Training Counselors to Work With the Families of Incarcerated Persons: A National Survey

Jessica Burkholder, David Burkholder, Stephanie Hall, Victoria Porter

The national epidemic of increasing imprisonment rates in the United States, also known as mass incarceration, disproportionally impacts communities of color. Additionally, the needs of children of incarcerated parents have been neglected. This study examined whether topics pertinent to mass incarceration and the impact on families are being addressed in counselor education programs. Of the 95 counselor educators who participated in the study, results indicated that the majority did not have training to work with families of the incarcerated and did not include information about working with families of the incarcerated in their courses. In addition to exposing students to discussions of implicit bias and data on mass incarceration, specific treatment modalities and protocols need to be developed and validated.

Keywords: mass incarceration, children, counselor education, communities of color, incarcerated parents

The rise of mass incarceration is dramatically affecting families and communities across the nation, with a disproportional impact on communities of color (Glaze & Maruschak, 2008; Graham & Harris, 2013; A. Lopez & Burt, 2013; C. Lopez & Bhat, 2007; Mignon & Ransford, 2012; Western & Smith, 2018). With the increase of persons involved in the criminal justice and legal systems, their families have been found to be more at risk for facing long-lasting life challenges within both the family system and society (Glaze & Maruschak, 2008; Luther, 2016; Mignon & Ransford, 2012; Phillips & Gates, 2011). Client advocacy is one of the most critical roles of the professional counselor (Hipolito-Delgado et al., 2016). The counseling profession is characterized by working with diverse individuals from heterogeneous communities. Counselors are needed to function as advocates, especially when families and communities are facing a sociocultural crisis (American Counseling Association [ACA], 2014; Hipolito-Delgado et al., 2016).

Both ACA and the Council for Accreditation of Counseling and Related Education Programs (CACREP) have identified advocacy, multicultural competence, and social justice as priorities in training and practice (ACA, 2014; CACREP, 2015). The ACA Code of Ethics instructs that “when appropriate, counselors advocate at individual, group, institution, and societal levels to address potential barriers and obstacles that inhibit access and/or the growth and development of clients” (ACA, 2014, Section A.7.a., p. 5). It also directs counselors to gain “knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent counselor in working with a diverse client population” (ACA, 2014, Section C.2.a., p. 8).

Counselor educators are directed to “infuse material related to multiculturalism/diversity into all courses and workshops” (ACA, 2014, Section F.7.c., p. 14). When describing professional and ethical practice, the CACREP standards require programs to instruct students on “the advocacy processes needed to address institutional and society barriers that impede access, equity, and success for clients” (CACREP, 2015, Standard F.1.e., p. 10). Further, the curriculum guidelines for social and cultural diversity emphasize counselor advocacy when instructing counselor educators to cover “strategies for identifying and eliminating barriers, prejudices and processes of intentional and unintentional oppression and discrimination” (CACREP, 2015, Standard F.2.h., p. 11). Although mass incarceration and its effects are not specifically mentioned in the ACA Code of Ethics or CACREP standards, these broad directives provide support for the specific argument that the scope of this crisis and its impact on families require attention in counselor training. Consequently, the purpose of this research study is to describe the current state of how counselor educators are providing training to counselor trainees to support families of the incarcerated.

The Rise of Mass Incarceration
The national epidemic of increasing imprisonment rates, commonly referred to as mass incarceration, has been a topic of alarm for nearly five decades (Garland, 2001; Glaze & Maruschak, 2008; Graham & Harris, 2013; A. Lopez & Burt, 2013; C. Lopez & Bhat, 2007; National Research Council [NRC], 2014; Sykes & Pettit, 2014). Although the United States accounts for 4.4% of the world’s population, nearly one quarter (22%) of the world’s prisoners are in the United States (American Psychological Association [APA], 2014; NRC, 2014). According to The Sentencing Project (2012), the United States continues to have the highest incarceration rate in the world, consistently increasing since the mid-1970s. The most recent statistics indicate that the United States has an incarcerated population of 2.2 million individuals (APA, 2014; Kaeble & Cowhig, 2018; NRC, 2014). This represents a 500% increase over the last 40 years (The Sentencing Project, 2012). More than 20% of those released return to incarceration within one year (Durose et al., 2014; Western & Smith, 2018). Researchers have found a correlation between imprisonment and individuals belonging to underserved (e.g., lower levels of education, low income, psychiatric treatment and substance abuse histories) and minority populations (Alexander, 2012; Cnaan et al., 2008; NRC, 2014).

Despite the race gap narrowing since 2007, Blacks are imprisoned at a rate 6 times that of Whites and at double the rate for Hispanics (Bronson & Carson, 2019). Because incarceration disproportionately affects minority group members, families of the incarcerated are more likely to be concentrated in minority communities (Graham & Harris, 2013). Consequently, even those children in the community whose parents are not facing incarceration are likely to be impacted by mass incarceration (Wakefield & Wildeman, 2011), as their communities may experience lower incomes, lopsided gender ratios, disrupted social integration and roles, high levels of joblessness, and increased crime (Crutchfield & Weeks, 2015).

An Invisible Group
Results from the National Survey of Children’s Health (U.S. Department of Health and Human Services, 2018) found that more than 7% or 5 million children in the United States have experienced a parent being incarcerated. Gathering current statistics is difficult for researchers. The majority of data on children of incarcerated parents has measured the number of parents in prison, leaving unknown data about the number of parents spending time in jail (Cramer et al., 2017). Because of this, there is reason to believe that the current number of children of incarcerated parents exceeds previous findings of 2.7 million children.

Children of incarcerated parents have frequently been described as an invisible group (Bernstein, 2005; Bouchet, 2008) that bears the collateral consequences of mass incarceration. There are many reasons for the invisibility. Although the children have not committed any crimes, their parent’s incarceration impacts much of what is important to them—family bonds, housing stability, safety, self-image, and social relationships. The criminal justice system does little to support family relationships and there is frequently poor communication between social service organizations and families that may be beneficial for the children (Bernstein, 2005). Those caring for the children often experience high levels of stress (Poehlmann et al., 2010), and families fear stigmatization and may keep secrets or refrain from disclosing an incarceration (Phillips & Gates, 2011).

When a parent is incarcerated, one of the first losses is physical separation between parent and child. Most parents report no physical contact with their children following incarceration (Bocknek et al., 2009). Visitation with parents has been found to be beneficial to the attachment relationship and the child’s overall well-being (Poehlmann et al., 2010) but is often infrequent and not child friendly. Visits can be costly, and relationships may be strained with the child’s caregiver. Children frequently have to travel long distances, endure long wait times, and meet with parents in environments that can feel intimidating and stressful. Mignon and Ransford (2012) found that almost half of the mothers they surveyed never had a visit from their children, and visits became less frequent for those with longer sentences. Yet prisons that implemented child-friendly visitation interventions and allowed for physical interaction demonstrated greater visitation benefits to those children (Poehlmann et al., 2010). Some benefits included improved maternal perceptions of the relationship and improved self-esteem in the children.

This loss associated with the physical separation of parent and child has been discussed in the literature and is commonly referred to as ambiguous loss because children experience the loss without closure. The ambiguity of their parent’s abrupt removal can disrupt children of incarcerated parents from finding meaning in the loss and disrupt the development of coping strategies (Bocknek et al., 2009). Children also experience stigmatization associated with ambiguous loss. In contrast to children who are separated from their caregivers by death, deployment, or divorce, it is often not socially acceptable for children of incarcerated parents to grieve the loss of parents because such parents are viewed as criminals (Phillips & Gates, 2011).

Children of incarcerated parents experience the loss of both fathers and mothers, and there are substantially more fathers in prison than mothers. But since the late 1970s, the growth rate for women in prison is more than double the growth rate for men (Sawyer, 2018). When mothers are incarcerated, the disruptions the child experiences are magnified, as children are more likely to lose their home and their primary support. Children with incarcerated mothers have been found to experience more stress and more risks than those with incarcerated fathers (Poehlmann et al., 2010). Maternal incarceration is often more closely associated with factors such as poverty, substance abuse, and mental health issues (Turney & Goodsell, 2018).

Experiencing the incarceration of a parent has been found to impact the long-term well-being of children (Turney & Goodsell, 2018). Children of incarcerated parents have increased risk for health issues, stigmatization, poverty, negative social interactions, behavior problems, school truancy and failure, and substance abuse (Poehlmann et al., 2010; Turney & Goodsell, 2018). Turney (2018) found that children with incarcerated parents are more than 5 times more likely to face adverse childhood experiences than those without an incarcerated parent. Often these children were already at risk, and the incarceration compounds these inequities. It is important to note that the research on children of incarcerated parents is fraught with selection bias and focus on negative outcomes. Very little research exists that examines protective factors and environments beyond urban, lower-income communities of color. Graham and Harris (2013) cautioned that this narrow research focus can decrease potential positive outcomes. A review of the current literature on children of incarcerated parents revealed that this narrow research trend continues.

Stigmatization and Families of the Incarcerated
Many experts consider stigmatization to be one of the most significant negative consequences of parental incarceration. Families are not stigmatized based on a specific trait they possess, but rather based on being associated with the incarcerated person (Phillips & Gates, 2011). This phenomenon is known as courtesy stigma and results in a spoiled identity for family members (Luther, 2016). The stigmatization may come from other family members, peers, teachers, social service agencies, and mental health providers. Children may be seen as “guilty by association” or perceived as being “deviant” like the parent that is incarcerated (Luther, 2016, p. 1265). In order to avoid stigmatization, families often keep the incarceration a secret, but children tend to fare better when they know the truth. Stigmatization can increase feelings of shame and impact the child’s willingness to reunite with parents (Harris et al., 2010). Foster and Hagan (2015) found parental incarceration leads to social exclusion for children into their 30s, and as a result can contribute to intergenerational socioeconomic inequality.

Purpose of the Research
The longstanding need for increased support in communities impacted by mass incarceration is clear (Harris et al., 2010). Increased awareness of the United States’ imprisonment crisis has prompted research initiatives to better understand community needs. Recent data on adverse childhood experiences suggested that children with incarcerated parents are even more vulnerable than previously thought (Turney, 2018). The developmental needs of families and children of the incarcerated are not being appropriately attended to in the literature (Holmes et al., 2010; Turney, 2018). Although research is clear that children of incarcerated parents and the family system face disequilibrium when parental incarceration occurs (Harris et. al., 2010; Luther, 2016; Phillips & Gates, 2011; Wachter Morris & Barrio Minton, 2012), 58% of new professional counselors reported having either minimal training or no training at all in individual or family-level trauma and crisis preparation (Wachter Morris & Barrio Minton, 2012). Brown and Barrio Minton (2018) found that school counselors wanted more training and resources to work with children of incarcerated parents and their families. This lack of training created barriers and ethical dilemmas in attempting to support children with incarcerated parents. Brown and Barrio Minton recommended counselors learn about families of the incarcerated through reading and participating in professional development opportunities, but the curricular experience of professional counselors working with populations affected by incarceration appears predominantly absent from the literature.

The incongruence between the urgency of mass incarceration affecting communities and the lack of literature exploring how to support families of the incarcerated demands further research. Two key research questions organized our exploration: (1) Are topics pertinent to mass incarceration and its impact on families being addressed in the classroom? (2) If so, how are these topics being included?


The sample included full-time counseling professors in CACREP-accredited counseling programs in the United States. The researchers compiled an email list of 356 CACREP liaisons from the list of accredited programs on the CACREP website. Upon receiving IRB approval, CACREP liaisons were contacted and asked to forward the email invitation to full-time faculty in their departments. The request for participants was also posted to the Counselor Education and Supervision Network Listserv. The email served as an invitation to participate, contained a synopsis of the purpose of this research, and included an online Survey Monkey link. Informed consent was collected using an electronic consent form. Demographic information was gathered after consent had been obtained.

Ninety-five counselor educators began and completed the survey. Sixty-nine female and 26 male individuals participated, ranging in age from 29 to 78 years. A majority of the participants identified as White or of European descent (n = 61, 64%); 18 (19%) identified as African American/Afro-Caribbean or of African descent; five (5%) identified as Hispanic/Latinx, five (5%) identified as Asian/Polynesian or of Pacific Island descent, and five (5%) identified as multiracial. One person (1%) did not identify a race or ethnicity.

Of the participants, 20 (21%) were full professors, 22 (23%) were associate professors, 43 (45%) were assistant professors, nine (10%) were non–tenure track full-time instructors, and one (1%) was a clinical coordinator. Sixty-five (68%) came from master’s-only programs, and 30 (32%) came from combined master’s and doctoral programs. All CACREP regions were represented with 33 (35%) from the Southern region, 27 (28%) from the North Atlantic region, 21 (22%) from the North Central region, nine (10%) from the Western region, and five (5%) from the Rocky Mountain region.

The researchers created a brief survey that could lead to a description of the current state of counselor training on issues of mass incarceration and families of the incarcerated. Using broad survey research was necessary because there is currently nothing on this topic in the counseling literature. Eight questions were included in the survey: 1) Do you include the topic of mass incarceration in any of your courses? 2) If yes, what courses? 3) If yes, how do you cover this topic? 4) Do you include working with families of incarcerated persons in any of your courses? 5) If yes, what courses? 6) If yes, how do you cover this topic? 7) Have you received any training on these topics? and 8) If yes, describe.


When asked whether they included the topic of mass incarceration in their courses, only 35 (36.8%) of the counselor educators surveyed answered yes. The most frequently noted course was Multicultural Counseling, under many different titles such as “Social and Cultural Diversity Issues in Counseling” or “Cultural Diversity.” Other courses noted were Foundations of Clinical Mental Health, Career Counseling, Addictions, Diagnosis, Trauma, Practicum, and Internship. Only one participant responded, “every class I teach.” When surveyed whether they included working with families of the incarcerated in their courses, 27 (28.4%) of the counselor educators answered yes. This too was most frequently covered in a multicultural counseling course but also was included in school counseling, child and adolescent counseling, and crisis counseling courses.

Using an open-ended question, participants were asked to describe how they covered the topics. The vast majority of the responses were “discussion.” These discussions were prompted by topics or readings on issues such as “systematic oppression,” “the intersection of race and social class,” “mandated clients,” and “vicarious trauma.” Two participants described developing a special topics course on incarceration and one participant invited a guest speaker related to families of the incarcerated.

When counselor educators were asked whether they had received training on these topics, only 30 (31.58%) reported that they had. But, when the participants described the training that they had received, it is notable that 19 (63.3%) of those reporting training described experiences with incarcerated persons, not specifically the families. Seven (23.3%) of those who responded had attended conference presentations on the topics of incarceration and families of the incarcerated. Two participants (6.7%) had completed research on incarcerated persons. Only one counselor educator (3.3%) described an extended training experience specific to families of the incarcerated. Finally, one (3.3%) participant described the topics being integrated into their doctoral program that was combined with rehabilitation counseling.


The purpose of this research was for counselor educators to articulate whether topics relevant to mass incarceration and the effect on families were addressed in their classrooms, and if so, how they were addressed. Because no similar research has been reported, this study was singular in seeking to investigate how or if counseling faculty prepare their students to work with families affected by incarceration. This study did not aim to produce generalizations that apply beyond the research sample.

Nevertheless, it is essential to compare what was discovered in this study with what is documented in the literature. This study found that the majority of counselor educators were not covering mass incarceration or families of the incarcerated in their coursework, nor had they received training to do so. The findings of this study also provide the beginnings of a blueprint for what counseling programs and faculty can do to prepare students to work with children and families affected by incarceration.

For this study, comparing our findings with a body of literature is difficult because such literature does not exist, excepting the study by Wachter Morris and Barrio Minton (2012). Wachter Morris and Barrio Minton reported that 57.51% of professional counselors reported having minimal to no training in working with individual or family-level trauma and crisis preparation. Although Wachter Morris and Barrio Minton’s research did not target families of the incarcerated, this population does fall under the umbrella of individual and family trauma. Like that study, the present study demonstrated that a majority of counseling students are likely not receiving intentional, purposeful training on working with the trauma associated with incarceration. Although close to 30% of our participants did include mass incarceration and families of the incarcerated in their courses, the majority of how the topics were addressed was based on whether it arose out of discussion of broader multicultural topics. It also is reasonable to conclude that because a counseling literature search focused on training students to work with children of incarcerated parents only resulted in one webinar (Brown, 2016), a large majority of professional counselors are not adequately prepared to work with this population.

The findings of the present study may generate discussion of future recommendations and directions that counselor educators and supervisors may explore and implement. The majority of faculty in this research were not trained in the topics of mass incarceration and counseling children and families of the incarcerated, and unsurprisingly the majority did not include any training for their students. As with any topic under the umbrella of multiculturalism, counseling faculty should incorporate mass incarceration and working with children of incarcerated parents when addressing implicit bias with students (Boysen, 2010). In light of the massive numbers impacted by mass incarceration, we recommend this topic be included as required content in counselor education training. One way to ensure its inclusion would be to include persons who are incarcerated and their families in accreditation standards. At a minimum, the topic should be included in textbooks and used in case examples throughout training programs.

Counselor educators should highlight the stigma and spoiled identity that children of incarcerated parents experience and describe stigma management techniques (Luther, 2016) counselors can teach when working with these children. In addition to exposing students to data on mass incarceration and discussions of implicit bias (e.g., Alexander, 2012; Kaeble & Cowhig, 2018; Phillips & Gates, 2011), specific treatment modalities and protocols need to be developed and validated that fulfill the education and ethical expectations (ACA, 2014; CACREP, 2015) to address systemic barriers, advocacy, and cultural competence (Hipolito-Delgado et al., 2016).

Continuing education trainings could provide an opportunity for counseling associations and programs to address important content that may not receive adequate or consistent attention in required coursework. Counseling associations could choose conference themes that would encourage training and research on the needs of families of the incarcerated. Counseling programs could consider continuing education trainings as a method of communicating the program’s values and priorities, such as attention to social justice. Additional benefits may include strengthening their reputation, improving retention, maintaining relationships with alumni, and building relationships with the local clinical community.

Limitations and Future Research
The researchers recognize that the small, purposive, and heterogenous sample limits generalizability of the findings. Additionally, issues with data that rely on self-report have been well documented (Coughlin et al., 2009). Although these limitations make the present study narrow in scope and generalizability, these limitations are features of the positivist tradition aimed at finding “facts” and “truth.” This nascent study sought to establish a beginning understanding of how counselor educators are addressing mass incarceration in the classroom.

There are many directions for future research. It would be valuable to use qualitative research methods to learn from counselor educators who are effectively integrating and instructing on families of the incarcerated to provide a template for pedagogical inclusion. Research focusing on counseling students can serve to further the understanding of curricular experiences with mass incarceration and children of incarcerated parents. Research with practicing counselors can provide insight into the current landscape in the profession, including how families and children of incarcerated parents are affected and how professionals address these concerns. In that vein, outcome research with these children would be useful, as would the development of an instrument that can identify key clinical treatment areas.

Mass incarceration is a national crisis impacting more than 5 million U.S. children and their families (U.S. Department of Health and Human Services, 2018). This study was an attempt to provide a foundational understanding of the preparedness of counseling faculty and how they train students on this issue. The magnitude of the crisis, alongside the absence of counselor training, should cause counselors to consider our responsibility to ensure adequate counselor preparation in this area. By doing so and providing recommendations for programs to consider, it is hoped that more research will be undertaken to further underscore the importance of the topic and illuminate new understandings.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.


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Jessica Burkholder, PhD, NCC, ACS, LPC, is an associate professor at Monmouth University. David Burkholder, PhD, ACS, LPC, is an associate professor and department chair at Monmouth University. Stephanie Hall, PhD, NCC, ACS, LPC, is an associate professor and founding department chair at Emory & Henry College. Victoria Porter is a master’s student at Monmouth University. Correspondence may be addressed to Jessica Burkholder, 400 Cedar Ave, West Long Branch, NJ 07764,

Children of Incarcerated Parents: Considerations for Professional School Counselors

Jeffrey M. Warren, Gwendolyn L. Coker, Megan L. Collins


The rate of school-aged children with incarcerated parents continues to rise in the United States. These children are especially prone to experiencing social-emotional, behavioral, and academic issues in school as a result of various factors, including general strain and stress associated with incarceration. Given their unique role in schools, professional school counselors are well positioned to provide support to children of incarcerated parents. This article presents a review of relevant literature, including key theories that explain the challenges faced by children with incarcerated parents. The impact of incarceration on children as well as protective and risk factors are presented. Finally, strategies and resources school counselors can use when working with this population are offered.


Keywords: incarceration, school counselors, children, risk factors, protective factors



The United States has the highest incarceration rate in the world (Graham & Harris, 2013). Over the last 30 years, the rate of incarceration has significantly increased, and as a result the number of children whose parents are incarcerated has risen (Boudin, 2011). In 2007, approximately 809,800 incarcerated parents in the United States had minor children (Glaze & Maruschak, 2008; Graham & Harris, 2013). In 2008, around 2.7 million children of incarcerated parents were under the age of 18, with most incarcerated parents having two or more children (Johnson & Easterling, 2015). The rate of parental incarceration has continued to grow over the last decade. According to the National Resource Center on Children and Families of the Incarcerated (2014), approximately 10 million children have experienced parental incarceration at some point in their lives.


Although reasons for jailing or imprisonment vary, a central concern persists: the impact of parental incarceration on children. The sudden disruption of a close relationship can cause traumatic stress and inadequate care—factors that influence and in some cases delay a child’s development (Nesmith & Ruhland, 2008). Incarceration often leads children to experience unwarranted stress, lack of supervision, socioeconomic strain, and additional responsibilities at home (Robertson, 2007). Many children suffer emotionally, mentally, physically, and academically as a result of the loss of a parent to jail or prison. The identification of educational resources and support mechanisms are central to ensuring that the needs of children with incarcerated parents are met.


Operating within their scope of practice and the national model advanced by the American School Counselor Association (ASCA; 2012), school counselors can offer enhanced services to support children with incarcerated parents. However, school counselors have expressed the need for additional training and resources to effectively work with this student population (Brown, 2017). Without a firm understanding of theory, research, and best practice for working with children of incarcerated parents, school counselors can fail to deliver sufficient support. In this article, we aim to further develop school counselors’ knowledge and increase awareness of available resources for working with this student population. To this end, we present historical and theoretical perspectives of parental incarceration and describe the effects of incarceration on children. Support mechanisms applicable to school counselors’ work with children of incarcerated parents are provided.


Incarcerated Parents and Their Children: An Historical Perspective

Between 1991 and 2007, there was a 79% increase in the number of parents in state and federal prisons and an 80% increase in the number of children with incarcerated parents, because some parents had more than one child (Glaze & Maruschak, 2008). In 1999, over 1.3 million children had a father in a state or federal prison; almost 130,000 children had a mother in prison (Mumola, 2000). Since 1990, the rate of female prisoners has grown at a rate of 106% compared to 75% for male prisoners (Lopez & Bhat, 2007). The average age of children who have an incarcerated parent is 8 years old; one in five children with an incarcerated parent is under 5 years old (La Vigne, Davies, & Brazzell, 2008). The Pew Charitable Trusts (2010) estimated that one in 28 children has an incarcerated parent. One in 14 children has had a parent incarcerated at some point in their life (Murphey & Cooper, 2015).


Historically, children of color experience parental incarceration more frequently than White children. For example, “African American children were nearly nine times more likely to have a parent in prison than Caucasian children. Hispanic children were three times more likely than Caucasian children to have a parent in prison” (Lopez & Bhat, 2007, p. 141). More recently, the Annie E. Casey Foundation (2016) reported that African American, Hispanic, and American Indian children were significantly more likely than their Caucasian peers to have an incarcerated parent. Today, the rates of parental incarceration remain polarized by race. Morsy and Rothstein (2016) indicated that 10% of African American students have an incarcerated parent, with 25% experiencing parental incarceration at some point in their life. Perhaps these statistics are, in part, explained by the mass incarceration of persons of color resulting from social injustices that stem from initiatives such as the war on drugs. The use of incarceration in the United States to retaliate against nonviolent drug offenses has contributed to a large number of children separated from their parents and explains the emotional and psychological distress they often experience (Allard, 2012).


Theoretical Perspectives on Incarceration

Numerous sociological, criminal justice, and psychological theories articulate the effects of incarceration. General strain theory and attachment theory, in particular, are useful to conceptualize the impact of incarceration on children. These theories offer valuable insights for school counselors who aim to support children with incarcerated parents. However, it is important that these theories only serve to guide school counselors toward greater awareness of this population rather than to dictate services; no two children are impacted by incarceration in the same manner.


General Strain Theory

General strain theory originated from the work of Merton (1938). The theory explicates the manner in which individuals experience strain and their response to the strain during adverse situations. According to general strain theory, a lack of goal attainment, negative experiences, and loss can lead to strain (Brezina, 2017). Individuals who experience strain are more susceptible to emotions and behaviors that lead to problematic outcomes. As strain intensifies, more extreme responses often emerge.


Incarceration of a parent can lead to strain on the child and caregiver left behind. As a result of parental incarceration, fewer caregivers provide for the household. Additionally, children of incarcerated parents often are limited in resources required to meet their basic needs. Nichols and Loper (2012) suggested that the removal of financial and social resources can contribute to the strain experienced by both the child and the caregiver. Therefore, children generally are unable to respond in acceptable ways to the social, emotional, and academic expectations or challenges of school.


Strain can have a significant effect on a child’s academic performance and motivation. As strain increases, the child can become vulnerable to feeling disconnected from school (Nichols & Loper, 2012). When children are in strained homes, their focus shifts from academics to difficulties faced within their microsystems. Children with an incarcerated parent might become more concerned with food security or personal safety. Adolescents are often tasked with taking on more responsibilities to alleviate the strain and work to help support the family or care for siblings because of the loss of a parent to incarceration; school is no longer a top priority.


The well-being of caregivers also is a concern. When dysfunction arises in the home, the caregiver and child experience stress or strain. When a parent is incarcerated, there is less supervision of the child “due to the indirect effect of increased strain on their caregiver” (Nichols & Loper, 2012, p. 1456). The parent or guardian who remains in the home with the child often is ill-equipped with the time and resources necessary to provide adequate supervision and support. The adjustment as a new primary caregiver can determine their ability to provide basic needs, support, and protection to the child. The caregiver often has ongoing concerns about the level of protection and support that they can provide for the child (Feeney & Woodhouse, 2016; Shlafer & Poehlmann, 2010).


Myers et al. (2013) indicated that children of incarcerated parents often live in adverse conditions. Many of these children live in poverty or have an unstable home life. Although children typically are unaware of the strain they experience, they are aware of the strain on their caregiver and often try to alleviate that stress by taking on more responsibilities (Nesmith & Ruhland, 2008). Notably, incarceration adds to the strain of an already potentially unstable living condition.


Attachment Theory

Attachment theory emerged from Bowlby’s (1958) work with children and parents. This theory suggests that children who are consistently cared for have stronger and healthier attachments with their caregivers. Alternatively, when parents provide inconsistent support, children maintain less secure attachments. According to Bowlby (1988), the quality of early parent–child interactions plays a significant role in the development of a child’s relationships across their lifespan.


Based on attachment theory, a child’s attachment organization, or the manner in which they attach to caregivers, is disrupted when a parent becomes incarcerated (Nichols & Loper, 2012). These disruptions, such as those that occur when children move from one caregiver to another, can have detrimental effects (Kobak, Zajac, & Madsen, 2016; Shlafer & Poehlmann, 2010). For example, children who fail to receive direct attention from their parent or guardian can feel confused and lack support for academic and social-emotional development.


Dallaire, Ciccone, and Wilson (2012) and Dallaire, Zeman, and Thrash (2015) explored the effects of parent incarceration on child and parent attachment. In instances of a noncontact visitation policy (i.e., physical contact between the incarcerated parent and child is forbidden), children experienced more insecurity and disorganization, including vulnerability, emotional distance, isolation, tension, and anger. The “experience of parental incarceration represents a significant family stressor that may negatively impact children’s feelings of safety and security” (Dallaire et al., 2012; p. 161). Poehlmann (2005) stated that in order for young children to cope with the detachment of their incarcerated parent, they must have additional emotional support.


Additionally, Shlafer and Poehlmann (2010) used the Attachment Story Completion Task to assess the relationships of children ages 2.5 to 7.5 years old and their incarcerated parent. The majority of the children studied fit the criteria for an insecure attachment with their incarcerated parent. Alternatively, children who received consistent care by one individual as opposed to multiple caregivers were classified as having a secure relationship with their caregiver (Shlafer & Poehlmann, 2010). A key determinant of a child’s level of attachment is the ability to be in close proximity with another attachment figure and feel protected. Attachment theory and general strain theory are useful frameworks for conceptualizing the impact of incarceration on the children with whom school counselors frequently work.


Impact of Incarceration on Children

Children’s experiences with parental incarceration are vast. Some children have witnessed their parent’s crime or observed their arrest. Children also experience custodial separation, instability in living arrangements, and stressful visitations with their parents who are in jail or prison (Davis & Shlafer, 2017). Moreover, these experiences impact the mental health, behavior, and academic performance of children.


Disruption at home because of incarceration often weighs heavy on the life of a child, leaving them unattached, dissociated, and strained (Murray, 2007). For example, early signs of antisocial behavior were present in children who experienced parental incarceration before the age of 10 (La Vigne et al., 2008). Additionally, Kjellstrand, Reinke, and Eddy (2018) found that parental incarceration led to an increase in externalizing behaviors during adolescence. Incarceration can lead to a host of mental and behavioral health issues, including anxiety and depressions (Johnson & Easterling, 2015; Murray & Farrington, 2008; Wilbur et al., 2007), aggressive behaviors (Geller, Cooper, Garfinkel, Schwartz-Soicher, & Mincy, 2012; Johnson & Easterling, 2015; Sharp & Marcus-Mendoza, 2001; Wildeman, 2010), delinquency or criminal activity (Huebner & Gustafson, 2007; Kjellstrand & Eddy, 2011; Murray, Janson, & Farrington, 2007; Murray, Loeber, & Pardini, 2012), and school-related problems (Cho, 2011; Hanlon et al., 2005; Johnson & Easterling, 2015). Nichols and Loper (2012) suggested that these effects often extend beyond children to other household and family members.


Children who have a parent in jail or prison often are viewed differently than their peers. For example, peers and teachers can associate the actions of an incarcerated parent with that of the child. Dallaire, Ciccone, and Wilson (2010) found that students with incarcerated parents were more likely considered at-risk and faced stigmas in the school setting. Moreover, teachers maintained low expectations of students with incarcerated parents; knowing that a parent was incarcerated was a factor in determining expectations and the perceived competence level of a student. This is especially problematic for students of color who frequently are susceptible to low expectation from teachers (Liou & Rotheram-Fuller, 2019). Children with incarcerated parents are often stigmatized as inferior because of their parents’ life choices and subsequent incarceration (Shillingford & Edwards, 2008). This stigma can lead students to feel unaccepted by school staff and classmates, and disconnected from the academic environment (Nichols & Loper, 2012). In an attempt to manage the stigma, children often do not disclose information and isolate themselves from relationships (Saunders, 2018).


Cho (2009) indicated that the negative effects of having an incarcerated parent often are short-lived and do not last the entirety of a child’s educational career. However, the effects of parental incarceration on a child’s academic performance are evident. For example, Dallaire et al. (2010) suggested that children who have an incarcerated parent or guardian are at risk of academic difficulties or eventually drop out of school. Most children do fairly well in school and eventually go on to have a good life; however, a significant number of children do not share such a positive fate (Shillingford & Edwards, 2008).


Long-Term Effects of Incarceration

Martin (2017) referred to children of incarcerated parents as “hidden victims” (p. 1) because often the impact of incarceration on the child is not considered. However, when children witness a parent’s arrest, for example, they can experience high levels of stress that can result in a traumatic emotional response (Johnson & Easterling, 2015). The stress children experience as the result of an incarcerated parent or guardian can continue as long as that parent is incarcerated, and in many cases, after the parent or guardian returns home. Factors that can have a long-term impact on the child include duration and frequency of disruptions in caregiving relationships (Johnson & Easterling, 2015; Murray & Murray, 2010; Parke & Clarke-Stewart, 2003); degree of economic and residential stability (Geller, Garfinkel, Cooper, & Mincy, 2009; Phillips, Erkanli, Keeler, Costello, & Angold, 2006); social stigma and pressure to keep the incarceration hidden (Saunders, 2018); and having a parent that is physically absent, yet socially and emotionally present (Bocknek, Sanderson, & Britner, 2009).


Children of incarcerated parents can learn attitudes, behaviors, and a way of life that positions them for lives similar to their parents. Aaron and Dallaire (2010) found that children who had parents with a history of incarceration reported more delinquent behavior. This finding was moderated by a parent’s recent incarceration. Similarly, Farrington (2000) found that the conviction of a parent was a predictor of their child’s antisocial behaviors and eventual incarceration. These findings suggest that exposure to parental incarceration and related issues may result in children becoming incarcerated themselves. However, a variety of risk and protective factors often serve to facilitate the outcomes of these children.


Risk and Protective Factors

Separation or loss of a parent is considered one of six indicators of adverse childhood experiences (ACEs), according to Felitti et al. (1998). Findings from a study conducted by Turney (2018) suggested that children experience five times as many ACEs when they have an incarcerated parent. ACEs can impact brain development and lead to impulse control issues, emotional dysregulation, and the inability to anticipate consequences, recognize social cues, and manage interpersonal conflict (U.S. Department of Health and Human Services, 2015). These psychological challenges also can result in poor school performance, gang involvement, substance use, and pregnancy.


Children often have an insecure attachment with their parent when support and encouragement are inconsistent (Poehlmann-Tynan, Burnson, Runion, & Weymouth, 2017). According to Shlafer and Poehlmann (2010), some children have a positive relationship with their incarcerated parent, while others report negative experiences. Children who have no contact with their incarcerated parent often have greater feelings of alienation and minimal attachment. The Federal Interagency Working Group for Children of Incarcerated Parents (2013) suggested that children, especially those in the adolescent stage, typically work toward finding an equilibrium between individuality and their connection to society. However, the separation between the parent and child during incarceration impedes the ability of the child to acquire the proper social skills needed to function effectively on a daily basis.


In some instances, children are unable to recover from the traumatic experience of parental incarceration. As a result, children are at risk of becoming antisocial, internalizing symptoms, and struggling academically (Murray & Farrington, 2008; Shlafer & Poehlmann, 2010). When parental incarceration is recurrent, children are at risk of continuous emotional strain; oftentimes children do not know how long their parent will be gone or when they will return (van Agtmael, 2016). Children can become defiant, aggressive, antisocial, experience a loss of self-esteem, have difficulty sleeping, or develop an attachment disorder, and may go on to exhibit other problematic behaviors if they lack support during these times (Lopez & Bhat, 2007). Children of incarcerated parents are at higher risk for exposure to stress, violence, and abuse (Phillips, Burns, Wagner, Kramer, & Robbins, 2002; Shillingford & Edwards, 2008). These experiences can further exacerbate a child’s struggle to manage life, including school, with an incarcerated parent.


According to Johnson and Easterling (2015), the majority of children who experience parental incarceration employ a combination of coping strategies to manage the situation including “de-identification from the incarcerated parent, desensitization to incarceration, and strength through control” (p. 244). However, a variety of protective factors can serve to help thwart or reduce the negative impact of parental incarceration on children. Frequent contact visits (i.e., physical contact is allowed) and quality communication with the incarcerated parent can serve as protective factors for the child (Cramer, Goff, Peterson, & Sandstrom, 2017). Kumpfer, Alvarado, and Whiteside (2003) identified several such protective factors, including self-control, academic self-efficacy, and family supervision. The identification of and access to positive influences and role models, engagement in leadership opportunities through school or community organizations, social-emotional skill development, as well as maintaining faith and hope also are factors that help mitigate the impact of incarceration (Adalist-Estrin, Krupat, deSousa, Bartley, & Hollins, 2019).


A key protective factor is the positive relationship the new caregiver forms with the child (Buss, Warren, & Horton, 2015; Cramer et al., 2017). A secure and stable home for children of incarcerated parents offers an opportunity to overcome challenges and succeed in school and life. School counselors can help facilitate student success through the use of a variety of targeted approaches and resources that serve to protect children with incarcerated parents.


Approaches and Resources for School Counselors

Professional school counselors offer a variety of services within a comprehensive school counseling program that can meet some of the needs of children with incarcerated parents. Many of these services are well-suited for supporting this group of children. Although these services often are beneficial to these children and their caretakers, in many instances, alternative or targeted services are needed. Therefore, it is important for school counselors to consider students’ strengths and needs within the context of emerging literature and evidence-based practices. A variety of strategies and resources rooted in theory and research are available to support school counselors’ efforts to develop and promote protective factors for children of incarcerated parents.


Determining Student Strengths and Risk

In order to provide targeted services and support, school counselors must first identify students who have incarcerated parents. Strain is not always obvious to teachers or school counselors, and families, caregivers, or students may not readily seek help. As a result, building and maintaining healthy relationships with parents, grandparents, or other guardians is central to identifying and meeting the needs of these students (Hollihan & Krupat, 2016). School counselors also should consider becoming familiar with community professionals who are likely to interact with children of incarcerated parents. For example, Brown and Barrio Minton (2017) suggested that when school counselors collaborate and consult with community stakeholders such as social workers, child protective services, mental health counselors, and other child advocates, they better understand the child as well as acquire pertinent information that facilitates meeting the needs of the student. School counselors who are proactive and regularly demonstrate community investment as a component of their comprehensive school counseling program are well-positioned to identify, assess, and meet the academic and social-emotional needs of children of incarcerated parents.


Once a student is identified as having an incarcerated parent, school counselors are encouraged to conduct an assessment to determine the risk and protective factors for the student and the family. Students, teachers, caregivers, and other stakeholders can provide valuable information during the assessment process (Petsch & Rochlen, 2009). Measurements such as the Child Behavior Checklist, Teacher’s Report Form, and Youth Self-Report, available via the Achenbach System of Empirically Based Assessment (2019), are valuable tools for capturing family, teacher, and student concerns. These instruments assess for social problems, anxiety, depression, cognitive issues, and aggressive behaviors. School counselors can use these types of instruments to identify areas of support and formulate approaches that meet the students’ academic and social-emotional needs. It is important that assessments and student support plans are completed in a collaborative manner while remaining sensitive to the students’ and caregivers’ experiences.


The assessment process should include an evaluation of the student’s family history, school performance, and risk and protective factors. It also is important to assess current services and determine the lack of services that may not be available, but needed (Solomon & Uchida, 2007). School counselors should consider age as a factor when determining the needs of children of incarcerated parents. Younger children can process potentially traumatic situations, such as the incarceration of a parent, differently than older children (Buss et al., 2015). Unhealthy coping, along with emotional and behavioral problems at this stage of development, are likely to arise and should be taken into account when determining needs (Parke & Clarke-Stewart, 2003). Furthermore, school counselors should determine the exact relationships between the incarcerated parent, the caregiver left behind, and the child. In some instances, the incarcerated parent or caregiver is not the biological parent, yet the relationship is strong enough that separation can significantly impact the child. The caregiver left behind often is the other parent or a grandparent, but in some cases is a foster parent (Glaze & Maruschak, 2008; Graham & Harris, 2013).


School counselors are encouraged to gather as much data as possible in order to determine the risk and protective factors at play for the family and child. Additionally, school counselors are encouraged to be aware of and reflect on their own perceptions of incarceration and ensure those beliefs do not interfere with their assessment of student needs or the services provided. School counselors must be sensitive and understanding of the needs and worldviews of the family and student’s culture, especially their views on incarceration. Furthermore, when discussing incarceration with the family or child, it is important to specify the type of incarceration (i.e., jail, prison) and use terms such as felon, con, and inmate with caution, or not at all. A child will perceive the severity of his or her parent’s incarceration based on how it is described (Bennett, Lewis, & Hunsaker, 2012). Prison often is perceived more negatively than jail because of different aspects between the two such as demographics, sentencing, and capacity.


Children who have an incarcerated parent or guardian often struggle with a variety of significant social-emotional, behavioral, and academic problems in school (Poehlmann, 2005). Professional school counselors who understand student challenges, as well as strengths, can intervene and support this group of children who often are vulnerable and underserved. School counselors should recognize the benefit of home–school–community collaboration in assessment and consider it an important aspect of implementing effective strategies that can help children of incarcerated parents succeed.


Strategies and Interventions

Comprehensive school counseling programs that align with the ASCA National Model (2012) include components that aim to meet the needs of all students. A number of direct and indirect student support services exist that encompass strategies and interventions that can increase protective factors for children of incarcerated parents. Brown (2017) suggested these services are essential to meeting the needs of these children. However, school counselors are encouraged to utilize results of a needs assessment when determining the provision of targeted services within a system of support. For example, school counselors can offer support prior to and after visits with the incarcerated parent; these are isolated occasions that can present emotional challenges for the child. Alternatively, some students who display ongoing, unhealthy emotions or behaviors may need more intensive support, such as small group or individual counseling. Goals of these services should include building on student strengths, fostering resilience, and addressing challenges that directly impede student performance.


During individual and small group counseling, it is important for school counselors to broach the topic of incarceration with caution; school counselors should not disclose this information during group work, yet provide a safe space for the student to do so. Bibliotherapy and expressive art strategies can serve as valuable opportunities for children of incarcerated parents to gain awareness and process their thoughts and feelings. As such, school counselors are encouraged to maintain access to developmentally appropriate literature on incarceration via their own collection or the school’s library. For example, the book Far Apart, Close in Heart (Birtha, 2017), written for elementary-age children, explores life with an incarcerated parent, and Clarissa’s Disappointment (Sullivan, 2017), a book written for upper-elementary and middle school students, is about the transition of a parent out of prison. Books such as Surviving the Chaos: Dontae’s Story: Daddy, Jail & Me (Bell, 2013) and Coping When a Parent is Incarcerated (DeCarlo, 2018) are appropriate for upper-middle and high school students. These resources are useful for facilitating family conversations about incarceration as well. School counselors who know that parental incarceration often impedes student performance are best positioned to help students develop protective factors including strong relationships with peers and the community, appropriate social and self-regulation skills, and academic achievement (Lopez & Bhat, 2007).


School counselors are well-positioned to advocate for children of incarcerated parents through the delivery of in-service trainings and other awareness-building activities. Given their role, teachers are often the first school staff members to have academic or behavioral concerns for a child with an incarcerated parent. However, Brown and Barrio Minton (2017) suggested that many school personnel, such as teachers and other school staff, face barriers when working with children of incarcerated parents because of their inability to identify them and meet their needs. In-service training for teachers, administrators, and other stakeholders can increase awareness of the negative effects of parental incarceration on the social-emotional and academic development of students. For example, school counselors can share the video, School Staff: Supporting Youth with Incarcerated Parents (, followed by an open discussion during a staff meeting. School counselors can empower school staff through the dissemination of information that challenges barriers, stereotypes, and stigmas about this student population. It is important for teachers to explore their beliefs and feelings about incarceration as well as their perceptions of students with incarcerated parents. For example, teachers who maintain a deficit ideology toward children with incarcerated parents are not best equipped to meet their needs (Gorski, 2016). Additionally, school counselors should advance schoolwide trauma-informed practice initiatives, address insensitive schoolwide policies, and encourage collaborative efforts to remove barriers that impede the well-being of children of incarcerated parents (Buss et al., 2015). Through basic knowledge, skill development, and collaboration, teachers and other school personnel can support children of incarcerated parents and help facilitate success in and outside of school.


Finally, collaboration is useful when engaging a variety of stakeholders while working with children of incarcerated parents. Stakeholders can include caregivers, mental health providers, correctional officers and facilities, school resource officers, teachers, and social workers. For example, Brown (2017) found that professional school counselors consulted and collaborated with school social workers to support students who needed financial assistance because of parental incarceration. School counselors also can provide targeted and intentional consultation to teachers and administrators to address student academic and behavioral performance concerns (Warren, 2018). School counselors are encouraged to coordinate with stakeholders to facilitate the incarcerated parents’ access to report cards and virtual participation in school-related meetings. Maintaining community connections can help establish a wealth of resources that can be delivered to children of incarcerated parents and their caregivers. When student or family need necessitates therapeutic services, school counselors should refer the family to a community-based agency.


It is important for school counselors to support the academic, social-emotional, and career development of children with incarcerated parents. However, school counselors are encouraged to not engage in the provision of long-term counseling, unless there are extreme circumstances. Resources such as the Children of Incarcerated Parents Program (New York City Office of Training and Workforce Development, 2019) and those listed below offer a variety of community-based services and are eager to partner with professional school counselors to promote protective factors for children with incarcerated parents.


Complementary Resources

Several organizations across the nation offer resources and informational material that aim to reduce risk factors for children of incarcerated parents. For example, the National Mentoring Resource Center ( provides a wealth of information on mentoring children with incarcerated parents. This program is designed to strengthen services that focus on the academic and social-emotional development of children who are experiencing parental incarceration (National Mentoring Resource Center, n.d.). The program provides no-cost training and assistance as well as evidence-based support services to students. Benefits of this mentoring program include practice reviews, webinars, a blog, implementation strategies, and additional readings.


The Prison Fellowship (, a faith-based organization, trains community stakeholders in restorative practices. This organization provides resources that help link children and caregivers to support groups and other services. A central focus of this organization’s work is to restore the relationship between incarcerated parents and their children. The Prison Fellowship (n.d.) supports families and children of incarcerated parents by offering a variety of resources and programming such as the Angel Tree, a Christmas present donation program for children of incarcerated parents. School counselors should consider the religious beliefs of families prior to making a referral to the Prison Fellowship.


In addition to the National Mentoring Resource Center and the Prison Fellowship program, Save Kids of Incarcerated Parents (SKIP; supports children of incarcerated parents by conducting academic and behavioral support groups. The program offers an online community that serves as a vehicle for teenagers of incarcerated parents to connect. SKIP (n.d.) provides research reports and other useful practitioner-focused resources. The program also provides online and hands-on training to interested participants. Trainees are provided relevant information for working with children who experience parental incarceration. School counselors may find it beneficial to collaborate with programs such as SKIP because of its focus on community involvement and partnerships with other support services.


Finally, the Service Network for Children of Inmates ( provides a model of comprehensive, community-based services for children of incarcerated parents. Based in Florida, this network has demonstrated the role state-based agencies can play in supporting children of incarcerated parents. The organization works to re-establish positive relationships between parents and children by facilitating bonding visits and providing assistance with linking children and their families with community services for support. The organization offers support groups for children to develop and refine social and emotional skills to help offset the negative impact of parental incarceration (Service Network for Children of Inmates, 2008). School counselors are encouraged to visit these organizations’ websites, utilize the resources they provide, and seek out similar organizations in their state or region. School counselors can stay informed when working with children of incarcerated parents by visiting the following websites and taking advantage of the resources they offer: the Child Welfare Information Gateway (; (; National Institute of Corrections (; and The National Resource Center on Children and Families of the Incarcerated (



The number of incarcerated parents has continued to grow over the past decade, and children of color are more likely to experience the incarceration of a parent (Graham & Harris, 2013). Children of incarcerated parents face a number of challenges, including stigma, low expectations and academic performance, social and emotional issues, and behavioral difficulties. For example, Cho (2009, 2011) and Shlafer, Reedy, and Davis (2017) found that students of incarcerated parents were more likely to receive disciplinary referrals and earn lower grades, and were less connected to and engaged in school. These children are often required to navigate the experience of their parent’s incarceration with little support while attempting to proceed with their day-to-day lives, including the everyday demands of school. School counselors can play a vital role by helping to support and advocate for these students. Research on incarcerated parents and the impact of incarceration on children is scant, especially in school counseling literature. However, there is clear evidence that the incarceration of a parent can significantly impact children. The degree to which children are impacted by incarceration is dependent upon a host of factors, including age and support system, and symptoms can emerge in a variety of ways.


A central goal when working with children of incarcerated parents is to increase protective factors while attempting to minimize risk factors. It is important for school counselors to identify and assess for risk and strengths of children in their school who have incarcerated parents. These students should be supported within the context of their lived experiences. Knowledgeable school counselors can effectively serve children with incarcerated parents through a comprehensive school counseling program. In most cases, specifically designed programming is not required. Alternatively, some students may require additional school counseling services as well as community-based support. The recommendations provided in this article are based on theory and the best evidence available for working with students who have incarcerated parents. School counselors who are knowledgeable of the impact of incarceration and related support mechanisms can play an integral role in offering support and advocating for students.


In addition to utilizing the resources provided in this article, school counselors are encouraged to seek professional development to further their knowledge, attitudes, and skills for working with children of incarcerated parents. School counselors can serve as valuable advocates and strive to disseminate relevant information to teachers, school administrators, and the caregivers of children with incarcerated parents. It is important for teachers to develop empathy and provide a consistent and nurturing classroom environment for all students, especially those with incarcerated parents. Additionally, school counselors should place the emotions and behaviors of students with incarcerated parents within the context of theory and research when consulting with teachers. In order to best support these children, collaboration and the willingness of professional school counselors to intervene is critical.



Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.





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Jeffrey M. Warren, NCC, is an associate professor at the University of North Carolina at Pembroke. Gwendolyn L. Coker is a graduate student at the University of North Carolina at Pembroke. Megan L. Collins is a professional school counselor in Robeson County, NC. Correspondence can be addressed to Jeffrey Warren, 1 University Drive, Pembroke NC 28372,


School-Based Child Sexual Abuse Prevention: Implications for Professional School Counselors

Rebecca Cowan, Rebekah F. Cole, Laurie Craigen


The purpose of this qualitative collective case study was to explore the experiences of four key internal stakeholders who are involved with a school-based child sexual abuse prevention program in a southeastern state in the United States. In order to explore the experiences of participants, in-depth, semi-structured interviews were conducted. After the data were collected, transcribed, and coded by a qualified research team, three main themes emerged from this study. These themes highlighted the importance of school-based child sexual abuse prevention education, various program impacts resulting from child sexual abuse prevention and intervention within a school setting, and barriers to implementation of child sexual abuse prevention programs in school settings. Implications for professional school counselors, including how they can assist with the implementation of child sexual abuse prevention education, are discussed. Finally, inherent limitations to the research design and implications for future studies are addressed.


Keywords: sexual abuse, prevention, children, collective case study, professional school counselors



In 2017, there were 57,964 reports of child sexual abuse (CSA) in the United States (U.S. Department of Health and Human Services [DHHS], 2018). However, the incidence of CSA is likely higher, as cases of sexual abuse often go unreported (Leclerc & Wortley, 2015; Wurtele, 2009). Overall, between 7.5%–16% of males and 19.7%–25% of females report a history of CSA (Dube et al., 2005; Pereda, Guilera, Forns, & Gòmez-Benito, 2009), and approximately 39 million adults in the United States are CSA survivors (Child Molestation Research and Prevention Institute, 2015). More than 3 million children are victims of CSA, with a mean age of onset of 11.2 years of age (Broman-Fulks et al., 2007). CSA has been linked to a variety of health and mental health issues, including substance abuse, suicide attempts, sexual revictimization, high-risk sexual behavior, anxiety, depression, cognitive disturbances, post-traumatic stress disorder (PTSD), gastrointestinal issues, and chronic pain (Dube et al., 2005; Irish, Kobayashi, & Delahanty, 2010; Lalor & McElvaney, 2010; Sabella, 2016; Wurtele, 2009). Therefore, because of the high incidence and resulting consequences of CSA, prevention is paramount (Letourneau, Eaton, Bass, Berlin, & Moore, 2014).


Abel and Harlow (2001) reported that CSA perpetrators represent a variety of ethnicities and socioeconomic groups. Ninety percent of perpetrators know their victims; only 10% of perpetrators sexually abuse children unknown to them. Sixty-eight percent of CSA perpetrators sexually abuse children in their own families (e.g., biological children, stepchildren, nieces, nephews, grandchildren) and 40% sexually abuse children within their social circle (Abel and Harlow, 2001). Additionally, 5.9% of all girls and 0.3% of all boys in the United States are sexually abused by a known adult (Finkelhor, Turner, Shattuck, & Hamby, 2013). CSA perpetrators who sexually abuse boys report an average of 10.7 victims as compared to 5.2 victims of perpetrators who sexually abuse girls (Abel & Harlow, 2001). Those who sexually abuse both boys and girls report an average of 27.3 victims (Abel & Harlow, 2001).


     Professional school counselors play an important role in CSA prevention. They are federally mandated to report suspected cases of abuse (Federal Child Abuse Prevention and Treatment Act, 2010), including CSA, and also provide counseling services to victims and organize advocacy efforts (American School Counselor Association [ASCA], 2015; Sikes, 2008). Furthermore, professional school counselors are in the position to address barriers and support the implementation of CSA prevention programs within their schools. These school-based prevention efforts are imperative; despite the high incidence of children who are sexually abused, research indicates that many parents do not educate their children about CSA at home (Kenny, Capri, Thakkar-Kolar, Ryan, & Runyon, 2008). Therefore, it is vital that evidence-based CSA prevention programs are provided within the schools so that children have an opportunity to gain knowledge and personal safety skills.


In 1995, 67% of children ages 10–16 reported that they had participated in a school-based CSA prevention program (Finkelhor & Dziuba-Leatherman, 1995). However, this percentage has significantly declined in recent years because of increased focus on other topics, such as bullying prevention, standardized testing, substance use, and intimate partner violence (Morris et al., 2017; Wurtele, 2009). Despite this shift, the implementation of CSA prevention programs within school systems remains ideal because of the ability to concurrently reach multiple children in that setting (Finkelhor, 2009; National Sexual Violence Resource Center [NSVRC], 2011; Tutty, 2000; Wurtele, 2009). However, in recent years, there has been resistance to establishing CSA prevention education within the schools, as some believe that talking about sexual abuse is not appropriate in a school setting (NSVRC, 2011; Wurtele, 2009). Additionally, according to Topping and Barron (2009), CSA prevention programs might be limited because of constraints on funds and time. Some CSA prevention education critics also argue that these types of programs place an unfair burden on the child to report or prevent CSA attempts and that it may not be appropriate to expect children to defend themselves against perpetrators (Finkelhor, 2007; Rudolph & Zimmer-Gembeck, 2018). However, many opponents have “offered little evidence that support their claims of potential negative side-effects” (Kenny et al., 2008, p. 50). In fact, Walsh, Zwi, Woolfenden, and Shlonsky (2015) found in their meta-analysis of several school-based CSA prevention programs “evidence of improvements in protective behaviours and knowledge among children” (p. 2). Furthermore, this increase in knowledge and skill was seen in children regardless of the type of CSA prevention program that was implemented. A study conducted by Gibson and Leitenberg (2000) provided further evidence of the effectiveness of CSA prevention programs, as they found that 9% of participants who had participated in a school-based prevention program were sexually abused compared to 16% who had never participated in CSA prevention.


     In order to effectively implement CSA prevention programs within the schools, a better understanding of these challenges and barriers needs to be gained. Findings from this study may promote awareness, enhance programming, and contribute to prevention efforts for CSA. The purpose of this collective case study research was to explore the experiences of several key internal stakeholders who are currently involved with a CSA prevention program in a southeastern state in the United States. The primary research question answered by this study was: How do key internal stakeholders who are involved with a school-based CSA prevention program describe their experiences with program implementation?




Collective case study research (Yin, 2003) was utilized to explore the experiences of internal stakeholders and their views of a school-based CSA prevention program. The case study tradition focuses upon the constructivist paradigm in which the truth is relative and reliant on one’s unique perspective (Baxter & Jack, 2008). According to Creswell (2007), in a collective case study, “the inquirer purposefully selects multiple cases to show different perspectives on the issue” (p. 74), and this type of approach is often utilized when the unit of analysis is a program. According to Patton (2002), a case study may represent one single program or case. However, within that single program case, a researcher can conduct case studies of several participants. Utilizing the qualitative case study tradition facilitates an issue being explored through multiple lenses, rather than just one (Baxter & Jack, 2008). This approach helps “multiple facets of the phenomenon to be revealed and understood” (Baxter & Jack, 2008, p. 544).



Purposive and criterion sampling (Creswell, 2007) were utilized to recruit four key internal stakeholders for this study. Each participant had been involved with the program for at least one year (range = 1–25 years). For the purpose of this study, a stakeholder meant “people or small groups with the power to respond to, negotiate with, and change the strategic future of the organization” (Eden & Ackermann, 1998, p. 117). Two participants included in this study were current board members and two were current staff members.



This nonprofit CSA prevention organization is dedicated to preventing CSA through the education of children. Their 45-minute performance for children in kindergarten through fifth grade features a puppet who provides children with guidance on how to respond when faced with potentially dangerous situations. A safety net of professionals from Child Protective Services (CPS) and the police department, in addition to school counselors, are present at every performance so that any child who comes forward to disclose sexual abuse is properly cared for with the correct protocols in place. This CSA prevention program has resulted in the arrest and incarceration of 158 CSA perpetrators.



The principle investigator (PI) conducting this study is a Caucasian female in her thirties. She is a licensed professional counselor and has a PhD in counselor education and supervision. The PI has experience treating children who have been sexually abused and adults who were sexually abused during childhood. Two additional researchers assisted with research design and data analysis. Both researchers have doctoral degrees in counselor education and supervision and are licensed professional counselors. One of the researchers has a master’s degree in school counseling and the other researcher has an EdS in school psychology. They are knowledgeable in treating children who have been sexually abused and have experience working within school settings. Engaging a research team of three researchers helped to reduce researcher bias and generated triangulation for the research study (Creswell & Poth, 2018).


Data Collection

Individual interviews were conducted in a southeastern U.S. city. The PI met with participants in a confidential space and informed consent was reviewed and signed prior to the commencement of data collection. After informed consent was given, the PI individually interviewed participants using a semi-structured interview guide pertaining to their experiences as key internal stakeholders involved with this CSA prevention organization. These interviews were audiotaped and transcribed verbatim and lasted approximately 30–45 minutes. All participants were assigned a unique identifier (number) in order to protect confidentiality.


Data Analysis

Transcripts were initially read through by the researchers to gain an overall familiarity with them. The researchers then engaged in content analysis by open-coding the data (Patton, 2002). Through this analysis, patterns and themes were identified and overlapping data was deleted. Researchers developed coding schemes independently and then together they compared and discussed similarities and differences (Patton, 2002). Word tables were utilized to organize the data from each individual case (Yin, 2014). The analysis of these individual word tables allowed researchers to draw cross-case conclusions. Data across cases were analyzed and similarities and differences were noted (Eisenhardt, 1989; Miles & Huberman, 1984).


Strategies for Trustworthiness

In an effort to achieve trustworthiness of the data, triangulation was attained (Baxter & Jack, 2008) as multiple sources were used to collect data, including semi-structured individual interviews, demographic sheets, and program documents. Clarifying researcher bias was another strategy employed for trustworthiness as bracketing, through the use of reflexive journals, was utilized by the researchers (Tufford & Newman, 2010). Bracketing was completed prior to data collection so that the researchers were made aware of their assumptions and biases. Finally, a thick description, as defined by Patton (2002) as having “detailed description and rich quotations” (p. 438), was used as an overreaching strategy to increase the trustworthiness of this study.




A total of three themes emerged from the data analysis: (1) importance of school-based CSA prevention education, (2) program impact within a school setting, and (3) barriers to implementation of CSA prevention within school systems.


Theme 1: Importance of School-Based CSA Prevention Education

This theme includes the participants’ perspectives on the importance and value of CSA prevention education within the school setting. The following sub-themes are included in this section: (1) children and (2) parents and teachers.


Children. The majority of participants discussed the importance of child abuse education so children could implement good boundary setting and learn the language they need in order to express themselves if they feel they are at risk. When outlining the importance of educating children on this issue, one participant discussed how if children are not educated about boundaries and body safety starting at a young age, this could potentially leave a gap for this type of abuse to take place. She stated, “They groom them at a young age and so they break down their resistance and by the time they get to middle and high school, they are assimilated already into this lifestyle and so they think it is normal.” Another participant had similar thoughts and discussed the importance of empowering children to protect themselves. She stated, “We can’t protect them all the time, and I think it is important to give them the knowledge that what’s happening to them is wrong and that they can make a difference by saying no.” Likewise, another participant discussed how teaching children to protect themselves from predators is “fundamental.” She went on to ask the question, “How do you go to school and learn to become a successful adult and have good decision-making if you are carrying this around?” Another interview revealed, “At every turn around every corner, there is someone who is looking to take advantage of that child,” and that child needs to understand how to protect him- or herself. This participant went on to describe the importance of equipping children with the language they need to express what is happening to them. He stated, “What kind of language does a 6-year-old child have to be able to tell an adult that they are being sexually abused? They don’t have a way to even express what’s happening to them.”


     Parents and teachers. Many participants identified a significant need for parents and teachers to become educated on how to talk with children about these issues. One participant discussed how many parents do not know how to educate their children or how to appropriately respond if a child discloses sexual abuse. She stated, “Parents need to not just be talking about this big, bad rapist” and discussed how parents need to educate their children beyond “stranger danger.” A participant also touched on the importance of educating parents: “I do think we need to be more aggressive with the adult education piece . . . it’s an adult problem, it needs an adult solution.” Another participant shared similar thoughts and discussed how parents should be providing this type of education to their children at home. He stated, “As parents, as people in authority positions, we should be the ones answering those questions versus them hearing it from their classmate, or in the streets, or in the locker room.”


Another participant discussed how some parents might be averse to having their child participate in CSA prevention education at school. He discussed how these parents might be concerned about discussing CSA with children who have not previously been exposed to sex and how perhaps this type of discussion could pique their curiosity. This participant countered this by stating, “What better way to do it in a controlled environment and you can answer the questions that they may have.” Another participant also discussed how some parents do not believe their children should learn about CSA prevention at school, but that many of these children are simply not being educated at home. He stated, “What those parents don’t understand is that while they may be proactive in what they’re doing in educating their children about these types of things, 90% of the kids in schools today are not getting this education at home.” Another participant went on to discuss how teachers also do not get enough training on this topic. He stated, “That’s something that’s got to change. They got to get the training that surrounds this issue to be able to understand the issue and wrap their head around what’s happening in their classrooms.”


Theme 2: Program Impact Within a School Setting

Many of the participants discussed how CSA prevention programs within the schools can provide children with the courage to speak up and learn how to protect themselves from potentially dangerous situations. One participant discussed the appreciation he has for how this particular CSA prevention program creates a support system so that children may feel comfortable coming forward and disclosing sexual abuse. He highlighted how law enforcement officers, social services, and school administrators are present throughout the performance “so you have a support system that is right there that says . . . you can have the courage to share if something like that has happened.” Another participant shared similar thoughts and discussed how this particular CSA prevention program is “different” because of the safety net of professionals they have available throughout the production.


Two participants shared their personal experiences with witnessing CSA disclosures as a result of the program. One participant discussed her personal experience of watching children come forward and disclose sexual abuse after participating in the program. She stated, “I really believe the program works. In 25 years, I have seen kids come forward, you know . . . and kids learn how to prevent it from happening.” Another participant described how he had witnessed children disclose prior and current sexual abuse after participating. He stated that when children come forward and tell a teacher, “if we can . . . save one child from the horror of being sexually abused by an adult, then this program is worth its weight in gold.”


Numerous perpetrators have been prosecuted because of disclosures that occurred after children participated in this program. One participant stated, “Having 158 perpetrators prosecuted comes from when she [the director of the program] was in all the elementary schools here in the city.” However, this may be underestimated, as disclosures and prosecutions as a result of the program were difficult to track because of confidentiality and the sensitive nature of the information. Another participant also discussed prosecutions as a result of this program. He stated, “We’re seeing the prosecutions go up because there’s been more exposure of what has taken place in the dark, and so either way, it is a great success.”


Theme 3: Barriers to Implementation Within School Systems

This theme includes the participants’ perspectives on the barriers and obstacles toward implementing this CSA prevention program. The following sub-themes are included in this section: (1) funding issues, (2) a taboo topic and negative attitudes, (3) intervention is stressed, and (4) community support.


     Funding issues. Funding was identified by all participants as a major barrier to implementing CSA prevention programs, as many school systems do not have funding allocated to support this effort. One participant stated, “I’m researching grants that we can apply for and there is plenty of grant money out there for treatment, but not prevention.” Another participant believed that perhaps fundraising for this cause is difficult because the topic makes many people “feel very uncomfortable.” She further stated, “Everybody’s opening up their wallets for ALS, everybody’s opening up their wallets for autism, and those are all great causes . . . but CSA prevention is removed from them.” A third participant discussed how important it is to “champion legislative funding” and discussed how this is “key” to the implementation of CSA prevention programs within the schools in the future.


     A taboo topic and negative attitudes. Participants also discussed how sexual abuse is a “taboo” topic that is often viewed very negatively and, therefore, is often not discussed. In return, this leads to barriers to implementing CSA prevention programs. One participant discussed how many individuals seem to be in denial about the prevalence of CSA. She discussed how people need to “just open up the communication on this really disgusting tabooed subject. People don’t want to talk about it, people don’t want to hear about it. It’s so uncomfortable.” She went on to state, “Someone coined the phrase, ‘Not in My Backyard.’ It’s in every backyard.” Another participant shared similar thoughts. He discussed how some are opposed to CSA prevention programs as they believe these programs are similar to sexual education or that the topic is not “age appropriate.” However, he suggested that these individuals “would be amazed at what children already know and would be amazed at what they’re being exposed to already.”


Participants noted that attitudes about CSA prevention tend to be negative and this hinders efforts in implementing these types of programs. For instance, when one participant was asked what she would like to see changed regarding CSA prevention programs, she stated, “What would I see changed? Just people’s attitudes towards it.” Another participant explained how people working within the school systems often negatively view CSA prevention programs. He discussed how difficult it can be to get “buy-in from school administrators when school administrators know they have kids in their school who are being sexually abused and they know that if they see this program that they are going to possibly come forward.” He went on to discuss how CSA disclosures often result in a “tremendous amount of paperwork for them [school administrators], it creates huge logistical issues like dealing with parents and dealing with CPS and the police” and how this could potentially fuel resistance to implementing these programs. Another participant discussed how their senator supports CSA prevention education, but only in middle and high schools. He stated, “There is a reason for that . . . whether they believe that the elementary school students would not be an appropriate age demographic or whether they thought they would get some resistance, maybe from parents.”


     Intervention is stressed. Participants emphasized how too much focus is often placed on the intervention of CSA, whereas more attention needs to be focused on prevention. When discussing what he would tell people when explaining why CSA prevention is important, one participant said he would invite them to visit juvenile court and watch as he puts a child on the stand who must disclose CSA. He challenges people to think about how these children must find the courage to relive their experience all over again on the witness stand “in front of the judge, in front of the jury, in front of strangers . . . then you tell me how important it is that we educate our kids about child sexual abuse prevention.” Another participant said, “I think that as the general population becomes more educated about the fact that you can prevent the issue from happening, I think they could see that it’s more important to put money into prevention than treating something.” This participant went on to explain the importance of “getting people interested in prevention more than just putting the fire out once the fire starts . . . I think people wait until it’s too late and then they rather put out the fire and until it becomes a fire, they don’t want to have to deal with it.” A third participant shared similar thoughts: “It needs to be more preventive and more proactive and we need to start talking about it.”


     Community support. Community support was identified by participants as being difficult to come by but essential to the successful implementation of CSA prevention programs. One participant discussed how “there are so many fundraisers . . . and you have to pick and choose what you are passionate about,” noting that not too many people choose to support CSA prevention. Another participant discussed the importance of networking with community partners in order to gain additional support. In particular, he highlighted the importance of developing trust between the organization and community partners. He stated, “When you know a person and you have a relationship with a person, it’s easier to trust them to always do the right thing.” A third participant discussed his personal efforts related to attempting to gain additional community support: “Every opportunity I get to talk to a person about the program, I do . . . I ask them to get in touch with me if they have any questions.”




In this study, the participants emphasized that addressing the often taboo topic of sexual abuse with children is imperative. They discussed how the topic of sexual abuse is frequently avoided, especially by parents and guardians—a trend that is confirmed by the professional literature (Kenny et al., 2008). The participants noted that this avoidance hinders opportunities for both prevention and intervention in the lives of children. Notably, with education, parents and guardians are empowered to teach their children about ways to avoid sexual abuse. These discussions are crucial to preventing harm to children and providing them with the knowledge and awareness they need to protect themselves. Additionally, participants discussed how the focus on “stranger danger” by parents neglects the most common perpetrators of sexual abuse—acquaintances. Deblinger, Thakkar-Kolar, Berry, and Schroeder (2010) supported this finding, as they also found that the parents who discuss CSA with their children can erroneously focus on the dangers of interacting with strangers and not with individuals the child may already know. Additionally, Deblinger et al. found that the number of parents who stated that they desired to educate their children about CSA at home was more than those who had actually followed through with this task. Therefore, parents may lack the knowledge they need in order to adequately address this issue with their children. Professional school counselors are in an ideal position to help fill this void by developing educational opportunities for parents and guardians, so they feel better equipped to talk with their children about CSA. It would be prudent to include information about perpetrators so that parents do not solely focus on strangers when discussing safety with their children.


Professional school counselors also can play an important role in the education of teachers, administrators, and other school staff. The participants in this study discussed how there may be some resistance on behalf of school administrators to implement CSA prevention programs because of fear about the logistical issues that may result from disclosures. Therefore, as also discussed by Sikes (2008), it is important that a protocol is in place for when children disclose sexual abuse. Professional school counselors can assist with the development of this protocol and can educate school administrators and teachers about how to appropriately respond to and report disclosures of CSA. Professional school counselors should clearly define which individuals are mandated to report suspected CSA to CPS and in what timeframe the report must be made. A reporting form could be developed in order to streamline this process (see Sikes, 2008). Additionally, professional school counselors should provide educational resources to teachers and school administrators on how to identify signs of CSA.


In response to the taboo placed on discussing CSA, the participants described how their program offers stakeholders a vehicle for openly discussing CSA, as it provides a forum for creating awareness regarding the dangers of sexual abuse. In addition, the participants were proud of the community awareness that the program created, allowing for the prosecution of child sex abusers in the community. CSA prevention should not only include education of children, but also the general public, professionals, and other stakeholders (Wurtele, 2009). Professional school counselors can be an important vehicle for this type of collaboration. The participants all discussed how having social services, the police, and CPS as part of their program helped to provide a safety network for when CSA disclosures were made. According to the NSVRC (2011), “prevention programs designed for children are only one of many components of a successful community effort to prevent CSA. The burden of prevention should also be distributed across community members, organizations, and social structures” (p. 3). Participants also discussed how imperative it is to develop strong community partnerships to work together to help prevent CSA. Therefore, it could be noteworthy for professional school counselors to focus on building these partnerships so that funding and support may be bolstered for such programs to continue or be implemented within schools.


The participants also discussed how intervention is often stressed and prevention is overlooked in the treatment of CSA. This could be due to limited scholarly research that provides evidence for the effectiveness of CSA prevention programs (Rudolph & Zimmer-Gembeck, 2018). CSA prevention programs characteristically utilize a risk-reduction approach in which children are educated about sexual abuse and learn the skills necessary to avoid and report abuse (NSVRC, 2011). However, empirical support of these programs is limited (Lynas & Hawkins, 2017; Topping & Baron, 2009), as CSA prevention programs are difficult to measure (Lynas & Hawkins, 2017). In response to the lack of outcome data, the NSVRC has put forth that “additional rigorous evaluations of child sexual abuse prevention programs are needed” (2011, p. 6). Additionally, few follow-up studies have been conducted in order to determine if knowledge from these prevention programs has been retained and, more importantly, whether children can apply this knowledge to real-world scenarios. Professional school counselors can assist with the development and implementation of research and program evaluation studies in order to provide additional evidence in support of CSA prevention programs within the schools. Implementation of research within a school setting is no easy feat, as multiple approvals are necessary in order to ensure research participants are not harmed and that research is conducted in an ethical manner. Therefore, school administrators can be hesitant to approve research conducted within this setting. Professional school counselors can collaborate with administrators and make a strong case for why this type of research is absolutely necessary, so that more evidence-based CSA prevention programs are developed.


Program fidelity is another issue that has been identified within the literature when it comes to the evaluation of CSA prevention programs (Johnson, 1994; Lynas & Hawkins, 2017). Program evaluation research has indicated that when teaching about CSA, teachers can leave out content because of their own personal discomfort. This type of modification to program material could potentially impact findings of program evaluations and might minimize program effectiveness. Therefore, when educating teachers about CSA prevention, professional school counselors could discuss how sensitivities may arise while teachers deliver this type of content to their students, as well as how to ensure they are adhering to the protocol of the selected program (Lynas & Hawkins, 2017). If personal sensitivities arise because of a teacher’s own history of CSA, it may be prudent for the professional school counselor to connect these individuals with mental health providers within their community.


Limitations and Implications for Future Research


This study lays the groundwork for qualitative as well as quantitative analysis of CSA prevention programs and other similar programs that exist. The results of qualitative research designs inherently are limited in their ability to be extended to a wider population (Atieno, 2009). Our case study design was limited to four participants. In addition, as the researcher is the primary research instrument in our qualitative research design, our biases could have influenced both data collection and analysis (Anderson, 2010). Thus, the validity of the findings might be called into question.


Additional quantitative research might survey participants’ understanding of the material presented both before and after the program, measuring the knowledge that they gain. Further, a future phenomenological qualitative study might examine the experiences of the participants themselves as they process the material they encounter in a CSA prevention program. Future qualitative research studies might explore parents’ perceptions of CSA education and the ways in which they are currently addressing this issue with their children. This exploration also could highlight areas that need further parent education in order to help them prevent CSA in the lives of their children. Finally, future studies could focus on the experiences of professional school counselors as they work toward the prevention of CSA.




CSA is a major public health concern affecting thousands of children in the United States (U.S. DHHS, 2018). Although research is limited to the efficacy of CSA prevention programs, outcome data indicates that effective programs promote education and awareness, decrease stigma, and increase rates of reporting sexual abuse. Results from this collective case study yielded three central themes: the importance of school-based CSA prevention education, program impact within a school setting, and barriers to the implementation of CSA prevention within the schools. The data that emerged from the participants provide valuable perspectives on the challenges and benefits of CSA prevention programs and how professional school counselors may advocate for their implementation within the schools.


Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.





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Rebecca Cowan, NCC,  is a professor at Walden University. Rebekah F. Cole, NCC, is an assistant professor and Director of the School Counseling Program at Arkansas State University. Laurie Craigen, NCC, is an associate professor at Boston University School of Medicine. Correspondence can be addressed to Rebecca Cowan, School of Counseling and Human Services, Walden University, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401,

Utilizing Trauma-Focused Cognitive Behavioral Therapy as a Framework for Addressing Cultural Trauma in African American Children and Adolescents: A Proposal

Ricardo Phipps, Stephen Thorne


This article proposes a model for an intervention designed to mitigate cultural trauma in African American children and adolescents using trauma-focused cognitive behavioral therapy (TF-CBT), an evidence-based practice for treating post-traumatic stress in children and adolescents. There is a paucity of approaches to treat cultural trauma in African American youth and the negative effects cultural trauma can have on academic performance and social interactions. This proposed intervention includes a mentoring program focused on the use of TF-CBT to help African American children and adolescents and their families in constructing positive self-images that support resilience and empowerment.

Keywords: cultural trauma, trauma-focused cognitive behavioral therapy, African American, children, empowerment


The complexity of traumatic experiences and their influence on psychological well-being expand far beyond the current diagnostic nomenclature and symptom descriptions available in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013; Burstow, 2005). Researchers and practitioners acknowledge that post-traumatic stress disorder (PTSD) has been observed in individuals not directly affected by narrowly defined traumatic experiences, creating the occasion for the study of such phenomena as vicarious traumatization or secondary traumatization, particularly when associated with mental health providers and caretakers who show PTSD symptoms because of their exposure to the stories of clients (Pearlman & Saakvitne, 1995). Beyond this concept of vicarious traumatization, researchers and practitioners also note the experience of intrafamilial PTSD symptoms driven by the display of symptoms in one or more family members. When this phenomenon involves the effects of trauma extending to other generations in the same family beyond the generation of the person experiencing primary trauma, mental health professionals have labeled this transgenerational trauma or intergenerational trauma (Danieli, 1985).

Transgenerational transmission of trauma was first documented in the literature in reference to Holocaust survivor families, with an emphasis on the psychological states of the second generation of survivor families (Danieli, 1985). The children of individuals who survived concentration camps displayed muted emotions and other symptoms of grief, loss, and depression. Researchers are currently focusing on better understanding transgenerational trauma in families affected by a variety of traumatic contexts, including child sexual abuse (Frazier, West-Olatunji, St. Juste, & Goodman, 2009), natural disasters such as Hurricane Katrina (Goodman & West-Olatunji, 2008), and immigration trauma (Phipps & Degges-White, 2014). In addition to the study of transgenerational transmission of trauma within family systems, there also is a growing scholarly interest in the effects of collective traumatic experience upon groups of people and how the traumatic experience affects subsequent generations. The term historical trauma has been used to describe the traumatization of Native American peoples at the hands of European colonizers, resulting in mass genocide and geographic displacement (BraveHeart & DeBruyn, 1998; Whitbeck, Adams, Hoyt, & Chen, 2004). Distinctly, but similarly, the construct of cultural trauma has been identified in reference to the enslavement of peoples of African descent in the United States and the subsequent oppression through “Jim Crow” practices that occurred post-emancipation (Eyerman, 2004). Cultural trauma is linked to the psychosocial outcomes that have resulted from the cultural wounds left by the experience of chattel slavery, which refers to the usually permanent holding of another human being as personal property with no rights (Eyerman, 2004; Stamm, Stamm, Hudnall, & Higson-Smith, 2004). DeGruy (2005) has referred to this phenomenon as post-traumatic slave syndrome. Vontress, Woodland, and Epp (2007) have described the psychological after-effects of enslavement and subsequent oppression and discrimination of African Americans as cultural dysthymia, suggesting that African Americans often experience a low-grade depression, or dysthymia, as a result of systemic oppression, which can affect academic, occupational, and social functioning, but do not meet other criteria for more severe depression diagnoses. Smith (2004) coined the term racial battle fatigue to depict the psychological and physiological stressors and subsequent behavioral responses some African Americans experience in reaction to repeated, cumulative racial discrimination.

Historical and cultural trauma has been recognized to be a part of the experiences of various marginalized, indigenous groups throughout the world who have undergone mass atrocities at the hands of colonizers, such as Japanese American survivors of internment camps (Nagata & Cheng, 2003), Palestinian youth (Giacaman, Abu-Rmeileh, Husseini, Saab, & Boyce, 2007), victims of the Rwandan genocide (Schaal & Elbert, 2006), and Mexican and Mexican American immigrants (Phipps & Degges-White, 2014). In the immediate and long-term aftermath of traumatic experiences, individuals have exhibited similar internalized and externalized behaviors that are characteristic of post-traumatic stress disorder and that are seen as responses to the collectively experienced trauma. Although some of the aforementioned groups underwent traumatic experiences that spanned a period of a few months or years and occurred within the last century, the history of the enslavement of African peoples in the Americas and their subsequent oppression and discrimination originated centuries ago and has endured since the first Africans were brought to the Americas. Given such prolonged exposure, the symptoms of historical and cultural trauma are highly pronounced in those African Americans who lack the protective factors needed to counter the disempowering effects of enslavement and oppression (Vontress et al., 2007).


A Brief Overview of Cultural Trauma

DeGruy (2005) and Reid, Mims, and Higginbottom (2004) proposed that African Americans have sustained traumatic psychological and emotional injury because of enslavement, exacerbated by social and institutional inequality, racism, and oppression. The effects are thought to be linked even to physical health disparities, which place African Americans at higher risk for certain medical conditions (Sotero, 2006). Wilkins, Whiting, Watson, Russon, and Moncrief (2013) and DeGruy (2005) asserted that the restrictions of slavery prompted enslaved African American parents to stress to their children the necessity of not confronting Whites, resulting in frustration with life in an oppressive system in which individuals were not permitted to question injustice. In the generations since the emancipation of slaves and the enactment of Civil Rights legislation passed to eliminate racial discrimination and unequal treatment, African Americans in large numbers continue to experience political disenfranchisement (Barnes, 2016), economic struggle (Croll, 2018), social marginalization (Benner & Wang, 2014), workplace discrimination (Hagelskamp & Hughes, 2014), housing segregation (Roscigno, Karafin, & Tester, 2009), and academic disparities (Morris & Perry, 2016). Sztompka (2000) characterized the aforementioned historical phenomena as limited collective agency, which refers to a sociocultural tendency of a group to be inhibited in positively transforming its own oppressed condition both because of external barriers and because of internalized hopelessness. Internalized responses to this limited collective agency influence self-esteem, relationships, occupational functioning, and overall psychological well-being. Linked to this are higher rates of depression and anxiety than seen in other ethnic groups, higher rates of exposure to individual and community violence, and higher rates of psychosis and other psychiatric challenges (Vontress et al., 2007).

Just as all individuals who are exposed to traumatic experience do not display symptoms of PTSD, not all African Americans display overt symptoms of cultural trauma or display them to the same degree. Rasmussen, Rosenfeld, Reeves, and Keller (2007) argued that the subjective interpretation by individuals of traumatic experience largely dictates whether their response will be pathological or whether adaptation and resiliency mechanisms will enable them to self-stabilize. Varying degrees of perceptions of limited agency, because of a plethora of factors, such as socioeconomics, educational achievement levels, family attachment and protective dynamics, and even skin tone dynamics, lead to a wide range of responses to the residual social milieu left behind by enslavement, “Jim Crow” practices, and current-day racially motivated injustice.

In a now dated publication, Pouissant and Atkinson (1972) linked exhibited feelings of rage and passivity among some African Americans to intrapsychic functioning learned during slavery as a survival mechanism. They further explained that this dynamic of rage and passivity was adopted in response to witnessing the brutality faced by enslaved peers who did challenge slave owners. Tatum (2002) postulated that this reaction to historical oppression has morphed into a number of responses to social injustice today, namely assimilation, crime, delinquency, or protest. This cultural trauma affecting African Americans has particularly and directly impacted the well-being of African American children and adolescents.

Assimilation, along with internalized racism, is no more evident than in the original and duplicate “doll studies” first launched by Clark and Clark in 1939. African American children showed preference for White dolls over Black dolls when asked to identify which were beautiful and good. Subsequent critique of the research methodology used by the Clarks and replicated and expanded studies have highlighted inattention to such details as how the skin tone of Black dolls shown to participants or developmental stage would influence their racial self-identification (Jordan & Hernandez-Reif, 2009). However, the study still demonstrates that one of the effects of cultural trauma is a preference for majority culture and characteristics over one’s own.

In terms of crime and delinquency, a long-standing trend of disproportionate numbers of African American men in the U.S. criminal justice system is paralleled by disproportionate numbers of African American males receiving disciplinary measures in schools (Monroe, 2006; Noguera, 2003). It can be argued that these statistical trends are connected to stereotyping and targeting of African American males as offenders. Alternatively, Conger et al. (2002) asserted that higher levels of externalizing symptoms and problematic behaviors in African American children and adolescents are correlated with systemic oppression and economic distress. These attitudes and behaviors, though not prevalent in the experience of all African Americans, indicate a pervasive stress that does not seem to mitigate over time and across generations. This pervasive stress has had a significant effect on the academic performance and school behavior of African American students. Thompson and Massat (2005) found in a sample of African American sixth graders attending inner-city Chicago public schools that academic achievement was significantly related to post-traumatic stress, family violence, and witnessing violence.

Cholewa and West-Olatunji (2008) have framed the academic performance divide that separates out some African American children as cultural discontinuity, highlighting a preference for Eurocentric ways of communicating, relating, and behaving in American schools. Cholewa and West-Olatunji asserted that those whose cultural background does not align with this preferred European style often find themselves marginalized in school environments, which can affect their access to academic instruction. Morris and Perry (2016) furthered this discussion by highlighting the existence of higher suspension rates of African American students and identifying the negative impact that this disparity has on African American students’ academic performance. Using data from the National Longitudinal Study of Adolescent Health, Benner and Wang (2014) concluded that segregation of students into schools in certain areas based on race and socioeconomics resulted in lower academic performance. Although researchers have not explicitly investigated the impact of cultural trauma as a complex construct on the academic performance of African American youth, the aforementioned studies indicate considerable support for the influence of various components of cultural trauma on academic performance, such as the pressure to change one’s communication style to fit a preferred Eurocentric model or the experience of being confined to a school environment with limited resources. Just as the external factors of cultural trauma and the related stressors caused by cultural trauma have perpetuated achievement divides between African American students and other groups, we propose that intentional, external interventions are needed to mitigate the effects of cultural trauma.


Interventions in Response to Cultural and Historical Trauma

Culturally sensitive curricula and character-building programs have been designed to stimulate learning and positive self-image in students of color (Vontress et al., 2007). Jarjoura (2013) adamantly maintained that such programs must be relational and address exposure to various types of traumatic experience. Jaycox (2004) created the Cognitive Behavioral Intervention for Trauma in Schools (CBITS) program as a model for working in inner-city school settings with children and adolescents of ethnically diverse backgrounds who exhibited symptoms of post-traumatic stress. The overall objective of CBITS is to reduce behavioral problems and optimize social and academic performance in students with trauma histories. Successful utilization of CBITS with Native American school children has been documented by Morsette et al. (2009). Honoring Children, Mending the Circle (HC-MC) is a structured program designed to address traumatic symptomatology in Native American children through a blending of evidence-based, trauma-focused cognitive behavioral therapy and culturally appropriate indigenous practices (BigFoot & Schmidt, 2010). BigFoot and Schmidt (2010) sought to provide an intervention in HC-MC that addressed both the high rates of exposure to traumatic events as well as the pervasive cultural, historical, and intergenerational trauma experienced by Native American children and youth, commonly referred to by BraveHeart and DeBruyn (1998) and Whitbeck et al. (2004) as historical trauma.

With the specific needs of African American children in mind, the Celebrating the Strengths of Black Youth (CSBY) program was developed as a strengths-based, small-group approach to building positive racial identity and nurturing self-esteem among African American children. CSBY focuses on teaching students skills to handle the typical challenges that Black students face related to race (Okeke-Adeyanju et al., 2014). President Barack Obama (2014) initiated My Brother’s Keeper as a mentorship program for boys of color to provide a space for accountability, guidance, and support, recognizing the need for culturally relevant approaches to help boys of color transcend barriers created by external stressors and internalized racism. Educators in various parts of the United States have designed schools and curricula around these same mentorship ideals, such as Urban Preparatory High School in Chicago (King, 2011) or Gesu School in Philadelphia (Thorne, 2015). At the core of their mission is a recognition of the need to diminish the “cultural gap” that exists between those who educate children, and the children and their families themselves. Part of bridging this cultural gap involves acknowledgment and understanding of past and present traumatic experience endured by African American people across generations. It is not only educators who need support in developing heightened awareness of these historical and current phenomena; children and their families sometimes need assistance in understanding the historical context for the current divide that often disadvantages African American children.

As models are continuously developed to address historical and cultural trauma, there is growing awareness of the need for culturally sensitive programs that target African American children and youth affected by cultural trauma and are rooted in evidence-based practice. With this in mind, we propose an approach to diminishing the effects of historical and cultural trauma in African American children and adolescents that utilizes the principles of trauma-focused cognitive behavioral therapy (TF-CBT) and key aspects of African American racial identity development and Afrocentric values and strengths.


Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Cohen, Mannarino, and Deblinger (2006) developed Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) as a relatively short-term, integrated approach aimed at the reduction of negative affective responses, distorted cognitions, and maladaptive behaviors that can arise from trauma exposure. TF-CBT utilizes gradual exposure to reminders of the traumatic experience and supports participants in constructing trauma narratives that focus on strengths and empowerment. Clinicians utilizing TF-CBT work to engage parents so that their support of their children is maximized. TF-CBT has proven successful with children and adolescents between the ages of 3 and 18.

The core components of TF-CBT include Psychoeducation and Parenting Skills, Relaxation, Affect Regulation, Cognitive Restructuring, Trauma Narrative, In Vivo Exposure, Conjoint Parent–Child Sessions, and Enhancing Safety Planning. The acronym P-R-A-C-T-I-C-E provides a shorthand reminder of these core components (Cohen et al., 2006). The Psychoeducation and Parenting Skills component focuses upon discussion and education about child abuse in general and the typical emotional and behavioral reactions to physical, emotional, and sexual abuse. This component helps both clients and parents understand that their reactions to trauma experience are typical and that there are evidence-based, effective responses to these behaviors.

Clinicians teach relaxation techniques as a precursor to exposure interventions. Techniques, such as focused breathing, progressive muscle relaxation, and visual imagery, help child and adolescent clients cope with overwhelming, negative emotions that can accompany trauma exposure so that they do not abandon the exposure therapy part of healing because it is distressing. The Cognitive Restructuring component involves clinicians helping their clients and parents better understand how thoughts, feelings, and behaviors are interrelated and how to identify and restructure distorted ways of thinking (Cohen et al., 2006).

The construction of a trauma narrative involves gradual exposure exercises, inviting clients to communicate about the traumatic experience and eventually create a verbal, written, symbolic, or artistic account of the traumatic experience. This provides an opportunity for the clinician to further identify any distorted cognitions related to self-blaming or guilt held by clients and to help with restructuring them into more realistic and empowering ways of thinking (Cohen et al., 2006).

Through in vivo exposure, clinicians introduce gradual reminders of the trauma in environments that are in the everyday experience of the clients or that are significant to the traumatic experience. The relaxation techniques learned earlier in therapy are then utilized to facilitate reduction of distress when clients are reintroduced to settings that trigger traumatic memories. Clinicians facilitate enhanced communication through conjoint parent–child sessions, particularly assisting parents in offering needed support in the home when traumatic memories are triggered. Lastly, clinicians focus upon offering education and skills building related to maintaining personal safety, boundaries, and healthy interpersonal relationships so that clients feel empowered to advocate for themselves more effectively when future stressors arise in life (Cohen et al., 2006).

Although a great deal of research has been conducted studying the use of TF-CBT with child and adolescent survivors of sexual abuse (Cohen, Deblinger, Mannarino, & Steer, 2004), TF-CBT also has been shown to be effective with clients who have been exposed to community violence (Voisin & Berringer, 2015), traumatic grief and loss (Cohen & Mannarino, 2004), and even natural disasters (Jaycox et al., 2010). TF-CBT has been designated as evidence-based because of the number of random control treatment studies supporting its effectiveness. de Arellano et al. (2014) documented 10 random control treatment studies that support the effectiveness of TF-CBT in various trauma exposure contexts, seven of which compared TF-CBT participants with active control groups and three compared TF-CBT participants with wait-list control groups. Five of these studies assessed the effectiveness of TF-CBT with child survivors of sexual abuse (de Arellano et al., 2014). O’Callaghan, McMullen, Shannon, Rafferty, and Black (2013) conducted a study of Congolese girls affected by war and sexual exploitation, using a single-blind, parallel design, randomized control study, and found significant reduction in symptoms in participants treated with TF-CBT. The intervention was administered to participants in a group format in this study of Congolese war survivors.

Jensen et al. (2014) conducted a randomized control study using TF-CBT in which 156 youth in a community mental health clinic, ranging in age from 10 to 18, presented with a variety of trauma histories; the results showed significantly fewer PTSD symptoms, less depression, and greater improvements in functional impairment for those treated with TF-CBT. A field trial of children in New Orleans exposed to the trauma of Hurricane Katrina who received TF-CBT treatment both in schools and in mental health clinics showed significant reduction of PTSD symptoms (Jaycox et al., 2010). Cohen, Mannarino, and Iyengar (2011) documented similar effectiveness of TF-CBT with children exposed to intimate partner violence.

Researchers are continuously expanding the trauma contexts for which TF-CBT is utilized and studied, indicating its robustness and solidifying its evidence-based quality (Cohen et al., 2011). Given the highly adaptable nature of TF-CBT in treating children and adolescents affected by traumatic experiences, we propose an approach to addressing cultural trauma in African American children and adolescents that uses TF-CBT as its basis.


TF-CBT as a Frame for Cultural and Historical Trauma Treatment

Using the major components of TF-CBT denoted in the P-R-A-C-T-I-C-E acronym, we have drafted the following intervention to address cultural trauma in African American children and youth. This intervention is tailored to early adolescents, namely middle school students (ages 12–14), and should be adjusted when used with younger or older participants. The program is a group intervention that can be utilized in an after-school setting at a school, a church, or community center. Ideally, the program spans 16 weeks, which would roughly correspond to a school semester if conducted in the school setting. Warfield (2013) advocated for the modification of TF-CBT by practitioners to fit the cultural context of clients while maintaining the integrity of the model. To foster sensitivity to the more collectivist outlook seen in African American communities, the proposed program is community-based, involving a group approach to treatment, as opposed to a more individualistic, Eurocentric approach to treatment, which might only involve the child and clinician, with sporadic parental involvement.

Psychoeducation and Parenting Skills. From the beginning, the program is family focused. Thorne (2015) maintained that parental engagement is a critical component in the building of community networks that will support the academic and social success of African American children. Given that participants will have different experiences of family and differing family structures, participants are invited to identify a support team of at least three significant persons who will constitute “family” for the purposes of the program—a strategy utilized by Boys’ Latin Charter School in Philadelphia (Thorne, 2015). This team of three is expected to attend some family sessions and will be supported in initiating regular conversations outside the program setting about the program goals.

The introductory session of the program draws participants and their team of three together for an informational presentation on cultural and historical trauma, discussing the history of the enslavement of people of African descent in the United States, the subsequent era of segregation, the ongoing Civil Rights movement, and how these historical experiences have affected the African American family today. Ongoing psychoeducation about historical trauma may take the form of group visits to museums that highlight African American history, such as the Smithsonian Museum of African American History, the Museum of Civil and Human Rights in Atlanta, or any local museum of African American history, followed by group processing of the experience.

Relaxation. Soto, Dawson-Andoh, and BeLue (2011) cited a connection between the experience of racialized stress and discrimination in African Americans with physiological reactions to stress, such as anxiety. Cultural trauma involves a pervasive, ongoing perception of racialized stress and discrimination that can be associated with restlessness, sleep disorders, muscle tension, and other symptoms. TF-CBT stresses the importance of self-soothing and coping mechanisms that stimulate relaxation in tense situations. Muscle relaxation, deep breathing exercises, and guided imagery are promoted by TF-CBT–oriented clinicians. The proposed program places similar emphasis on the teaching of these relaxation strategies.

Spirituality, prayer, and meditation are other mechanisms that are commonly used by African Americans to manage stress and cope with and challenge discrimination (Hayward & Krause, 2015). Spirituality is a very personal expression, meaning participants will likely demonstrate a large amount of variety in their attitudes toward spirituality. Without promoting any specific spiritual tradition, participants will be invited to explore their spiritual beliefs and practices and connect them to how they cope with racism and discrimination.

Affect Regulation. The TF-CBT model also highlights the significance of the development of emotional intelligence (Cohen et al., 2006), including the proper identification of emotions and the conscious choosing of appropriate and healthy emotions. In the case of cultural trauma, as participants learn more about the history of racial power dynamics in the United States, negative emotions may increasingly arise. As a strengths-based program, emotions, such as anger, frustration, and outrage, are honored and recognized but are seen as transitions to constructive approaches to eliminating unequal power dynamics.

According to Chaplin (2015), gender differences exist in how humans express emotions, best explained through a combination of biological, psychosocial developmental, and social constructionist factors. For example, adolescent girls are thought to experience symptoms of depression significantly more often than adolescent boys (Hankin & Abramson, 2001). Along racial lines, there are differences according to gender in how African Americans typically respond to the systemic oppression and discrimination associated with cultural trauma (Vontress et al., 2007). African American boys may suppress anger and dissatisfaction with school incidents, particularly those involving microaggressive behaviors targeting them or more blatant forms of discrimination (Thomas & Stevenson, 2009). Likewise, suppressed anger may be redirected into other expressions, such as hypermasculinity, which may be interpreted by instructors and school administrators as unfounded defiance.

Role play is effective in helping participants reflect upon how they express emotions and how emotional expression influences the identities that they are striving to form (Brown, 2003). Schonert-Reichl and Lawlor (2010) documented the effectiveness of a mindfulness education program in helping fourth to seventh graders develop emotional competence and in fostering positive emotions. Both mindfulness exercises and role play can be used to help participants broaden their emotional vocabulary, experiment with various methods of controlling emotional expression, and practice new ways of communicating emotions honestly and productively. Anderson and Stevenson (2019) highlighted reactions that parents of children and adolescents of color may have when they find out their sons or daughters have been exposed to discriminatory racial encounters, one of which is described as “preparation for bias.” This includes pointed conversations about how to handle potentially dangerous encounters such as racial profiling, with opportunities to allow young people to rehearse how they will respond to situations that may generate panic in the moment. Role play in this proposed program affords the opportunity for candid preparation of participants for life incidents that may be fueled by racial discrimination.

Cognitive Restructuring. Black identity development models, such as the Cross model, underscore that the beginning of racial identity development in people of color is often characterized by positive beliefs about the dominant group and negative beliefs about their own cultural group (Cross, Parham, & Helms, 1991). In the case of African American middle school students, such negative self-beliefs may present in such subtle manners that program participants are not aware and may even deny.

One approach to engaging participants in cognitive restructuring of distorted cognitions about race, self-image, and privilege and power dynamics involves teaching young people about microaggressions directed toward African Americans. Role play is beneficial in creating a space for participants to reflect upon microaggressive behaviors and to correct the stereotypes upon which they are based. Córdova and Cervantes (2010) documented the experience of within-group discrimination among Latino youth based on English proficiency, documentation status, and generational status. In both African American and Latino American communities, within-group skin tone stratification, often referred to as colorism, perpetuates internalized racism, creating a preference for skin tones seen as lighter and more European (Hunter, 2016; Maxwell, Brevard, Abrams, & Belgrave, 2015). Reflection upon within-group microaggressions and internalized racism is utilized to foster participants filtering out negative self-images that they have incorporated based on the manner in which oppressive systems have depicted African Americans as well as individuals from other racial/ethnic groups.

Trauma Narrative. As an important component of the TF-CBT model, trauma narration creates the space for deconstruction and reconstruction of the young person’s understanding of the traumatic experience (Cohen et al., 2006). The clinician monitors for cognitive distortions that might suggest the young person is still blaming self or viewing self through a lens of weakness. Trauma narration is designed to help individuals further claim their own strengths and resources.

In the context of cultural trauma of African Americans, African American children and adolescents often have mistaken views and understandings of the history of African peoples and the history of African Americans (O’Donovan, 2009). They may not be aware of how their own personal families’ histories intersect with key moments and movements in African American history, which suggests a lack of knowledge about family strengths, empowerment, and triumphs over oppressive systems.

A critical part of addressing cultural trauma is the deconstruction and reconstruction of family history. Given the dynamics of slavery, African Americans are often not able to trace their ancestry in the same way that European Americans are able to. Students engaged in cultural trauma programs will benefit from doing oral history interviews with elders in their families and communities to better understand the evolution of their families, the perspectives of the elders on family resilience and strength, and the hopes and dreams that elders have for the current generation of youth. Although there can be obstacles to tracing ancestry beyond the previous century, students can be challenged to explore possible family history scenarios based on the social contexts of African Americans living in the same geographic regions as their known ancestors.

Although the validity of DNA ancestry kits, such as or 23andme, has been questioned regarding their ability to provide accurate profiles of the ethnic origins of their consumers (Duster, 2014), these tools may still point users in the direction of developing a better understanding of their family histories. In an effort to help students bridge their family histories beyond the Americas, ancestry kits may be used to give students information about African ancestry so that they may research particular countries and tie their history into how they understand their own familial contexts.

This portion of the program is necessarily collaborative in that students will have to reach out to family members for information. It is advised that students complete this with direct involvement with their support team of three significant persons. Upon completion of the project, ideally students will present their information in a spirit of pride to the whole program group with the help of their support team.

n Vivo Exposure. The TF-CBT model encourages the use of in vivo exposure of participants as reminders of the traumatic experience in order to desensitize them to anxiety-provoking reactions (Cohen et al., 2006). In vivo exposure helps to minimize avoidance of stimuli that can trigger memories of the traumatic experience. In lieu of avoidance, participants are supported in using the coping mechanisms they have learned to manage their anxiety.

One aspect of cultural trauma that can greatly influence academic performance and social relationships is low self-efficacy. Low self-efficacy can lead to avoidance of academic challenges as well as unfamiliar social interactions (Uwah, McMahon, & Furlow, 2008). Mathews, Dempsey, and Overstreet (2009), in a study of African American children ages 10–13, found an inverse relationship between exposure to community violence and the academic performance and attendance of students. According to these researchers, the experience of community violence trauma is often associated with a lack of engagement in school activity and an overall sense of powerlessness. Interventions that foster an increase in self-efficacy can enhance students’ willingness to engage in new experiences—academic, occupational, or interpersonal. In reference to cultural trauma of African American children and adolescents, deliberate exposure to opportunities to execute projects and work that can both benefit others as well as enable students to demonstrate leadership and learn new skills can build self-efficacy and result in other positive benefits.

Scales, Blyth, Berkas, and Kielsmeier (2000) concluded from a study of racially and socioeconomically diverse middle school students that service learning (experiential educational moments that revolve around action and reflection) is positively correlated with concern for others’ social welfare, frequency of talking with parents about school, and increased belief in the efficacy of helping behaviors. Stott and Jackson (2005) highlighted growth in self-awareness and self-efficacy as additional benefits for middle school students. Song, Furco, Lopez, and Maruyama (2017) concluded from research with college students from underrepresented groups, not limited to racially diverse groups, that service learning can have a positive impact on their educational outcomes. Thus, service learning opportunities are proposed to expose participants to challenges that may be apparent in their communities and to foster a sense of power in terms of being a part of positive change and community growth.

Service learning opportunities that involve collaboration between students and parents may take the form of neighborhood clean-up days in underprivileged communities, collecting or preparing food to be distributed to homeless populations, or visits to nursing homes to share personal items that have been collected for residents. Reflection time after the project offers students the space to discuss apprehensions they had, the internal processes they used to overcome those apprehensions, and the new self-images they own since the experience.

Conjoint Sessions. The responses children and adolescents receive from their parents and guardians are powerful influences in how young people attribute meaning to trauma, including cultural trauma. Frankish and Bradbury (2012) conducted a qualitative study with Black South African families about how the decision of older family members to refrain from discussing the horrors of apartheid violence with their children and grandchildren born after the end of apartheid in 1994 has often resulted in the development of inaccurate narratives about the past. The proposed program capitalizes upon the power of parental figures, family, and other significant influences to help shape a balanced picture of the past and present and a healthy image of self. The conjoint sessions are woven through the TF-CBT model, with particular emphasis on conjoint sessions after the participant has completed the trauma narrative (Cohen et al., 2006). In this proposed program outlined to address cultural trauma, conjoint sessions are also woven throughout the process. The “family” is invited to actively participate in the Psychoeducation and Parenting Skills stage, in the Trauma Narrative stage, and in the In Vivo Exposure stage. Ideally this high level of parental involvement will stimulate conversation about the themes of the program when students are at home or in other family settings. In summary, “the family” has a critical role to play in ensuring that the narrative from which participants learn to operate is an accurate one.

Enhancing Safety. In the TF-CBT model, the Enhancing Safety component is designed to help participants develop safety plans so that they feel more empowered to advocate for and protect themselves if they find themselves in positions of danger or vulnerability. This could include helping participants generate a list of trustworthy persons to whom they can reach out if uncomfortable situations arise or helping participants assemble emergency contact numbers. Rather than encouraging hypervigilance, the Enhancing Safety component sends the message to participants that they have the power and skills to protect their well-being (Cohen et al., 2006).

Anderson and Stevenson (2019) highlighted the efforts that parents of color may engage in after discovering that their children have experienced a discriminatory racial encounter, such as unfair treatment in school because of race, or after a highly publicized racially motivated assault, such as the fatal shooting of Trayvon Martin. Parents may use affirmational messages to assuage thoughts in their children that victims of discrimination are to blame. In this sense, teaching safety and protective factors is both about the protection of young people from physical attack or violation and about their protection from assault on their identity. In the context of cultural trauma, safety from the effects of cultural traumatization can be promoted through relationships with positive role models who will continue to support growth in self-esteem among student participants. Role models also can serve as accountability partners beyond the parental or family system so that students have other positive and supportive voices as they individuate from their caretakers. Enhancing safety involves teaching participants through case examples and role playing how to recognize systemic oppression and discrimination and how to solicit the support of family, church, and community to confront discrimination and oppression through appropriate administrative, community, and political channels. Helping students identify a cause about which they feel passionate and teaching them about self-advocacy through a letter-writing campaign is a practical strategy that can be used to facilitate this skill.



In conclusion, the potential utilization of TF-CBT as an intervention to address cultural trauma in African American youth requires a large amount of creativity and adaptation to the needs and resources of each participant group. We identify the following recommended priorities for those seeking to use the TF-CBT framework in this context.

First, the format of this program to address cultural trauma in African American middle school students ideally should take place in environments that are not reminiscent of traditional classroom spaces. We propose a program that is informative and inspiring, but not framed as an extension of usual school time. Although logistics might dictate the use of school spaces, it is suggested that efforts be made to decorate program spaces with youth-friendly and culturally relevant art and symbols, perhaps selected or created by participants when possible. If students experience traditional classrooms as a place of disempowerment, efforts are encouraged to promote a sense of ownership and positive investment in the program space by participants.

Second, program leaders—who might be school administrators, teachers, school or professional counselors, social workers, clergy, or community activists—are charged with building relationships with participants and their families to help them engage in their own within-family dialogues about the existence of cultural trauma, and also about the resources within families and communities to challenge and upset the existing power dynamic that has held African American people in a position of social disadvantage for centuries. Initial recruitment for the program as well as ongoing engagement will require program leaders to do regular check-ins to make sure participants, especially parents and guardians, understand the vision of the program and see that they are integral parts of its success. It is recommended that persons in the community who are seen as charismatic and engaging be invited to use these strengths to elicit and maintain participation.

Third, it is important that young people participating in the program feel respected and heard. In the face of conversations and discussions about very difficult and painful subject matter, such as past or present family traumas or racial violence, differing viewpoints may emerge along the lines of age and generational perspectives. Without sacrificing the effect of the wisdom and experience adults bring to the conversation, an environment that is open to the perspectives of youth participants is crucial. Program leaders should have some experience and training in active listening and facilitating difficult dialogue.

Lastly, this adaptation of TF-CBT to address cultural trauma is a time-limited program. Realistically, youth participants will need reminders and reinforcement of the lessons they learn about their family history, their cultural identities, and themselves. As they continue to develop psychosocially, new stages of growth will bring about new challenges that may cause participants to further question the manner in which the program prompted them to make sense of the world in which they live. In role model and mentorship relationships that participants are encouraged to develop, it is recommended that ongoing and long-term efforts be made to help participants continuously reflect upon and reintegrate their sense of empowerment so that it fits their reality as they progress into high school, college, and beyond. The manner in which a middle school student understands cultural trauma might be very different from the manner in which a college student conceptualizes cultural trauma.

Without denying or minimizing what has taken place and continues to persist (i.e., the historical oppression and current discrimination of African Americans on the basis of racial background), this approach to addressing cultural trauma emphasizes the adoption of an empowered sense of self and a heightened sense of collective agency that allows for creative self-transformation even in a society that continues to exhibit systemic injustice.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



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Ricardo Phipps, NCC, is Assistant Director of Student Counseling Services at Marymount University. Stephen Thorne is a chaplain and adjunct professor at Neumann University. Correspondence can be addressed to Ricardo Phipps, 2807 N. Glebe Rd., Arlington, VA 22207,

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

Yanhong Liu, Dan Li, Yanqing Xu

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

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

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

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

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

Indiscriminate Friendliness (IF)

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

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

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


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

Evolution of Diagnostic Criteria

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

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



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

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

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

Sampling and Recruitment

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

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


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

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

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

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

Research Design

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


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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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


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

Research and Clinical Implications

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

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


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

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest or funding contributions for the development of this manuscript.


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