sense of gender identity. 
• 7.13 - We recommend health care professionals and parents/caregivers support children to continue to explore their gender throughout the pre-pubescent years, regardless of social transition. 
• 7.14 - We recommend the health care professionals discuss the potential benefits and risks of a social transition with families who are considering it. 
• 7.15 - We suggest health care professionals consider working collaboratively with other professionals and organizations to promote the well-being of gender-diverse children and minimize the adversities they may face.

Healthcare professionals working with gender-diverse children must be well-trained in gender diversity across the lifespan. This training should also encompass general child and family mental health and expertise in working with neurodiverse conditions such as autism spectrum disorders and ADHD. For those without direct training in these areas, collaboration with experts who possess this knowledge is essential. This is particularly important given the noted overlap between transgender identities and autism; many autistic children are trans, and vice versa, though the reasons for this correlation are not fully understood and continue to be a subject of research.

The diagnostic criteria for autism, primarily based on studies of cisgender boys, may not accurately reflect the experiences of cisgender girls or transgender children. Recent research indicates that the manifestation of autism characteristics can differ significantly in these groups compared to the established DSM-5 criteria. This highlights the necessity for ongoing education and adaptation of diagnostic approaches to better serve a diverse population.

WPATH also emphasizes the importance of continuous professional development. Healthcare providers are encouraged to pursue continuing education to stay abreast of evolving practices and theories, ensuring they are equipped to provide the most effective support. Conducting comprehensive assessments that integrate information from multiple sources is also recommended. These assessments should aim to develop tailored intervention recommendations that support the child's mental health and well-being without pushing medical transitions.

It is crucial that assessments and interventions neither encourage nor discourage a child’s gender expression. The goal is to support the child in a manner that respects their self-identified gender needs. Assessments should thoroughly consider the child's environment, including family, school, and community contexts, utilizing multiple informants such as teachers, parents, extended family members, and other community figures to comprehensively understand the child’s situation.

Understanding the legal context in which the child lives is also vital. For example, if a child resides in Texas, it is important to know the specific legal implications for transgender youth in that state. Assessments might explore various dimensions such as the child’s gender identity and expression, any dysphoria or incongruence they experience, the strengths and challenges faced by the child and their family, experiences of gender minority stress, levels of support within the school, faith community, and extended family, potential conflicts within the family regarding the child’s gender, and the child’s overall mental health.

In comprehensive assessments for transgender and gender-diverse children, it's vital to gather a detailed medical and developmental history. This includes identifying any potential risks such as past trauma, abuse, suicidality, and co-occurring family stressors like chronic illness, homelessness, or poverty. Understanding the mental health of parents, caregivers, and siblings and the family's overall dynamics is also crucial.

Additionally, assessing the child's neurocognitive functioning and language skills is important. These factors can influence how accurately the child and their family report gender identity and expression. External pressures from family or school environments may compel a child to conform to certain gender expressions, and recognizing these influences is essential for accurate assessment and support.

Continuing education is imperative in this field. Professionals must stay informed about legislative changes, ongoing research, and evolving best practices. The recent introduction of the Standards of Care 8 underscores the importance of keeping knowledge current. In cases where it benefits the child and family, consultation or psychotherapy can be valuable, and it's crucial that this care coordinates with other aspects of the child’s life, such as school and faith communities.

Providing psychoeducation is a crucial element of working with transgender children and their families. Parents and children often require extensive information, especially as children approach puberty and begin considering their options regarding gender-affirming medical treatments. It is vital for healthcare providers to offer comprehensive details about available interventions, such as puberty blockers, ensuring that the family fully understands their effects and implications.

If a child expresses interest in exploring gender-affirming treatments, it is essential to discuss the potential impacts on fertility, as this is a common concern among families. Discussing fertility preservation options can help alleviate some anxieties about the future and aid families in making informed decisions. However, it's important to remember that if a child or their parents are not interested in these treatments, they should not be pressured or obligated to consider them.

Supporting a child's exploration of their gender identity is fundamental, whether or not they choose to socially transition. This support includes affirming the child's gender identity in a manner that respects their individuality and personal journey. It's also worth noting that a social transition can vary across different contexts. For example, a child might transition socially at home but not at school. Whether or not to disclose a social transition is a personal decision and should be guided by the child's comfort and safety, especially in environments where anti-trans legislation may affect their rights.

Additionally, it is crucial to address any concerns the family might have about sexual functioning, which can be a sensitive topic for some. While not all families will want to discuss this aspect, providing clear and age-appropriate information is essential for those who do. Furthermore, sex education should be introduced before puberty. This education should be inclusive, providing all children, including those who are transgender or gender-diverse, with the knowledge they need to understand their bodies and the changes they will undergo. This preparation concerns physical health and fosters a supportive environment that respects and affirms the child's developing identity.

When discussing social transition for transgender children, it is essential that the initiative for such a transition originates from the children themselves, not from assumptions made by their parents. For example, a parent should not deduce a child’s gender identity simply because they dislike traditionally gender-typed colors like pink and suggest the child might be a boy. Instead, the child should express their own desires and interests, and the transition should reflect their wishes.

Families can discuss with the child the advantages and disadvantages of social transitioning. It's important to note that social transition may occur in varying contexts; a child might transition at home but not at school, which is acceptable. Sometimes, a child may socially transition at a very young age, around 3 to 6 years old. In these cases, it's possible that neither their classmates nor their teachers are aware of the transition. This lack of disclosure is generally acceptable and often preferred to protect the child's privacy. This privacy should be respected unless external circumstances, such as anti-trans legislation, require disclosure. However, ideally, no one should be compelled to discuss their transgender identity involuntarily.

Exploring the risks and benefits of social transitioning is crucial. On the positive side, social transitioning can significantly enhance a child’s psychosocial adjustment and overall well-being. Research indicates that the mental health of socially transitioned children often parallels that of their cisgender siblings and peers, suggesting fewer mental health disparities than those observed in gender-diverse children and adolescents who have not transitioned socially. Supportive family environments frequently accompany these transitions and likely contribute to positive mental health outcomes.

However, there are potential downsides. Social transition may expose children to risks such as bullying or ostracism, particularly if they do not conform to established gender roles within their school or community. Additionally, the internal stress from experiencing gender incongruence can be a source of distress for gender-diverse children. 

Importantly, all children, including those who are transgender and gender-diverse, have the right to be supported and respected in their gender identities. They are a particularly vulnerable group, and the social determinants of health significantly impact their well-being. For these marginalized minorities, robust support from families and schools is crucial, playing a critical role in fostering their health and overall development.

WPATH Standards of Care 8: Adolescents

Let's switch our focus to adolescents. When discussing this age group, we refer to the Standards of Care 8 outlined by WPATH. It’s important to note that the numbers I mention correspond to specific standards within these guidelines.

• 6.1 - We recommend health care professionals working with gender-diverse adolescents:
  • 6.1.a - Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
  • 6.1.b - Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
  • 6.1.c - Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
  • 6.1.d - Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender-diverse adolescents
  • 6.1.e - Continue engaging in professional development in all areas relevant to gender-diverse children, adolescents, and families.
• 6.2 - We recommend health care professionals working with gender-diverse adolescents facilitate the exploration and expression of gender openly and respectfully so that no one particular identity is favored.
• 6.3 - We recommend health care professionals working with gender-diverse adolescents undertake a comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns and seek medical/surgical transition-related care, and that this be accomplished in a collaborative and supportive manner.
• 6.4 - We recommend health care professionals work with families, schools, and other relevant settings to promote acceptance of gender-diverse expressions of behavior and identities of the adolescent.
• 6.5 - We recommend against offering reparative and conversion therapy aimed at trying to change a person’s gender and lived gender expression to become more congruent with the sex assigned at birth.
• 6.6 - We suggest health care professionals provide transgender and gender-diverse adolescents with health education on chest binding and genital tucking, including a review of the benefits and risks.
• 6.7 - We recommend providers consider prescribing menstrual suppression agents for adolescents experiencing gender incongruence who may not desire testosterone therapy, who desire but have not yet begun testosterone therapy, or in conjunction with testosterone therapy for breakthrough bleeding.
• 6.8 - We recommend health care professionals maintain an ongoing relationship with the gender diverse and transgender adolescent and any relevant caregivers to support the adolescent in their decision-making throughout the duration of puberty suppression treatment, hormonal treatment, and gender-related surgery until the transition is made to adult care.
• 6.9 - We recommend health care professionals involve relevant disciplines, including mental health and medical professionals, to reach a decision about whether puberty suppression, hormone initiation, or gender-related surgery for gender-diverse and transgender adolescents are appropriate and remain indicated throughout the course of treatment until the transition is made to adult care.
• 6.10 - We recommend health care professionals working with transgender and gender-diverse adolescents requesting gender-affirming medical or surgical treatments inform them, prior to initiating treatment, of the reproductive effects, including the potential loss of fertility and available options to preserve fertility within the context of the youth's stage of pubertal development.
• 6.11 - We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, health care professionals working with transgender and gender-diverse adolescents involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible.

The first standard involves the requisite training, licensing, and credentials necessary when working with transgender adolescents. Importantly, while one does not need to be a mental health professional to assess a transgender-diverse adolescent, mental health professionals are generally best suited for this role. Typically, it is recommended that a mental health professional conduct assessments, especially those related to blockers, hormones, or surgery. However, a well-trained primary care physician could also competently perform this evaluation.

Additionally, those working with autistic or neurodivergent adolescents should seek ongoing training and professional development to ensure they are providing the most informed and effective care. It's crucial to facilitate the exploration and expression of gender in an open and respectful manner, ensuring that no specific identity is favored. This means avoiding any bias that might influence an adolescent either to embrace or reject a trans identity or to adhere strictly to the gender assigned at birth. The goal is to maintain a neutral, supportive space that allows youth to explore their identity at their own pace.

Conducting a comprehensive biopsychosocial assessment of adolescents is essential in a collaborative and supportive manner. It's important to recognize that not all children who are gender-diverse will continue to identify this way into adolescence. Similarly, adolescents may vary significantly in how quickly they consolidate their gender identity. This process occurs rapidly for some, while it evolves more slowly for others. This variability underscores the need to meet each youth where they are and proceed at a pace that respects their individual process.

Robust evidence supports the benefits of gender-affirming medical treatments in adolescents, but it's crucial to note that this evidence is based on clinical settings that incorporated detailed, comprehensive diagnostic assessments over time. There is no supportive evidence for making medical or surgical decisions without a thorough and prolonged assessment process. Therefore, the recommendation is clear: comprehensive diagnostic biopsychosocial assessments are necessary and represent the evidence-based approach for managing gender-diverse youth.

When working with families and schools, similar to interactions with children, it's crucial to avoid any approaches akin to reparative or conversion therapy. Such practices, aimed at changing a child's experience of their gender or eliminating gender incongruence, are not only ineffective but also harmful and unethical. Extensive research indicates that these methods can have detrimental effects on adolescents' well-being.

Health education on tucking and binding is also essential. If patients are engaging in these practices or are interested in doing so, it is important to provide proper guidance. Many teens might be tucking and binding unsafely, using materials like ace bandages or excessively tight tape, which can disrupt circulation and lead to issues such as back and chest pain, shortness of breath, and overheating. For example, one patient reported wearing two to three binders simultaneously, keeping them on while sleeping and during exercise, which is highly inadvisable. Binders are not meant for prolonged wear, especially not during sleep or physical activity, and should not be substituted with ace bandages. There are binders specifically designed for safe use, and these should be recommended instead. Notably, 87% of transgender masculine individuals, those designated female at birth who are transitioning to a more masculine identity, have a history of binding.

Discussing tucking, which involves retracting the testes and penis for a smoother appearance at the groin, is also crucial. This practice can affect sperm production and fertility, necessitating thorough educational support on these topics. Menstrual suppression is another consideration; it can be managed with various agents, regardless of whether the patient is using testosterone or puberty blockers. Some individuals may opt only for menstrual suppression without pursuing hormone therapy. Just as some cisgender women choose not to menstruate for personal comfort, similar options should be accessible for transgender individuals. Options include estrogen and progestin medications, oral progestins, and IUDs.

Puberty blockers, or GnRH (Gonadotropin-releasing hormones) analogs, can also suppress menstruation. However, testosterone, while it can suppress menstruation, may not immediately stop uterine bleeding, and breakthrough bleeding can occur. Importantly, testosterone is not a form of birth control and is teratogenic, meaning it can cause harmful effects on a fetus if pregnancy occurs. Therefore, it is vital to provide sex education and discuss birth control options with sexually active patients who could become pregnant, even if they are not menstruating. Ovulation and the potential for pregnancy can still occur in individuals using testosterone or puberty blockers who do not menstruate.

Providing ongoing support throughout the duration of puberty suppression, hormone treatment, or surgical interventions is crucial until the transition to adult care is complete. This process should not be limited to a single evaluation, after which the adolescent is sent on their way with prescriptions for hormones or puberty blockers. Decision-making is an ongoing process that requires constant support, especially as adolescents experience changes that might affect them differently than anticipated.

All of the research and evidence supporting these interventions were conducted in settings that fostered ongoing clinical relationships between the adolescents, their families, and their providers. This continuous support within multidisciplinary settings, where medical and mental health professionals collaborate closely, is essential for effective treatment. It’s important to understand that the evidence base comes from these types of collaborative environments.

Both medical and mental health professionals should be involved in both the initial evaluation and the ongoing care concerning blockers, hormones, and surgery. It’s not sufficient to have only mental health support; medical professionals must also be involved. While only one letter from a professional is required to proceed with treatment, this letter should reflect the entire team's comprehensive assessment and consensus, encompassing medical and mental health perspectives.

The multidisciplinary team might include professionals from various fields, such as adolescent medicine or primary care, which is often needed to confirm the stage of puberty. Endocrinologists may be required to prescribe hormones or puberty blockers, while psychologists, psychiatrists, and social workers address mental health aspects. Speech-language pathologists might be involved in voice training, along with support staff and the surgical team.

Discussing fertility is crucial when considering gender-affirming treatments for adolescents. It is essential to address the potential for fertility loss associated with various treatments and explore options for fertility preservation.

Puberty blockers are fully reversible, meaning they do not typically impact long-term fertility. However, transitioning directly from puberty blockers to hormones could potentially result in fertility loss. Furthermore, genital surgeries, although less common among adolescents, can have an irreversible impact on fertility. Therefore, discussing fertility preservation options, such as egg retrieval or sperm preservation, is important. It is vital that both parents and the adolescent understand the pros and cons of these options thoroughly.

Differences in perspective between parents and adolescents regarding reproductive capacity can lead to disagreements. Parents might place a high value on the potential for grandchildren, whereas the adolescent may express a clear disinterest in having children. Such disparities underscore the importance of facilitated discussions that help both parties understand each other’s viewpoints and the implications of treatment decisions.

It is also crucial to consider the adolescent’s decision-making competency regarding their future reproductive choices. While many adolescents feel certain about not wanting children, their desires and life circumstances could change as they mature. Guidance from professionals experienced in adolescent development and family dynamics is essential in these discussions. These professionals should help set realistic expectations for fertility preservation outcomes and ensure that these discussions are informed and based on the adolescent’s and family’s needs and values. These conversations need to occur both before initiating any medical intervention and throughout transition.

Fertility counseling is often recommended, even if preservation is not pursued. However, it is important not to coerce adolescents into fertility preservation if it is not aligned with their or their parents’ wishes. Procedures like egg retrieval can be distressing and physically uncomfortable, particularly for transmasculine individuals, due to the highly gendered nature of most reproductive health environments.

I'm currently working with an adult patient who was going through the egg retrieval process prior to continuing on testosterone. They experienced significant anxiety, partly because they had previously undergone the procedure. The environment, heavily feminized with images of women, did not align with their transmasculine identity, adding to their discomfort. They also found the process physically uncomfortable and painful.

These considerations must be navigated sensitively, ensuring that discussions about fertility preservation are inclusive and respectful of the adolescent’s gender identity and personal preferences. The decision to undergo fertility preservation is complex and must balance medical possibilities with the psychological comfort and personal desires of the adolescent, making professional guidance and open communication essential throughout the process.

It's crucial not to make assumptions about an adolescent's goals, especially given the limited research in this area. There is existing research involving childhood cancer survivors, which suggests that some participants experienced regret and distress over missed opportunities for fertility preservation. However, the experiences of transgender individuals may differ significantly.

Involving parents or guardians in both assessment and treatment is generally standard practice, with the assessment often occurring over multiple sessions—individually with the child, with the parents, and then together. This process can be extensive. Exceptions may occur, such as in cases where the adolescent is in foster care, under Child Protective Services, or where parental involvement might be harmful due to issues like abuse. However, in the majority of cases, parental or guardian involvement is crucial. Depending on the institution’s policy, consent from one or both parents might be necessary.

Parents and caregivers can provide valuable insights into the adolescent's gender development, medical and mental health history, and overall level of functioning. Discrepancies in reports between the adolescent and their parents about mental health can also provide critical information for understanding the youth's needs.

Working closely with parents is vital. It is essential to educate them about the treatment process, follow-up care, and potential complications. It’s important to take parents' concerns seriously and address their questions thoroughly, which can help in assessing the influence of peers or social media on the adolescent's understanding of gender.

There may be instances where parents do not consent to treatment. While some may still be generally supportive of their child’s gender identity, others may hold unsupportive or even antagonistic views. These perspectives, while challenging, are important to engage with as part of the therapeutic process. Many parents, with appropriate support and psychoeducation, may become more accepting and supportive of their trans and gender-diverse children over time.

Thus, continuing to work with families remains critical regardless of their initial stance on medical care. Even if a parent does not consent to specific treatments, supporting them can still positively impact the family dynamics and the well-being of the adolescent.

The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (All of them must be met):

• 6.12 - We recommend health care professionals assessing transgender and gender-diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when:
  • 6.12.a - The adolescent meets the diagnostic criteria of gender incongruence as per the ICD-11 in situations where a diagnosis is necessary to access health care. In countries that have not implemented the latest ICD, other taxonomies may be used, although efforts should be undertaken to utilize the latest ICD as soon as practicable.
  • 6.12.b - The experience of gender diversity/incongruence is marked and sustained over time.
  • 6.12.c - The adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.
  • 6.12.d - The adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed.
  • 6.12.e - The adolescent has been informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development.
  • 6.12.f - The adolescent has reached Tanner stage 2 of puberty for pubertal suppression to be initiated.
  • 6.12.g - The adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated.

When discussing gender-affirming medical and surgical treatments, it's imperative that the adolescent meets the diagnostic criteria for gender incongruence as outlined in the ICD-11. If the ICD-11 is not yet implemented within a specific healthcare system, an alternative classification, such as the DSM-5, may be used. However, the ICD-11 is generally preferred because it categorizes gender incongruence under conditions related to sexual health rather than mental and behavioral disorders. This shift is significant as it reflects a more current understanding that gender diversity is not a mental health condition, similar to historical changes in the classification of homosexuality.

The ICD-11 allows for diagnoses such as gender incongruence of adolescence or adulthood (HA60) for adolescents, gender incongruence of childhood (HA61) for children, or unspecified gender incongruence (HA6Z). This classification is less pathologizing and helps reduce stigma compared to the DSM-5’s diagnosis of gender dysphoria.

It's essential to recognize that adolescents may experience shifts in their gender-related experiences and needs. Therefore, they should ideally demonstrate several years of persistent gender diversity and incongruence before initiating less reversible treatments such as hormones or surgery. Puberty suppression is particularly beneficial as it can provide adolescents experiencing distress from the changes associated with puberty the time to decide if they want to undergo the typical changes of their biological puberty or pursue hormone therapy.

However, prolonged periods without hormones can impact bone health and density, making the extended use of puberty suppression treatments a complex decision. While several years of observation and assessment are ideal, practical considerations, including potential impacts on physical health, must also be taken into account. Social transition can provide significant relief and additional time for adolescents to explore their gender identity before making any medical decisions.

While we have already discussed reproduction and fertility, it is vital to reiterate the importance of these topics in the context of gender-affirming care.

A critical aspect of treating adolescents involves ensuring they have the emotional and cognitive maturity to consent to or assent to treatment. This typically requires both parental consent and the adolescent's assent. The adolescent must fully understand the treatment, including the ability to evaluate the risks and benefits. They must appreciate the nature of their decision, especially considering the long-term consequences of irreversible treatments such as hormone therapy or surgery.

To make an informed decision, adolescents need to clearly communicate their choices and understand the timelines for expected changes from treatments like hormones. They should be aware of what is reversible, partially reversible, and irreversible, weighing all the pros and cons to determine if the treatment aligns with their needs.

It's crucial to assess whether the adolescent can thoughtfully consider the future implications of partially or fully irreversible interventions. This includes evaluating if they have the self-reflective capacity to understand how their gender-related needs and priorities might evolve over time. Adolescents should consider their responses if their perspectives on gender identity change in the future.

Additionally, it's essential to determine if the adolescent can manage the day-to-day and long-term aspects of a medical treatment. This includes adhering to medication schedules, attending necessary medical follow-ups, and handling any associated responsibilities.

When considering the capacity to consent, it's essential to evaluate all aspects thoroughly, particularly mental health concerns, which are prevalent among transgender youth. This demographic may face a range of mental health issues, including depression, self-harm, suicidality, and eating disorders. When such concerns are present, the priority must be safety and stabilization. For instance, an adolescent grappling with suicidality or an active eating disorder may not be in a position to make informed decisions about gender-affirming medical or surgical treatments. Furthermore, these conditions could potentially destabilize them further, prompting careful consideration of whether they are ready for such treatments.

Mental health concerns can also complicate the assessment process. It may be challenging to distinguish between gender incongruence and other mental health issues, such as compulsions, special interests associated with autism, or symptoms stemming from trauma or psychosis. Such complexities necessitate a nuanced approach to evaluating the adolescent's true needs and readiness for transition-related care.

Moreover, if an adolescent is experiencing a depressive episode, it could impair their ability to engage in thoughtful decision-making. For autistic adolescents, persistent communication differences and a preference for concrete or rigid thinking can further complicate discussions around treatment options and future planning.

Treatment adherence is another critical consideration. An adolescent dealing with severe depression might struggle to consistently take prescribed medications or follow through with post-surgical care. While mental health issues do not need to be fully resolved before proceeding with gender-affirming treatment, they must be sufficiently managed to ensure the adolescent can safely participate in and benefit from treatment.

Regarding treatment timing, it's crucial that adolescents reach Tanner stage 2 before initiating puberty blockers. For hormones and surgery, the recommendation generally includes at least 12 months on hormones before considering surgical options. This duration allows for anatomical changes necessary for certain procedures, such as breast augmentation, and ensures that the adolescent has adequate time to psychologically adjust to the physical changes hormones induce.

Gender-Affirming Care: Outcomes

Let's discuss the outcomes associated with gender-affirming interventions. There is substantial evidence indicating that these interventions improve mental health outcomes. These interventions, which include puberty blockers, hormone therapy, and surgery, have been shown to lead to a resolution in gender dysphoria. This resolution is often associated with enhanced psychological functioning and increased satisfaction with body image.

It's important to note that trans adolescents generally exhibit poorer mental health compared to their cisgender peers. However, studies have shown that after undergoing puberty suppression, their mental health tends to improve significantly. Additionally, trans males who have undergone hormone therapy report lower levels of depression and anxiety compared to those who have not yet started hormone treatments. These findings underscore the potential benefits of gender-affirming interventions in improving mental health.

It's crucial to recognize that while these interventions can markedly enhance mental health, their impact varies. Not all adolescents will experience the same benefits, particularly if they have preexisting mental health issues. Gender-affirming treatments specifically address gender dysphoria; they do not directly treat other mental health conditions. Therefore, it is possible for an adolescent to continue experiencing mental health challenges even after undergoing hormone treatments, surgery, or puberty blockers. This highlights the importance of comprehensive mental health care that addresses all aspects of an adolescent’s well-being, not just those related to gender dysphoria.

What About Regret & Detransition?

Research concerning regret and detransition is a topic that garners significant attention, often highlighted in various articles due to public concern. However, studies indicate that the rates of adolescents choosing to cease puberty blockers are relatively low. For example, two Dutch studies from 2018 and 2019 found that only about 2% to 3.5% of adolescents chose to stop puberty suppression. It's crucial to note that puberty suppression is entirely reversible, so stopping these treatments does not result in long-term or sustained effects.

Regarding detransition, research shows that while some adolescents do detransition, they do not necessarily regret initiating treatment. For instance, an individual might have achieved the desired irreversible effects from hormone therapy, such as a lower voice, and choose to discontinue treatment while still feeling positive about the decision to start it.

A significant study conducted between 2014 and 2020 by a gender diversity service in Western Australia that provides gender-affirming care to children and adolescents up to 18 years tracked 552 closed referrals and provided insightful data. Out of the 548 patients included in the study, only a very small percentage, 5.3%, re-identified with their birth sex after being referred. Remarkably, only two patients, approximately 1% of those who received some form of treatment such as puberty suppression or hormones, later re-identified with their birth sex. The findings suggest that some individuals might re-identify during the assessment process and choose not to proceed with treatment.

It is essential to distinguish between detransition and regret. Detransition refers to the cessation of the medical transitioning process, which does not necessarily imply regret about the decision to start. Furthermore, the rates of re-identifying with the birth sex are exceedingly low, and stopping hormone therapy does not always mean re-identifying with one's birth sex. Individuals might continue to identify with the same or a different transgender identity but decide against continuing medical transition.

This complexity underscores the need for nuanced understanding and support in the realm of gender-affirming care, recognizing that the paths of gender identity and transition are highly individual and not uniformly linear.

Clinical Approaches

Let's briefly review some clinical approaches. Since we've covered these extensively, I'll quickly summarize the key points.

Supporting TGD Youth

• The role of advocacy
  • Join community organizations
  • Join with parents and families
• Provide psychoeducation and training
• Make your voice heard in schools, with medical providers, in politics/courts, and in the media
• Support youth in their families, schools, and communities
• Understand the role of multiple minority stress
• Address barriers to accessing care

Advocacy plays a crucial role in supporting transgender and gender-diverse youth. It is vital to engage with community organizations, collaborate with parents and families, and make one's voice heard in various settings, including schools, medical environments, political arenas, and the media.

Family Interventions

• Providing psychoeducation
• Allowing space for families to express reactions to their child's gender
• Emphasizing the protective power of family acceptance
• Utilizing multiple modalities of support, 
• Giving families opportunities for allyship and advocacy
• Connecting families to TGE community resources
• Centering intersectional approaches and concerns 
• Types of support:
  • Emotional
  • Instrumental 
  • Appraisal
  • Informational
• Parental support is essential!

In working with families, it is important to provide education and space for them to express their reactions to their child's gender identity, even if those reactions are not always positive. Emphasizing the protective power of family acceptance is crucial. Employ multiple modalities of support and provide opportunities for allyship and advocacy. For example, connecting families with advocacy organizations and community resources can help them support their children more effectively. It is also important to consider intersectional approaches, acknowledging that these families may face additional challenges related to other marginalized identities.

Studies have shown that family support can take various forms, including emotional support, such as expressions of love, empathy for mental health issues, and communication about emotions. Instrumental support might include financial assistance, help with healthcare, and support during social and legal transitions. Appraisal involves giving feedback and affirming the child’s gender, helping choose a name, or helping choose pronouns. Informational support includes providing advice and sexual health information. These elements are crucial in helping transgender children feel supported by their families.

Guidelines for Schools

• Create a welcoming environment
• Create antibullying measures – and actually enforce them!
• Provide opportunities to explore medical transition options if indicated 
• Use the youth’s name and pronouns correctly
• Support the youth in connecting with LGBT groups, trusted staff, and peers

It is essential to help schools create a welcoming environment in the educational setting. This involves implementing and enforcing anti-bullying measures, using the youth’s chosen name and pronouns correctly, and providing opportunities for medical transition if indicated. Schools should also facilitate connections with LGBT groups, trusted staff, and LGBT peers. In one school, for example, affirming teachers displayed symbols on their doors to indicate their support, allowing LGBT students to identify allies.

Unfortunately, the risks of inadequate support are starkly highlighted by incidents like the case of Nex Benedict, a non-binary student in Oklahoma. Nex was reportedly bullied and attacked and tragically found dead the following day. This case underscores the severe impact that bullying and lack of support can have on the physical and mental health of transgender youth, emphasizing the importance of robust advocacy and protective measures in all environments that influence the lives of these young individuals.

Ethical Considerations

Ethical considerations are critical, especially when working with transgender youth. As we conclude today's discussion, it's important to emphasize the role of ethical guidelines in guiding professional conduct.

Ethics Codes

Always refer to the ethics codes specific to your profession. These codes provide a framework for addressing the complex situations you may encounter and ensure that you uphold the highest standards of practice. Additionally, be well-informed about the legal and ethical environment in your state. Local laws and regulations can significantly impact how services are provided to transgender youth, and staying informed ensures that your practice meets professional standards and regional legal requirements. 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/ethics
• 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

The Ethics of Gender-Affirming Care

The ethics of gender-affirming care, particularly for transgender youth, involves navigating complex issues that require a nuanced understanding of medical ethics and human rights perspectives. The World Professional Association for Transgender Health (WPATH) and its Standards of Care emphasize the ethical principles of self-determination and the right to access healthcare.

When deemed capable, adolescents should have the autonomy to make decisions about their healthcare. This often involves dual consent—both from the adolescent and their parents. However, the ethical principle of self-determination supports an adolescent's right to choose their own treatment, assuming they have the capacity to consent. This principle is particularly poignant in cases where gender-affirming care is deemed medically necessary, as it is the only treatment known to effectively address gender incongruence and has been shown to lead to significantly positive outcomes.

However, it is crucial to ensure that adolescents receive appropriate education about their treatment options and a thorough and thoughtful assessment process. This ensures they truly understand and can consent to their treatment, safeguarding against potential harm that could arise from treatments they are not fully prepared to undertake.

It is also important to recognize that choosing not to intervene—allowing puberty to progress without interruption—is not a neutral act. For many transgender adolescents, this could lead to intense distress and negative psychological outcomes. Inaction, under the guise of avoiding harm, can itself be harmful.

For example, I am currently working with a 20-year-old who began hormone therapy at around 17 or 18, with parental consent. However, prior to this, there was a period of confusion and non-consent from the parents. During this time, she obtained hormones via the internet, stating that it was life-saving and that her friend, by facilitating access to hormones, literally saved her life. While it's not ideal to encourage unsupervised medical interventions, this situation underscores the lengths to which individuals may go to alleviate their distress.

Moreover, consider the patient who wore three binders to flatten their chest despite the physical pain it caused. This example highlights the severe distress associated with experiencing gender incongruence and the potential risks individuals might take to find relief.

Ethics and the Law

When ethics and law are in conflict, particularly in the realm of gender-affirming care for transgender youth, professionals face significant challenges. Instances where laws may label supportive parents as potential child abusers simply for consenting to gender-affirming care for their children highlight the stark contrasts between ethical medical practices and legal mandates. This was a proposed law in Texas, and a psychologist took that law to court. These situations are distressing, not only to the families affected but also to the professionals involved.

In states where gender-affirming care is restricted or banned, families sometimes resort to extreme measures, such as traveling to neighboring states or even countries where such care is accessible. For example, families in Texas might travel to New Mexico to receive the necessary treatments that are prohibited in their home state. This places a financial and emotional burden on the families and highlights the disparities in healthcare access based on geographical location.

For mental health professionals and psychologists, these conflicts between ethics and law underscore the importance of being actively involved in policymaking. Advocating for laws that reflect current scientific understanding and best practices in healthcare is crucial. Many policymakers may lack awareness of the latest research or the scientific consensus on issues related to gender identity, which can lead to legislation that is not only scientifically unsound but also harmful.

Professionals can leverage their expertise to educate policymakers, participate in legislative processes, and challenge unjust laws in court. The case of the psychologist who took such a law to court is a prime example of how professionals can actively defend ethical practices and support the rights of transgender individuals.

Conversion Therapy

Conversion therapy, often referred to as reparative therapy, attempts to change an individual's sexual orientation or gender identity. It is important to acknowledge that this practice is ineffective and unethical. Research and clinical consensus have demonstrated that gender incongruence cannot be "treated" or altered through such therapeutic approaches; they simply do not work.

Gender-affirming treatments are the only interventions that have been shown to alleviate the distress associated with gender dysphoria. These treatments support the individual’s gender identity rather than attempting to change it, which is crucial for improving mental health outcomes.

Moreover, it's worth noting that conversion therapy is illegal in several states, reflecting its disapproval within the professional community and its recognition as a harmful practice. Engaging in or endorsing conversion therapy goes against the ethical guidelines of most professional bodies in the mental health field. As such, it is vital for professionals to avoid any involvement in practices that attempt to change a person's sexual orientation or gender identity.

Confidentiality

Finally, confidentiality is a critical ethical consideration when working with transgender youth. It is imperative not to disclose a child's gender identity to their parents or family without the child's explicit permission. Often, a child may reveal their gender identity to a healthcare provider while still not being ready to come out to their family.

To manage expectations and protect confidentiality, it is advisable to include specific provisions in the consent forms that are discussed and agreed upon with the parents at the onset of treatment. These provisions should clearly state that while issues of significant risk will prompt a breach of confidentiality — for example, if the child is in danger — the details of the child's gender identity will remain confidential if sharing those details poses no immediate risk.

Furthermore, it is important to discuss with the child the potential mental health impacts of coming out to their family. This conversation can help prepare the child for various outcomes and ensure they are making informed decisions about their disclosure.

Additionally, be cautious about documentation. In large healthcare systems, where multiple providers may access a patient's records or where parents can view their child's medical information, it is crucial to document sensitively. If certain information, such as the child's discussed gender identity, needs to be kept confidential, ensure it is documented in a way that respects the child's privacy.

Overall, establishing clear guidelines about confidentiality from the start with both the child and their parents can prevent misunderstandings and protect the child's privacy while under your care.

Resources

• APA Guidelines for Treatment of Transgender & Gender Diverse Practice 
• WPATH Standards of Care, Version 8
• UCSF Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People

References

ACLU. (2024). The ACLU is Tracking 484 Anti-LGBTQ Bills in the U.S. Retrieved from https://www.aclu.org/legislative-attacks-on-lgbtq-rights-2024

Andrzejewski, J., Pampati, S., Steiner, R. J., Boyce, L., & Johns, M. M. (2021). Perspectives of transgender youth on parental support: Qualitative findings from the resilience and transgender youth study. Health Education & Behavior, 48(1),74-81.

Call, D. C., Challa, M., & Telingator, C. J. (2021). Providing affirmative care to transgender and gender diverse youth: disparities, interventions, and outcomes. Current Psychiatry Reports, 23, 1-10.

Cavve, B. S., Bickendorf, X., Ball, J., Saunders, L. A., Thomas, C. S., Strauss, P., & Moore, J. K. (2022). Reidentification with birth-registered sex in a Western Australian pediatric gender clinic cohort. JAMA pediatrics, 178(5), 446-453.

Coleman, E., et al. (2022). Standards of care for the health of transgender and gender diverse people, Version 8. International journal of transgender health, 23(Suppl 1), S1–S259. 

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.

Hays, P. A. (2008). Entering another's world: Understanding clients' identities and contexts. In P. A. Hays, Addressing cultural complexities in practice: Assessment, diagnosis, and therapy (2nd ed., pp. 65–83). American Psychological Association.

Johns, M. M., Zamantakis, A., Andrzejewski, J., Boyce, L., Rasberry, C. N., & Jayne, P. E. (2021). Minority stress, coping, andtransgender youth in schools—Results from the Resilience and Transgender Youth Study. Journal of School Health,91(11), 883-893.

Malpas, J., Pellicane, M. J., & Glaeser, E. (2022). Family-based interventions with transgender and gender expansive youth:Systematic review and best practice recommendations. Transgender Health, 7(1), 7-29.

Reed, E. (2024). Anti-Trans Legislative Risk Assessment Map – February Update. Retrieved from https://www.erininthemorning.com/p/anti-trans-legislative-risk-assessment-96f

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.

Trans Legislation. (2024). What is Happening With Anti-Trans Bills in 2024? Retrieved from https://translegislation.com/

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. 

Georges, E., Brown, E. C. B., & Cohen, R. S. (2024). Prohibition of gender-affirming care as a form of child maltreatment: Reframing the discussion. Pediatrics, 153(1), 1–5.         https://doi.org/10.1542/peds.2023-064292

Handler, T., Merchant, M., Guzik, C., Chen, S., Kralik, N., Ojo, A., & Zaritsky, E. (2024). Diagnosis and time to treatment for pediatric patients with gender dysphoria. Journal of LGBT Youth, 21(1), 20–28. https://doi.org/10.1080/19361653.2022.2139788

Pomarico-Denino, V. (2024). Gender-affirming care for the adolescent patient. Nurse Practitioner, 49(3), 11–18.  https://doi.org/10.1097/01.NPR.0000000000000147

Rangi, S. K., Rehmer, J., & Ferrando, C. A. (2024). Prevalence of Polycystic Ovarian Syndrome in young and adolescent transmasculine patients presenting for gender-affirming care. Journal of Pediatric & Adolescent Gynecology, 37(1), 51–55. https://doi.org/10.1016/j.jpag.2023.09.003

Restar, A. J., Layland, E. K., Davis, B., Thompson, H., & Streed, C. (2024). The public health crisis state of transgender health care and policy. American Journal of Public Health, 114(2), 161–163. https://doi.org/10.2105/AJPH.2023.307523

Editor’s note: This text-based course is an edited transcript of the webinar, Supporting Children Who Been Affected by Divorce, presented by Sybil Cummin, MA, LPC, ACS.

Learning Outcomes

After this course, participants will be able to:

• Describe the effects of divorce on children based on different developmental stages.
• Identify how best to work with children impacted by divorce.

• Identify assessment tools for working with children impacted by divorce.

Introduction 

I specialize in working with what a lot of people consider high-conflict divorce. That term actually really is intimate partner violence or domestic violence by another name. But we are not solely looking at those really contentious divorces here or abuse here. We are going look at a little bit of that, but also just in general children and how they are affected by divorce, and what you can do in your work with the children or work with the parents to help them get through that and to be a protective factor for them.

Limitations/Risks

This presentation is an overview of how children and adolescents are affected by divorce, by different developmental stages, and how to treat them. However, if you are going to go into the world and you are going to work with kids or parents, make sure that whatever clinical work you are doing is within your scope of practice. So if I am sharing about play therapy today in some instances, but you have never taken a play therapy training course, your supervisor is not trained in play therapy. You need to do more training before you hop in with those children.

Divorce in the United States

 I assume that you all know a little bit about divorce and that it does affect children, but I am hoping that you walk away with things that you can better see when it presents to you and know some of the research around what is actually causing the difficulties for our children and how to work with that.

Divorce in the United States was 2.3 per every 1000 marriages in 2022. This is a decrease from the previous years. There has been a little bit of a decrease for five or six years. I do not know all the reasons for the decrease. I know there was a pretty good uptick directly after COVID, but not sure if there is a continued decrease in that. Not sure why, but the APA still estimates that between 40 and 50% of all marriages are going to end in divorce. What we are here to learn about is the risk to our children. So research shows that there is a 16% increase in the risk of behavior problems for children ages 7 to 14 when their parents divorce. This age group, the elementary age group, seems to be the most negatively affected.

Children of divorced parents are one and a half to two times more likely to live in poverty and to engage in risky sexual behavior as they get older. So we know divorce does affect kids.

Why is This Important?

Why is it important to know the numbers and know the stats? Because guess what? If you are working with kids, you are going to work with divorce, and a large percentage of the kids you work with have had this experience. And whether it is divorce or separation, I am using the term divorce as a catchall for that. There are some legal things that can cause some issues with our children. Specifically with divorce, but really any separation of the family.

 But I want to point out that there are a lot of things that we can do, that parents can do, that our schools can do, that everyone can do that will offer protective factors so that they do not have long-term negative effects. And so I think our goal as mental health professionals is to offer those things that will allow them to process what they are going through and thrive later on in their lives. 

Is it Really the Divorce that Affects Them?

Is it really divorce that is negatively affecting our children? Actually, no. So it is not the process of divorce or families being separated that really has a long-term negative effect on our children. Will it affect our Children? Yes, absolutely. So if you have the most amicable separation and divorce, the kids will still have some effects. They have to figure out new scheduling, where they'll live, and different things like that. But they typically adjust really well, and there are no long-term effects.

So what actually is causing these long-term negative effects is what's going on right before or before the separation and divorce, what's going on after the separation and divorce. Research shows that pre-divorce and post-divorce behaviors by the parents is more likely to be the cause of longer-term negative effects on a child with high conflict relations before and after having the greatest negative effects.

It is the behavior of the parents. That feeling in the home, or the arguing in the home. The stuff going on in the home before the separation happens, and then the talking trash about the other parent, or counter-parenting, and all of these things that happen after the separation and divorce that are causing problems.

So that is really important for us to know, especially if you are working with parents because these are the pieces that really need support. We need to support the kids through and hopefully, like fingers crossed, that parents will be on board to make changes in their behavior because it really negatively impacts the Children. So I bring up ACEs, which are adverse childhood experiences, because if we look at why those, especially those pre-divorce behaviors, are negatively affecting our children, we can see it through the ACEs because one of the questions on the ACEs is about, you know, have parents been separated or divorced when you were a child? It is one of the ACEs, but if we look at some of the other ones, so did you often feel that no one in your family loved you or thought you were important or special, or did they spend time with you? Was there domestic violence in the home? Was a household member depressed or mentally ill?

So that is what the parents are going through, maybe before or directly after the abusive relationship, or not an abusive relationship, any relationship, right? If they cannot connect with their children because they are distracted, they are anxious and depressed. If they are not able to meet their child's needs and meet their child's attachment needs, they are going to be impacted.

 I will talk about it throughout, but it is really important for the parents to get their work done and do their own work because it is their stuff that will negatively affect the children for the most part. And this is really the spillover hypothesis. So this is when negative behavior patterns and emotions, those high levels of emotions within the parents, spill over and cause problems with their children.

So, again, as I mentioned before, their parenting quality may decrease because they are dealing with so much within the marital or romantic relationship. This happens a lot in domestic violence-related cases. The protective parent or the victim parent, the target parent, or whatever you want to call them, is needing to focus on survival.

So they may have really inconsistent discipline, and the discipline is solely around, "I need my kids to behave so that my partner doesn't harm us, and so maybe I will give in when I wouldn't have given in because I just need them to be quiet." So things like that are what actually negatively affect our kids.

Common Reactions to Divorce 

What are some common reactions to divorce for children? We will go through the different ages and stages of children. I'm going to point out that I am not doing infant mental health care. I am trained in working with ages three and up. Infants to two years old have different reactions to things, and you need to look out for things in a different way.
Ages 3-6

We are going to start with preschool age. They are going to experience fear because their home base is changing. Maybe they have a primary attachment figure, a person who is with them all the time that, kisses their booboos, gives them the Band-Aid, feeds them, and does the majority of the care. And if all of a sudden, they are not going to be with that person all the time, that causes a great amount of fear. Or if the parent is acting weird, that causes fear. They will have pretty extreme confusion because this makes zero sense. They do not have the cognitive structure to understand marriage and divorce, and "we do not love each other anymore."  These conflicts are above their level of understanding.

No matter how well you explain it, there is going to be confusion. They may experience some guilt because, in their minds, they are to blame. They might pair, "Oh, I always had a tantrum, and now my parents do not live together,” They may pair things because they are trying to make sense of their world.

At this age, we are looking for regression. So very often in this age group, you will see separation anxiety and potty problems, like they have been potty trained for a year, and now they are not potty trained anymore. Maybe an increase in acting out, and it is because their whole world is a mess right now, and they are not sure what to do.

They have no sure way of getting their needs met. So they are going to try these different ways to get their needs met. So, I talked a little bit about this, but there is so much uncertainty for these children. They do not know what it means. The change in the family might be considered their fault. Change in the family is hard for anyone, but really hard for children of this age because, again, there is not really a way to explain it to where they are going to really understand. And when we do explain it, we need to be almost as black and white as possible, very specific. This is going to happen, this is going to happen, and this is going to happen.

A lot of times, we talk about the number of sleeps before you go to the other parent's home, things that they understand. Although, what I see most often in my practice are attachment concerns. And that is because very often, as I mentioned, these children do have a primary attachment figure, and their world goes to pieces when they are not with that attachment figure all the time. And the way our family court system is set up is that they will not get to most likely be with their primary attachment figure all the time. Okay, so moving on to this tougher age group, ages 6 to 12.

Ages 6-12

This age group starts to experience different things. They are going to start experiencing grief, and this is because they will be making more meaning of what is going on. They have ample cognitive processing and understanding to make some meaning out of this. They also remember potentially when the family was together, and so there is grief of that togetherness that they might experience. They also will experience guilt. And I tell parents this very often. Until they can fully understand it, they are going to try and find a reason why. Because not knowing the reason why is actually scarier than if it was their fault. And so very often, they will still, as many times as you tell them, they will still take on some of this as their fault.

They will experience anxiety, maybe, right? They do not always. And what does that look like? Because in this age group, we need to be aware it does not always look like they are nervous or scared. It could look like they are really aggressive, they are acting out, they may have blow-ups or a lot of parents come into my practice, and they are like, "Oh, my child has really big feelings." Or, "These explosions, and we're not sure where the explosions come from." Very often, that is anxiety based.

We also really need to pay attention to those physical and somatic symptoms, headaches, stomach aches, and a lot of restlessness. Teachers might notice that they are really tired in class, struggling with executive functioning, or they cannot concentrate. Because in their nervous system minds, their world is kind of a wreck, and they may not or do not feel safe, so they might be in that hypervigilant state.

And so, guess what? When you are in that fight or flight state, your thinking brain goes offline. So those are some of the things we see with anxiety.

With depression, we see similar things with regard to lack of concentration and struggles with focus. We also will see a little bit more of the withdrawal or irritability and really pushing people away. They have moved down into that lower level of our nervous system, which has shut down. And so they may seem not to care. And in a school setting, it is like they are giving up really easily or they are not trying. We will see a lot of that. They may show a lot of anger, they may act out to get their needs met, or they may completely withdraw.

A lot of the research that I have been reading and in my experience, this is the toughest age, and it really is because they have some memories of good times. Even some clients that I have worked with, whose parents have been divorced for four or five years, still have this desire, this wish that their parents would be back together, even though they know things feel fine separated and they are consistent with their schedule, and they understand the schedule and they kind of understand the thing, they still have that grief and that desire for them to get back together.

If we think about what is the life of an elementary-age student or an elementary-age child, their lives are in the home. They are doing things with their parents, with the family, hopefully. If they have athletics or sporting events, the family is with them, or the parents are with them. If they have friends, friends come to the home, or they do these play dates, right? So it is, their lives are really based within that home, that system in the home. And that will start to change as we will see their lives kind of move more into a friendship world where friends and peers are more important. So moving on to our teens.

Ages 13-18

I love my teens, just to put that out there. They are a lot of fun. They also will experience that same grief. Their anxiety may look different than elementary age because now they actually have language for what they are going through. They will be more aware of their bodies for the most part. So, if their hearts are racing and they are in that fight or flight, they are more likely to have panic attacks because they are really aware and noticing, "Oh my gosh, my heart and I'm feeling this way." So you might see a little bit more of that. You still will see struggles with concentration because their brains are in fight or flight. They may be more embarrassed, which adds to that anxiety of, "What is going on in my home?" And not wanting people to know that because fitting in is the most important thing, And developing those peer relationships.

With depression, we will start seeing more self-harming behaviors in this age when they are having these really big feelings about the divorce. You might see more anger directed toward their parents, or they can be directing it inward with self-harm. Outwardly, you might see this a little bit more at school, some withdrawal, but that is actually somewhat normal depending on if they are just withdrawing from the family. But what you will really start to see in this age group, which is actually a protective factor for this age group, is a relief. They will be able to often point out that they feel relieved that they do not have to live in high conflict all the time and that their life will be better when their parents separate.

So that level of relief that very often my teens feel, I think, kind of prevents it from being as hard as it is for elementary-age children. They can also understand things a little bit better. They can understand some of the nuances of divorce and some of the nuances of a romantic relationship. And unlike elementary-age children,  teens' lives are more outside of the home. Developmentally, they want to be with their peers more. That is where their connections are going to be. They will have a little bit less of a connection with their parents at home. They do not want to be at home. And so as long as they have those outside supports, they will actually do a little bit better than those elementary children who can not go hang out with a friend on their own, they can not ride their bike to their friend's house and just be on their own, right? And so that is really, really helpful.

What Can You Do to Help?

What can we do to help? So I want to talk a little bit about assessment because you are going to assess these children differently depending on age and depending on situations.

Assessment

These are some of the actual assessments, like pen and paper type assessments, that you can do with them:

1. Pediatric ACEs and Related Life Events Screener (PEARLS)
2. Positive Childhood Experiences (PCE)
3. House Tree Person
4. ACEs or PACEs with teens
5. Parent Intake Information

I use the PEARLS assessment in our practice as opposed to ACEs, especially with our younger ones, because ACEs is technically meant for older teens who can fill it out for themselves. It is not meant for parents. PEARLS is very specific. The PEARLS questions are almost identical to the ACEs questions. They are worded differently and from a caregiver's perspective.

Since we are going to get the caregiver's perspectives on things, then it is really important to focus on a strengths-based approach and a strengths-based assessment. So I really like looking at Positive Childhood Experiences (PCE). These are the protective factors that children are going to have. If children have several of these, they are going to have fewer negative long-term effects from the divorce. Some of the questions on the PCE are:

• Did they feel comfortable?
• Does your child feel comfortable, or do they feel comfortable talking to family about their feelings?
• Do they feel like there is a sense of belonging at school or outside activities?
• Do they have other adults in their ecology that pay attention to them and take an interest in them?

 So if you want that protective factors look, I would take a look at that assessment.

When you are working with younger children, I do this sometimes with younger teens, but I do this all the time with my ages three and up or 3 to 11 and 12; the House-Tree-Person assessment.

As I said in the initial disclaimer of risks, do not do this assessment without further reading just based on what I say here because it is not enough.

There are specific ways to assess using the House-Tree-Person, which is an evidence-based model. But basically, what it looks like is you are going to hand the child a piece of paper. There is a specific way to hand the paper over, and they are only using a pencil or a black crayon because we do not want to add colors into it because then you are assessing all types of things, and we want to make it pretty specific about what we are assessing.

You are going to ask them, "Please draw for me a house. Let me know when You are finished." That is all you are saying. And they will draw a house. You are going to do the same thing for tree and person, "Please draw for me a tree. Let me know when You are finished. Please draw for me a person." They are going to do it.

 I actually add to this, based on a training I went to that was amazing. I ask for them to draw a person of the other gender, and that is what I am looking at, or I sometimes say, "Another gender," or "A different gender" because when I learned it, things were not as gender-fluid as they are now. And so that is not how they talked about it, but that is kind of how I do it. You really look at who they are connecting with, who do they kind of relate to in that person. And then I ask, you could ask this without doing the whole House-Tree-Person, "But please draw for me your family doing something together." I get so much from that assessment, from just that one piece of the assessment.

So what you are looking at is how do they feel within themselves? That is actually the tree. How do they feel within their system? That is the house. And there are specific questions I ask for each picture to assess. So, again, if that piqued your interest, go do some more reading and learning on that because it is a really cool assessment.

With older children, I do ACEs or PACEs, and PACEs is just adding the protective, so it is the protective and adverse childhood experiences scale.

And then, one of the areas you are going to get the most information in is parent intakes. So I highly recommend that if the parents are separated, you do separate intake sessions with each parent if your work environment allows that because you are going to get so much data from this. What parent is talking about the child and how the child's been affected? What parent is talking about how horrible the other parent is? What did it look like? And you do not even have to ask this question because you will know, based on how they talk about the other parent, how they talk about the child. But in asking about their child's experience of the divorce, you will get so much information about what life looks like for the child.

I almost always do them separately because, typically, one parent, if the parents are together, they are not going to feel as open to sharing all the information as if they are with their co-parent. On occasion, we have that because there is a really comfortable relationship with them, but we very often do it separately. And some of that is to protect yourself, to CYA. And I am going to talk about that a little bit later.

Goals

Okay, what is our goal? So the goals for therapy or your time with your children. So I get lots of time. I am in private practice. I get to see children for a long period of time should it be beneficial to them. So if your situation is you get them for just a little bit of time, or you get to see them in a school setting, or hospital setting, it may look different.

Ages 3-6

In general, your goal for this age is really to provide a safe place, provide a safe place for your kiddo to provide you as a safe person and a safe vessel for them to figure this out and to realize they are safe as long as they are safe and to help them get safe if they are not. So You are going to, it is your job to also, one of the goals is to give the parents the skills necessary to support a child in a developmentally appropriate manner And really focusing, again, this is my bias because this is how I view children but really reinforce the secure attachment.

And if there is not a secure attachment with one parent, both parents, whatever it might be, is to really support improving that and then to help build the child support system and protective factors around them outside of the family unit.

So how do we do this? We play. Trying to do some talk therapy with ages three to six is, in my opinion, not very helpful. We are not even going to teach coping skills. We are not even going to use that language. We are going to use ourselves. We are going to use them for play. You can use art. You can do some directives because this group is in preschool, so they can follow some directions and things.

It is my bias that we do non-directive play, but play. And so some of the themes of play that you might see are themes of power and control, where they really want to take control of the session because when their world is muck, they have no control, zero control. Why is it so important to get the blue sippy cup instead of the pink sippy cup? Because they have no power and control in their worlds. So maybe they have not had that freak out in a long time about the sippy cup or about the specific spoon that they want to  use, and all of a sudden, they have regressed, and they are back to "The blue cup is the only cup that will work, and I am going to have a huge tantrum." 

That is power and control. So in the play therapy room, they are probably going to tell you what to do, right? That my imagination is usually wrong in these cases, and they would like me to do things very specifically. I give them that power in the play therapy room. That is the wonderful thing about working with children is I get to give them some power.

They may play hide and seek, and this really is attachment-based. So this is actually something I share with parents to do with their children, is, right, that hide and seek when they are little, and it is like, "Oh my gosh, my littlest is Garrett, he is eight. So we do not play hide and seek anymore, really, but like, gosh, I really hope I can find Garrett. Where is he? I am going to miss him so much if I can not find him. Oh, I love that he laughs this way," or, "He's such a good hider." 

All of those things are all about attachment and them feeling like you want them and you would go out of your way to find them and do anything for them. You will see that in the play therapy room all the time. They may bury things in the sand, and usually, my question is, does it feel safe under the sand, or does it feel scary under the sand? And so sometimes it is habitual, sometimes it is anything, and they are just going to keep doing their work, and we are a safe person to be there while they do their work.

Nurturing play is really common. So making me food in the play therapy room, being with babies. If they are having a really hard time and they are feeling a lot of that angst and aggressiveness, I did not put this in here because a lot of places do not have these items in their room, but I sword fight all the time with this age group, and again, in that power and control dynamic, I let them win, or we have fire, you know, play guns in our office. And so sometimes they will use those to really take on a high level of power and control in the room and to get out aggression. And then we are going to have parent involvement, okay?

This age group does not live in a bubble. So unless there is child abuse and neglect that you highly suspect, sexual abuse, things like that, we are going to involve the parents as much as possible because the children go home. We have them for 50 minutes a week, maybe, or maybe you see them in school more, but you get them for like 10 minutes, or whatever that might be. So we are going to give our recommendations to parents. We are going to help them with attachment and things in the home.

Ages 6-12

Ages 6 to 12, guess what? Our goal for the first one is the same. We really want to allow our children a safe place to process their situation, that we are a safe vessel. Usually, at this age, they will start to ask about what I am going to tell their parents.

And so as the child gets older, the level of confidentiality, not secrecy, but what we are going to share with parents, is going to shift. So those younger ages, I share a whole heck of a lot unless it is a domestic violence situation, a high-conflict divorce situation where they are in family court. Then I share very little, and I will talk about that later. And so at this age group, same thing. If there is all of that stuff, we share very, very little. But now, I am going to even with my like 4, 5, 6-year-olds, I might say something in the room like, "Wow, when you play with my sand tray, your body seems so calm. Can I tell your mom that?" 

Because guess what? This child needs some sensory stuff at home to calm their stuff down, right? So I still am almost asking for a release of information from a four-year-old basically, but I am still that, I hold that, the time in the room with my children very, it's really important to me. So that will increase here. And for you to be safe and feel safe, you really have to stick to that. So if I am going to email parents about something, I let my children know, like, "Hey, you know what? I am going to send an email to your parents about X, Y, and Z." Or maybe I did it because I needed to do it before the session.

I am going to  let them know, "Hey, I emailed your parents about X, Y, and Z. What are your thoughts about that?" Just so that we can still be their safe person. Our goals are to increase their skills and communication, emotional intelligence, window of tolerance, and improve kind of their comfort in sharing their feelings, giving them that language to be able to share what is going on so that they can get their needs met in a different way than acting out. So this is a little bit different than those younger kiddos where we are going to do most of it. I still do mostly play with this age group, but there is a little bit more, this sounds bad, and I do not mean it bad, but of an agenda.

We can use the play to do these things and use ourselves to do these things. We are going to give parents skills to support the child, again, in a developmentally appropriate manner, still focusing on attachment because that is one of the number one kind of protective factors for these children. And then the same thing is to really build the child support system and ecology outside of the, just the therapy room, just the family unit. We are going to play. We are going to play still. You can use some directive activities. You can share coping skills, things they can try at home. The themes of the play are very similar. They do hide and seek less often, but some of those younger children do, and they'll do it in a different way.

It might be hiding something of importance in the play therapy room in the sand, and I have to find it. We want to give them as much autonomy in the room as possible. They should be physically safer in your room, so you do not have to have as many boundaries with them. So that increases their power and control, and autonomy. Again, the swordplay or other weapons play will come up. Nurturing play comes up, and it might look a little bit differently. So I am thinking about like that 10, 11, 12, they are probably not going to make you food. Sometimes they will, they may not play with babies anymore in your office, but they may want to sit close to you as you draw, or they may draw you something, right?

They are like, "This is for you" kind of thing. So they'll show some of that nurturing. And then, again, still focusing on attachment, you'll see some attachment stuff. Sometimes they'll reenact some things where You are like, "Hmm, they do not have a safe attachment at home," or, "They are only attached to their dog at home. They do not feel connected to other people." I do this through a sand tray very often. It is looking at attachment in different ways through a sand tray.

And then, what is their parental involvement? I talked about this. You are going to disclose less, and you might be facilitating family sessions.

So if you were trained in family therapy, and it makes sense to do this, then you can do some of this, and it's likely to help these children explain how they are feeling, right? Giving them a voice rather than a typical family therapy session where You are looking at the entire system as kind of like you are equally involved with them. If You are working with this child, they are yours. They are your person. And so there will be some bias within the family sessions because you are the person protecting and loving on that child, right? You are going to help them share their voice versus a family therapy setting where everyone has the same amount of voice, I guess, if that makes sense.

If it is, again, in that high conflict divorce nature, which is an abusive kind of situation or coercive control, we are not going to do that.

Ages 13-18

All right. Teens, we need to again be safe, really non-judgmental for them to kind of process, talk trash, right? Being that place so that we are not going to share information with parents unless we have to or unless the teen has said it's okay, that is the only time with this age group that I share. So if there is a safety concern, yep, we gotta share. But if they are really angry about something a parent did or whatever it might be, we will not share these things with parents without our teen's consent.

And typically, it would be within a family therapy type setting rather than us telling a parent because it's, our goal is to increase autonomy and things. To increase their communication skills, emotional intelligence, and interpersonal effectiveness. I do a lot of this here in this age group of how can they get their needs met in a way that they feel good about themselves no matter the outcome. So I do a lot of that work with my teens to help them increase autonomy. I really like doing kind of a values sort or identifying values and clarifying those with our teens because they may see that they do not align with their parents on certain values. And what is really fun is when they realize they do not align with their peers.

Sometimes it is wonderful therapeutic work. And then, again, to build that child support system, and they are going to have a more active role in this. I do not need to always contact the school counselor, and I do not need to do these things. We are going to give that to them to do as they grow older. These are kind of the themes or the things that I really focus on with my teens who are dealing with divorce, really with anything, but specifically with divorce, is really focusing on connection and using myself in the room talking about that process, not just the content. It really helps with that interpersonal effectiveness. We really focus on confidentiality, a value sort. So if You are like, "What is a value sort?" 

If you look up ACT therapy. So acceptance and commitment therapy, they have a ton of different ways. You can get value cards, you can just write your own, whatever it is. But doing that with teens is really, really helpful in their healing process here. You can teach some coping skills, so maybe they are having a really hard time, and they are using self-harm. So we can give them ways to manage their, you know, manage their nervous system, to calm them down, basic skills to not self-harm in the moment, things like that. So you can do that, like coping skills stuff, and then, again, with the parental involvement, it will be less and usually done within a kind of family session thing, but again, your person is your teen in this, and so You are helping them share their voice.

I do hold my teens accountable, so if they are being boneheads, right, and I hear about something they are doing from their parents, it is a way, you can not hold them accountable. It is not like the teen is always right in these situations, but really your goal is to help them share their voice, and you are that safe person that has their back in doing that.

How Are We Helping Parents?

How are we helping parents? I wish more of these parents would come in, but most of the time, these parents are coming in to have me fix their children or have someone in my practice fix their children. But what we can do is give them a lot of education.

A lot of the things I give them are on development. So what does this look like for a three-year-old? What is important with attachment, and why is attachment so important? So a lot of psychoeducation on this. I do psychoeducation on divorce is not what actually harms your children. It is you all's behavior before and after that harms your children. I do it in a very nice way. Parents do not usually dislike me after that, but I do educate them on that. We focus on creating consistency at both homes if possible. Not possible very often when there is domestic violence and there has been a separation, but we know that consistency and structure helps to build safety for our children, no matter the age.

And so wherever we can find consistency, we do it. We really focus on the importance of not using the child as a confidant or a messenger between parents. This is really harmful; it kind of goes back to that pre and post-divorce or separation stuff. If it is possible and you have access to parents, like I have access to parents within my practice, I really try and focus on creating a sense of team. So parents do not often, you know, they may not get along, but in a lot of cases, they do want what is best for their children. And so in that way, we are all three, or unless there is, you know, stepparents and things like that, our goal is team, and we are team kid, right?

And so if we can create that, it will be really helpful for our clients. And then offering referrals for individual services or other supports because if our parents work through their stuff, our children will be better, I promise.

Protect Yourself to Protect the Child

All right. So this piece is important because I actually care about you as well, not just our children. When you are working with a divorced family, you and your license are more at risk. So I hope I am not scaring you all away from working with children. We need so many more child therapists in our world. But you do need to know how to protect yourself so that You are actually protecting the child and your relationship with the child in your sanity as well.

Get Your Documentation Ducks in a Row 

Okay. So one of the most important things, if you do not take anything else away from this webinar, this training, you are taking this away. You need to get your documentation ducks in a row. You need to know your state's and licensing laws on getting consent for mental health treatment. The most common reason for a founded grievance in my state is around a therapist not getting proper consent. And what I mean by this is you need to get consent from both parents unless there is a specific document, and this is when we are talking about separation and divorce that says you do not. And guess what? Still then, if the other parent's involved, I try to get consent because it will actually protect the child, it will protect your relationship with the child, it is going to protect if there is intimate partner violence and post-separation abuse, it will protect the protective parent or the victim parent.

 I know that is really hard for a lot of therapists. For a while, I was like, "Ah, I do not want to get consent from the other parent. Ah, you know, they are abusive. Why do I need to get consent from them," blah blah blah. They are preventing the child from getting mental healthcare, all the things. But you need to focus on best efforts to get consent even if there is a court order saying you do not need it. And then also knowing your laws in your state about the age that a minor can consent for their own mental health treatment, and what that actually means and what you need to do to make sure that happens. So know your state's and licensing rules, protect yourself, and have really good initial paperwork.

Your disclosure and consent need to be just airtight when you are working with divorce. And I work with a higher level of acuity. I work mostly with families where there is family court involvement, and there has been abuse and neglect, and there has been domestic violence. I work with a lot of those cases. So it is really important. You might get a case, and you do not know that is what it is, and that is what it is. So You are going to have amazing initial paperwork that spells out everything. What does confidentiality look like? What do you have to mandate report? These are required, but you are going to have it just like tied with a bow beautifully. When You are documenting in your notes or your treatment plans, or whatever it might be, you are going to document as if a judge is reading your notes. So enough information for them to get a sense of what is going on, but not so much information that your child is at risk for a parent learning something that would harm the child. For those things, you use your psychotherapy notes, and again, know the laws in your state and your license regulations about psychotherapy notes. I get to write notes that are a part of their file, but it is not with their file if subpoenaed. If that makes sense, it is like doctor's notes. So anything that I need to remember but I do not want in the file, I am going to put it there. So really do some good research.

Managing Parent Contact

Another thing is how you manage parent contact. So triangulation when there is separated parents, just know it is going to happen. It is not if. It is when. And so, what are ways that you can eliminate triangulation?

Email communication. In my paperwork, I state that if so, get consent in your initial paperwork, but if it is a divorced family, I require them to allow email communication for this purpose. And if they do not want me to use email communication for whatever reason, then they are not going to work with me because this is that important in helping me eliminate triangulation. If there is a court, an order of protection, then I cut and paste so that if my file was ever subpoenaed or I was brought into court, and one of the parents is like, "She is biased. She never gives me the information." I have it.

Look, this one matches exactly this one. All of my emails go out to both parents. So the same email to both parents, no bias. Sybil is not showing bias. If there are safety issues, then I work on what I email, and again, if there is no protection, we do it a little bit differently.

Your payment agreement, get it upfront. It is not your job to decide one way or the other, like, "Oh, well, this session, Dad pays, and this session, Mom pays." No, we just need to get paid, right? That is not our thing. And so, at times, we can do that if it is really easy. But usually, we charge one card, and then they get to figure that out on their own. I do not have time for that. And that should be in a court order, and then you are going to limit what you share with parents to themes and recommendations. This protects your child so that if you are in a post-separation abuse situation where there has been domestic violence, and they are in family court, we just need to limit what we share with parents so that they can not use it against the child or the other parent.

Oh No! I Just Got a Subpoena!

Oh, no! I just got a subpoena. I hope you all's stomachs did not just go in your throat, but guess what? You might get a subpoena. So clearly, if You are working in an agency, they will have their rules around subpoenas and all of that stuff. But if you are in a private practice setting, a small group practice, or whatever it might be, your first step is to contact your malpractice insurance, and if you have an attorney, your attorney, if you do not have an attorney, I have one on a retainer because I work with a really high acuity population.

Your insurance company can get you access to an attorney so that they can prep you if they need to. They can help you with whatever it is. And unless you have that attorney quash it, which will cost you money, it is out of your pocket, which means you do not want to go, and you have a court order that you do not go, you have to go. So I have heard a lot of people be like, "Oh, but I do not go to court, I am not going to, I do not go." If you get a subpoena, you have to go unless you have an attorney quash it for you. And a judge might not allow it. They might say, "Oh, guess what? You actually have to go."

So, this is why your paperwork needs to be beautiful. You need to get releases to speak in open court. We cannot give any recommendations on parenting time unless you have performed a custody evaluation. In addition, in my paperwork, I have paperwork that they sign regarding payment for testimony.

Your Take Aways 

So remember your takeaway is that pre and post, or divorce behaviors are what typically have long-term effects on children. Children are going to be affected in different ways due to their developmental stages. We can offer protective factors in working with these children and parents. And you really, really, really need to put policies in place to protect yourself. The reason I say it is to protect yourself, to protect the child, is because if you are not doing a good job protecting yourself, then you are not protecting the child you are working with.

Think of it this way, if you have developed this amazing relationship with this child, and then all of a sudden, the child is not going to see you any longer because a judge says, you know, "Oh, yeah, you actually are biased. Look, you have only talked to one parent the whole time," or, "You didn't try and get consent," or, you know, you get a grievance so that you can not work with that child anymore.

So putting the policies in place and having your paperwork beautiful is what is going to protect the child you are working with. And if you are working where there has been intimate partner violence or domestic violence, your paperwork needs to be perfect to protect the target parent. And this is my whole spiel like I could go on for days. In fact, I just did a continued training on post-separation abuse because it is really, really important that you do a good job of communicating with parents in the way that I specified and that your paperwork is how it is to work with these children because it will protect that victim parent in family court to some extent. 

Resources

• 10 Effects of Divorce on Children and Helping Them Cope
• Pediatric ACEs and Related Life Events Screener (PEARLS)
• UCL Centre for Longitudinal Studies: Timing of parents' split matters for children's mental health, new research reveals 
• What’s the Hardest Age of Children to See Their Parents Split?
   

References 

Bertelsen, B. (2023). Staying with the conflict – parenting work and the social organization of post-divorce conflict. Journal of Family Studies, 29(1),   46–62. https://doi.org/10.1080/13229400.2020.1869578

D’Onofrio, B. &  Emery, R. (2019). Parental Divorce or Separation and Children’s Mental Health. World Psychiatry, 18(1), 100-101. doi:10.1002/wps.20590

Fincham, F.D. & Stanley, S.M. (2002). The Effects of Divorce on Children. Couples Research and Therapy Newsletter, 8(1), 7-10. 

Hunter, J. & Trussle, J. (2016). Helping Preschoolers and Elementary-Age Children Adjust to Divorce. University of Missouri Extension. https://extension.missouri.edu/publications/gh6613#:~:text=Preschoolers typically respond to% 20divorce,never see that parent again

Kuo, S. I., Thomas, N. S., Aliev, F., Bucholz, K. K., Dick, D. M., McCutcheon, V. V., Meyers, J. L., Chan, G., Kamarajan, C., Kramer, J. R., Hesselbrock, V., Plawecki, M. H., Porjesz, B., Tischfield, J., & Salvatore, J. E. (2023). Association of parental divorce, discord, and polygenic risk with children’s alcohol initiation and lifetime risk for alcohol use disorder. Alcoholism: Clinical & Experimental Research, 1. https://doi.org/10.1111/acer.15042

Lansford, J.E. (2009). Parental Divorce and Children’s Adjustment. Journal of the Association for Psychological Science, 4(2). 140-152. 

Lee, C.M. & Bax, K.A. (2000). Children’s Reactions to Parental Separation and Divorce. Pediatric Child Health, 5(4), 217-218. doi: 10.1093/pch/5.4.217

Lindsey, E. W., Colwell, M. J., Frabutt, J. M., & MacKinnon-Lewis, C. (2006). Family Conflict in Divorced and Non- divorced Families: Potential consequences for boys’ friendship status and friendship quality. Journal of Social and Personal Relationships, 23(1), 45–63.

Low R.S.T., Overall N.C., Cross E.J., & Henderson A.M.E. (2019). Emotion Regulation, Conflict Resolution, and Spillover on Subsequent Family Functioning. American Psychological Association, 19(7), 1162–1182. doi: 10.1037/emo0000519

Martin, M.J., Sturge-Apple, M., Davies, P.T., Romero, C.V., Buckholz, A. (2017). A Process Model of the Implications of Spillover from Coparenting Conflicts into the Parent-child Attachment Relationship in Adolescence. 29(2), 417-431. doi: 10.1017/S0954579417000086

Pender Baum, R. L. (2023). Working With High Conflict Divorce and Custody Cases: An Interview With Lynn Louise Wonders. Family Journal, 31(2), 188–192. https://doi.org/10.1177/10664807221132804

Spaan, J., van Gaalen, R. & Kalmijn, M. (2022). Disentangling the Long-term Effects of Divorce Circumstances on Father–Child Closeness in Adulthood: A Mediation Analysis. Eur J Population, 38,1183–1211. https://doi.org/10.1007/s10680-022-09636-1

Tullius, J.M., De Kroon, M.L.A., Almansa, J. et al. (2022). Adolescents’ Mental Health Problems Increase After Parental Divorce, Not Before, and Persist Until Adulthood: A Longitudinal TRAILS Study. Eur Child Adolesc Psychiatry, 31, 969–978.

Villalovos, K., & Heiden, R. K. (2023). The Handbook of Systemic Family Therapy, Systemic Family Therapy with Children and Adolescents. Journal of Marital & Family Therapy, 49(1), 283– 284. https://doi.org/10.1111/jmft.12602

Editor’s Note: This text is a transcript of the course Understanding and Supporting Children and Teens with ADHD, presented by Heather Schmitt, PhD, LP.

Learning Outcomes

After this course, participants will be able to:

• Define ADHD, including common symptoms and features
• Describe brain-based developmental differences between children with ADHD and their neurotypical peers
• •dentify strengths and support areas in children and teens with ADHD
• Describe practical, evidence-based strategies that promote self-regulation and executive functioning skills

Introduction

Regarding the limitations and risks of this topic, I'll be talking about this from a neurodevelopmental perspective. Although it's based on the latest science and research, other approaches to treatment or perspectives can enhance progress or understanding that aren't incorporated in this specific course. Also, this course, as titled, will focus on child and teen populations. I will not be addressing young adults or adulthood.  Additionally, my training and expertise as a licensed psychologist have been developed in the context of clinical settings and a background in school psychology.  I'm not a certified neuropsychologist. I don't conduct hospital-based work.  Lastly, this course will not be a deep dive into the topic; rather, it is intended to provide a nice breadth of knowledge.

Abbreviations

Some abbreviations that will be used throughout the course are listed below.

• ADHD: Attention-deficit/hyperactivity disorder
• ADHD-I: ADHD, predominately inattentive presentation
• ADHD-HI: ADHD, predominately hyperactive-impulsive presentation
• ADHD-C: ADHD, combined presentation
• EF: Executive functioning

ADHD Defined

I want to define ADHD and provide some background information from a diagnostic standpoint so that you have an accurate understanding of what it is.  Under the umbrella of ADHD, there are different ADHD presentations.  In other words, diagnostic labels are used to describe ADHD, and they are based on two different types of clusters of symptoms.  There is the inattentive cluster (ADHD-PI) which was previously known as ADD, there is the hyperactive-impulsive cluster of symptoms (ADHD-PHI), and there is the combination of both (ADHD-C).

Previously and pretty extensively, these were called types of ADHD. Very recently, there's been a change to that wording to call them presentations. The change was made to emphasize that at different times an individual with ADHD may have more or less of one of those dimensions present. It's not a distinct or separate type of ADHD. 

ADHD-PI

The first presentation is the primarily inattentive type. This tends to be the child or teenager that might be described as a daydreamer or a "scatterbrained" individual. They have a lot of difficulties maintaining attention and listening, following through with different instructions and tasks, and keeping tasks and physical materials organized. They are easily distracted by things going on around them.  They might be forgetful and lose or misplace items. They have difficulty with attention to detail, and these children might avoid or dislike tasks that require sustained mental effort, which tends to be a lot of academic-focused work.

The highest rate of inattentive presentation is among adolescents. That means that of all of the individuals preschool through adolescents diagnosed with ADHD, the highest rate is among adolescents. Think of it as the expectations of younger children versus those of older children as they mature. It kind of matches development. Difficulties with these skills will be noticed more in adolescents, and these types of skills can become even more critical to success and independence.

ADHD-HI

The next presentation is the hyperactive impulsive predominant presentation. This is the child who is often "driven by a motor." They might be fidgety or restless, have difficulty staying in their seat, or prefer to stand up to do things. They might run or climb around excessively. They have difficulty doing things quietly, even if it's playing by themselves or speaking when it's a quiet environment. The child may talk excessively and may impulsively blurt things out rather than waiting to share what they have to say. They interrupt others and have difficulty waiting their turn.

For this presentation, the highest rate is among the preschool population. As children age towards school age and adolescence, that percentage is lower. You'll see why when I talk more about brain development. 

ADHD-C

Third is ADHD-C, which is the combined presentation. With all the symptoms mentioned above, these children show a fair number of both of those clusters of symptoms. The highest rate of ADHD-C tends to be among school-aged children. Developmentally, it makes sense that difficulties with those skills become more apparent versus observing a preschooler or an adolescent who might have ADHD.

According to the DSM-V, there are other factors to consider for a child to be diagnosed with ADHD. First, it has to emerge in childhood and be inconsistent with what we would expect for their age in terms of their ability to sit still, pay attention, remember things, etc.  Typically we expect to see this earlier in childhood; at least has to be by age 12.

Also, the number of symptoms that must be present differs by age. Up to age 16, six of the previously mentioned symptoms must be present to meet the criteria for that presentation. If they're 17 years old or older, then five of those symptoms must be present. Think of each of those presentation clusters as a group of symptoms. If a child has six or more symptoms in the hyperactive-impulsive cluster, then they meet the criteria.  Do they have six or more inattentive symptoms? Then they meet the criteria for ADHD-PI. If it's both, then they would be combined.

The DSM-V also has a specifier for the amount of impairment or how severe those symptoms are. A child may present with symptoms in two clusters, but it may minimally impact them at home and school. An ADHD-Combined presentation might also be mild. But if a child presents with eight inattentive symptoms and, two of them are hyperactive-impulsive, but there is considerable impairment across all settings (social, academic, home, extracurricular), then that child would be diagnosed with ADHD, primarily inattentive, and specified as severe.

The ADHD Brain

Next, I want to describe the ADHD brain. This is important for understanding what ADHD looks like and why.

Genetic Factors

ADHD is highly hereditary. Genes are the biggest contributor to ADHD. It's truly one of the most genetically-influenced disorders. It exceeds anxiety, depression, and many other disorders that we know are heritable. It is rivaled, maybe, by bipolar disorder and autism, which are also fairly similar in hereditariness.

We know about genetic factors because of different family studies. For example, research has shown that there is an elevated risk of ADHD among biological relatives of children that have been diagnosed. Depending on the study, 10-35% of biological relatives are at risk of having ADHD when a child does. If a parent has ADHD, there's a risk of up to 57% of children presenting with it. All of that speaks to the high hereditary factor.  We also know through adoption studies that there is no increased risk of ADHD. This further supports the role of genetics and biology. When discussing genetics, we typically don't attribute ADHD to chromosomal abnormalities, differences, or extra chromosomes. For example, we don't see Fragile X or Down's syndrome as causing ADHD. However, children with those rare genetic abnormalities may be at increased risk for developing ADHD or presenting with those symptoms.

Neurological Factors

Many neurological factors related to ADHD can be tied to brain structures and how they function. MRI studies and other brain imaging have shown differences in the volume or the size of select brain regions and reduced blood flow to these particular regions. There is typically a  significantly smaller right frontal region of the frontal lobe, which is kind of the "boss" of the brain.

Areas like the basal ganglia, corpus callosum, and anterior cingulate cortex are impacted regarding executive functioning skills as well as other higher-order skills that I will discuss shortly. Basically, structure and functional differences emerge when an individual has ADHD.

We also know there are many neural networks. One network seems to relate to hyperactive symptoms or motor systems in the brain being highly active. Another network underlies more of the attentional symptoms related to planning-related executive functioning skills. A third network mediates or impacts impulse control, and a fourth neural network explains self-regulation difficulties which is a type of gateway to the emotional brain or when the limbic system gets highly activated. All of these networks are known to influence the presentation of ADHD symptoms.

The last neurological factor related to ADHD is neurotransmitter deficiencies. This hasn't been as established as the other factors, but there is clearly a role for dopamine and norepinephrine levels. We know this because individuals with ADHD often respond positively to stimulant medications that address neurotransmitters distributed in the brain's neural networks described above.

Environmental Factors

Several environmental factors can cause ADHD. This does not include psychosocial factors like teaching or child-rearing approaches. There is no current credible evidence that ADHD exists purely because of social factors. With environmental factors, I'm referring to how things in the environment might interact with the genetic factors that a child is predisposed to. Those types of factors, particularly environmental biological factors, can impact the development of ADHD.  For example, exposure to toxins (e.g., smoking, alcohol) during pregnancy and fetal brain development has shown some relation to ADHD causality. Also, low birth weight, any associated minor brain hemorrhaging, and environmental toxins, such as postnatal lead exposure in the first two to three years of life, can cause ADHD.

Role of Medication

Lastly is the role of medication. There's a growing amount of research suggesting that treating ADHD with medication may actually result in more normalized brain development. Basically, there is a neuroprotective effect, meaning comparative medications are never used if there's an effective dosage of a stimulant used to increase brain activity in underactive neural networks. We see continued increases in the functioning of those brain regions with that medication use. So, functioning can be closer to typical as those medications are used.

Brain Development: ADHD versus Neurotypical

An important way to think about and understand the neurodevelopmental basis of ADHD is by comparing brain development between individuals with ADHD and their neurotypical peers. An imaging study by Shaw and colleagues (2007) compared how the brain matures in ADHD versus neurotypical peers. Maturation in these studies is defined as the cerebral cortex thickening. When the outer layer of the brain, that neural tissue (i.e. gray matter), is at its peak thickness, that is considered maturation. Once the brain reaches that point, it starts thinning, which is that "pruning stage" you may have heard of in brain development. The purpose of that pruning stage is to make the brain more efficient post-puberty during the teenage years. So scientists want to know when does the brain reaches maturation, meaning it's heading into that pruning stage and becoming more efficient. When scientists looked closely at the ADHD brain compared to normal development, they found that the ADHD brain follows the same pattern of maturation, but the rate is quite delayed in children with ADHD.

For youth with ADHD, the researchers found, on average, a three-year delay in different brain regions compared to their age-matched peers. Specifically, they found a delay in the maturation of the prefrontal cortex, which is largely responsible for executive functioning skills and often affected by individuals with ADHD. 

Interestingly, the motor cortex matured faster in the youth with ADHD. Researchers speculate that this mismatch might account for some of the restlessness and fidgety symptoms that are common in children with ADHD. The thought is that the brain is maturing at a different rate, and there is a big gap in the difference at that maturation stage, a three-year difference when a child has ADHD versus a child who doesn't have ADHD.

Common Myths

It is important to understand common myths of ADHD so that we can debunk them when they come up in different situations. 

Myth 1: ADHD doesn't exist

The first myth is that ADHD doesn't exist. The child's just lazy, and they're unmotivated. I hear or see these labels a lot. At the same time, some youth who struggle with ADHD have passions and strengths outside of the classroom. I always encourage families and other professionals to reframe this idea of a child being unmotivated. It is more likely that they have a skill deficit. It's not that they won't do a certain task as a matter of principle or because they're lazy, it's because they can't do it.  In terms of ADHD not existing, plenty of research validates that ADHD is a neurological lifelong disorder.

Myth 2: Someone with ADHD cannot pay attention and/or sit still

The idea that someone with ADHD cannot pay attention or sit still is false. There are times when they can sit still and/or pay attention.  ADHD affects people in non-preferred, difficult tasks or demanding environments. For example, attentional difficulties occur when the child's expected to sit for a long period of time and there are a lot of demands on their attention, versus sitting still while passively watching a movie about a topic they're very interested in. This can be really frustrating about ADHD and how it presents for certain people. It's consistently inconsistent sometimes. A child might be able to do something in one situation or in one setting, but they struggle the next time. 

Myth 3: Someone with ADHD cannot complete their work, get good grades/test scores

ADHD is not related to intelligence or IQ. I'm sure you've also seen this often: "When a child with ADHD can pay attention, they're quite smart." It's not about being unintelligent. There are many gifted individuals who also have ADHD.

Myth 4: ADHD can be caused by the environment - like parenting approaches or TV/video games

As I said before, no credible evidence indicates that social environment alone can lead to a child developing ADHD. We know because of the sibling and twin studies I referenced earlier. After accounting for those genetic factors, there's little variation that can be explained by other things. Social factors like parenting approaches or video game use certainly impact functioning and possibly outcomes for a child, but they do not alone single-handedly create ADHD.

Myth 5: Medication can cure ADHD or become addictive

Another myth is that medication can cure ADHD or, problematically, ADHD meds become addictive. First, there are no medications that cure ADHD. The medications are used to effectively treat the symptoms and address the brain-based differences so the person can manage tasks temporarily.

Regarding addiction, there is no credible evidence that using stimulant medications to treat ADHD in childhood leads to an addictive disorder in adolescents or adulthood. That said, are there individuals who misuse stimulant medications? Of course. But when those medications are used as prescribed, in a therapeutic dose, there's no evidence of addiction. In fact, there's evidence of quite the opposite. With appropriate use, medications can be a protective factor.  In other words, it decreases the likelihood that someone will misuse substances to self-medicate or unhealthily cope with difficulties that arise.

Myth 6: Children eventually outgrow ADHD

The last myth is that children eventually outgrow ADHD. Although there are many ADHD symptoms that improve over time, most adults diagnosed with ADHD at a young age have some difficulties that persist. Remember, since the normal pattern of maturation is simply delayed, that can explain why many youth with ADHD are first described as immature. Their brain development is likely similar to a child that is younger at that point in time. But as the child ages, that maturation starts to catch up to their peers a bit. It may seem like they outgrew it, but what is really happening is that gap or difference in maturation and brain development starts to close as they age.  By age 15 or 20, those functioning differences or discrepancies become less noticeable or milder in presentation than their peers.  But they aren't actually outgrowing it 100%.

Identifying Strengths and Support Areas

It's important to identify strengths and support areas for any child, particularly the child with ADHD because it's highly likely that he or she has received much negative feedback about their areas of difficulty. Think about some behaviors that can be disruptive or challenging, particularly for hyperactive impulsive children. Researchers have found that children with ADHD are exposed to much more criticism and correction than their neurotypical peers. They're often viewed and described as not living up to their potential. They are labeled the class clown, disruptive, the troublemaker, and lazy.  In fact, this is so significant that experts in ADHD have estimated that by age 12, children with ADHD have received 20,000 more negative messages from their parents, teachers, or their peers than children without ADHD. That is a significant number.

Think about the classroom.  It's probably realistic to guess that a child with ADHD might get a negative correction or a comment from a teacher every 20 minutes or three times an hour, "Sit down in your seat." "Go back and focus on your work." "Stop talking to your friend." "Get started." A student is in class for six hours a day, 180 days a year.  That's more than 3,200 corrections or criticism statements that are directed at that child. They're not ill-intended, but that's a lot of negative feedback. That's not including parent comments, coach comments, corrections, or comments from their peers. The point is that these youth are at risk of developing a damaged view of themselves and a negative view of school. So, it becomes very important to incorporate strengths into a child's everyday life. 

Find out what the child is passionate about and good at.  It is important to actively embrace their strengths and what they care about outside of school. Incorporate those things, and give them attention and value. I can't emphasize this to parents enough. Children with ADHD are just as smart as other children. They're often creative, outgoing, intuitive, artistic, and artistic. They have the ability to become wildly successful adults. Let's ensure we're doing justice to those attributes.

Another important aspect when working with a child with ADHD is to recognize that they work harder than most of their peers because the world is not built for their brain. A child with ADHD tends to struggle a lot in that traditional academic setting where you sit still, you listen, you pay attention, you do worksheets, et cetera.

They spend so much time, about six hours a day, doing tasks or activities that can be excruciatingly difficult and not super-rewarding for them.  It's actually a strength that they are managing to get through the academic world. A good analogy is it's like being on an NBA team, but you're the shortest guy. You made it to the NBA, and you're obviously a skilled basketball player, but you probably had to work a lot harder than someone who was tall. You might have to compensate and come up with skills like a fancy hook shot or a drop back three in order to play at the level of your taller teammates.

Another way to support those with ADHD is to meet them where they are. We should not be making expectations based on what a same-aged peer can do or what a neurotypical sibling did at that age.  Often, ADHD challenges aren't about a knowledge deficit; rather, the child just can't perform. So think about how can we get this child one step closer to performing while meeting them where they are.

We also want to regularly recognize growth, especially when they receive criticism and corrections. Find ways to give positive feedback and praise even those small steps towards success. Encourage teachers, parents, coaches, et cetera to be extra mindful and do it in a systematic way. For every one criticism or correction you're giving (it's okay to do that), be sure to give them at least three to five positive reinforcement comments. Provide some praise that's deserved for how hard they're working.  This might require looking outside the school arena. Balance that need of, "We're going to focus on you getting your homework done and succeeding academically," with what the do outside of the school. Where can we give them their praise?

Another aspect related to embracing strengths and understanding is psychoeducation. Often, the child misunderstands what ADHD is, and there can be a lot of stigmas.  For example, I recently started meeting with a middle schooler who had previously been in therapy to target difficulties with organization and impulsiveness. He's taking medication but didn't understand why he was taking it.  He also didn't know he had ADHD. So I spent some time explaining what ADHD is and isn't so that he could better understand his brain and why certain things are hard. As we discussed that, he explained that students at his school use ADHD to mean stupid or dumb. So, it was basically a derogatory statement.   And he honestly believed that's what it meant. When he learned he had ADHD, he thought that meant he was stupid or dumb. So that education piece is so important.

Lastly, we must practice flexibility and creativity.  Think about those passions and strengths the child has and how you can change what you are doing or how you can structure tasks to help the student succeed.  For example, I frequently give breaks for focus time and work time and therapy. Instead of doing a fun activity at the end of the session, I do 15 minutes of focus and work and then take a short break to do a fun or physical activity. I am also more intentional with incorporating movement around the room.  I'm finding ways to embrace that child's activeness and incorporate it as a strength in the work that they need to do in therapy. 

Some additional examples of strengths are: 

• Can do many things at once
• Ambitious
• Have many different ideas
• Can tell when others are hurting
• Strong emotions
• Determined, won’t easily give up
• Social
• Passionate about things interested in
• Love telling others their opinion
• High energy
• Love to move around
• Adventurous
• Kind to people
• Imaginative, creative
• Great with animals
• Good at knowing history
• Play video games well
• Amazing builder
• Very artistic

The idea is to reframe our thinking.  It might be easy to say the child is too distracted. However, we could say the child can do many things at once. Rather than saying a child is overly sensitive, maybe we say they can really tell when others are hurting. Rather than saying a child is too talkative, we can say that they love telling other people about their opinion, which is a strength. 

Support: Self-Regulation & Executive Functions Skills

Although there's no single agreed-upon definition of what executive functioning (EF) is, many agree that it's often a key deficit area for children with ADHD. All of these different processes are housed in the prefrontal cortex of the brain, where that slower maturation occurs.

These abilities center around the concept of self-regulation. Self-regulation is any action an individual directs at themselves to result in a change in their behavior to achieve a certain outcome or goal in the future. All of these different skills, organizing and starting, staying focused, keeping our attention there, managing distractors, and keeping our emotions in check, are working together to help us toward that goal.  They involve regulating ourselves. Regulating our behavior, regulating our emotions, and regulating our brain or our cognitions.

Here is an example. I have a New Year's resolution to eat healthier snacks with less sugar. I walk into a coffee shop and immediately see this beautiful display of pastries and cookies. The situation might tempt me to buy something that will ruin my resolution. To deal with that, while I'm waiting for my latte, I focus on my phone instead of the cookies. Or maybe I'll walk to the far side of the shop so I don't see them as much. I might even visualize how good I will feel eating something healthier. All of this involves self-regulation.

Many executive functioning skills are at work in this scenario.  I have to be aware that I'm in this dilemma and that I'm having this urge. I have to inhibit that emotional response or thought of, "Oh my gosh, that cookie would go perfectly with my latte, and I want it." I have to redirect my attention away from that display case. I have to look at my phone and manage my attention accordingly. I need to talk to myself and visualize the future and what outcomes might be most helpful. That's a lot of working memory. I am also brainstorming different ways to cope with my urge and thinking of different things I could do. I need to organize myself and problem-solve.  

To identify self-regulation or executive functioning skills systematically, I recommend information-gathering with parents, teachers, and other people who work with the student. There are also some normed questionnaires, such as the BRIEF-2, the CEFI, and the BDEFS-CA, that can give a sense of impairment or show where the biggest challenges are. They all range from age 5-18.

There are also some informal checklists, such as the Executive Skills Self-Assessment (in Hansen, 2013), that targets executive functioning skills in teenagers. It has a nice, brief self-report inventory.  It asks different questions about how true something is for that teenager, then groups those questions into specific skills that may need to be addressed. 

Evidence-Based Strategies

Overview

Regarding ADHD treatment, medication is the primary recommendation for children, which is often not what people want to hear. I'm definitely not a pill-pusher by any means. I'm a psychologist, and I do therapy. But because of those brain-based differences, medication can be such a game-changer in addressing that biological piece. It can be a critical part of treatment, but it's not the end all be all. Research consistently shows medication can provide some benefit.  Behavioral approaches and targeting skills can provide some benefit as well. But if medication is combined with behavior therapy, that is where we see the most benefit for most individuals with ADHD.

When it comes to behavioral supports, there are two categories. One category focuses on the environment, and the other focuses on the individual. Environmental supports are behavioral therapy approaches that typically involve parents or the school. We are structuring the environment so that the child can be successful because of how their brain develops and how it works.

With the individual-focused category, there is evidence for some of those CBT approaches to treat ADHD-related challenges. Again, it's most helpful to think about ADHD difficulties as a performance deficit, not a knowledge or a skill deficit. Often a child with ADHD can understand what they need to do or what something means, but they struggle to perform it. They just can't do it in the moment because their attention is hard to regulate; they're easily distracted and can't inhibit their impulses. This is key for intervening effectively and appropriately and understanding what's difficult, when, and why.

Consider looking at different inconsistencies to determine where there's a skill deficit versus a performance deficit. For example, maybe a child can organize his backpack really well but has a disastrous desk. Is it because he doesn't know what being organized looks like or what it means? Probably not. He can probably describe a clean desk as having pens in a pouch and papers stacked up neatly. The student has the knowledge but can't put it into action. Maybe the classroom only does desk cleanings once a month, so he's left to his own devices to implement strategies. At the end of the day, he can't perform it even though he understands it. But he can keep his backpack organized. Why is that? It might be because the child's parent works with him daily and reminds him where things belong. They've color-coded and labeled everything and put a system in place to help him keep up with it. So, the environment becomes key to providing social supports where those problems exist.

Strategy 1: Instruction/Task Delivery

The first environmental strategy is how you present instructions or tasks to the child. There are hallmark symptoms of difficulty paying attention to details and keeping attention. Our instructions need to be simple and to the point. The fewer words, the better.  If it's too lengthy or wordy, we will lose the child's attention. 

The visual piece is also key. By having something visual, it takes what would load onto the frontal lobe, or working memory, and puts it in the real world.  

How we present commands is also important to consider.  It can impact how likely the child is to listen and understand. Here are some examples of what NOT to do:

• "Let's" commands  - These are unclear, tell the child that you will help and that the two of you are doing the task together. Instead, make those commands very clear in terms of what's expected, "You need to pick up your plate" or "Please grab that toy." Not, "Let's do it."
• Vague commands - "Stop it." "Be good." That's short and sweet but very unclear for the child. Instead, remove any need to think or pay more attention and say exactly what you want, "Place your hands in your lap" or "Walk slowly with me." Make it specific.
• Chain commands - If you tell a child with ADHD, "All right, go upstairs, take a shower, brush your teeth, grab that laundry and throw it down to me, then put on your pajamas and start to read before bed," they might get as far as the stairs.  These tasks must be broken down into at least one or two steps.
• Buried commands - Again, thinking about their attention, we don't want to bury our instructions.  For example, we don't want to say, "It's going to rain today. The forecast is calling for a lot of storms, so please put on your coat, or you might get wet and track water into the house, and it will be a mess." It's okay to have long conversations or to elaborate, but when giving an instruction or an expectation, get straight to the point. Give one small detail, such as, "Put on your coat; we're leaving."

Also, check for remembering. It can be helpful to have the child repeat the direction back to you so you know they were attending and listening. However, just because they can repeat it back to you doesn't mean they can do it. Be sure to follow some of the other strategies that were discussed previously. 

Another strategy that can help youth with ADHD initiate the next task, shift attention, manage emotions, and be flexible is to give warnings for transitions versus shifting focus abruptly. For example, if we play a card game in a therapy session, instead of suddenly saying,  "Okay, time to stop. We have to get back to practicing our coping skills," I'm going to give a reminder at the start of the session, "Remember we have a short break, and then we get back to work." As we approach the transition, say, "Remember, three more minutes until 45." The transition may not go perfectly, but it does make it easier for the child the more we can warn about those transitions.

Strategy 2: Externalize Information

I mentioned this earlier, but externalizing information and having many visual cues are great ways for the child to access the steps or the details they need without depending on their working memory. This is great for homework time, routines, different rules or expectations at school, tasks that must be completed, notes with reminders, or anything that involves a certain amount of time.

We can also use a timer as a visual.  ADHD can be thought of as a "nearsightedness" with time or time blindness. It can be thought of as a time disability.  Children with ADHD often don't use that internal clock to manage their behavior and to organize. We want to incorporate learning or experiencing how long tasks take or how much time has passed. When it comes to time and timers, we can practice that with them.  For example, "Let's see how long it takes to walk to the mailbox and back. We'll time it every day and learn how many minutes that takes." Being able to estimate time helps with learning to plan and complete tasks efficiently and effectively.

Visual schedules are also great. It can be very helpful for children with ADHD to have proportional blocks of time. If I'm showing that first, we have school and then we have soccer practice, but we know that school is six hours and soccer practice is one hour, we want to make activities visually proportional to the amount of time spent doing them versus the same size.

Visuals should be appealing.  We may need to revamp them or use new ones more often for children with ADHD than other children.  We want to capture their attention in the moment versus blending in the background. So think about changing photos or letting a child pick a new visual or a new font so that it continues to be exciting and relevant for them.

Strategy 3: Swift, Frequent, & Potent

This next strategy is related to the time disability concept.  We want to decrease the time between when something happens, how we respond to it, and the outcome. We want it to be swift. We want to act quickly and often with children with ADHD. 

Regarding immediacy, we want the correction or praise to be given right after the behavior occurs.  Delays of any kind make it less effective for children with ADHD. This applies to giving rewards or punishment. If the behavior happened 10 minutes ago, it may well have been last year. The connection is not there. 

Frequency is the idea of giving more praise for tasks that seem simple or that children without ADHD can do without much effort.  Also, a child with ADHD will have the urge or impulse to do something else, especially if what's expected is unrewarding or tedious. So think about frequency and give positive feedback throughout a task, not just at the end of it.

Finally, there is potency. I mentioned earlier that we compete with the environment for the child's attention and ability to regulate. Anything that's implemented has to be prominent and stand out. Reinforcers have to be more powerful. The same is true with punishment. We need to think about how we can increase the strength of a reward. We might have to change that formula, especially when considering potency. Children with ADHD habituate much quicker to rewards. Many people will say, "Oh, that's not really working anymore." However, we can keep the system and the rewards but change the potency. Think about changing it and making it more potent or interesting for them. 

Strategy 4: Resource Replenishment

The frontal lobe, which houses executive functioning abilities, requires a lot of mental resources and effort within the brain. It's like water in a reservoir or in a glass. When we're using our executive functioning skills, that resource is exhaustible, there's only so much in the cup, and it's going to drain.  Different tasks are going to drain that cup quicker.  If it's something more difficult, lengthy, or boring, that water will drain faster. For children with ADHD, that cup is much smaller because of their developmental delay, and it often empties quicker.

This is where replenishing is key. We can replenish with routine physical exercise and movement. We don't want schools using recess as a punishment and removing it. That is a refuel time. We can replenish during executive-functioning loaded tasks. When a lot of sustained effort or persistence is required, or something is long, these children need breaks during that task. They can be brief, but they'll need them during and after, with rewards along the way.

Strategy 5: Facilitate “Social Economy”

Another key strategy is what I call "social economy." We want to promote positive social opportunities and successes for these children. They can exhibit poor social behavior or be viewed negatively by peers because of their difficulties. For example, there are studies in which a peer is told, "Oh, this kid has ADHD," when that is not true (the experimenters are just saying that), and they proceed to play and interact with that child differently and more negatively than if the peer was not told the child had ADHD. So, it's important that peers see this child with ADHD in a positive way. 

The way we can do that for them is to plan and structure opportunities for success.  At home, have structured play dates where you're setting limits on activities that they can or can't do. You're making it more formal versus just running around and playing. Maybe you're doing a science experiment or a craft. These children need that one-on-one at first to succeed with a peer, and then you can slowly add more children.

They're probably going to need more adult check-ins or facilitating appropriate behaviors. Social interactions and opportunities might have to be shorter at first. We want to ensure they are going well and smoothly; then, we can increase the length of time or the number of people.

Also, keep in mind what the goal is. Is it simply for them to have a friend over? Then, focus on that and not correct a bunch of other behaviors. Ways this can look at school is giving the child special jobs that their peers see them doing well and getting a lot of positive attention. It can be earning privileges for the class. For example, maybe one of their rewards is the class gets a bonus recess. That can facilitate a positive economy for that student. And remember, it is common for children to misunderstand or misuse the ADHD label. We have to make sure peers are educated on neurodiversity so that there is acceptance and receptiveness to those differences.

Strategy 6: Social Behavior Skill Training

Research suggests that social skill training can be very effective. But a key piece is promoting generalizing. How do we do that? We give direct instruction on a social skill, rehearse it, coach the child directly, and then give feedback. Social skills are like making conversations or sharing how we follow along with rules during a game, or take turns.  Working on that in a session is helpful, but we must focus on generalization. Oftentimes, there is this train-and-hope philosophy of the child learning the correct thing to do, and now they will go do it.  But they can't enact it well because they're not self-monitoring in that moment. They can't regulate their impulses, so they need an adult or a parent to coach them and promote their successful use of it. Plus, those adults are more likely to be in naturally occurring situations. We can do social skills training to generalize by coordinating across settings and with different adults to reinforce the skill.

Here is a sample practice sheet that I might have a child take outside of a session. Maybe we're focusing on back-and-forth conversations, so we practice building a conversation together, like building a tower. So I will have them practice it. I will have them notice situations, and the parents will help them monitor them and become more aware.

Strategy 7: Organizational Skills Training

Difficulty with organizational skills becomes prominent around third grade, and then it persists. Third grade has a curriculum where students are expected to be much more independent. So early intervention, particularly before middle school, becomes key because we know as students advance into middle school, there are many more demands on organizational skills. They have numerous classes or homework and less adult supervision.

Similar to social skills training, there's a lot of direct instruction in organizational skills. You're rehearsing and coaching the child in the moment. Tracking tasks is a good example. How do I record my assignments? How do I manage materials or time? What are some ways to organize my room or my binder? 

We can teach them to track how long tasks take or plan what to do first, second, third.  We can teach them how to break tasks into steps and monitor progress. We are working on these organizational skills in a clear, direct way. There are numerous great curriculums available for organizational skills training.

It will be important to incorporate rewards. Learning organizational skills is hard, so using the system or starting to learn steps will be important when focusing on this with a child with ADHD. And as always, we're scaffolding. So the adults are present and engaged while helping the child build and maintain that system.

A few more examples include a child who is having difficulty turning in their homework. I want to think through all of the steps involved in that and what skills we want the child to develop.  Is it writing it down in their notebook or bringing home the right materials? Another example here is a teenager who is working on organizing their room. We want to think about the steps it takes to clean and organize that space. 

All of these examples are based on some organizational skill training workbooks or materials that are included in the resources.  

Summary

My goal with this course was to describe what ADHD is, including common symptoms. Explain brain-based differences between children with ADHD and their neurotypical peers, including common myths. Identify strength areas and support areas. And discuss how to implement practical, evidence-based strategies that promote self-regulation by adapting the environment and working with the child directly.

Questions and Answers

Do you think ADHD in adolescence is overdiagnosed?

That's a hard question because I think right now is a time when we're becoming more aware of it. But I will add that often, ADHD can be misidentified. So just because a child is distracted doesn't mean they have ADHD. Many kids with anxiety, for example, are highly distracted. They're thinking about things that could go wrong or trying to monitor themselves, and they're thinking about it and worrying. So we know anxiety can affect executive functioning and attention.  So, I think it can definitely be misdiagnosed if we just assume a child who's inattentive must have ADHD. That's where getting a comprehensive evaluation, a comprehensive neuropsych evaluation or psychoeducational eval is such an important piece before we just jump to conclusions.

Does positive or negative reinforcement work for children with ADHD, or is ADHD something a young child, like a second grader, wouldn't be able to control?

It's a balance. We don't want to expect a behavior that the child cannot, but we do want to promote a behavior for success. So a lot of that brings me back to this expectation I have for this second grader.  Are my expectations based on another second grader who doesn't have ADHD, and I'm setting the bar too high?  If so, that will be impossible for the child with ADHD to reach because of those neurodevelopmental differences. Or am I thinking about something the child needs to do to succeed and steps we can reinforce and promote to make that happen? So, it varies on the individual case, but, often, we need to ensure that our expectations are realistic. We also have to ask if the environment makes it possible. I think that becomes a huge question. I'm expecting this kid to regulate their emotions, but if I have an environment that's overwhelming their executive functioning skills, they won't be able to regulate that emotion.

Do you have recommendations regarding school or homework skills like organizing spaces?

I do. There is an organizational workbook listed in the references. I would highly recommend looking for anything that's described as organizational skills training. That is very evidence-based.  I'm not promoting certain material, but this is a really great curriculum that talks about different trainings and skills and helps to break them down into steps.

How do you teach neurodiversity in the classroom?

There are a lot of great children's books, especially for younger students, that are wonderful at illustrating what strength lies in diversity and what it means, and what it doesn't mean. They are written in a way that's accessible for children too. Often in the classroom, I recommend that teachers include them in their curriculum. Have that be the story time, have that be the topic, without singling out a specific child if the child doesn't want to share that about themselves. These stories are a great way to create an environment of understanding and acceptance. Videos that explain what ADHD is are great resources too.  There's a really good one on YouTube that is cartoon-style, and it's a child explaining to another child that they have ADHD, here's what it is, and here's what it means. 

References

American Psychiatric Association (APA). (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Barkley, R. A. (2022). Improving clinical diagnosis using the executive functioning—self-regulation theory of ADHD. The ADHD Report, 30(1), 1-9.

Barkley, R. A. (Ed.). (2018). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (Fourth edition). Guilford Publications.

Connaughton, M., Whelan, R., O'Hanlon, E., & McGrath, J. (2022). White matter microstructure in children and adolescents with ADHD. NeuroImage: Clinical, 102957.

Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current concepts and treatments in children and adolescents. Neuropediatrics, 51(05), 315-335.

Gallagher, R., Abikoff, H.B., & Spira, E.G. (2014) Organizational skills training for children with ADHD. The Guilford Press.

Hansen, S. (2013). The executive functioning workbook for teens. Instant Help Books.

Miller, K. (2018). Thriving with ADHD: workbook for kids. Althea Press.

Shaw, P., Eckstrand, K., Sharp, W., Blumenthal, J., Lerch, J. P., Greenstein, D. E. E. A., ... & Rapoport, J. L. (2007). Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Proceedings of the national academy of sciences, 104(49), 19649-19654.

Tourjman, V., Louis-Nascan, G., Ahmed, G., DuBow, A., Côté, H., Daly, N., & Sadek, J. (2022). Psychosocial interventions for attention deficit/hyperactivity disorder: A systematic review and meta-analysis by the CADDRA guidelines work GROUP. Brain sciences, 12(8), 1023.

Editor's note: This text-based course is an edited transcript of the webinar Pediatric Abusive Head Trauma: Recognition, Prevention, and Long-term Impact, presented by Alison D. Peak, LCSW, IMH-E.

Learning Outcomes

After this course, participants will be able to:

• Examine the legislation requiring PAHT continuing education, its origins, and its intentions.
• Identify the prevalence of PAHT, warning signs, and long-term outcomes.
• Analyze effective prevention programs and their role in preventing and mitigating PAHT in communities.

Introduction

We will talk about some heavy stuff today, and I want to ensure you know I will share stories as I share content. I encourage you to slow down, recognize your thoughts and emotions, and take care of yourself as we walk through this together. My great passion is working on behalf of children from birth through age five and their caregivers, working clinically, programmatically, and systemically on behalf of little ones and those who care for them. I also want you to know that I'm a social worker. I identify deeply as a social worker and love my work. It is part of who I am and all the things that come with me. It'll be a big part of my perspective and the stories I tell today.

I also want you to know that in the process of becoming a social worker, I spent four years as a floater in an early childcare center, so I have also been in early childhood classrooms. I remember working with 15 two-year-olds simultaneously and all the pieces that come with that. I remember those kiddos who were the first ones in the door, the last ones to leave, and who often spent more time with us than they did with caregivers at home. Even in that place of having children in your physical presence for long periods, there are still questions about what happens when they leave and what the rest of their day looks like.

This course is for both social workers and early childhood educators. I'll do my best to wear both hats and keep in mind all the different stories and perspectives you bring. Before we jump in, I want you to take a moment. I'm going to guide you through a grounding activity. As I said, we're going to deal with some pretty heavy content today, so I always like to make sure that we're deeply connected to our space and place and are present as we dive into these things.

I invite you to find a comfortable space. Make sure as you sit that your bones are deeply connected to your chair and that your feet are firmly grounded. After you read the instructions, close your eyes or stare softly about six feet in front of you, whichever is best for you. You're going to take three deep breaths. As you breathe in, count to four, then hold the breath for a count of seven, then breathe out for a count of eight. Do this three times, then come back to the course.

Pediatric Abusive Head Trauma (PAHT) in Kentucky

In 2010, the Kentucky General Assembly passed a bipartisan bill requiring many disciplines to receive consistent training in pediatric abusive head trauma. That original piece of legislation is tagged as Kentucky House Bill 285. That legislation has now been morphed into state policy and can be found in various locations throughout the state code. The original legislation is tagged as Kentucky House Bill 285. At that time, the goal was to increase recognition of signs and symptoms of pediatric abusive head trauma, increase prevention efforts for pediatric abusive head trauma, and ensure that professionals who interact with young children are aware of the potential outcomes of pediatric abusive head trauma given its considerable relationship to child well-being and child abuse.

In the state of Kentucky, the following people must be trained in pediatric abusive head trauma.

• Law enforcement
• High school students
• Inmates in state penitentiaries
• Guardian ad litems (attorneys specifically for the child welfare sector)
• Prospective adoptive parents
• Childcare providers
• Pediatricians, radiologists, family practitioners, trauma physicians, and family medicine physicians
• Physician assistants and nurse practitioners
• Paramedics, medical technicians, and first responders
• Nurses
• Social workers

I think it's intriguing to think about how, as individuals get closer to years in which they are no longer children but are becoming parents, we are preparing them to know what it means to take care of littles and show up on behalf of them.

What is Pediatric Abusive Head Trauma (PAHT)?

First and foremost, what is it? Pediatric abusive head trauma describes a constellation of signs and symptoms resulting from violent shaking and impacting an infant's or small child's head. In mainstream media, this more often gets referred to as Shaken Baby Syndrome, but the medical terminology is pediatric abusive head trauma. This definition clearly states that this does not occur and is not caused by general play, falls from a couch, or other things of that nature. Pediatric abusive head trauma is one of the primary physical child abuse incidents that occur in early childhood.

PAHT in the News and Media

We first saw pediatric abusive head trauma come into the news and media in 1962. At that time, a physician named Dr. C. Henry Kempe was beginning to identify a connection between aggressive and neglectful parenting and long-term behavioral and mental health symptomology within children who were the recipients of that aggressive and neglectful parenting. Sometimes in the literature, it gets referred to as scary parenting, based on the idea that the caregiver is the source that the child is afraid of. We think about those consistent moments when caregivers are large and out of control. 

As I mentioned, we don't see this constellation of pediatric abusive head trauma with somebody who fell off the couch. Also, we know that all parents get upset sometimes, and kids get yelled at. However, at the other end of the spectrum, the parent may be the person children are afraid of and cannot seek comfort from. Think about really exaggerated, aggressive behavior, including physical abuse, intense emotional abuse, and neglect. Also, keep in mind the intense interpretations of a parent about a child's intentions.

Dr. Kempe's study in 1962 began to categorize these symptoms as battered child syndrome. It was revolutionary for the early '60s to think that child abuse occurred in all types of homes and all types of environments. This was not just seen in families experiencing extreme poverty or only in families with single-caregiver homes. They saw this show up in lots of places regardless of socioeconomic status or kind of caregiving dynamics. This laid the initial foundation for child abuse laws and mandated reporting. When this study came out, the recognition of battered child syndrome prompted legislation to realize that something had to be done. They couldn't just leave things where they were. There needed to be a response to this aggressive and neglectful parenting that deeply impacted these children.

A paper published in 1972 proposed the idea that the brain, as an organ, could sustain injury from being thrown about. They categorized it as whiplash-shaken infant syndrome. It also identified a triad of symptoms observable by X-ray that may or may not accompany other signs and symptoms of abuse, including cerebral swelling and hemorrhaging. Imagine being in a car accident, busting your head open, and needing stitches. There may not be an external manifestation of what is clearly an internal injury.

In 1997, a British nanny was charged with the murder of an eight-month-old baby in relation to a series of symptoms that physicians and police called shaken baby syndrome. This case sparked a series of concerns and awareness from the greater US public about shaken baby syndrome and its potential impacts on children and child well-being. We see this evolution of language from battered child syndrome to whiplash shaken infant syndrome, to the concept of shaken baby syndrome, and, currently, pediatric abusive head trauma.

I was a child when this occurred and remember it fairly clearly because I had an infant cousin at that time. I remember my family being really cautious, more so than they had been in prior years, about who got to hold the baby and where they were standing or sitting when holding the baby. There was an increased awareness that something terrible might happen because of the increased conversations around shaken baby syndrome.

Within broader news media, there is increasing conversation about the role of investigation in child abuse reports. People are slowing down to ask, what is happening, and what is it that occurs in families when there is the experience of pediatric abusive head trauma? Current media is also highlighting that in previous years, people were quick to identify a "victim" and a "culprit" without allowing for the due diligence of an investigation that holds multiple outcomes as a possibility. It is rare to have clear evidence without proof of pediatric head trauma. It's unlikely we're going to catch it on camera. One of the things we are increasingly aware of is that some of the symptoms we begin to see in early pediatric abusive head trauma may be related to an event that occurred weeks or days prior and may not be the thing that happened most recently. 

Child Well-Being

Kentucky

Kentucky ranks 37th overall in child well-being for the United States. It ranks 38th in economic well-being for children but 26th in educational well-being for children. It ranks 42nd for family and community well-being. This ranking highlights an above-average presence of alternative caregivers, such as grandparent or kinship placements, single-parent homes, and high poverty. This does not include children engaged in the state child welfare system.

Nationally

Nationally, three out of every thousand children are in foster care. On average, the US spends about $1.3 billion on foster care placements, care, and associated adoption costs every year. Child welfare is not cheap. For the nation to step in and take care of vulnerable children and families comes at a price. I live and work in Tennessee, and right now, there are nearly 30,000 children in foster care in the state of Tennessee. While it might only be three out of every thousand, that is still a significant number of kids.

Regarding the connection between child welfare and child well-being, we want to consider those placement disruptions associated with foster care or other similar arrangements are generally connected to a six-month regression in development for each placement disruption. Statistically speaking, if we have a three-year-old who's removed from their primary caregiver and placed in a foster home, that's one disruption. If that foster home says, "I cannot manage this child. They're going to have to go someplace else," and they are then placed with another foster home, that's a second disruption. Then let's say, heaven forbid, that foster home says, "Oh my goodness, I have had an elderly parent who now has an end-of-life need, and I'm going to no longer be able to foster," and that child moves again, that would be the third disruption. Some of our kiddos in child welfare can be disrupted fairly frequently. It is not uncommon that in most states, children in foster care have an average of three and a half placements in their first year in child welfare.

If a child has three placement disruptions, and we think about that from a mathematical standpoint, that would be an average regression of 18 months' worth of development. That means we are in a place in child welfare where the children in foster care often function as children much younger than their chronological age and present with some significant challenges. Some states have what can generally be referred to as privatized foster care. These states will have programs or nonprofits where parents are allowed to give temporary custody to an agency instead of their child being placed in child welfare for things like rehab stays, short-term incarceration, and homelessness that appears as though it will resolve at some terminal point. Those may not be technically foster care, but they would be very similar. Those kinds of placement disruptions become connected to that six-month regression.

Taking care of our kiddos who've already had experiences of trauma and potentially scary parenting becomes really important because the more there is disruption, the more compounded we see the impact on development and delays. When possible, children are best raised in the care of their families. When that is not possible, we look for permanency in other settings. One of the major goals of child welfare is to try to keep kids in homes and connected to families as much as possible. Awareness, prevention, and intervention opportunities around pediatric abusive head trauma reduce the likelihood of child welfare placements or duration of placements and reduce the cost of long-term out-of-home stays.

Child Welfare

Kentucky

In 2020, 66.9 per every thousand children in Kentucky were the identified minors in a child welfare investigation. Remember, I said about three out of every thousand children go into foster care, but about 67 out of every thousand have some related Child Protective Services (CPS) report. CPS is generally a division of the child welfare system. Of those roughly 67 per thousand kids who were part of a child welfare investigation, about 17 of them had a substantiated abuse finding.

A substantiated abuse finding can be defined in a couple of ways. When a child welfare report comes into the mandated reporting system, it becomes the responsibility of that part of the child welfare system to identify whether or not a report is "valid." There are lots of reasons why a report might not be valid. There are times that folks have told me that they filed a report because they saw a caregiver spank a child in a grocery store, but they didn't know the child, didn't know the caregiver and didn't have names or any information. While they called that in, at the end of the day, the child welfare system couldn't figure out who it was. There's no way to connect it to an individual or to an option to investigate further. All of those calls pretty much get screened out because there's not enough information there to do anything with them.

There are also calls that get made to child welfare that may not rise to the definition of what is considered dependent abuse or neglect. I can think of reports I have filed that did not meet that qualification. There have been times when I was very worried about a family's dynamics and very concerned that choices were unhealthy. That can be difficult to communicate. Unhealthy decision-making does not necessarily equate to unsafe and may not leave bruises or indicate that a child doesn't have a place to sleep and a roof over their head. Those can be screened out.

There are many other reasons a report may not be "substantiated." But a substantiated abuse finding means that the state agrees that there's an issue and that we need some support. Those supports can look like lots of different things, such as foster care or additional services in the home. Of those 17 per every thousand children in Kentucky with a substantiated abuse report, not all of them entered the foster care system. However, of those roughly 17 per thousand, about one per every hundred thousand was specifically a child abuse-related fatality, meaning that the abuse had been egregious enough that the child did not survive. For 2020, there were about 16,750 children in foster care across the Commonwealth. Of those, about 15% were under a year old, and about 47% of all foster care children were age five or younger.

Nationally

I also highlight that, nationally, about 16% of all children engaged in child welfare were one year or younger. Nationally, 42% of all the children in child welfare were age five or younger. Kentucky is not alone in this. Consistently across all the states, infants and young children have the highest rate of engagement with child protective services and the highest rate of removal.

It's a curious statistic to take a step back and reflect on because, most of the time, when folks think about foster care, they think about school-aged children and often think about teenagers. They may have a picture in their head of a 15-year-old who needs a place to go because things at home are so intense and difficult. While nationally, 58% of the kids in child welfare are not aged five or under, the single largest age bracket engaged in child welfare is birth to five. Most of our kids in foster care are young. Most of them are in developmental spaces where they cannot fully give words to their experience or have the kind of cognitive development to connect cause and effect. They cannot understand how they got here and where they are.

Why?

Children aged five and under are at the most risk for CPS investigation and removal because infants and young children are much more dependent on caregivers. When we think about allegations of neglect that are substantiated to removal, it may be the difference between healthy and safe. A 10-year-old can find their own Pop-Tarts. While that may not be great, and it may not be the nutritional density that we would hope for, the reality is that they're fed. Often it is because they feed themselves. A two-year-old won't do that.

They are also less verbal or nonverbal than older children, meaning they cannot be an active narrator about their experiences. I think that makes pediatricians, CPS workers, and others involved aware of what may be happening in the world of young children. Whereas, I think, for older kids, there's some expectation that they'll tell us when something is wrong.

Littles have big emotions in little bodies. As part of the developmental trajectory, even with typical developing, best-case-scenario kiddos, the number of meltdowns children have between birth and 18 continuously decreases. Even more emotional kids have emotional stability the older they get. But littles have a lot of big feelings. One of the statistics we use in ZERO TO THREE talks about how the average number of meltdowns for a two-year-old in a day is about one meltdown every 24 minutes. It is typical that about every half an hour, a two-year-old is completely melting down with all the tears and feelings. We know as kids get older, that tends to dissipate. They can better internalize their coping skills, self-regulate in those moments, and hang in there a little bit longer with all those big emotions.

Children under five are also more at risk for CPS investigation and removal because they've got first-time parents. Often, families will tend to stabilize with repeat children, and first-time parents are often overwhelmed. Babies may very well find themselves welcomed into overwhelmed caregiving systems, where there may be a parental mental illness and parental substance abuse, and grandparents who don't live close by or have their own mental health and substance abuse concerns.

Coming into those spaces, I frequently say, "All babies mean change." The most wanted and planned-for and hoped-for babies mean change and change is hard. I had a meeting this morning with a colleague, and I said, "How's your week been?" She said, "You know, four-month sleep progression plus a time change is not my favorite weekend." Even the most wanted and planned-for babies can be hard. When this may have been a baby who was not planned for or when we think about systems that are already overwhelmed with mental health concerns, low socioeconomic status, and substance abuse concerns (risk factors), welcoming a very needy, very dependent, nonverbal being into the space is often a tipping point.

Across all states, it doesn't really matter where you are; the single largest category age-wise for kids at risk of child abuse is under six weeks of life. The first six weeks of life is the most volatile time and the most likely time for an incident of physical child abuse, specifically for that physical child abuse to be pediatric abusive head trauma.

Babies

As I said before, babies mean change. Even wanted, adored, and loved babies mean change. Change can be really hard, and a new baby is a major adaptation. I think about others in my world who say, "I wanted this baby so much, and I never leave my house. I haven't seen anybody else in weeks. I wanted to apply for this promotion, but it would be more time, and I don't have it to give." Even in the place of intentionally thought-about children, there's change. When we have not had the privilege of slowing down to think about what a baby may mean, that change will be even harder. I use the word privilege intentionally because when we think about insight and reflection, there is truth about it being a privilege. Not all of us live in spaces without risk factors such as mental health concerns, substance abuse, low socioeconomic status, incarceration, legal charges, etc.

When working to survive, we don't often slow down to think and wonder what this might be like. How might it be for all of these things to be different? Because we're just trying to keep a roof over our heads and keep going. Hold in mind that babies mean change. Also, hold in mind that the process of becoming a parent is one of the most emotionally evocative life changes that occur. It's a real dynamic shift to suddenly have someone who needs you far more than you have needed other folks. In that process of being needed and needing help, becoming a parent calls back to the parent's own experience of being parented.

When we've got a parent who had their own history of early neglect, abuse, or emotional abandonment, then when there is a new baby, there is a deep remembering that, oh, I want to do all of these things for this kiddo that I did not get, and grief that they did not get those things. Or, we see parents who say, "Well, it was good enough for me. I don't know why it wasn't good enough for them." We hear that a lot, and so in the process of becoming a parent, we call back to what it was for us to be parented and make decisions from that information.

Early childhood has a certain aspect of universality that nothing else has. Out of everybody who completes this course, there will not be a piece that everybody's ever had. Not everybody will have experienced psychosis. Not everybody will have dealt with a substance abuse issue. Not everybody will have a learning disability. But every single person who accesses this material will have at one time been three. In that space of thinking about infants and young children, there is a universality that also calls us to think about what it was for us to be little and how people cared for us.

I made the caveat early on about leaning into how you are feeling and thinking. Take time to take care of yourself. Take a moment to get up and walk around the room. Find some water and come back. The reality of the parallel between our work, the children we see, and the experience of what it was to be children ourselves is closely connected. As we walk through the next part of our time together, I will tell some stories. I mentioned that I'm a social worker. What I don't know that I named quite prolifically is that my clinical specialization is in severe early childhood trauma, and a lot of that looks like physical abuse.

I always find it very important to name at this point that some of my stories can be quite intense to hear. For me, they are humans, and so I know all of their stories. I know the funny moments in addition to the sad moments. I know the things that make them great and wonderful human beings. You all will get a snapshot for the purposes of educational demonstration. Sometimes that's intense material, and I want to name that outright.

The First Six Weeks

When we think about the statistic that the first six weeks of life are the highest likelihood for an incident of physical child abuse, most often pediatric head trauma, there are a number of reasons. One is that birth can be very traumatic. Frequently, unexpected complications, surgeries, the sense of feeling out of control, or recovery can take longer than expected. All of those things can be frustrating for caregivers.

When I think specifically about labor and delivery complications, mama may be out of pocket, those complications may result in longer healing time, or it may mean that mom is sleeping or has her own physical limitations. I think about a friend of mine who ended up having an emergency C-section and, six weeks later, had to have her gallbladder removed. She didn't sit upright for about 2 1/2 months. Some limitations from unexpected complications can put increased stress on an alternate individual. Sometimes that might be whoever that second biological caregiver is. It may be support from extended family called in, a nanny, or some other type of interim childcare that was hired. That person then is going to be in the position of the primary caregiver for that tiny baby.

The other piece, when we think about the experience of the first six weeks of life, is that the body releases several hormones immediately upon giving birth. The first we'll talk about is oxytocin. Oxytocin is the hormone that tells us to love babies. I always make this joke, and I inevitably get somebody who says, that's not accurate. But brand-new newborn babies are generally not that cute. If you take a step back for a moment and think about it, they're red and slimy, and they're really squished and swollen. Babies get cute after a few weeks as they fill out and have their appropriate color. But, right after they are born, babies are not particularly cute. Again, someone will always argue with me that their newborn baby was very cute, but I will also say that I think that's the oxytocin talking.

The hormone oxytocin that's released at birth is the thing that tells us from an evolutionary, biological state that we're supposed to love for and care about babies. It is the hormone released when you see a picture of a baby, and everybody in the room goes aw. It's a collective shared experience because our brain says, "Oh, that's a thing you're supposed to take care of. That's a thing you're supposed to love." It also happens with dogs. I would say it happens with cats, but I'm not a cat person, so I don't register with that experience. So oxytocin gets released, and we have this kind of euphoria that happens with a deep biological sense to take care of this being.

The second thing that happens is that your hormones crash into a pre-pubertal state. Think about that. You go from age 30 to 13 in about 45 seconds. That can make people fairly moody. For most folks, there's a period of about two weeks of what gets referred to as the baby blues, but for some folks, it can trigger some significant mental health concerns. Both of those pieces together, the hormone release and the possibility of birth trauma and complications, can increase our risk factors and shift our stress.

The other piece is the baby themselves. Babies are not blank slates. Babies come into the world with their own personalities. With that personality, they also bring parents' perceptions of who that baby is. In the first six weeks of life, babies' primary goals are to try to get in a pattern around breathing, eating, and sleeping. That's the goal in the first six weeks, meaning we don't have a pattern in those first six weeks.

Sometimes they're sleeping a lot, not sleeping, or cluster feeding, where they eat about 20 minutes apart and then don't eat for six hours. They're just trying to figure out how to breathe and get into a pattern of being. In the first six weeks, babies often cry excessively without the ability to be soothed. In infant and early childhood mental health, we talk about the concept of being with. One of the examples we give is the process of being the caregiver to a young child, walking the floor, and having no solution. If you have been the caregiver to littles, you know what it is to be up at 2:00 AM, pacing up and down a hallway with a screaming baby, saying, "I don't know what you want. I'm still here, but I have no idea what you want." We've tried all the things we know to try. In the first six weeks, the periods of really intense crying without the ability to be soothed are much more common. Also, during that time, babies don't sleep regularly. They're not predictable and are not yet in a pattern.

That also means that caregivers don't sleep regularly. Think about caregivers who may have had a traumatic experience. Their hormones are off and may have triggered some mental health episodes. Now they have only slept for three hours in the last 24, and their baby is screaming at the top of their lungs. They don't have any paid maternity or paternity leave. They're also concerned about whether or not they're going to make rent because Mom can't go back to work because now she has all of these complications from surgery. All those factors together in the first six weeks can make for a really intense perfect storm.

It is not uncommon in early childhood that parents perceive babies as fussy. There's always the reality that parents perceive their children to be in specific ways that the rest of the world may not. I think about some of the kiddos that I work with clinically that parents will describe as difficult, and they're no more difficult than anybody else. This is not an early childhood example, but we recently had a family who was extremely frustrated and kept referring to their 14-year-old as distracted. The 14-year-old was on Snapchat and losing track of time. They weren't distracted. They were just 14-year-olds on electronics. The same is true with infants. Some families perceive their baby to be fussy and, internally, feel less successful at calming that baby or soothing the process.

We talked about the oxytocin release right after labor and delivery. Remember, this release starts the biological process of bonding that leads us to an attachment relationship. There are situations in which we know that caregivers will produce less oxytocin. These include a history of major depressive disorder, severe mood disorders, anxiety, and obsessive-compulsive spectrum disorders. By virtue of that, this immediate bonding hormone may not be as strong.

When we know that families have support in place and they've got good resources, many families navigate that and can overcome and find their way. But that's not the case for all of our families. While the body will produce oxytocin as a biochemical reward for taking care of something and loving a thing, there's also the reality that the body produces cortisol whenever we're super stressed. When we're stressed, that cortisol comes out, and it says, "Something is wrong. Something is wrong. You have to fix it." I often tell my little kids that it's our brain's fire alarm. It's the thing that beeps and tells us something might not be safe.

In that first six weeks, we're trying to find those cues, develop our patterns, and be in that place. As the baby is soothed and parents feel successful, oxytocin produces the biochemical reward that says, "You did it. See? We did it together." Babies also produce oxytocin that says, "This person can help me feel better. Everything will be okay." On the other side, when we don't feel successful in that place, our body produces cortisol because it is stressful. The crying is really intense, which overwhelms the caregiver, who often feels they aren't doing things right. This will also produce increased cortisol levels in infants, who say, something's not right, and I don't know why, but I can't get calm.

Thinking about our folks engaged in child welfare when there have been persistent incidents of physical abuse and neglect, the overproduction of cortisol long-term can have neurological implications that we can see. Children have an intense stressed time in infancy and early childhood. They are much less able to tolerate shifts and change and self-regulate. Even as they age, they become much more easily overwhelmed and stressed and much quicker to respond to lower-level stimuli. I refer to this process as the ABA of neurodevelopment. If you do a thing well and connect, you get the oxytocin reward. Your brain says, "Good job." That's the thing you should do. When we're unable to find each other and match, our brain produces cortisol, which often means we don't want to do this and want to fix this as quickly as possible. That back and forth begins to add to that place of rhythm and getting into a routine, finding our own way. The first six weeks of that kind of cue and response helps lay that foundation.

The Crying Curve

In 1991, Barr, Kenner, et al. conducted a study examining infant crying to determine what happens, what it means for babies to be fussy, and how bad it is. The study found that generally, crying peaks in intensity and frequency at about six weeks old and then decreases. That study is usually referred to as the crying curve. Now, while the study found that, generally, crying peaks at six weeks and then decreases, that crying curve looks different for all babies. Even in stable, sustainable, consistent, and predictable caregiving environments, some babies just cry more, and others don't cry as much. While they may also reach their peak at six weeks, they may not have cried as much to begin with, and then also cry even less after that six-week mark. But, pretty consistently, crying increases and peaks at about six weeks and then dissipates from there forward.

The information gained from the crying curve established some containment that the experience of "fussy" crying was, to some extent, predictable and typical. We can say that the first six weeks will be rough, but it'll get better. We can't say how much better or exactly when, but we know it decreases after the first six weeks. That gives some normalcy to this process. The National Center on Shaken Baby Syndrome used this initial information from the crying curve to develop the awareness campaign called PURPLE Crying.

PURPLE Crying

PURPLE is an acronym that stands for:

• PEAK of Crying
• Unexpected
• Resists Soothing
• Pain-Like Face
• Long Lasting
• Evening

We know there will be a peak of crying in the first six weeks, which can often be unanticipated. For example, everything seemed fine, and now they're crying for the next 45 minutes, they're not easily soothed, they appear quite distressed, and it can last a while, more commonly in the evening hours. The Period of PURPLE Crying is a period of time, so the awareness campaign hopes to emphasize that this is a typical early childhood development phase, much like biting. No one loves that, and it's not a fun phase. If you've ever been the caregiver of a kiddo who was a biter, you know we want this phase to be over quickly. It is a typical early childhood development phase that we can name and talk about. We can normalize that this event occurs in early childhood and parenting. When we name a thing, we can contain a thing. It also emphasizes that there's an end. That end may not be today. Tomorrow may only be marginally better. But the reality is that there will be an end.

Pediatric abusive head trauma most often occurs during this intense six-week crying curve of the Period of PURPLE Crying. We discussed this already, but parents often report higher-than-average stress around crying when they perceive their baby to be fussy. Whether that baby's actually crying more or less than other babies does not matter. Parents will report increased stress because they perceive their children to be fussy. Some of this can also come from a parent's background or cultural expectations of whether children should be seen and not heard. Is there an expectation that babies obey even when they're very young? By this kind of excessive perceived crying, what does that say about this baby? Is this baby going to be a problem child? Is this baby going to disrupt life as I expected it?

I have heard parents say, "See, this baby already won't listen to me. How am I supposed to parent them when they get older?" That's pretty common. Perceptions of babies begin before birth and are often connected to parents' experiences as a child and to their thoughts about being a parent. One of the things we often wonder about in this space is, who is this baby, and who is this baby to me? Again, I feel like I should asterisk here before I launch into these stories. Know this is about to be intense content.

I think about families where I saw this play out. One of the families I think about most intensely was a family seeing me for their ninth child. The eight prior had all been removed from child welfare, placed, and adopted in various dynamics. The ninth child, who was seeing me, was currently placed in foster care. The 10th baby was born during that process of services. There were many stories about the 10th baby. One time, they got to the office, brought the baby in a stroller, and I dropped into what we generally refer to as mother ease, that vocal tone you use when talking to babies. I said, "Oh, sweet girl, what's the matter?" Her mom looked at me and said, "Nothin'. She just knows when she's around people she doesn't like." This was a four-month-old baby. The four-month-old baby, I promise, did not have an objection to my personality. Her mother, however, did. This is an example of the perception of how we understand babies and what we understand their cues to be.

Here's another story about that same family. There was one time they were with me when Mom asked for a bottle. Dad pulled the bottle out of the diaper bag, shook it up, looked at it, and said, "I'm pretty sure this has gone sour." Mom said, "Ah, she'll learn to live with it," took the cap off, and fed it to her anyway. This is a moment where there is that question of how we perceive who this baby is and who this baby is to me.

Pediatric abusive head trauma occurs most often in kids under six months old. It is generally connected to a caregiver's sense of being overwhelmed, feeling out of control, and having limited support or skills to navigate these intensive periods of crying. We know that higher risk factors in other situations increase risk factors for pediatric abusive head trauma and that frequently, afterward, parents will say, "I did not know how to make it stop. I did not know what to do." 

Facts and Figures

Pediatric abusive head trauma occurs in about 1,300 child abuse cases annually. It is the leading cause of child abuse-related deaths in the US. While on a case-by-case basis, it doesn't often happen, usually at the point that it is recognized, which is part of our conversation today, it is very often fatal. For those kids who survive those traumatic experiences, the associated care, rehabilitative supports, educational supports, and child welfare interventions cost the US about $13.5 billion annually.

Possible Signs and Symptoms of PAHT

Possible signs and symptoms of pediatric abusive head trauma include seizures, difficulty breathing, cerebral swelling, and an infant being unable to lift their head when previously they could. A lot of these symptoms are associated with swelling, both cerebrally and into the spinal cord. Other signs and symptoms include unequal pupils, subdural hematomas, lethargy, and decreased muscle tone. With hematomas, there are times that pediatric abusive head trauma could be associated with stroke.

PAHT and Spinal Injuries

A study from the Cleveland Clinic found that spinal injuries are an often undiagnosed component of pediatric abusive head trauma that likely occurs more often than PAHT itself. Since there's no humane way to test pediatric abusive head trauma, the study took car crash mannequins and looked at the force of impact on the spine and the brain. Of the 131 mannequins in the crash simulations, 96% met the criteria for a spinal injury, while only 22% met pediatric abusive head trauma criteria. 

As a clinician, I am now much more curious about my kiddos, who I know were involved in stressful early caregiving experiences. They may not have a diagnosis of pediatric abusive head trauma or even some symptoms, but what is the likelihood of some spinal damage that may result in low muscle tone, frustration, or increased pain response? Because of this study, we know that it's highly possible and likely that roughly cared-for babies may experience neck and spinal injuries before any neurological impact or PAHT.

PAHT and Cerebral Functioning

Animal simulations of pediatric abusive head trauma have highlighted a clear connection between subdural hematomas and oxygen loss that occur during shaking or other abusive interventions. The initial cerebral impact can stop oxygen during shaking or other abusive interactions. Loss of oxygen means long-term damage to cells within the brain, which can result in a lack of weight gain, growth restriction, and ongoing respiratory concerns. It can also cause issues with your frontal cortex, which is cause and effect, working memory, reading comprehension, and other things that come much later down the developmental trajectory.

Long-Term Outcomes

Thinking about the long term, pediatric abusive head trauma can cause learning disabilities, fine and gross motor delays, speech delays, cerebral palsy, seizures, and cognitive impairments. Cerebral palsy is a cluster of symptoms that can be diagnosed from a myriad of onsets. Still, it is possible that an event of pediatric abusive head trauma could result in a cerebral palsy diagnosis.

Cerebral Damage

Our brain has three primary regions that impact our social-emotional functioning: the frontal cortex, which sits at the front of your brain, your limbic system, and your brain stem. The frontal cortex supports cause-and-effect, impulse control, and higher levels of thinking. Damage in this area will result in increased impulsivity, difficulty with self-regulation, and learning difficulties. Our limbic system supports access to words and memory. Damage in this area may result in speech delays or speech loss and concerns with long-term, short-term, and working memory. Our brain stem is responsible for heart rate, blood pressure, and body temperature. Damage to the brain stem is generally life-threatening.

Risk Factors

We've talked a lot about risk factors, including the perception of the "fussy baby." Parental mental health concerns are a huge risk factor. When parents are more stressed, they are more likely to respond aggressively when they don't feel like they can problem-solve. In addition to mental health concerns, substance abuse concerns are a risk factor. Parents recently in recovery will fall into this category of being fairly stressed and unable to access all their coping skills.

Also, factors that contribute to low oxytocin include placement with alternative caregivers, single-parent homes, and fathers/boyfriends/stepfathers in the first six weeks of life. Previously I talked about the oxytocin release that happens at birth. That is a biologically triggered response, meaning if you didn't biologically give birth to this baby, you would not have an immediate oxytocin response. When we look at non-biological caregivers, we know that their oxytocin response comes on at about six weeks of life. Euphoric flooding will occur, but it's just not at the same time because there's not a biological process there. Fathers, boyfriends, and stepfathers often end up being the "aggressor" in the first six weeks of life. For example, we may have a mama out of commission for some complication. We've got a father, boyfriend, or stepfather with their own risk factors. We don't have that biological support online yet to say, "I know you're upset, and you've been crying for 45 minutes, but you're really cute." That will increase that difficulty in single-parent homes or with alternate caregivers.

Poverty, low socioeconomic status, and low education are also risk factors. Domestic violence, another risk factor, is part of a very stressed system in which some level of aggression has become typical for navigating big feelings. That then becomes a risk factor that we're going to use that same kind of dynamic with everybody around us, including the littles.

Another risk factor is prior CPS reports. Most infants and young children with pediatric abusive head trauma are found to have evidence of other forms of maltreatment, such as bruising or broken bones. I often think about young children and finger bruises. Thinking through what you might see, you should not have four oddly spaced bruises on the upper part of your bicep. Broken bones are commonly seen in shaking, and you may see a baby with bones in various healing stages. One of the other significant pieces we think about with that CPS report is story inconsistencies.

A Case Vignette

Here's a case vignette to think through. It is a real story and is a case that I worked on. All names and major indicating features have been changed for HIPAA compliance purposes.

Bella is a 10-month-old who was referred for therapy due to excessive crying, difficulty being consoled, and extreme physical responses when visiting with her biological caregivers. Bella was removed from biological caregivers at 3 1/2 months old after EMTs were notified that Bella had stopped breathing. EMTs found Bella unconscious upon arrival, with excessive bruising to her head and face. EMTs transported her to a large, Level 1 trauma hospital, who later identified several broken bones in various stages of healing, including a femur break, a collarbone break, and a broken arm. Bella is the first child of her parents, who live in an under-resourced rural area. Upon questioning, the biological caregivers reported that Bella had been at home with a younger cousin and that a game system controller had fallen off the coffee table and hit Bella in the head.

Holding that in mind, I invite you to pause for a few moments and consider what risk factors you see. What risk factors might not be named that we might be curious about?

Mandated Reporting

In the Commonwealth of Kentucky, any person who has reason to believe a child is dependent, neglected, or abused must report this to the Cabinet, the state or local police, or the local prosecutor's office. That results in making everyone in the Commonwealth of Kentucky a mandated reporter. It's not one's single burden, but everybody's job to do it. If there is suspicion that abuse or neglect may have occurred, individuals in Kentucky are to notify the Cabinet for Health and Family Services. While we are all mandated reporters, confronting the need to make a call can often be emotionally evocative, especially if it's not something you've done before. The first one is always really hard. After 15 years, I've made a lot of CPS calls. They don't bother me anymore. But, in the beginning, they do as you think about what will happen, if it's the right call, and what comes next.

Your role as a mandated reporter is to state facts. Authorities decide what happens next. Our role as mandated reporters is never to investigate, only to state what we know. Then it is up to the folks on the other end, trained in that, to decide where to go from here. Not all reports result in CPS involvement. An overwhelming majority of reports do not result in the child's removal. Even those reports that are substantiated, most get therapy, maybe rehab, and some supportive options. A child is rarely removed and placed in foster care. When that happens, there has to be substantial evidence that that was the choice to make, usually partly because of the legal burden.

PAHT as Public Health

Figure 1. Promotion, prevention, intervention, and treatment of pediatric abusive head trauma.

We've talked a lot about pediatric abusive head trauma and the idea of medical terminology or risk factors or those pieces, but there is also the reality that it is part of public health. When we think about public health models, we're looking for promotion efforts that reach about 100% of the population. Then we look at prevention efforts that reach about 40% of people with higher risk factors and need more intensive support. About 10% of the population will need some intervention and treatment services to address a problem, not just to prevent there from being a problem.

One example of a promotion effort is this course. Another example is that Kentucky must provide some level of education to all high school students. That's 100% of the population. You're getting this information if you go to high school in Kentucky. 

Protective Factors

While all families have risk factors, we also want to name that all families have protective factors. When we think about the promotion, prevention, intervention, and treatment levels, we want to leverage the places where families have protective factors and increase parenting capacities to promote positive parenting during challenges. Babies are going to cry, and it's going to be stressful. It will be 2:00 AM at a four-month sleep progression on the weekend of a time change, and those are hard days. Leaning into those protective factors and supporting that place of building positive parenting goes a long way. The protective factors include:

• Knowledge and attachment
• Knowledge of parenting through a developmental lens
• Parental resilience
• Social connections
• Concrete supports for parents
• Social and emotional competence for children

We want to build out nurturing and attachment, knowledge of parenting through a developmental lens, and parental resilience. Often mental health literature presents an expectation that people are born with an internal resilience that will unfold itself magically and that if people are "resilient," they'll figure it out on their own. We know from resilience as a broader topic that resilient people know how to navigate their resources and access what they need. Others may need help building this. Regarding parental resilience, we're talking about those parents who can step away and say, "I've been at this for 45 minutes. My time is up. It is someone else's turn." They can step out, take a deep breath, and come back in.

Social connections mean they're not alone, have somebody to call, and have concrete supports. An example is that the baby goes to Grandma's house every Tuesday. There are predictable, consistent options available to parents. We're building social and emotional competence for children. This begins by thinking through and giving even the smallest babies words like, "You are so upset. Everything feels so big right now. We're going to figure it out together." 

Nurturing and attachment include supporting routines, predictability, and shared affect. Shared affect means matching affect. I think about a child we did an observation with a couple of months ago. One of the things we do is ask a parent to leave a room for a brief time so that we can watch the separation and reunion. The caregiver left the room, the child burst into tears, and the caregiver started laughing on the other side of the door. There was a fundamental disconnect in that affect. The child is deeply sad and upset, and the caregiver's affect doesn't match what is expected when seeing the child so upset. 

To build the protective factor of parenting and child development knowledge, provide parenting classes and bite-sized, brief information regarding child development and developmentally appropriate behaviors. For example, you may say, "Have you ever heard of PURPLE Crying? Let's check out this website together." Remind parents of developmentally appropriate behaviors and that things like biting happen and are normal. Increase parental resilience, support stress management, frustration tolerance, and flexibility.

Social connections include things like parent cafes. Many states do parent cafes electronically through Zoom so they can be done late at night. Parents don't have to have transportation, and they don't have to leave their houses. There's flexibility, and it doesn't have to be 3:00 PM while getting somebody off the bus. Many churches host moms of preschoolers (MOPs) groups or other support groups. 

Concrete supports for parents include WIC offices, Early Head Start, rental assistance, and paid parental leave. I also think about our home visiting sector, including Healthy Families, Nurse-Family Partnership, and Parents as Teachers. There is a variety of home visiting programs. Building social and emotional competence for children includes giving words to feelings and emotions. Becky Bailey's "Conscious Discipline" and the Whole Brained Child can help do this.

Promotions That Work

Let's talk about some promotions, preventions, and interventions that work. A study in Texas conducted from 2017 to 2018 worked with 63 Hispanic mothers to provide education and consultation around infant crying and crying behaviors. The study identified these mothers as Hispanic. Generally, we think about that as Latinx, so I cannot define what they mean by Hispanic. The pre/post tests found that mothers' knowledge and beliefs around infant crying had shifted significantly. Once we talked about it, gave them some education, and normalized it, we saw a change. What is curious about this study is that the pre and post-tests still revealed continued concerns that the information might not apply to their baby. That goes back to the sense of perception of who they are. Am I doing this right? Am I good enough? Is there something wrong? That internal worry, what I often refer to clinically as the heart, can persist even when our head tells us, no, we know differently now.

In Egypt, there was a study of 150 mothers who were given an educational curriculum regarding pediatric abusive head trauma and infant crying. Pre/post-tests were utilized to assess mothers' knowledge, attitudes, and beliefs about infant crying. Post-tests revealed improved knowledge, attitudes, and beliefs and improved implementation of the coping skills gained through the curriculum.

In Turkey, a randomized control trial study administered an eight-week course on skills to calm crying babies and build awareness of pediatric abusive head trauma. Post-tests were administered for the intervention and control groups. Results were statistically significantly higher in the intervention group than in the control trial group, meaning that when they compared an intervention with doing nothing, those who got an education could shift their knowledge and awareness.

Synthesizing Findings

When we think about those promotion efforts, we know education matters. When we talk to caregivers about infant and early childhood crying, we normalize what can be a really difficult experience. When we're able to provide skills to families around self-regulation, they're often able to implement those skills and successfully navigate the trying times of parenting. They can recall that education and hold onto it at 2:00 AM when they walk the floor for 45 minutes.

Preventions That Work

In Kentucky, the statewide home visiting program is called Health Access Nurturing Development Services (HANDS). It is funded by the Maternal Infant Early Childhood Home Visiting program (MIECHV), which provides federal dollars to states to provide early prevention services to at-risk families. Those MIECHV-funded opportunities have federal oversight and specific requirements around implementation and fidelity. HANDS supports first-time parents from prenatal to age three for enrollment. They will stay with a family upon enrollment until that child's third birthday. However, there is a requirement that families must face multiple risk factors. There are places in the US that do what's referred to as universal home visiting, which means everybody's got access to it regardless of socioeconomic status or risk factors. But that's pretty rare and doesn't happen often. I encourage you to look up your state's MIECHV and find out what kind of programs they provide. There are 15 or more curriculums that the federal government approves. 

Other in-home nursing supports, such as Nurses for Newborns or Nurse-Family Partnerships, are prevention options that support families in prenatal to early infancy. These programs provide additional resources, in-home support, lactation consultants, and increased screening and referrals for post-partum depression or parental mental health needs. It's like having a pediatric medical home for the parents. All of them have really strong outcomes.

Interventions That Work

Look back at figure one, and you'll see the top tier is intervention. This represents ten percent of the children who have had something happen, and now we have to figure out how to repair things that are not going well. This is infant and early childhood mental health in the early childhood sector. This broad-range clinical field takes a psychodynamic perspective. It states that behaviors are rooted in survival and are recognized to have subconscious depth beyond verbal value. Infant and early childhood mental health services are heavily play-based.

Earlier I told you about the family with the four-month-old baby. In that space of rooted-in-survival, it was deeply evocative to watch that mom feed the baby a potentially soured bottle. As a mandated reporter, I had to call that into their DCS worker, but the other piece was that mama had spent many years of her life without food. She had learned that if you've got something, you eat it regardless of whether it's what you want because you don't know where your next meal will come from. Part of her was rooted in thinking; this baby would take what she gets because we may not have another option someday. The infant and early childhood mental health lens will hold that parent's experience and recognize the motivator for behavior while also being able to say, like, "We can't do that."

Interventions in the early childhood sector include child-parent psychotherapy (CPP) and parent-child interaction therapy (PCIT). CPP is evidence-based for kids as young as six weeks old. Infant-parent psychotherapy is what they're calling the perinatal version. That would work even with moms who have yet to give birth. CPP is dyadic, meaning it is caregiver- and child-focused and frequent, meaning it should happen once a week or more. The assessment phase is lengthy, and it takes a long time to get to know everybody and put all the pieces together. CPP is really intentional about its process. It is what we refer to as trauma forward, meaning that we are intentionally addressing potentially traumatic events that may have occurred.

PCIT is an intervention generally used in children two-and-a-half years old through six years old. We may have a kiddo who has had a pediatric abusive head trauma and who's now getting PCIT. That intervention is behaviorally-based, typically focused on compliance, and parent-coaching focused. It is not technically a trauma treatment but should be fairly intensive with weekly sessions. The assessment period is less, and the duration and frequency of sessions vary. Clinicians are highly trained in parent-child work.

Parent-child interaction therapy (PCIT), child-parent psychotherapy (CPP), trauma-based relational intervention (TBRI), Theraplay, and infant-parent psychotherapy are all evidence-based for kids under six years. I want you to know about them. If you're a social worker and a clinician, I encourage you to find some training because there are never enough early childhood clinicians available in any state. As early childhood educators, I encourage you to know that vocabulary to advocate for the families and kiddos you work with. I want you to know that these interventions exist and should be considered. We should be asking about these things.

Regardless of your perspective, there should be caution around any modality with young children that don't heavily involve the caregiver. There should also be caution around heavily talk-based interventions such as CBT for children under five years or where there are language delays. I am always curious how someone can treat an 18-month-old when no caregiver is involved. 18-month-olds are horrible agents of change, so we must rely heavily on caregiver involvement. Play is the language of children. Play is how they tell us about their fears, how they tell us about the wonderful things, and all the space in between. We want to look at their play and consider it pretty intensely.

Summary

Regardless of our professional role, we can offer families the following tips and skills. Take a deep breath and count to 10. Call somebody for emotional support. Many states have fussy baby lines with somebody you can call to walk you through what it is to be in the moment with a really fussy infant. Call a pediatrician. There could be a medical concern. Sometimes babies cry excessively because things hurt, so check it out and make sure that there's not a problem going on. Advise caregivers to leave babies only with trusted caregivers or those who've had a background or reference check.

As we think about the research findings and our promotion, prevention, and intervention sectors, reflect on what caregivers are going through. Considering the study in Texas, is it that parents' concern that something is "wrong" with their baby persists despite education to the contrary? What causes them to think, maybe it is me, perhaps something is wrong with us, or maybe we are not figuring it out? Hold and name that anxiety, and think through some of the skills we talked about that we might be able to share in whatever setting we're in to support caregivers to care best for their fussy babies.

Our Role in PAHT

So what's our role in pediatric abusive head trauma? First of all, our role is to talk about it. A colleague of mine often says, "Lots of things are green, but that doesn't make them all grass." Grass is a thing. The same is true here. PURPLE Crying is a thing. Lots of things can elicit tears, but this really is its own thing. It's important to remember that caring for young babies is difficult and unique for every caregiver. It's a different journey for everybody involved. Know and remind caregivers that services, resources, and supports are available.

Our role is also to report it. If you've observed concerning behavior, interactions, or signs of abuse or neglect, then we are compelled by state mandate to report it. If you're not sure, but you're worried, or something feels off or just not quite right, consult a mentor, leader, or trusted colleague. 

Questions and Answers

How is pediatric head trauma diagnosed?

Generally, much like my vignette about Bella, an event occurs that then becomes presented to an ER. We generally see X-rays, CAT scans, and other types of MRIs or imaging. Within that imaging, we're going to see that subdural hematoma. We'll see cerebral swelling and an impact point that may not be obvious externally. We may not have a child who's got a laceration and stitches, but through that imaging, we will see those kinds of symptoms.

Are there any free assessment tools that social workers or early childhood providers can use to assess risk factors for head trauma?

A couple of parental stress indexes are good tools that will give you risk factors across a broad range. They look at everything from socioeconomic status to parents' caregiving dynamic. An inventory called a Life Stressor Checklist (LSC) is helpful for social workers in thinking about what are all the things that a parent comes to this parenting relationship with. It's a thorough history of parents' perception of their baby and what it means to bring it into the world.

Do you have any suggestions for resources for working with parents and families, especially those that are at risk of causing head trauma?

I spoke about the MIECHV program. I'm a huge fan of MIECHV and have had the great privilege of working with them in the Tennessee statewide MIECHV program. Different states disseminate that differently. The evidence-based home visiting sector does such an incredible job. WIC offices are generally fairly well-trained in connecting folks in early prenatal and infancy to local resources. If there's an Early Head Start in your area, I strongly suggest you connect with them. Most states demonstrate Early Head Start as home visiting, not as childcare. That means you'll have somebody going into houses, looking at things, being responsive to phone calls, and connecting with folks in those first three years.

I also am a huge proponent of Part C services under Early Intervention. Even if a child is not terribly developmentally delayed if you think there is any reason that the child might need a developmental assessment, make that Part C referral. Those folks are great to come out. Even when development is on track, they're always offering parenting support groups or options about community-based programs, and they know what's available locally.

References

A complete list of references is available in the course handout. 

Editor's Note: This text-based course is a transcript of the webinar, Promoting Executive Functioning Skills in Children and Adolescents, presented by Bryce Hella, PhD, Licensed Psychologist, Clinical Social Work.

Learning Outcomes

• After this course, participants will be able to describe executive functioning skills.
• After this course, participants will be able to explain the current state of research on EF interventions.
• After this course, participants will be able to identify and list several EF strategies with children.

Introduction

Great, thank you so much.  The limitation of the presentation is that this is an initial and broad overview of executive functioning in the pediatric population. It's not meant to be used to create a comprehensive treatment plan. The most common potential risk following the presentation could be attempting to make a treatment plan based on the information I provide.

What are Executive Functions

A good place to start discussing executive functions is what they are. Executive functions are brain functions similar to an air traffic control system. It's how we retain and work with information in our bodies and brains. It's higher-order processing, those things that make us human and differentiate us from animals. It allows us to filter distractions and switch mental gears.

Developmentally, executive functioning skills tend to emerge in preschool. But existing data suggests that they're not fully mature until about the early 20s for females and mid to late 20s for males. Executive functions are housed in the frontal lobe, the last part of the brain to develop, which is developing well into a person's 20s.

An interesting fact about executive functioning is that it's found to be more predictive of school success than IQ. The thought is it's not necessarily how smart you are that predicts how well you do in school, but it's how well you can inhibit the impulses to, for example, watch TV instead of study. How well do you keep your tasks organized and turn things in on time? Executive functions are important, particularly for academic success.

Executive Functioning Subtypes

There are many different subtypes of executive functions. Executive functioning is a broad term to describe many different kinds of mechanisms and behaviors that people engage in or don't engage in.

Inhibition

Inhibition is fairly self-explanatory. This is a person's ability to inhibit their impulses. A classic study on behavioral inhibition is the marshmallow test, where a researcher brings a young child into the lab, puts a marshmallow on their plate and says something like, "Please don't touch this marshmallow when I leave," or  "Right now you have one marshmallow. Don't eat it.  I'm going to leave, but if you can wait and not eat it, when I come back, you'll get two or three marshmallows." The study is great because children work hard to inhibit the impulse to eat the marshmallow.

Organizing and Planning

Organizing and planning are also pretty self-explanatory. How well do people keep organized? Can they organize their belongings? For children, is their backpack a mess? Is their bedroom a mess?

Planning is knowing, for example, that next week I have a partial day of school. I know next week is a final exam. That means my schedule has changed. I have tests that I need to study for. I have a final paper that I need to write.

Task Initiation

Task initiation is a fancy way of saying "getting started" with something. This would be the opposite of procrastination. For example, I have a project that I need to do. I can sit at my computer, but I don't get started. Instead, I check my email or go on social media. This is how well do you get started with a task.

Shifting

Shifting is an interesting skill. We see many children with issues with transitioning, having the ability to shift from a preferred task to a nonpreferred task. You might see a tantrum, for example. This is not only being able to shift behavior but also mental sets. For example, I'm working on a math problem and trying to use a strategy that works for similar math problems, but I'm getting stuck. A shifting mental set is being able to step outside of, "I've tried this problem-solving approach, I'm working hard at it, but it's not working. I need to try something different." They can shift from the initial mental set to something else.

Emotional Control

We don't necessarily think of emotions as being regulated by the prefrontal cortex. But being able to control one's emotions and not have a big emotional or behavioral reaction is considered a higher-order executive function.

Self-monitor and Modify

Self-monitor and modify is pretty similar to shifting. This is being able to say, "The last time that I studied for my biology test, I crammed it in the night before. I tried to do flashcards, but I got an 'F.' This time, I might need to try a different strategy." Maybe they could schedule times to study or use a different strategy besides flashcards.

Working Memory

Working memory is holding short bits of information in your head long enough to do something with it.  If I give you my phone number and you have to remember it long enough just to get it in your phone, that would be working memory. Another example is given a two-step direction or a three-step direction, can you remember all three of those steps?

Working memory is also important for students with copying notes from the board. If I have a short working memory and I can only remember a couple of words at a time, I'm going to be constantly looking up at the board and looking down to write. As a result, tasks can take a lot longer. 

Goal-directed Persistence

Goal-directed persistence is being able to see the long-term implications of your behavior. It's continuing a task even if you're not getting an immediate response, reaction, or gratification. You're able to persist and push through with your behavior.

EF Example 

I like to use the example of holiday shopping at the mall. Although I think this is becoming an outdated example as people aren't shopping at malls for holidays as much as they used to. But, let's say you're given the task of doing holiday shopping at a shopping mall for ten members of your family, and you have to think through the steps you need to take to come home with ten presents for ten different people.

The executive functioning skills that are activated in this example are planning, organizing, and shifting attention.  For example, "I went to Bath and Body Works, and there's a long line there. I know that the mall is closing in two hours, and if I spend all my time in this line, I will probably not get the other stuff on my list done." 

Budgeting requires you to plan out how much you have left to spend. You need to remember all of the people that you need to buy things for versus having a list. If somebody has something specific on their list, and you can't find their size, or if the store is out of that item, you have to be flexible and shift your mindset to consider what else that person might like.  Also, finding a parking spot and remembering where you parked also requires executive functioning. 

All of these executive functions are activated during complex tasks such as shopping.  And some people might find this an unpleasant experience because it is a complex task involving many executive functioning skills. Even adults with weak executive functioning skills may find going to the mall to buy ten presents overwhelming.

EF and Childhood Disorders

Research suggests that there are several childhood disorders that have some implications for executive functioning deficits and difficulties.  The most common disorder that's characterized by executive functioning deficits is ADHD. Individuals with ADHD demonstrate delays in executive functioning skills, sometimes up to three to five years delay in school. A fourth grader with ADHD may be more like a first grader with their executive functioning skills.

Aside from ADHD, there are many other disorders that have implications and go hand-in-hand with executive functioning deficits. Children with learning disabilities oftentimes have executive functioning issues.  With autism spectrum disorder, it's not uncommon to see executive functioning deficits in emotional control and shifting. Being able to shift from preferred activities to other activities is a common executive functioning deficit with autism spectrum disorder.

Interestingly, depression and anxiety also have implications for executive functioning deficits, although we don't always think of those as disorders of the brain. The theory is that there are other more primitive parts of the brain that are activated when people have depression or anxiety. When those parts of the brain are activated, like the amygdala, it overrides the ability of the frontal lobe to be effective.

For example, my emotions are heightened if I have social anxiety and I'm sitting in the classroom terrified of getting called on because I don't want to be embarrassed in front of my class. I have a lot of adrenaline rushing through my body, and I feel my heart race, making it hard for me to do a working memory task where I have to remember something for a short time. So, depression and anxiety are surprisingly associated with executive functioning difficulties, and a lot of research suggests that.

Schizophrenia is not a common disorder for children and adolescents. The typical age of onset for schizophrenia is between 18-22 years old. So, child and adolescent onset of schizophrenia is very, very rare. But there are many studies that suggest people diagnosed with schizophrenia in the 18-21-year-old timeframe or later typically had some executive functioning deficits in childhood and adolescence.  When doing a comprehensive evaluation for early onset schizophrenia, executive functioning abilities are also typically evaluated.  That does not suggest that a child with executive functioning issues in childhood and adolescence will automatically develop schizophrenia. This is more retrospectively, in that you can look back and see that the groundwork was laid during childhood and adolescence. 

Finally, fetal alcohol spectrum disorders and traumatic brain injury (TBI) also have implications for executive functioning deficits.

How to Assess EF

There are two primary ways to assess and evaluate executive functioning deficits. The first is by questionnaire, and the second is by individually administered tests. The most common questionnaire in psychology is the Brief-2, which looks at many different executive functioning domains. There's a parent report, a teacher report, and a self-report version of the Brief-2 for older children. This questionnaire gives us a good sense of how the child is doing with their executive functioning skills in the real world.

There are several individually administered tests: 

• DKEFS 
• NEPSY-2 
• Comprehensive Trail Making Test
• Tower of London 
• Wisconsin Card Sort
• Test of Everyday Attention for Children

These are typically administered by a psychologist or somebody trained to give these types of tests, usually in the context of a comprehensive battery of other assessments.  One-on-one testing with a psychologist and the self-report, parent report, and teacher report questionnaires, oftentimes indicate how an individual's executive functioning skills translate into the real world.

EF Expectations by Age

Again, generally speaking, the frontal lobe and executive functions are the last part of the brain to develop. They develop throughout the course of childhood. What we expect to see in preschool is being able to run simple errands, do simple tasks, and can mostly inhibit behaviors like "don't touch," "don't run on the street," and "be safe."

Additional demands that are considered reasonable for kindergarten to second grade include being able to sit down and do homework for 20 minutes. In contrast, a preschooler might not be able to do that. On average, kindergarten through second-grade children can inhibit more complex behaviors, they can tidy a bedroom or a playroom but probably can't clean an entire house or bathroom. 

In third to fifth grade, children are typically able to run small errands, perform chores that take a little longer, spend an hour on homework, and plan simple projects like book reports. They can behave appropriately when a teacher is out of the classroom and plan for things that are days in advance.

Moving into middle school age, there are some additional reasonable expectations, such as performing chores around the home, including daily responsibilities and occasional tasks, babysitting younger siblings or other children for pay, using a system for organizing schoolwork, including assignment books, notebooks, etc. They can follow complex school schedules involving changing teachers and changing schedules, plan and carry out long-term projects, plan time, including after-school activities, homework, family responsibilities, and inhibit rule-breaking in the absence of visible authority.

EF Strategies

Next, I want to discuss executive functioning strategies by focusing on the research and describing different strategies that can be used with children and adolescents.

In general, the research on executive functioning interventions is very mixed. There are many different ways to try and improve executive functioning skills, and the approaches are ever-changing. 

• Computer-based EF training: There is a public market for computer-based executive functioning training, which is online training for simple executive functioning tasks such as improving working memory by remembering long strings of numbers or longer strings of information. The challenge with those types of programs is that they're highly expensive, not covered by insurance, and the research does not have much external validity. The research that's being done on those programs tends to be done in-house by the company, and there are limitations to that research. They will typically do a pretest of a working memory task, for example, and then a post-test of the same working memory task. Then the research will suggest that "Yes, there might be a few points gained in a working memory score when you're testing it the same way."  But that doesn't necessarily translate into improved working memory in the real world. So I always caution people who are thinking about doing some of that computer-based executive functioning training because there isn't much evidence supporting its use. 

A similar example is giving an IQ test and then training the individual on the items from that test.  We would expect their IQ score to improve.  But if that individual's grades don't improve and they don't know how to study better, is that a helpful change? 

• Physical activity: There is some research suggesting that any type of physical activity can have a small impact on executive functioning skills, particularly with emotion regulation, emotion control, and some inhibition.
• Mindfulness: Has a moderate effect on tasks, such as shifting and controlling emotions.
• Teaching "real life" executive functioning skills: There's some research to support that this is an effective and cost-effective strategy, as well. If you can implement real-life executive functioning skills training in a classroom or at home, that can translate into being able to study better, organize better, plan better, et cetera.  
• Neurofeedback and biofeedback: This strategy has mixed results regarding how well it impacts executive functioning skills.  Additionally, it tends to be expensive. It's not that they're ineffective. But there isn't strong data to suggest whether they're effective or ineffective.

Task Initiation

Let's discuss some specific strategies for task initiation.  Again, task initiation is being able to get started on something, such as sitting down, opening up a Word document, and starting to type out the first paragraph of a research paper. A quote that I like is, "If you're having trouble getting started, the first task is too big." You probably need to start with a smaller step.  If I need to write a research paper, it needs to include a reference portion, information from five sources, it needs to have an introduction, a body, and a conclusion.  It needs to be six pages, for example. We can make that task easier by breaking it into smaller chunks; maybe set small due dates for those chunks.  

I may be having a hard time getting started with the first paragraph, but I have three sources that I can read and put into my references. I can summarize and write the main points I want to cover in the paper. All of those smaller chunks are doing something to get started.

Another strategy for writing assignments is to provide some sentence starters, "The first paragraph sentence could start like this...," or, "This is how you could start your introduction...," or "Here are some sentence starters for the body of the paper...,"

Another task initiation strategy that works for adults, too, is setting aside 5-10 minutes to work on the paper. If, at 10 minutes, you're in a good flow and you can keep going, great. And I think, in general, that is what happens. You get started, do 10 minutes, and think, "I can do more." But if that doesn't happen, you still got some work done in 10 minutes or at least got started. 

For school-age and adolescent students, provide them with samples of a good quality finished product. For these students, the task may so daunting, and they don't know where to start because they don't know what the end is supposed to look like. Sharing samples of finished products can be helpful.

Organization: Papers

Keeping papers organized is often a big issue for students and adults too.  Papers from school are stuffed into backpacks, desks, and lockers.  And there's really no perfect method for organizing them.  To see if a method works, you need to pick one and stick with it. For children, it can be helpful to have daily check-ins. During that daily check-in, a teacher or other staff member can check to see if all papers are filed in the correct section, and there are no loose papers in the backpack. If that's not the case, the adult oversees or sits with the child as they reach that goal or do that for the day.

There could be weekly or bi-weekly check-ins to review the student's folder to see what needs to be finished, what needs to be thrown away, what needs to go in a different location, what things need to be saved, et cetera.

Planning and Time Management

There are some general recommendations for people who have executive functioning deficits, particularly as they start to have more organizational responsibilities.  Having a planner is highly recommended by the end of elementary school and in middle school and high school. I often see that people are resistant to planners. But with smartphones and technology, there are electronic planners. There are also planners and calendars available through their school operating systems or on a Chromebook that they have through the school. Even using paper and a pencil to handwrite lists and notes is helpful. 

Ask what the student's preference is to increase buy-in.  And explain, "I know it's annoying. I know it's daunting. But it's going to help you get better grades. It will help you turn in the work you're completing. You're not turning it in because you didn't write it down, or you didn't organize it or put it in the right spot."

Also, a planner should always be open and out during homework time.  It's an integral part of their homework and looking at their schedule, what they have coming up for the week, and if they wrote everything down. It can also be a good idea to have them write in the planner if there is no homework in a particular class or in general.  A lot of times, students come home with nothing in their planner, and they will say, "Oh, I don't have any homework." Having the student write "none" or "no homework" can help clarify if nothing written in the planner means that it just didn't get written down or there is truly no homework.

Also, have the student use checkmarks to cross things off and indicate that something is complete.  Have a teacher sign off on the planner to ensure they wrote everything down appropriately. And set goals with the child or teen to participate cooperatively in the nightly check-ins.

Time Management: Studying and Long-term Projects

I work with many adolescents on time management for studying and long-term projects.  I want to teach them how to spend their time doing the things that get the most bang for their buck and not worrying quite as much about the little things. 

For example, it's generally helpful to have checklists for studying. There is a particular checklist, or "menu," for studying that discusses different studying strategies.  The first is "passive strategies," which should be used sparingly because they are not very effective.  These are strategies such as rereading what you read, rereading your notes, highlighting, rewriting notes, reading or watching SparkNotes. Those are considered to be more passive strategies for studying. It is better to use "active strategies" such as making a study guide, making flashcards, creating a concept map, organizing notes, completing a review packet without checking over the answers, and attending a review session or a study group.

Then there are "active strategies with feedback," which are sort of the gold standard studying strategies and include quizzing myself with study guides and flashcards, taking practice tests AND checking the answers to see what I got right and wrong.  Research suggests that if we get immediate feedback on the things we get wrong, and go back and figure out the actual answer, then we're going to remember that and put it into our long-term memory better. Redoing tests or homework, having someone quiz me, completing a review packet with checking answers, and meeting one-on-one with a teacher to get feedback about what you understand or don't understand are all active strategies with feedback. 

Have a list of studying options. For example, what are they going to prioritize for this particular test? Have the student set out a calendar of what they will do four days before the test, three days before the test, two days, and one day before the test. There is data to support that cramming for a test the day before doesn't help to learn the information and perform as well on a test versus spreading it out over the course of four days.

Also, in regard to time management and planning, have students set aside chunks of time for their obligations. For example, if I'm in school from 8:00-3:00, that's an obligation. Then, from 4:00-5:00, I have soccer practice. There's an open space between school and soccer practice, but there might be some drive time. There's a drive home and a drive to soccer practice. So, the time between school and soccer practice is only about 30 minutes. However, I might also need to change my clothes and have a snack, etc., during that time.  We can help them visualize how much time there is for their obligations and put those things on their calendar. Then, they can see how much open time there is for other activities they want to do.  Having students block out time for their obligations in a planner can show them that they only have, for example, four hours Monday-Friday to study for their math test.  That can be very helpful. 

Encouraging individuals to work backward on a calendar can also be helpful. For example, if I know my paper is due on December 15th and today is November 15, I can work backward and decide that the rough draft needs to be done by December 13-14th. If the rough draft needs to be done by December 13-14th, then all of my research needs to be done the week before, which is December 8th.  The idea is to help students realize that even though December 15th seems like a long time, there are a lot of pieces that need to be done well before that deadline, and they can't wait until the day before to start the paper. 

Goal-Directed Persistence

This is the idea of prioritizing your time when studying, working, et cetera. One strategy is to ensure that a study space that has been established for a child or adolescent has all the necessary supplies for homework. It can also be helpful for those who are visual to take a picture of what the study space looks like with all of their supplies. Then the student can compare the photo to their workspace before they get started and make sure they have everything that they need. 

Another strategy to help prioritize and work through tasks that people are less interested in is using the Covey Quadrant method. There are typically four work quadrants, with one quadrant for important and urgent tasks, one quadrant for tasks that are important but not urgent, one quadrant for urgent but not important, and a 4th quadrant for tasks that are not urgent and not important.  This method gives students a framework for deciding where their tasks and activities can be placed.  If a student can identify what a Q4 task is, then they know when they are supposed to be working on urgent and important tasks (Q1) and their important but not urgent tasks (Q2). They can prioritize their Q1 and Q2. People often operate in this urgent and important quadrant, "I have a test tomorrow. I have a paper due tomorrow. It's urgent, and I have to get it done. These are important things." They are operating in a crisis mode of, "I procrastinated, and now I have to do this thing. I HAVE to get it done."

The goal with the Covey Quadrant is to move tasks into Q2 (important but not urgent) so that most tasks that a person is doing are prioritized and are in that second quadrant. 

The third quadrant has tasks and activities that tend to take up a lot of time. They seem urgent because they're in our faces, but they're not important. Social media seems to capitalize on this "urgent, yet not important" with all the notifications you can get. We want to identify those types of tasks and add them to Q3. Then when I have something that I need to do that is Q2 or Q1, I can turn off my email or not open my social media. With children and adolescents, it can be very helpful to have them turn off their text messages, notifications, social media game requests, etc.  Make them inaccessible in their study space.  Have those be rewards for getting through the important tasks.

Self-Monitoring

Self-monitoring is recognizing how my behavior affects those around me and how my strategies help me get the output I want. For example, if I want to earn A's and B's for grades, how well does my strategy of cramming till the last minute work for me? We know that doesn't work for most students.  We need to teach them how to monitor that and be aware of how that works or doesn't work for them.

For younger children, this might look like building awareness of different things. "What do you think?" "What will we do if there's a long line at the store?" "What do you need to do first?" "What do you need to do next?"  This also prompts students to look at their visuals, schedules, and planners.  We want to bring their attention back to those strategies and have them use them, "What does your planner say about homework? Why don't you go get it out?" "What about that visual checklist that we have? Let's go through that," instead of a parent or teacher bringing attention to it and solving it.  We can say, "Let's look at the strategy that we've put in place to use. Let's see, we are using error checklists. This is a great strategy to use when you're done with your assignment." Maybe they completed all 30 math problems, but their handwriting is sloppy.  Ask them, "What does it look like to be done with your math? It means that I've looked through it, and there's a checklist. Is every single question answered? Check. Did I go through and double-check to see if the math makes sense? Check. Is my name on my paper? Check. Did I spell things correctly? Check." Using an actual checklist like that can be helpful.

Then, teach them to evaluate their own performance, "How well did you do?" "How well did that work for you?"  "What parts of the strategy did you like?" "What parts of it didn't work so well?" "Let's revise appropriately."

Working Memory

Working memory tasks, working memory interventions, as well as any general memory strategy, includes:

• Making sure that children are ready to hear important details before giving them instructions or directions.  For example, a classroom teacher will say, "Listen up, class, I'm going to tell you something important. I have important information." That prompts the students to be ready to listen and ready to learn. That helps them to not immediately forget what the teacher said.  is gonna help so that they don't forget it immediately.
• Repeat, rehearse, and review is self-explanatory.
• Attach meaning so the child can learn.  Provide a context, a story, or something familiar to them.  
• Mnemonics and crazy phrases to promote learning, such as remembering the names of the planets or the colors of the rainbow. 
• Recommended accommodations for memory weaknesses - There's not a lot of research to suggest that interventions for working memory have a lasting impact on a person's environment. Therefore, we will provide accommodations if a child has working memory difficulties. Some examples of accommodations include: 
  • Designated class note taker 
  • Recording lectures 
  • Access to teacher notes/presentations
  • Word banks
  • Visual checklists and to-do lists 
  • Post-it notes

Inhibition

When a child cannot inhibit behavior, it might be easy for them to, for example, hit their classmates to get their toy. That works. However, we need to teach a more pro-social strategy to inhibit the behavior, such as earning rewards. It will be harder for younger children to delay their gratification for very long.  A reward over the course of weeks or a month will probably be too long for a preschooler. 

We can use "first, then" approaches and review situations we think might arise. For example, we know the child likes to take others' toys. What are we going to do the next time that happens?

Emotional Control

Here are a few strategies for managing and working on emotional control.  Teach children how to label their emotions, practice relaxation strategies, like deep breathing, teach mindfulness strategies, and positive imagery.

Sustained Attention

Tips and strategies to improve sustained attention include using timers (e.g., We need to do this for 10 minutes, or if that is too long, change it to 5 minutes.)  According to some emerging research, headphones and white noise can help tune out distractions and help with sustaining attention. Physical proximity can also help.  This is having a teacher or an adult physically nearby when a child needs to be sustaining attention and staying on task.

Motivating Children and Adolescents

Children and adolescents are not inherently interested in improving their executive functioning skills. So, it can be helpful to have a reward system which we've discussed previously.  The reward system should reward them for practicing different strategies and achieving positive outcomes for using those strategies. Meaning instead of rewarding the child for getting an 'A' on an assignment, reward them for using their error checklist or planner that was put in place.  We want to reinforce what that can control, which is not likely the grade.  What they can control is how much they study and how much effort they put into something. 

There are some frequent pitfalls to remember when setting up a reward strategy for children.

• Inconsistency - this is the death of any intervention
• Poor description of goals - if the goal is not clear
• Getting rewards without meeting goals - Giving the reward when the child didn't actually earn it
• The child doesn’t have skills to obtain goals - Setting up a goal that is not in line with his/her grade or developmental level
• Long time intervals - Younger children will need more immediate gratification (e.g., same day or in the moment)
• Adults not “paying” - The person who set the reward "owes" them their rewards because they didn't have it when it was promised. The child never received the reward.
• Rewards aren’t really rewarding - The children didn't choose the reward, or it's a reward that is not exciting to the child.
• Not trying long enough 

I have included research articles, books, and websites about executive functioning and executive functioning strategies that are user-friendly and can be used with children and adolescents. 

Books/Websites for EF Strategies

• Smart but Scattered and Smart but Scattered, for Teens by Peg Dawson and Richard Guare
• Promoting Executive Function in the Classroom, by Lynn Meltzer
• Understood.org
• Beyond Booksmart (web-based coaching)

References

Gagne, J. R., & Nwadinobi, O. K. (2018). Self-control interventions that benefit executive functioning and academic outcomes in early and middle childhood. Early Education & Development, 29(7), 971–987. 

Kassai, R., Futo, J., Demetrovics, Z., & Takacs, Z. K. (2019). A meta-analysis of the experimental evidence on the near- and far-transfer effects among children’s executive function skills. Psychological Bulletin, 145(2), 165. 

Pauli-Pott, U., Mann, C., & Becker, K. (2021). Do cognitive interventions for preschoolers improve executive functions and reduce ADHD and externalizing symptoms? A meta-analysis of randomized controlled trials. European Child & Adolescent Psychiatry, 30(10), 1503–1521. 

Piovesana, A., Ross, S., Lloyd, O., Whittingham, K., Ziviani, J., Ware, R. S., McKinlay, L., & Boyd, R. N. (2017). A randomised controlled trial of a web-based multi-modal therapy program to improve executive functioning in children and adolescents with acquired brain injury. Clinical Rehabilitation, 31(10), 1351–1363.

Riccio, C. A., & Gomes, H. (2013). Interventions for executive function deficits in Children and adolescents. Applied Neuropsychology: Child, 2(2), 133–140. 

Takacs, Z. K. (2019). The efficacy of different interventions to foster children’s executive function skills: A series of meta-analyses. Psychological Bulletin, 145(7).

Takacs, Z. K., & Kassai, R. (2019). The efficacy of different interventions to foster children’s executive function skills: A series of meta-analyses. Psychological Bulletin, 145(7), 653–697. 

Zelazo, P. D. (2020). Executive function and psychopathology: A neurodevelopmental perspective. Annual Review of Clinical Psychology, 16(1), 431–454.