Term Paper. Topic: Evidence Based Practices to Guide Clinical Practices

· Explain the interrelationship between the theory, research, and EBP.

· Identify and discuss the research questions, sampling and sampling size, research designs, hypothesis, data collection methods, and research findings from each study.

Don't use plagiarized sources. Get Your Custom Essay on

Just from $13/Page

Order Essay

· Identify the goals, health outcomes, and implementation strategies in the healthcare setting (EBP) based on the articles.

· Discuss the credibility of the sources and the research/researcher’s findings.

· Minimum 5/maximum 7 pages paper (the body of the paper), without the references, in APA format.

· Minimum of 1 reference per page of the body of the paper, articles must be peer reviewed and must have been published within last 3-5 years.

Maximum 10% of similarity.

POWER POINT TO PRESENT THE TERM PAPER

Present your Term Paper in class, minimum 10/maximum 15 slides, excluding the title and reference slides.
Discuss how it relates to scholarship and EBP nursing practice.

Maximum 10% of similarity.

Quantitative Research on Critical Thinking
and Predicting Nursing Students’
NCLEX-RN Performanc

Elizabeth M. Romeo, MS, CRNP, FNP

AbSTRACT
The concept of critical thinking has been influential in

several disciplines. Both education and nursing in general
have been attempting to define, teach, and measure this
concept for decades. Nurse educators realize that critical
thinking is the cornerstone of the objectives and goals for
nursing students. The purpose of this article is to review
and analyze quantitative research findings relevant to
the measurement of critical thinking abilities and skills
in undergraduate nursing students and the usefulness of
critical thinking as a predictor of National Council Licen-
sure Examination-Registered Nurse (NCLEX-RN) perfor-
mance. The specific issues that this integrative review ex-
amined include assessment and analysis of the theoretical
and operational definitions of critical thinking, theoretical
frameworks used to guide the studies, instruments used
to evaluate critical thinking skills and abilities, and the
role of critical thinking as a predictor of NCLEX-RN out-
comes. A list of key assumptions related to critical think-
ing was formulated. The limitations and gaps in the litera-
ture were identified, as well as the types of future research
needed in this arena

H
igher education has attempted to change the way
in which the nursing curriculum is structured (Ad-
ams, 1999). It is no longer acceptable to teach only

knowledge-based facts and skills; instead, the emphasis
has shifted toward guiding students to become lifelong, in-
dependent critical thinkers (Lee, 2007). Starting in the late
1980s, colleges of nursing moved from evaluation of the cur-
riculum to assessment of student outcomes (Riddell, 2007).
Nursing faculty must continue this shift from an emphasis
on teaching nursing content to one focusing on the applica-
tion of nursing knowledge (Adams, 1999; Del Bueno, 2005).
The application of nursing knowledge within the nurs-
ing process is enhanced through utilization of the process
of critical thinking (National League for Nursing [NLN],
2007). Nurse educators remain accountable for creating
and implementing curricula that produce graduate nurses
who are able to use critical thinking skills to formulate ap-
propriate clinical and nursing judgments (Henriques, 2002;
Hoffman, 2006; NLN, 2007; Youssef & Goodrich, 1996).

The National Council of State Boards of Nursing
(NCSBN) is an organization through which boards of
nursing act collaboratively on matters of public health,
safety, and welfare (NCSBN, 2007). This organization is
also responsible for the development of the licensing ex-
aminations in nursing. Because the NCSBN considers
critical thinking to be an important component in nursing
education and the National Council Licensure Examina-
tion-Registered Nurse (NCLEX-RN) measures graduates’
competency for entry into practice, it is presumed that
critical thinking is one element of nursing that is tested by
the NCLEX-RN (Giddens & Gloeckner, 2005). According
to the NCSBN, the majority of items on the NCLEX-RN
are written at the application and analysis level of Bloom’s
taxonomy. Successful performance on the NCLEX-RN re-
quires the use of critical thinking to correctly answer ques-
tions at this cognitive level (Wacks, 2005; Wendt, 2003;
Wendt & Brown, 2000).

Received: October 30, 2008
Accepted: October 27, 2009
Posted: March 31, 2010
Ms. Romeo is Clinical Instructor, Gwynedd-Mercy College, School

of Nursing, Gwynedd Valley, Pennsylvania.
The author has no financial or proprietary interest in the material

presented herein.
Address correspondence to Elizabeth M. Romeo, MS, CRNP,

FNP, Clinical Instructor, 405 Stonebridge Road, Perkasie, PA 18944;
e-mail: romeo.e@gmc.edu.

doi:10.3928/01484834-20100331-05

RomEo

METhod FoR INTEgRATIvE REvIEw

The process that was used for this integrative review
was the template proposed by Whittemore and Knafl
(2005). Their method for conducting an integrative review
includes the following five stages: a problem identification
stage, with the definition of relevant terms; a literature
search stage, to identify all significant literature on the
topic; a data evaluation stage, with the recommendation
to include similar designs; a data analysis stage that en-
compasses data reduction, data display, data comparison,
conclusion drawing, and verification; and a final presenta-
tion stage that is generally reported in a table or diagram-
matic form (Whittemore & Knafl, 2005).

Problem Identification Stage and Identification of
Relevant Term

Critical thinking is an attribute that enhances one’s
skill in problem solving and decision making. The purpose
of this article is to review and analyze recent quantitative
research findings relevant to measuring critical thinking
abilities and skills in undergraduate nursing students
and critical thinking’s role as a predictor of NCLEX-RN
performance. The specific issues that this integrative re-
view will examine include assessment and analysis of the
theoretical and operational definitions of critical thinking,
theoretical frameworks used to guide the studies, tools to
evaluate critical thinking skills and abilities, and the role
of critical thinking as a predictor of

NCLEX-RN outcomes.

A list of key assumptions related to critical thinking will
be formulated. The limitations and gaps in the literature
will be identified, as well as the types of future research
needed in this area.

Theoretical definitions of Critical Thinking
Nursing has evolved from a simplistic occupation to a

complex and highly technical profession; therefore, nurses
have changed from being task-oriented team members to
becoming autonomous health care providers (Allen, Ru-
benfeld, & Scheffer, 2004). Due to the increasing complex-
ity of the clinical setting, the need to develop and nur-
ture critical thinking skills is paramount (Frye, Alfred,
& Campbell, 1999). A concise definition of the concept of
critical thinking is one that various disciplines continue
to struggle with today (Akerson, 2001; Allen et al., 2004;
Frye et al., 1999; Kataoka-Yahiro & Saylor, 1994).

The studies reviewed in this integrative review in-
cluded a variety of definitions of critical thinking. The
definition offered by Paul (1993) is that it is a method
of examining one’s thinking with the goal of improving
the thought process to make it clearer and more accu-
rate (Frye et al., 1999). In the study conducted by Wacks
(2005), the definition of critical thinking used was from
the work of Watson and Glaser (1980), who defined it as
a combination of one’s attitudes, level of knowledge, and
skills. Akerson (2001) offered yet another definition of
critical thinking that is specific to nursing and is based
on the work of Kataoka-Yahiro and Saylor (1994). Accord-

ing to Akerson, critical thinking is a process involving
critical, reflective, and reasonable thinking about prob-
lems specific to nursing practice that do not have a single
answer and is centered on deciding what to do or believe.
It also has been defined as a cognitive procedure that
drives problem solving and decision making (Henriques,
2002). Frost (2000) offered another definition of critical
thinking that is specific to nursing: critical thinking is a
process involving critical, reflective practice with a basis
in sound reasoning of intelligent minds that are commit-
ted to safe and effective patient care. The process of criti-
cal thinking is best measured from a holistic perspective
encompassing both abstract thinking and the practice
skills that are unique to the nursing environment (Hoff-
man, 2006).

one of the first intensive research studies done to de-
velop a widely accepted theoretical definition for critical
thinking was undertaken in 1990 by means of the Delphi
method. A panel of 46 experts from the United States and
Canada from different scholarly disciplines participated
in this 2-year project in an effort to globally define critical
thinking. Peter Facione, PhD, is internationally known
for his work on the definition and measurement of critical
thinking. His research on teaching and assessing critical
thinking has been ongoing for the past 40 years. Dr. Fa-
cione was a prominent member of The Delphi Report in
1990, which defined critical thinking as a decisive, self-
regulated judgment that promotes a forum in which to ad-
dress clinical and professional nursing issues in an effec-
tive method. According to Facione (1990), “critical thinking
is essential as a tool of inquiry” (p. 3). The ideal critical
thinker continually draws on past experiences and one’s
knowledge base to honestly and openly assess and resolve
complex issues in an orderly fashion (Facione, 1990; mor-
ris, 1999; morris, 1998).

Stewart and Dempsey (2005) defined critical thinking
from the specific standpoint of the American Philosophi-
cal Association (1990), which describes critical thinking
dispositions. These dispositions include attributes such
as “habits of the mind, intellectual virtues, a character-
ological profile, and a set of attitudes toward thinking pro-
cesses” (Stewart & Dempsey, 2005, p. 81). Critical think-
ing has also been defined as a vibrant, purposeful, logical
process that results in articulate decisions and judgments.
The process of critical thinking in this definition encom-
passes interpretation, analysis, evaluation, inference,
explanation, and self-regulation (Whitehead, 2006). The
final study reviewed did not provide a definition of critical
thinking (Youssef & Goodrich, 1996).

one definition of critical thinking that is important to
nursing and was not found in any of the reviewed studies
is the definition based on the work of Scheffer and Ruben-
feld (2000). They also used the Delphi technique with five
rounds of input to achieve a definition of critical thinking
specifically for the discipline of nursing. The participants
in that study consisted of an international panel of expert
nurses representing 9 countries and 23 states in the Unit-
ed States who worked from 1995 to 1998 to develop the fol-

Journal of Nursing Education • Vol. 49, No. 7, 2010 379

QUANTITATIvE RESEARCH oN CRITICAL THINKING

lowing consensus definition of critical thinking in nursing
(Scheffer & Rubenfeld, 2000):

Critical thinking in nursing is an essential component of
professional accountability and quality nursing care. Criti-
cal thinkers in nursing exhibit these habits of the mind:
confidence, contextual perspective, creativity, flexibility, in-
quisitiveness, intellectual integrity, intuition, open-mind-
edness, perseverance, and reflection. Critical thinkers in
nursing practice the cognitive skills of analyzing, applying
standards, discriminating, information seeking logical rea-
soning, predicting and transforming knowledge. (p. 357

)

LITERATuRE SEARCh

data Collection
The literature review was conducted via hand, Inter-

net, and database searches from January to April 2008.
Computer searches used
the Cumulative Index for
Nursing and Allied Health
Literature, ProQuest Nurs-
ing Journals, and Pubmed.
Search words that were used
in various combinations in-
cluded “critical thinking,”
“nursing, students,” “research
instruments,” “quantitative
research,” “pretest-posttest,”
and “NCLEX-RN results.” The
Cumulative Index for Nursing
and Allied Health Literature,
ProQuest, and Pubmed data-
bases produced 20, 10, and 23 articles, respectively, which
were selected based on specific inclusion and exclusion cri-
teria. The inclusion criteria were studies that were quanti-
tative in design, research articles published in professional
journals, and dissertations written in English, and they in-
volved undergraduate nursing students, described the use
of a critical thinking assessment tool, and were published
between 1988 and 2008.

Undergraduate nursing students were the population
selected because the majority of studies pertaining to
critical thinking are based on this group. The inclusion of
studies that contain a quantitative critical thinking tool
was necessary to measure the independent variable. The
rationale for the dates of the search was to coincide with
the implementation of the current format for the NCLEX-
RN as a pass/fail examination. Exclusion criteria included
qualitative research, graduate nursing students compris-
ing the population, editorials and articles published prior
to 1988, studies involving a specific intervention to en-
hance critical thinking with no correlation to NCLEX-RN
outcomes, abstracts without full text, case studies, letters,
or secondary sources.

There were 8 articles that met the criteria for inclu-
sion in this project. An ancestry search and citation-in-
dex search were conducted on the 8 articles, which were
initially found in the 3 different Internet databases. An

additional 4 articles that met the criteria were found,
for a total of 12 relevant articles for this integrative re-
view.

data Analysis and Interpretation
This integrative review revealed four different meth-

ods that have been used to study the critical thinking
abilities of nursing students in comparison to NCLEX-RN
outcomes. The first method used was the measurement of
critical thinking abilities at the beginning and at the end
of the nursing curriculum, which was used as a predictor
of NCLEX-RN success. A second method measured criti-
cal thinking abilities once at either the beginning or the
end of the nursing program and examined students’ criti-
cal thinking abilities as a predictor of NCLEX-RN suc-
cess. The third method used in one study measured criti-
cal thinking by means of repeated measurements taken

five times over the course of
the students’ education. The
final method that was used
in three studies examined
the differences between two
distinct types of students in
regard to their critical think-
ing abilities and NCLEX-RN
scores. The analysis and in-
terpretation of the articles
are categorized by these
methods. A summary table
of the studies is located in
the Table.

Key Assumptions from Integrative Review
Several assumptions of critical thinking that were ei-

ther implied or explicitly stated became apparent in the
course of this review (Hall, 1996; Stewart & Dempsey,
2005; Wacks, 2005):

l Critical thinking is widely accepted as a skill that is
necessary in the practice of professional nursing.

l Critical thinking skills can be taught, learned, and
measured.

l Students in the studies make an honest effort to per-
form well on the tests.

data Comparison
The state of the science in regard to studies that have

been conducted on critical thinking in nursing education
and practice is expansive, as found during the process of
this integrative review. However, few studies have exam-
ined critical thinking as a predictor of NCLEX-RN perfor-
mance. Several limitations in these studies were identified
in the process of this review. Some of the major limitations
identified were related to the lack of a theoretical or con-
ceptual framework, sampling issues, the definition of criti-
cal thinking, and measurement tools. The lack of quanti-
tative studies

available that use critical thinking as an

independent variable and NCLEX-RN as the dependent
variable substantiate the

need for further research.

The lack of quantitative studies

available that use critical thinking as an

independent variable and NCLEX-RN as

the dependent variable substantiate the

need for further research.

RomEo

Theoretical Frameworks
most quantitative research has the common underly-

ing goal of testing the relationships that are suggested by
theories. of the 12 studies that were reviewed, only 5 in-
cluded a theoretical framework that guided the research
(Akerson, 2001; Hoffman, 2006; morris, 1999; Wacks,
2005; Whitehead, 2006). Because there is currently not
one accepted theory of critical thinking, each of the 5 stud-
ies used a different theory, which further demonstrated
the infancy of the state of the science in studying critical
thinking. The remaining research studies did not include
any framework or theory as a guide for the study.

Theoretical definition of Critical Thinking
Because there is currently a lack of an accepted frame-

work for critical thinking, there is not a widely acknowl-
edged and accepted theoretical definition. As previously
noted, there is a plethora of both theoretical and opera-
tional definitions for critical thinking. As a discipline,
nursing is in need of agreement on and acceptance of one
of the current, concise theoretical definitions of critical
thinking for use in education and clinical practice (Adams,
1999; Frye et al., 1999; Hall, 1996; Stewart & Dempsey,
2005). Interestingly, neither of the current nursing-
specific definitions of critical thinking—the one developed
by the NLN for clinical nursing practice or the definition
from the work of Scheffer and Rubenfeld (2000)—were
used as the theoretical definition for critical thinking in
any of the studies that were analyzed. Because the theo-
retical definition of critical thinking is directly related to
a critical thinking theory, the exploration of these two fac-
tors needs be conducted simultaneously. The operational
definitions of critical thinking will remain tool specific,
with a need to continue studying the reliability and valid-
ity of the measures of critical thinking.

Critical Thinking Measurement Tools
The California Critical Thinking Skills Test. The

majority of the valid and reliable tools available to mea-
sure critical thinking skills and abilities are not specific
for use with nursing students. The measurement tool
that was used most frequently was the California Critical
Thinking Skills Test, which yielded mixed findings in the
reviewed studies. The California Critical Thinking Skills
Test is a 34-item multiple choice test that measures over-
all critical thinking skills, in addition to 5 subscales that
specifically assess analysis, evaluation, inference, and
deductive and inductive reasoning (Brunt, 2005; Phillips,
Chestnut, & Rospond, 2004). This is a timed test of 45
minutes, with a maximum score of 34 on the skills test
(Brunt, 2005).

Positive relationships of critical thinking skills and
NCLEX-RN success were found in half of the studies that
used this tool (Giddens & Gloeckner, 2005; Hall, 1996;
morris, 1999), although no statistical significance was
found in the remainder of the studies with the California
Critical Thinking Skills Test (Akerson, 2001; Henriques,
2002; morris, 1998).

The California Critical Thinking Disposition In-
ventory. The California Critical Thinking Disposition In-
ventory (CCTDI) is designed to measure a student’s procliv-
ity to think critically (Phillips et al., 2004). There are seven
identified dispositions or “habits of the mind” that are the
elements of one’s character that move one toward using
critical thinking skills. Each section has several questions
that evaluate specific thought habits; there is a subscale
score for each of the 7 subscales, in addition to a total score
for the test. For each subscale, a score below 40 indicates a
general weakness in that area, and a score above 50 rep-
resents a consistent strength. A total CCTDI score below
280 represents serious overall deficiencies in the student’s
critical thinking dispositions and a score above 350 shows
overall strengths (Giddens & Gloeckner, 2005; Phillips et
al., 2004). The 7 dispositions are as follows:

l Truth-seeking is a desire to gain the best knowledge,
even if it undermines one’s preconceptions or belief

l open-mindedness is a tolerance of views other than
your own, as well monitoring oneself for possible bias.

l Analyticity is demonstrated by the demand for ap-
plication of reason and evidence, awareness of problem
situations, and an inclination to anticipate consequences.

l Systematicity relates to one’s focus on approaching
all levels of problems and valuing organization.

l Critical thinking self-confidence is the trusting of
one’s own reasoning skills.

l Inquisitiveness relates to one’s curiosity and eager-
ness to acquire knowledge and learn explanations.

l Cognitive maturity is indicative of prudence in mak-
ing, suspending, or revising judgment. It is awareness
that multiple solutions can be acceptable (Facione, 2007;
Phillips et al., 2004).

Construct validity of the CCTDI was reported by Stew-
art and Dempsey (2005) as being established by Facione
and Facione (1992). validity for this instrument was
not reported in the remainder of the studies (Giddens &
Gloeckner, 2005; Henriques, 2002). Giddens and Gloeck-
ner (2005) were the only ones who reported statistically
significant findings when the total mean CCTDI exit
scores were found to be higher in the first-time NCLEX-
RN pass group than in the failure group.

The Watson-Glaser Critical Thinking Appraisal
Tool. The Watson-Glaser Critical Thinking Appraisal
(WGCTA) is a tool available to measure critical think-
ing abilities with three different forms of the instrument
available. Form A and Form B are parallel tools available
for use as pretest and posttest measurements, and Form
S is the latest, shortest version of the instrument (Wacks,
2005). The WGCTA Form S is composed of 16 scenarios and
40 items to be answered. This instrument has been found
to be appropriate for assessing critical thinking ability in
individuals with at least a ninth grade education. The as-
sessment is divided into five subsets: inference, recogni-
tion of assumptions, deduction, interpretation, and evalu-
ation of arguments. In the liberal arts setting, upper-level
students have higher scores than do entry-level students
on the WGCTA (Frye et al., 1999).

Journal of Nursing Education • Vol. 49, No. 7, 2010 381

QUANTITATIvE RESEARCH oN CRITICAL THINKING

The WGCTA total score and various subsets of the score
were found to be significant predictors of NCLEX-RN per-
formance (Frye et al., 1999; Wacks, 2005). In contrast,
Hall’s (1996) literature review suggested that WGCTA
may not be a valid measure of critical thinking in nurs-
ing students because it does not measure the cognitive
process underlying the nursing process. The WGCTA may
not be an accurate measure of the reasoning needed for
critical thinking and, ultimately, for making reasonable
clinical decisions. The question that arises both implicitly
and explicitly in these studies is the appropriateness of
non-nursing-specific tools as reliable and valid measures
of critical thinking abilities in nursing students.

other Critical Thinking Tools
There were five lesser known tools specifically de-

signed to measure critical thinking in nursing students
that were used by different researchers. These include
the Assessment Technologies Institute’s (ATI) instru-
ment, the Critical Thinking Assessment (CTA) test, and
three tests by the Educational Resources Incorporated
(ERI): the Nurse Entrance Test (NET), the Critical Think-
ing Process Test (CTPT), and
the RN Assessment Test. A
final critical thinking mea-
surement tool is the Scale of
Judgment Abilities in Nurs-
ing (SJAN).

The CTA is a 40-item ob-
jective instrument that was
developed to determine stu-
dents’ performance on spe-
cific critical thinking skills
at the beginning and end of
the nursing program. There
are six to eight questions
for each critical thinking
skill on the test. The goal
of the diagnostic pretest is
for development of instructional strategies by nursing
faculty to enhance higher thinking skills. The posttest
measures the student outcomes after the instructional
intervention and, as such, readiness for the NCLEX-
RN. The six competencies that are incorporated into
the ATI CTA are interpretation, analysis, evaluation,
inference, explanation, and self-regulation (Whitehead,
2006). This particular nursing-specific tool used to mea-
sure critical thinking has only been available since 2000
(Whitehead, 2006).

ERI designed three different tests to measure criti-
cal thinking at various times during the nursing cur-
riculum; however, only two of the tests will be described
in this integrated review. The first test that was used to
measure critical thinking skills in nursing students is
the CTPT. This tool assesses the following five levels of
abstract thinking: prioritizing/discriminating, inferen-
tial reasoning, goal setting, application of knowledge,
and evaluation of predicted outcomes (Hoffman, 2006).

The second test provided by ERI is the RN Assessment
Test, used by both Stewart and Dempsey (2005) and
Hoffman (2006) to assess the critical thinking abilities
of nursing students prior to graduation. This assess-
ment test provides a total score plus 32 subscale scores.
Five of the subscales are related to critical thinking
and are labeled as prioritizing/discriminating, infer-
ential reasoning, main idea and predicting outcomes,
application and knowledge, and evaluating predicted
outcomes.

The SJAN is another instrument that examines the
professional judgment of nursing students in four areas:
legal/ethical, problem solving and decision making, com-
munication, and leadership functioning (Youssef & Go-
odrich, 1996). The purpose of the test is to examine an in-
dividual’s ability to understand and apply knowledge. The
tool is composed of 28 multiple-choice questions and has
an equal number of questions in the four content areas.
Reliability and validity of the SJAN were not addressed
by the authors.

The tools that were developed to be used specifically
with nursing students also had differing results. The ERI

tests results were found to
have no statistical signifi-
cance in relation to critical
thinking and were even
deemed a measure of safe
practice rather than a direct
measure of critical thinking
(Stewart & Dempsey, 2005).
Hoffman (2006) reported the
exact opposite findings in her
study using the three ERI
tests that revealed a predic-
tive relationship of critical
thinking skills and NCLEX-
RN pass rates. The ATI CTA
and SJAN were used in stud-
ies that compared two diverse

groups of nursing students and their critical thinking abil-
ities. Neither study found significant differences between
the groups’ critical thinking skills; however, no attempt
was made in either study to correlate critical thinking to
NCLEX-RN scores (Whitehead, 2006; Youssef & Goodrich,
1996) (Table).

Sampling Issues
The majority of the studies used nonrandomized,

convenience samples due to the nature of the indepen-
dent variable of critical thinking as not being conducive
to manipulation. Sample sizes ranged from 24 (Akerson,
2001) to 437 nursing students (Hoffman, 2006). In gen-
eral, the majority of studies included primarily nursing
students at the BSN level with two studies that included
only ADN students (Wacks, 2005; Youssef & Goodrich,
1996) and one study that compared the critical think-
ing of BSN and ADN students (Whitehead, 2006). The
majority of the authors stated that their studies were

The current state of science on

measurement of critical thinking in nursing

students reflects a lack of adequate

sample sizes to effectively determine the

relationship of critical thinking scores and

NCLEX-RN outcomes.

RomEo

Ta
b

l
e

C
ri

ti
c

a
l T

h
in

k
in

g
i

u
rs

n
g

e
d

u
c
a
ti

o
n

S
tu

d
y

C
o

n
c
e
p

h
e

ry
D

e
s

n
a

n
d

To
o

l
R

e
li
a
b

il
it

y
a

n
d

V
a
li
d

it
y

R
e

s
u

lt
s

A
ke

rs
o

(2
0
0
1
)

C
T,

N
C

L
E

X
–

R
N

K
a
ta

o
ka

-Y
a
h
ir
o

a
n

d
S

a
yl

o
r

A
p

ilo
t

u
d

y.
A

c
o

n
ve

n
ie

n
t

sa
m

p
le

o
f

4
B

S
N

s
tu

d
e

n
ts

C
T

S
T

F
o

rm
A

(
K

u
d

a
r-

R
ic

h
a

rd
so

n
te

n
a

l c
o

n
si

st
e

n
cy

r
e

lia
b

ili
ty

c
o

e
ffi

ci
e

n
t

fr
o

m
0

.6
8

t
o

0
.7

).
C

ro
n

b
a

ch
’s

a
lp

h
a

0
.7

1
. C

o
n

st
ru

ct
v

a
lid

ty
a

cc
o

d
in

g
t
o

T
d

e
fin

iti
o

n
b

y
T

h
e

D
e

lp
h

i R
e

p
o

rt
.

C
o

n
cu

rr
e

lid
ity

b
y

o
rr

e
la

io
n

C
C

T
S

T
t

c
o

lle
g

e
G

P
A

a
n

d
S

A
T

v
e

rb
a

o
re

s.
N

C
L

E
X

-R
N

N
o

s
ig

n
ifi

ca
n

co
rr

e
la

tio
n

o
u
ld

e
t

e
st

d
b

e
tw

e
n

sc
o

e
s

o
ta

l a

n
d
s

u
b

a
le

)

d
N

C
L
E

X
a

d
a

ls
o
n

o
t

e
st

o
f

co
rr
e
la

tio
n
b

e
tw

e
e

n
t

e
n

u
m

e
r

o
f

q
u
e
st

n
s

to
p

a
ss

N
C

L
E

d
u

e
t

o
a

ll
su

b
je

ct
s

p
a

in
g

. T

m
e

f
o
r

e
xa

m
in

a
tio

n
a

n
d
C

sk
ill

s
h
a
d
s

g
n

ifi

ca
n
tly

n
e

a
tiv

e
c

o
rr
e
la

tio
n
.

F
ry

e
,
A

fr
e

d
,

&
C

a
m

b
e

(

1
9

9
9
)

C
T,
N
C
L
E
X
–
R
N

o
n
e
id

e
n
tifi

e
d

C
ro

ss
-s

e
ct

io
n

a
l d

e
si

g
n
a
n

a
lo

n
g

tu
d

in
a

l d
e

si
g

n
; a

n
ve
n
ie

s
a

m
p

le
o

f
1

3
2

e
sh

m
a

n
a
n
d

7
7

s
e

n
io

B
S

N
s

tu
d
e
n

ts
. L

o
n

g
itu

d
in

a
l

d
e
si
g

n
w

ith
2

7
f
re

sh
m

a
n
.

W
G

C
TA

(
F

o
rm

A
)

p
re

te
st

-p
o

st
te

(C
ro

n
b

a
ch

’s
a

lp
h

a
c

o
e

ffi
ci

e
n

t
=

0
.6

to
0

.8
5

).
C
o
n

te
n

t
va

lid
ity

e
xa

m
in
e
d

e
ve

a
l s

e
tt
in

g
s

a
n

d
c

o
rr
e
la

te
s

w
ith

e
ci

fic
o

b
je

ct
iv

e
s

o
f
e

d
u

ca
tio

n
a

ro
g
ra

m
s)

. N
C

L
E

X
-R

S
ta

tis
tic

a
l s

g
n
ifi

ca
n
t

d
iff

e
re

n
ce

b
e

e
e
n
t

h
e
u

n
re

a
te

fr
e
sh
m

a
n
a

n
d
s

e
n
io

r
C

T
s

co
re

s.
P

o
si

iv
e

o
rr
e
la

tio
n
w

a
s

fo
u

n
d
b

e
tw

e
e
n
C

T
s
co
re

s
a

n
d
N

C
L
E
X
-R
N
s

u
cc

e
ss

a
m

o
n

2
7

s
e
n
io

rs
. N

o
s

a
tis

tic

a
lly

s
ig
n
ifi
ca
n
t
d
iff
e
re
n
ce
b
e
tw
e
e
n
t

h
e

C
T

s
co

re
s

o
f

th
e

7
a

s
fr

e
sh

m
a
n
a

n
d
a

g
a
in

a
s

se
n
io

rs
.

G
id

d
e
n
s

G
lo

e
ck

n
e
r

(2
0

0
5

)

C
T,
N
C
L
E
X
–
R
N

N
o
n
e
id

e
n
tifi
e
d
N
o

n
e
xp

e
ri

m
e

n
ta

l e
x

p
o

s
fa

ct
o

r
e

e
a

rc
h

a
p

p
ro

a
ch

. A

o
n
ve

n
ie
n
ce
s
a
m
p
le
o

f
2

1
8

S
N
s
tu
d
e
n
ts
.
C
C
T
S

T
a

n
d

C
C

T
D

I
b

o
th

m
e

a
su

re
d

ic
e

. N

C
L
E
X
-R
N
C
C
T
D

I
(C

ro
n
b
a
ch
’s

a
lp
h

a
=

0
.9

0
o

n
t
o

ta
l s

co
re
a
n

d
r

a
n

g
e

f
0

.6
0

t
o

0
.7

8
o

n
s

u
b

sc
a

e
s.

C
o

n
st

ru
ct

va
lid
ity

e
st

a
b
lis

h
e
d
b

a
ci

o
n

e
a

n
d

F
a
ci
o
n

P
a

rt
ic

ip
a
n
ts

w
h

o
p

a
ss

d
t

h
e
N

C
L
E
X
-R

N
h

d
h

ig
h
e
r

C
C
T
S
T

sc
o
re
s

th
a
n
t

h
o
se

w
h
o
f
a
ile

d
. T

h
e
re

w
a

n
o

ta
tis

tic
a

lly

g
n

ifi
ca

n
t

ch
a
n
g

e
in

e
ith

e
r
C
T

s
ki

lls
o

r
d
is

p
o
si

tio
n
s

o
ve

r
th

co
u

rs
e
o

f
th

e
n
u
rs

g
c

u
rr

ic
u
lu

m
.

H
a
ll

(1
9
9
6
)

C
T,
N
C
L
E
X
–
R
N

,
C

o
g
n
iti

D
e
ve

lo
p

e
n
t

N
o
n
e
id
e
n
tifi
e
d
C
o
rr
e

la
tio

n
a

,
n

o
n

–
e
xp

e
ri
m
e
n
ta
l d
e
si
g

n
1

0
5

n
io

r
B

S
N
s
tu
d
e
n
ts

f
ro

m
a

co
n
ve
n
ie
n
ce
s
a
m
p
le
C
C
T
S
T
a
n
d

L
E

P
t
e

st
s.

N
C
L
E
X
-R

N
A

s
a

g
ro

u
p

d
id

n
o
t

e
m

o
n
st

ra
te

C
T

b
ili

ty
. C

T
a

n
d
fi

n
a

n
ci

a
l

st
a

tu
s

w
e
re

s
ig
n
ifi
ca
n
t
p
re

d
ic

to
rs

o
f
N
C
L
E
X
-R
N
s
u
cc
e
ss
.

H
e
n
ri

q
u
e
s

(2
0
0
2
)

C
T,
N
C
L
E
X
–
R
N

o
n
e
id
e
n
tifi
e
d
R
e

tr
o

p
e

ct
iv
e
c
o
rr
e
la
tio
n
a
l
d
e
si
g

n
. C

o
n
ve
n
ie
n
ce

m
p
le
o
f
1

5
2

B
S

st
u

d
e
n
ts
C
C
T
D

I,
C

C
T

S
T,

N
C
L
E
X
-R

N
,
P

re
–

N
u

rs
in

g
G

u
id

a
n

ce
t
e

st
s

co
re

s,
N

D
R

sc
o

re
s,

D
R

T
s
co
re
s

T
h

e
C

C
T

D
I

a
n
d
C

C
T
S
T

d
id

n
o

re
ve

a
l a

s
ta

tis
tic
a
l
si
g
n
ifi

a
n
ce

in
p

re
d
ic

tin
g
N

C
L
E
X
-R
N
s
u
cc
e
ss

T
h

e
b

e
st

p
re
d
ic
to
rs
f
o
r
N
C
L
E
X
-R
N
s
u
cc
e
ss

w
e

t
h

e
N

D
R
T
a

n
d
D

R
T

sc
o
re
s.

H
o
ff
m

a
n

(2
0
0
6
)

C
T,
N
C
L
E
X
–
R
N

P
e
rr

y’
s

E
th

ic
a
l

a
n
d
I

n
te

lle
ct

u
a
l

D
e
ve
lo
p
m

e
n
t

S
ch

e
m
e
D
e

sc
ri

p
tiv

e
c
o
rr
e
la
tio
n
a
l
a
n

a
ly

si
s

f
se

co
n

d
a

ta
f
ro

m
a
c
o
n
ve
n
ie
n
ce

sa
m
p

le
a

t
a

B
S

N
p

ro
g
ra

o
m

p
a

ri
n

g
4

3
7

s
tu
d
e
n
ts

ra
d

iti
o
n
a

,
n
=

3
1

8
a

n
d

a
cc

e
le

ra
te

d
,
n

=
1

1
9
)

E
R

I:
N

E
T,

C
T

P
T,

a
n

d
R

N
A

ss
e

ss
m

e
n

t
Te

st
. C

T
P

T
m

e
a

su
re

d
t
w

ic
e
. (

C
T

P
T

C
ro
n
b
a
ch
’s
a
lp
h
a

=
0

.9
3

. V
a

lid
ity

d
d

re
ss

e
d
w
h
e
n
s
tu
d
e
n
ts

’ s
co

re
s

im
p

ro
ve

d
f
ro

m
p

re
te

st
t
o

p
o

st
te

st
.

R
N

A
ss

e
ss
m
e

n
t
te

st
: C

ro
n
b
a
ch
’s

a
lp
h
a
=
0
.9

0
t
o

0
.9

4
. V

a
lid
ity
a
d
d
re
ss
e
d

b
y

d
e
ve

lo
p
e
r
w
ith

in
cr

e
a

se
in

s
co
re
s
fr
o
m
p
re
te
st
t
o
p
o
st
te

st
.)

N
E

T
r

e
a
d
in

g
c
o
m
p
re

e
n
si

o
n
s

co
re

s
(a

ft
e
r

co
m

p
le

tin
g
1

n
u

rs
in
g
c

o
u
rs

e
)

w
e
re

h
ig

h
ly

p
re

d
ic

tiv
e
o

n
R

N
A

ss
e
ss

m
e
n
t

a
n
d
N
C
L
E
X
-R

N
. C

T
P
T
a

n
d
R

N
A
ss
e
ss
m
e
n
t

sc
o
re

s
(a

t
e

n
d

o
f
p

ro
g
ra

m
)

w
e
re
p
re
d
ic
tiv
e
o

f
N

C
L
E
X
-R

N
.

M
o
rr

is
(

1
9
9
9
)

C
T,
N
C
L
E
X
–
R
N

B
e
n
n
e
r’s

N
o
vi

to
E

xp
e
rt

ilk
in

so
n
’s

e
sc

ri
p

tio

n
o

f
th
e
n
u
rs

in
g

p
ro

ce
ss

D
e
sc
ri
p
tiv
e
c
o
rr
e
la
tio
n
a
l
st
u

d
y

w
ith

8
3

s
e
n
io
r
B
S
N

C
C
T
S
T

g
iv

e
n

o
n

C
D

M
N

S
-c

lin
ic

a
l d
e
ci

si
o

n
m

a
ki

n
g

L
o

p
o
si

tiv

e
s

ta
tis

tic
a
l s

ig
n
ifi
ca
n
ce
b
e
tw
e
e
n
C
T
a
b
ili
ty
a
n
d

N
C
L
E
X
-R
N
p
a
ss

r
a
te

s.
N
o
s
ig
n
ifi
ca
n
ce
b
e
tw
e
e
n
t

h
e
fi

rs
t

a
n
d

e
co

n
d
s
e
n
io

r
se

m
e
st

e
r
C
T
s
co

re
s.

M
o
rr
is
(

1
9
9

8
)

C
T,
N
C
L
E
X
–
R
N
N
o
n
e
id
e
n
tifi
e
d

E
x

p
o

st
f
a

ct
o
c
o
rr
e
la
tio
n
a

l
w

ith
B

S
N

8
2

s
tu
d
e
n
ts
C
C
T
S

T
F

o
rm

s
A

(
ju

n
io

r
ye

a
r)

a
n

d
B

e
n

io
r

ye
a

r)
; N

L
N

P
A

X
-R

N
N

o
s
ig
n
ifi
ca
n
t
d
iff
e
re
n
ce
b
e
tw

e
e
n
p

re
te

st
a

n
d
p

o
st

te
st
C
T

a
b
ili

ty
. T

h
e
v

a
ri

a
b
le

s
e
t

a
s

a
w

h
o
le

w
a
s

re
la

te
d

o
e

xi
t

C
T

sc
o
re

s,
b

u
t

n
o
o

n
e
v

a
ri
a
b
le

d
e
m

o
n
st
ra
te
d
a

n
in

d
e
p
e
n
d
e
n
t

re
la

tio
n
sh

ip
t

o
C

o
c

o
m

b
in

a
tio
n
o

f
va

ri
a
b
le

s
w

a
s
p
re
d
ic

tiv
e

o
f
N

C
L
E
X
-R

N
o

u
tc

o
m
e
s.

Journal of Nursing Education • Vol. 49, No. 7, 2010 383

QUANTITATIvE RESEARCH oN CRITICAL THINKING
Ta
b
l
e
C
ri
ti
c
a
l T
h
in
k
in
g
i

n
N

u
rs
in
g

e
d

u
c
a
ti
o
n
S
tu
d
y
C
o
n
c
e
p
ts
T

h
e
o

ry
D
e
s
ig
n
a
n
d

S
a
m

p
le
To
o
l
R
e
li
a
b
il
it
y
a
n
d
V
a
li
d
it
y

R
e
s
u

lt
s

S
te

w
a
rt

D
e
m

p
se

y
(2

0
0
5
)

C
T,
N
C
L
E
X
–
R
N
N
o
n
e
id
e
n
tifi
e
d
L
o
n
g

itu
d

in
a
l d
e
sc
ri
p
tiv
e

d
e
si
g

n
. A

c
o
n
ve
n
ie
n
ce

sa
m
p
le
o

f
5

5
B

S
N

st
u
d
e
n
ts
C
C
T
D

I,
E

R
I,
a

n
d
N
C
L
E
X
-R
N
C
C
T
D
I

b
sc

a
le

s
a

n
d
t

o
ta

l s
co

e
w

e
re

b
o
th

s
ta
tis
tic
a
lly

si
g
n
ifi
ca
n
t
w
ith

t
h
e
C

T
s
u
b
sc
a
le
o
f

in
fe

re
n

tia

l r
e
a
so

n
in

h
a
vi

n
g
a

c
o
rr

e
la

tio
n
t

o
G

P
A

. W
ilc

o
xo

n
s

ig
n
e
d
r

a
n
ks

h
o
w

e
d

n
o
s
ig
n
ifi
ca
n
t
d
iff
e
re
n
ce

s
b
e
tw

e
e
n
C
T
d

is
p
o
si

tio
n
s
o
f

th
o

se
w

h
o
p

a
ss

e
d
a

n
d
t
h
o
se
w
h
o
f
a
ile
d
N
C
L
E
X
-R

N
. E

R
I

R
N

a
ss

e
ss
m
e
n
t
sc
o
re

s
d
id

n
o
t

co
rr
e
la

te
w

ith
a

n
y

C
C
T
D

I
su

b
sc
o
re

s—
in

te
rp

re
te
d
t

o
m

e
a
n
t

h
a
t

E
R

I
d
o
e
s

n
o
t

re
fle

ct
a

ro
p

e
n
si

ty
t

o
C
T.

W
a
ck

s
(2

0
0
5
)
C
T,
N
C
L
E
X
–
R
N

B
a
n
d
u
ra

R
e
tr
o

sp
e

ct
iv

e
,
d

e
sc
ri
p
tiv
e

co
rr
e
la
tio
n
a
l d
e
si
g

n
.

C
o
n
ve
n
ie
n
ce
s
a
m
p
le
o
f
2

6
6

s
tu
d
e
n
ts
f
ro
m
a
n

A
D

N
p
ro
g
ra
m
W
G
C
TA
(
F
o
rm

S
)

A
C

T,
G

P
A

,
a

n
d

N
C
L
E
X
-R
N

. A
ll

m
e
a
su
re
d
o
n
ce

u
p
o
n

a
d

m
is

si
o

n
. (

C
ro
n
b
a
ch
’s
a
lp
h

co
e

ffi
ci
e
n
t
=

0
.8

1
. C
o
n
te
n
t
va
lid
ity

e
xa

m
in
e
d

in
s

e
ve

ra
l s

e
tt
in
g
s
a
n
d

co
rr
e
la
te
s
w
ith

s
p

e
ci
fic
o
b
je
ct
iv
e
s
o
f
e
d

u
ca

tio
n

a
l p

ro
g
ra

m
s.

)
A
C
T
t
o
C

T
(

W
G
C
TA

)
(p

=
0

.0
0
0
6
)

a
n
d
W

G
C

TA
t

o
N

C
L
E
X
–
R
N

(
p

< 0

.0
0
2
)

w
e
re
s
ig
n
ifi

ca
n
t.

N
o
o

th
e
r

co
m
b
in
a
tio
n
s
w
e
re

si
g
n
ifi

ca
n
t;

W
G
C
TA
w
a
s

st
ro

n
g
e
st

p
re
d
ic

to
r

o
f
N
C
L
E
X
-R
N

p
e

rf
o
rm

a
n
ce
.

W
h
ite

h
e
a
d

(2
0
0
6
)
C
T,
N
C
L
E
X
–
R
N

N
o
t

id
e
n
tifi

e
d

b
y

n
a
m

e
—

co
m

p
e
te

n
ci
e
s

P
ilo

t
st

u
d

y
w

ith
a

co
n
ve
n
ie
n
ce
s
a
m
p
le
o
f
2

0
9

s
tu
d
e
n
ts

(
N

a
tiv
e

E
n

g
lis

h
,
n

=
1

9
2

,
N

o
n
n
a
tiv
e

E
n

g
lis

sp
e
a
ki
n
g
,
n
=

1
7

)
A
T

I
C

TA
-p

re
te

st
-p

o
st
te
st

. (
C

ro
n
b
a
ch
’s

a
lp
h
a
=
0
.6

9
4

. V
a
lid
ity

b
a

se
d

o
n
t
h
e
w

o
rk

f
F

a
ci
o
n
e
a
n
d

F
a

ci
o

n
e
a
n
d
r

e
se

a
rc

fr
o

m
T

h
e

D
e

lp
h

P
ro

je
ct

.)
N
o
s
ta
tis
tic
a
lly
s
ig
n
ifi
ca
n
t
d
iff
e
re
n
ce
s
w

ith
N

C
L
E
X
-R
N

p
a

ss
a
g
e
r

a
te

s
a
n
d
C

T
s
co
re
s
b
e
tw

e
e
n
g

u
p
s.

Y
o
u
ss

e
f
&

o
o
d
ri

(1
9
9
6
)
C
T,
N
C
L
E
X
–
R
N
N
o
n
e
id
e
n
tifi
e
d
A
p

ro
sp

e
ct
iv
e
s
tu

d
y.

C
o
n
ve
n
ie
n
ce
s
a
m
p

o
f
9

4
A

D
N

s
tu
d
e
n
ts

(t
ra
d
iti
o
n
a
l,
n

=
4

6
a

n
d

cc
e

le
ra

te
d
,
n
=
4
8
)

S
JA

N
t
o

a
ss
e
ss
C
T
g
iv
e
n

d
u

ri
n

g
s

e
co
n
d

se
m
e
st
e

r
a

n
d

1
8

m
o

n
th

s
la

te
r

d
u
ri
n
g

th
e

la
st

w
e

e
k

o
f
th

e
p

ro
g
ra

m
. S

TA
I

w
a

s
g

iv
e

n
t
w

ic
e
t
o
m
e
a
su

re
a

n
xi

e
ty

a
t

th
e
b
e

g
in

n
in

g
o

f
se
m
e
st
e
r
a
n
d

1
w

e
e

k
b

e
fo

re
fi

n
a

ls
. N

C
L
E
X
-R
N

. R
e

lia
b
ili
ty
a
n
d

va
lid

ity
n

o
t
a

d
d
re
ss
e
d

. S
JA

N
s
h
o
w
e
d
n
o

st
a
tis
tic
a

l s
ig

n
ifi
ca
n

t
d

iff
e

re
n

ce
s

b
e

tw
e

e
n

e
2

g
ro
u
p
s.

S
TA

I
re

su
lts

a
t

th
e
b

e
g
in

n
in
g
o
f
th
e
s
e
m
e
st
e
r
b
o
th
g
ro

u
p
s

h
a
d
h
ig
h
e
r

st
re

ss
t

h
a
n
a

t
th

e
e

n
d
,

w
ith

t
h
e
a

cc
e
le

ra
te

d
g

ro
u
p

h
a
vi

n
g
h

ig
h
e
r
st
re

ss
le

e
ls

t
h
a
n
t

h
e
t

ra
d
iti

o
n
a
l g

ro
u
p
. A

t
th
e

e
n

d
o

f
th
e
s
e
m
e
st

e
r,

b
o
th

g
ro
u
p
s

h
a
d
lo

w
e
r

st
re

ss
w

ith
o
u
t

a
n
y

si
g
n
ifi

ca
n
t
d
iff
e
re
n
ce
s
b
e
tw
e
e
n
t

h
e
2

g
ro
u
p
s.
N
C
L
E
X
-R
N

p
a
ss
a
g
e
r
a
te
s
b
e
tw
e
e
n
t
h
e
2
g
ro
u
p
s
w
e
re
n
o
t
si
g
n
ifi

ca
n
t.

C
T

=
c

ri
tic

a
l t

h
in

ki
n

g
; N

C
L
E
X
-R

N
=

N
a
tio

n
a
l C

o
u
n
ci

l L
ic

e
n
su

e
E

xa
m

in
a
tio

n
f
o
r

R
e
g
is

te
re

d
N
u
rs

e
s;

B
S
N
=

b
a
ch

e
lo

r
o
f

sc
ie

n
ce

in
n

u
rs

in
g
; C

C
T
S
T

=
C

a
lif

o
rn

ia
C

ri
tic
a
l T
h
in
ki
n

g
S

ki
lls

T
e

st
; G

P
A

=
g

ra
d
e

p
o
in

t
a
ve

ra
g
e
; S

A
T

=
S

ch
o
la

st
ic

A
p
tit

u
d
e
T

e
st

; W
G

C
TA

=
W

a
ts

o
n
G

la
se

r
C
ri
tic
a
l T
h
in

ki
n
g
A

p
p
ra

is
a
l;

C
C
T
D

I
=

C
a
lif

o
rn
ia
C
ri
tic
a
l T
h
in

ki
n
g
D

is
p
o
si
tio
n

I
n
ve

n
to

ry
; L

E
P

=
L

e
a

rn
in

g
E

n
vi

ro
n
m
e

n
t
P

re
fe

re
n

ce
;

N
D

R
T

=
N

e
ls

o
n
-D

e
n
n
y

R
e
a
d
in

g
T

e
st

; D
R

T
=

D
ia

g
n
o
st

ic
R

e
a
d
in
e
ss

T
e
st

; E
R

I
=

E
d
u
ca

tio
n
a
l R

e
so

u
rc

e
I

n
co

rp
o
ra

te
d
; N

E
T

=
t

h
e
N
u
rs
e
E

n
tr

a
n
ce
T
e

st
; C

T
P
T
=

C
ri

tic
a

l T
h

in
ki

n
g
P
ro
ce
ss
T
e
st
; C

D
M

N
S

C
lin

ic
a
l D

e
ci

si
o
n

-M
a
ki

n
g
in

N
u
rs

in
g
S

ca
le

; N
L
N

P
A
X
-R
N
=

T
h
e
N

a
tio

n
a
l L

e
a
g
u
e
f
o
r

N
u
rs

in
g
P

re
-A

d
m

is
si

o
n
R

N
e

xa
m
in
a
tio

n
; A

D
N

=
A

ss
o
ci

a
te
D
e

g
re

e
in

N
u

rs
in

g
; A

C
T

=
a

s
ta
n
d

a
rd

iz
e

d
a

ch
ie

ve
m

e
n

t
e
xa

m
in
a
tio
n
f
o
r

co
lle

g
e
a

d
m
is
si

o
n
s;

A
T

I
=
A
ss
e
ss

m
e
n
t T

e
ch

n
o
lo

g
ie

st
itu

te
; C

TA
=

C
ri

tic
a
l T

h
in
ki
n
g
A
ss
e
ss

m
e
n
t;

S
JA
N
=

S
ca

le
o

f
Ju

d
g
m

e
n
t
A

b
ili

tie
s

in
N

u
rs
in
g

; S
TA

I
=
T
h

e
S

ta
te

-T
ra

it
A

n
xi
e
ty

ve
n
to

ry
.

(C
o

n
ti

n
u
e
d
)

RomEo

conducted in one school of nursing and in a limited geo-
graphic area, which greatly reduced the generalizability
of the findings beyond their specific populations. In ad-
dition, the small sample sizes were identified as prob-
lematic by several researchers (Akerson, 2001; Frye et
al., 1999; Hall, 1996; morris, 1999; morris, 1998; Stew-
art & Dempsey, 2005) and the authors of only two of
the studies reported that a power analysis was calcu-
lated to determine the number of subjects needed to ad-
dress statistical and practical significance (Henriques,
2002; Hoffman, 2006). The current state of science on
measurement of critical thinking in nursing students
reflects a lack of adequate sample sizes to effectively
determine the relationship of critical thinking scores
and NCLEX-RN outcomes. A final limitation related to
sample size is the high degree of attrition that is found
with longitudinal studies in this population (Stewart &
Dempsey, 2005).

IMPLICATIoNS FoR NuRSINg EduCATIoN ANd
NuRSINg RESEARCh

The quest for identifying variables that are related
to NCLEX-RN outcomes continues as programs of nurs-
ing strive to adequately prepare students for success on
the licensure examination and in their future nursing
careers (Giddens & Gloecker, 2005; morris, 1999). Ad-
equate critical thinking abilities and skills have been
identified as a major component of the NCLEX-RN and
one’s ultimate success on this examination (Giddens
& Glockner; Hall, 1996; Hennriques, 2002; Hoffman,
2006). There is a need to create quantitative nursing-
specific tools that are rigorous, reliable, and valid to ad-
equately assess critical thinking abilities and disposi-
tions (morris, 1999; morris, 1998; Stewart & Dempsey,
2005; Youssef & Goodrich, 1996). Further research is
needed to develop a nursing-focused critical thinking
instrument to adequately measure critical thinking
skills and abilities in nursing students (Hall, 1996).
These measures of critical thinking abilities need to be
designed for specific use with both beginning and gradu-
ating nursing students. Utilization of these measures is
an area that requires immediate attention in nursing
research to identify those individuals who need to im-
prove their skills. Additional exploration and research
are then necessary to determine whether these quantifi-
able measures can be used to examine the role of critical
thinking skills and NCLEX-RN results.

NCLEX test-takers who failed the examination and
those who passed on their first attempt need to be studied
in greater detail to determine whether there is a statisti-
cally significant difference between the critical thinking
skills of those who failed and those who passed (Akerson,
2001; morris, 1998). In addition, further quantitative stud-
ies are needed to determine whether other factors, such as
attention to the setting, timing, and consequences of ad-
equate effort in the testing situation might also influence
critical thinking outcomes and success rates of first-time

NCLEX test-takers (morris, 1999; morris, 1998; Wacks,
2005; Whitehead, 2006).

CoNCLuSIoN

Critical thinking is an essential component in the
competency of nurses in today’s health care environment
(Henriques, 2002). The NLN Accrediting Commission
(2007) and the American Association of Colleges of Nurs-
ing (2008) have both mandated that nursing education in-
clude content and activities specifically designed for the
development and measurement of critical thinking skills.
Continued empirical research needs to be conducted to
better understand the role of critical thinking as a pre-
dictor of NCLEX-RN outcomes. To meet these demands,
nursing’s regulatory bodies must first agree on a definition
of critical thinking for the discipline and then, after deter-
mining a clear definition, settle on an applicable theory of
critical thinking for nursing educators to use as a frame-
work in curriculum development. Until nursing comes to
accept a consensus definition of critical thinking, the disci-
pline will continue to be disjointed in describing, teaching,
and evaluating this skill in the profession. once critical
thinking is adequately defined, nursing faculty and stu-
dents will have a clearer understanding of the role and
degree of critical thinking that is used in the NCLEX-RN.
This research related to critical thinking and NCLEX-RN
will aid nursing faculty in meeting one of their many re-
sponsibilities as an educator.

REFERENCES
Adams, B. (1999). Nursing education for critical thinking: An in-

tegrated review. Journal of Nursing Education, 38, 111-119.
Akerson, D. (2001). The relationship between critical thinking,

work experience, and study. Unpublished doctoral disserta-
tion, Saint Louis University, Saint Louis, missouri.

Allen, G., Rubenfeld, m., & Scheffer, B. (2004). Reliability of as-
sessment of critical thinking. Journal of Professional Nursing,
20(1), 15-22.

American Association of Colleges of Nursing. (2008). The essen-
tials of baccalaureate education. Retrieved from http://www.
aacn.nche.edu/Education/pdf/BEdraft

American Philosophical Association. (1990). Critical thinking: A
statement of expert consensus for purposes of educational as-
sessment and instrument. The Delphi Report: Research find-
ings and recommendations prepared for the committee on pre-
college philosophy. (ERIC Document Reproduction Service No.
ED 315-412.)

Assessment Technologies Institute, LLC. (2000). Retrieved from
http://www.atitesting.com/

Brunt, B. (2005). models, measurement, and strategies in devel-
oping critical thinking skills. The Journal of Continuing Edu-
cation in Nursing, 36, 255-261.

Del Bueno, D. (2005). A crisis in critical thinking. Nursing Educa-
tion Perspectives, 26, 278-282.

Facione, P.A. (1990). Critical thinking: A statement of expert con-
sensus for purposes of educational assessment and instruction:
The Delphi Report. millbrae, CA: The California Academic
Press.

Facione, P.A. (2007). Critical thinking: What it is and why it
counts. [Electronic version]. Insight Assessment, 1-23. Re-
trieved from http://www.insightassessment.com/t.html

Facione, P.A., & Facione, N.C. (1992). Test manual: The Cali-

Journal of Nursing Education • Vol. 49, No. 7, 2010 385

QUANTITATIvE RESEARCH oN CRITICAL THINKING

fornia Critical Thinking Disposition Inventory. milbrae, CA:
California Academic Press.

Frost, m.D. (2000). The critical thinking process test technical and
developmental report. Shawnee, KS: Educational Resources,
Inc.

Frye, B., Alfred, N., & Campbell, m. (1999). Use of the Watson-
Glaser Critical Thinking Appraisal with BSN students. Nurs-
ing & Health Care Perspectives, 20, 253-255.

Giddens, J., & Gloeckner, G.W. (2005). The relationship of critical
thinking to performance on the NCLEX-RN. Journal of Nurs-
ing Education, 44, 85-89.

Hall, G.H. (1996). Critical thinking in nursing education. Un-
published doctoral dissertation, The University of minnesota,
minneapolis.

Henriques, m.A.m. (2002). Predictors of performance on the Na-
tional Council Licensure Examination for Registered Nurses.
Unpublished doctoral dissertation, The University of South-
ern mississippi, Hattiesburg.

Hoffman, J.J. (2006). The relationships between critical thinking,
program outcomes, and NCLEX-RN performance in tradition-
al and accelerated nursing students. Unpublished doctoral dis-
sertation, University of maryland, College Park.

Kataoka-Yahiro, m., & Saylor, C. (1994). A critical thinking model
for nursing judgment. Journal of Nursing Education, 33, 351-
356.

Lee, K. (2007). online collaborative case study learning. Journal
of College Reading and Learning 37, 82-100.

morris, B.C. (1999). Relationship among academic achievement,
clinical decision making, critical thinking, work experience
and NCLEX-RN pass status. Unpublished doctoral disserta-
tion. Arizona State University, United States, Arizona.

morris, m.C. (1998). The relationship between critical thinking
ability and selected educational variables in baccalaureate
nursing students. Unpublished doctoral dissertation, Univer-
sity of Southern mississippi, Hattiesburg.

National Council Licensure Examination for Registered Nurses.
(2007). NCLEX-RN Examination: Test plan for the National
Council Licensure Examination for Registered Nurses. Re-
trieved from https://www.ncsbn.org/index.htm

National League for Nursing. (2007). Critical thinking in clinical

nursing practice/RN examination. Retrieved from http://www.
nln.org/testproducts/pdf/CTinfobulletin

Paul, R. (1993). Critical thinking: What every person needs to sur-
vive in a rapidly changing world. Santa Rosa, CA: Foundation
for Critical Thinking.

Phillips, C.R., Chestnut, R.J., & Rospond, R.m. (2004). The Cali-
fornia Critical Thinking Instruments for benchmarking, pro-
gram assessment, and directing curricular change. American
Journal of Pharmaceutical Education, 68(4), 1-8.

Riddell, T. (2007). Critical assumptions: Thinking critically
about critical thinking. Journal of Nursing Education, 46,
121-126.

Scheffer, B.K., & Rubenfeld, m.G. (2000). A consensus statement
on critical thinking in nursing. Journal of Nursing Education,
39, 352-359.

Stewart, S., & Dempsey, L.F. (2005). A longitudinal study of bac-
calaureate nursing students’ critical thinking dispositions.
Journal of Nursing Education, 44, 81-84.

Wacks, G.J. (2005). Relationships among pre-admission charac-
teristics in associate degree nursing programs as predictors of
NCLEX-RN success. Unpublished doctoral dissertation, The
University of Alabama, Birmingham.

Watson, G., & Glaser, E. (1980). Watson-Glaser Critical Thinking
Appraisal manual. San Antonio, TX: Psychological Corpora-
tion.

Wendt, A. (2003). The NCLEX-RN examination charting the
course of nursing practice. Nurse Educator, 28, 276-280.

Wendt, A., & Brown, P. (2000). The NCLEX examination. Prepar-
ing for future nursing practice. Nurse Educator, 25, 297-300.

Whitehead, T. D. (2006). Comparison of native versus nonnative
English-speaking nurses on critical thinking assessments at
entry and exit. Nursing Administration Quarterly, 30, 285-
290.

Whittemore, R., & Knafl, K. (2005). The integrative review: Up-
dated methodology. Journal of Advanced Nursing, 52, 546-
553.

Youssef, F.A., & Goodrich, N. (1996). Accelerated versus tradi-
tional nursing students: A comparison of stress, critical think-
ing ability and performance. International Journal of Nursing
Studies, 33, 76-82.

copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written

permission. However, users may print, download, or email articles for individual use.

ARTICLE

Mental Health of Transgender
and Gender Nonconforming Youth
Compared With Their Peer

Tracy A. Becerra-Culqui, PhD, MPH, OT/L, a Yuan Liu, PhD, b Rebecca Nash, MPH, c Lee Cromwell, MS, d W. Dana Flanders,
MD, DSc, c Darios Getahun, MD, PhD, MPH, a Shawn V. Giammattei, PhD, e Enid M. Hunkeler, MA, f Timothy L. Lash,
DSc, c Andrea Millman, MA, f Virginia P. Quinn, PhD, MPH, a Brandi Robinson, MPH, d Douglas Roblin, PhD, g David E.
Sandberg, PhD, h Michael J. Silverberg, PhD, MPH, f Vin Tangpricha, MD, PhD, i, j Michael Goodman, MD, MPHc

BACKGROUND: Understanding the magnitude of mental health problems, particularly life-
threatening ones, experienced by transgender and/or gender nonconforming (TGNC) youth
can lead to improved management of these condition

METHODS: Electronic medical records were used to identify a cohort of 588 transfeminine and
745 transmasculine children (3–9 years old) and adolescents (10–17 years old) enrolled in
integrated health care systems in California and Georgia. Ten male and 10 female referent
cisgender enrollees were matched to each TGNC individual on year of birth, race and/
or ethnicity, study site, and membership year of the index date (first evidence of gender
nonconforming status). Prevalence ratios were calculated by dividing the proportion of
TGNC individuals with a specific mental health diagnosis or diagnostic category by the
corresponding proportion in each reference group by transfeminine and/or transmasculine
status, age group, and time period before the index date.
RESULTS: Common diagnoses for children and adolescents were attention deficit disorders
(transfeminine 15%; transmasculine 16%) and depressive disorders (transfeminine
49%; transmasculine 62%), respectively. For all diagnostic categories, prevalence was
severalfold higher among TGNC youth than in matched reference groups. Prevalence ratios
(95% confidence intervals [CIs]) for history of self-inf licted injury in adolescents 6 months
before the index date ranged from 18 (95% CI 4.4–82) to 144 (95% CI 36–1248). The
corresponding range for suicidal ideation was 25 (95% CI 14–45) to 54 (95% CI 18–218).
CONCLUSIONS: TGNC youth may present with mental health conditions requiring immediate
evaluation and implementation of clinical, social, and educational gender identity support
measures.

abstract

NIH

aDepartment of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California;
Departments of bBiostatistics and Bioinformatics and cEpidemiology, Rollins School of Public Health, and
iEmory School of Medicine, Emory University, Atlanta, Georgia; dCenter for Clinical and Outcomes Research,
Kaiser Permanente Georgia, Atlanta, Georgia; eRockway Institute, Alliant International University, San Francisco,
California; fDivision of Research, Kaiser Permanente, Northern California, Oakland, California; gMid-Atlantic
Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland; hDepartment of
Pediatrics, Medical School, University of Michigan, Ann Arbor, Michigan; and jAtlanta Veterans Affairs Medical
Center, Atlanta, Georgia

Drs Becerra-Culqui and Goodman conceptualized and designed the study, contributed to the
acquisition of data, conceptualized the analysis plan, coordinated the interpretation of results
(including contributing expertise in epidemiologic methods and childhood developmental and/
or psychological outcomes), and drafted and finalized the manuscript; Drs Getahun, Nash, Quinn,
Roblin, and Silverberg and Ms Hunkeler conceptualized and designed the study, contributed to
the acquisition of data, critically reviewed the manuscript for important intellectual content

PEDIATRICS Volume 141, number 5, May 2018:e20173845

WHAT’S KNOWN ON THIS SUBJECT: Small, specialized, clinic-
based studies reveal a high prevalence of mental health
diagnoses and self-reported emotional and behavioral
problems among transgender and/or gender nonconforming
youth.

WHAT THIS STUDY ADDS: In this large cohort study of an
unselected transgender and/or gender nonconforming group,
youth experienced a high relative prevalence of mental health
conditions such as anxiety, depression, and attention deficit
disorders compared with their cisgender counterparts.

To cite: Becerra-Culqui TA, Liu Y, Nash R, et al. Mental Health
of Transgender and Gender Nonconforming Youth Compared
With Their Peers. Pediatrics. 2018;141(5):e20173845

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

As gender identity develops, it may
not match the gender of rearing or
gender assigned at birth, which are
typically based on the appearance
of external genitalia.1 – 3 When
gender identity differs from the one
assigned at birth, the terms gender
diverse or gender nonconforming
may apply.4, 5 Although the natural
history of gender nonconformity
presented in early childhood remains
an area of ongoing research, some
gender nonconforming children may
go on to adopt an identity that is
different from their assigned gender
(10%–30%, according to reported
estimates).6, 7 Researchers in studies
of gender development in the general
population support that gender-
typed behavior is noticeable and
stable between 3 and 8 years of age,
especially in children with relatively
high or low gender-typical behavior.8, 9
Individuals may identify as
transgender, a term that refers more
narrowly to those whose identity is
“opposite” of their assigned gender.10
Conversely, individuals who identify
with the gender assigned to them at
birth are sometimes referred to as
cisgender.10

An important priority for the health
of transgender and/or gender
nonconforming (TGNC) children
and adolescents is the identification
and management of mental health
conditions.11 – 13 These conditions
may be related to gender dysphoria,
which is defined as a feeling of
distress when one’s assigned gender
does not match their identity.14
In addition, children with gender
nonconforming behavior may
experience stress from prejudice
and discrimination because of being
part of a minority group, which can
create or exacerbate emotional and
behavioral problems.15

The literature on TGNC youth
consistently reveals a high
prevalence of self-reported emotional
and behavioral problems and mental
health diagnoses.16 – 23 Most of the
available data used to address

the mental health status of TGNC
youth come from specialized clinics
providing care to this population.24
Although researchers in clinic-
based studies offer detailed and
high-quality data, 25, 26 they often
lack information on individuals who
have not sought or had no access
to specialized care. Moreover, a
reliance on specialized clinics to
identify study participants may yield
relatively small sample sizes, making
it difficult to select comparable
reference groups from the same
underlying population.27

These issues motivated the
researchers in the Study of
Transition, Outcomes, and Gender
(STRONG), which was designed to
assess morbidity among TGNC people
overall and in the transfeminine
and transmasculine subgroups of
different ages, and captured in any
care setting. However, this study
communication is focused on cohort
members who first presented as
TGNC before their 18th birthday.
Our objectives in this study were
to estimate the prevalence of
mental health diagnoses among
transfeminine and transmasculine
children and adolescents at the
time of their initial presentation
(index date) and compare their
mental health status to that of their
cisgender counterparts.

METHODS

The STRONG was designed as an
electronic medical record (EMR)–
based retrospective and prospective
cohort study of members at 3 Kaiser
Permanente (KP) sites (Georgia,
Northern California, and Southern
California) in partnership with the
coordinating center at the Emory
University Rollins School of Public
Health. These KP sites provide
comprehensive health services
to >8.8 million members who are
sociodemographically diverse and
representative of their respective
communities.28, 29 In the clinical

setting, the identification of TGNC
youth may begin at age 13 years
during physical examinations as part
of the psychosocial and/or behavioral
assessment recommended by the
American Academy of Pediatrics30;
however, some TGNC children
may be identified earlier or later
in life. All activities were reviewed
and approved by the institutional
review boards of the 4 participating
institutions.

As described previously, 31, 32
persons with first evidence of
TGNC status between January 1,
2006, and December 31, 2014,
were identified on the basis of
International Classification of
Diseases, Ninth Edition (ICD-9)
codes and the presence of specific
keywords in free-text clinical notes
(Supplemental Table 5). TGNC status
was then verified (Supplemental Fig
1). A second free-text program was
developed with additional anatomy-
related or gender-affirmation
keywords, which were reviewed and
adjudicated for transfeminine or
transmasculine status (Supplemental
Table 6). Transfeminine and/or
transmasculine status was assigned
by using demographic information
from the EMRs of 220 children
whose gender assignment could
not be determined from text strings
because a validation revealed that
the demographic variable accurately
reflected assigned gender in 96%
of youth. Subjects with evidence of
disorders of sex development (eg,
variation of chromosomal, gonadal,
and/or anatomic sex development)
were excluded because they may
have distinct medical histories and
gender identity trajectories.33

Ten male and 10 female cisgender
KP enrollees were matched to each
member of the final validated TGNC
cohort on the basis of year of birth,
race and/or ethnicity, site, and
membership year of the index date.
Because reference group enrollees
had not been identified as TGNC by
the methods described above, they

BECERRA-CULQUI et al2
by guest on January 12, 2021www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/lookup/suppl/doi:10.1542/peds.2017-3845/-/DCSupplemental

were assumed to be cisgender (ie,
no evidence that gender identity
does not correspond to assigned
gender at birth). The race and/or
ethnicity categories used were non-
Hispanic white, non-Hispanic African
American, Asian American and/or
Pacific Islander, Hispanic, and other
races. Index date was defined on the
basis of the first recorded evidence of
TGNC status. For some TGNC cohort
members, <10 matched reference cisgender males or females were available; no TGNC individual was matched to <7 referents of either sex.

Subjects 3 through 17 years old
at the index date were included in
this study. Children <3 years old were excluded to reduce possible instability in gender identification and mental health diagnoses among the cohort.8 The ICD-9 codes for mental health diagnoses were grouped into

categories of conditions according
to recommendations from the
Mental Health Research Network34:
anxiety disorders, attention deficit
disorders, autism spectrum disorders,
bipolar disorders, conduct and/
or disruptive disorders, depressive
disorders, eating disorders, other
psychoses, personality disorders,
schizophrenia spectrum disorders,
self-inflicted injuries (including
poisonings), substance use disorders,
and suicidal ideation (Supplemental
Table 7). People could be represented
more than once if they had multiple
diagnoses and were thus counted in
each category for which they had a
diagnosis.

The prevalence of mental health
conditions in each of these categories
was calculated for 2 time windows:
any time (ever) and within 6 months
before the index date. These 2 time

windows were selected to examine
mental health status just proximal to
TGNC identification and to capture
longer-standing conditions diagnosed
at earlier ages (eg, autism spectrum
disorders). In these calculations,
the numerator for each disorder
or group of disorders included
persons with at least 1 relevant
diagnostic code recorded during
the time interval of interest. All
prevalence estimates were calculated
separately for transfeminine and
transmasculine subjects within 2
age groups: 3 to 9 years (children)
and 10 to 17 years (adolescents).
Age categorization was selected to
separately represent young school-
aged children and adolescents by
using the adolescent starting age of
10 years, corresponding to the World
Health Organization’s definition.35 To
assess differences in the severity of
the conditions of interest, additional

PEDIATRICS Volume 141, number 5, May 2018 3

TABLE 1 Characteristics of the TGNC Children and Adolescents Enrolled in the STRONG

Child and Adolescent Characteristics Transfeminine Cohort Transmasculine Cohort

Transfeminine
Cohort, n (%

)

Reference
Males, n (%)

Reference
Females, n (%)

Transmasculine
Cohort, n (%)

Reference
Males, n (%)
Reference
Females, n (%)

Age, a y
3–9 161 (27) 1605 (28) 1598 (28) 90 (12) 892 (12) 888 (12)
10–17 427 (73) 4206 (72) 4204 (72) 655 (88) 6448 (88) 6459 (88)
Health plan site
KPNC 344 (59) 3392 (58) 3378 (58) 431 (58) 4238 (58) 4245 (58)
KPSC 227 (39) 2249 (39) 2254 (39) 295 (40) 2915 (40) 2912 (40)
KPGA 17 (2.9) 170 (2.9) 170 (2.9) 19 (2.6) 187 (2.6) 190 (2.6)
Race and/or ethnicity
Non-Hispanic white 268 (46) 2633 (45) 2629 (45) 374 (50) 3663 (50) 3671 (50)
Non-Hispanic African American 53 (9.0) 523 (9.0) 521 (9.0) 57 (7.7) 564 (7.7) 564 (7.7)
Asian American and/or Pacific Islander 37 (6.3) 367 (6.3) 370 (6.4) 60 (8.1) 596 (8.1) 594 (8.1)
Hispanic 179 (30) 1779 (31) 1772 (31) 204 (27) 2018 (27) 2020 (27)
Other and/or unknown 51 (8.7) 509 (8.8) 510 (8.8) 50 (6.7) 499 (6.8) 498 (6.8)
Use ever before index date (average visits per y)
0 22 (3.7) 325 (5.6) 321 (5.5) 23 (3.1) 367 (5.0) 350 (4.8)
<1 15 (2.6) 568 (9.8) 530 (9.1) 25 (3.4) 763 (10) 746 (10) 1–3 127 (22) 1815 (31) 1879 (32) 154 (21) 2583 (35) 2562 (35) >3–6 171 (29) 1712 (29) 1781 (31) 240 (32) 2200 (30) 2235 (30)
>6–9 115 (20) 757 (13) 763 (13) 107 (14) 795 (11) 777 (11)
>9 137 (23) 631 (11) 528 (9.1) 196 (26) 630 (8.6) 675 (9.2)
Unknown 1 (0.2) 3 (0.1) 0 (0.0) 0 (0.0) 2 (0.0) 2 (0.0)
Use 6 mo before index date (average visits per mo)
0 101 (17) 2225 (38) 2062 (36) 111 (15) 2825 (39) 2502 (34)
<1 258 (44) 2846 (49) 2903 (50) 277 (37) 3531 (48) 3640 (50) 1–2 141 (24) 552 (9.5) 625 (11) 195 (26) 757 (10) 901 (12) >2 87 (15) 186 (3.2) 212 (3.7) 162 (22) 225 (3.1) 302 (4.1)
Unknown 1 (0.2) 2 (0.0) 0 (0.0) 0 (0.0) 2 (0.0) 2 (0.0)
Total 588 (2.1) 5811 (21) 5802 (21) 745 (2.7) 7340 (27) 7347 (27)

KPGA, Kaiser Permanente Georgia; KPNC, Kaiser Permanente Northern California; KPSC, Kaiser Permanente Southern California.
a Assessed at index date (date of first evidence of transgender status in EMRs).

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/lookup/suppl/doi:10.1542/peds.2017-3845/-/DCSupplemental

analyses were conducted for
admittance or most serious diagnoses
associated with hospitalizations.

Each prevalence estimate in the
TGNC cohort was compared with
corresponding estimates among
matched cisgender male and female
referents. For ease in presenting
results, cisgender males and females
will be referred to as male or female
referents. Referents were assigned
the same index date as the matched
TGNC cohort member. For rare
events (prevalence ≤10% in both
the TGNC and referent cohorts),
the prevalence ratios (PRs) were
approximated by calculating the odds
ratios with exact 95% confidence
intervals (CIs). For events with >10%
prevalence in either group, PRs and
CIs were calculated by using logistic
regression with the log link option.

In addition to the primary analysis
that captures the true prevalence
of mental health conditions, we

conducted sensitivity analyses to
address possible differences in
the prevalence of mental health
conditions because of differences
in health care visit frequency (use)
between TGNC cohort members and
those in the referent groups. We
excluded the index date from the
time window, and when the sample
size was sufficient (>5 cases in
each group), the PR estimates were
adjusted for use of care. Average
health care use was calculated for
each individual by dividing the total
number of visits by the cumulative
duration of enrollment; this was
expressed as the number of visits per
year of enrollment in the analyses of
“ever” prevalence and as the number
of visits per month of enrollment in
the analyses within 6 months before
the index date. In adjusted analyses,
average use was dichotomized for
each time interval as above (high)
or below (low) the median by using
cutoffs for the overall population.

Analyses were conducted by using
SAS version 9.4 (SAS Institute, Inc,
Cary, NC) with custom macros
developed at the Biostatistics and
Bioinformatics Shared Resource
at the Winship Cancer Institute of
Emory University.36

RESULTS

A total of 2164 cohort candidates 3
to 17 years of age at the index date
were initially identified in the EMR.
After validation, 1347 (62%) were
confirmed as TGNC. People excluded
from the TGNC cohort were most
often those with keywords referring
to family or partners, standard
disclaimers not related to care (eg,
listing indications for hormone
use), or evidence of disorders of
sex development. After excluding
subjects with unknown gender
assigned at birth (N = 14), the final
analysis data set was based on a
cohort of 1333 subjects matched with

BECERRA-CULQUI et al4

TABLE 2 Prevalence of Mental Health Diagnoses in TGNC Children Ages 3–9 Years Relative to Those in Referent Groups

Categories of Mental Health
Disorders

Prevalence in
Transfeminine
Subjects, N (%)

PR (95% CI)a in Transfeminine
Subjects

Prevalence in
Transmasculine
Subjects, N (%)

PR (95% CI)a in Transmasculine Subjects

Versus
Reference

Males

Versus Reference
Females

Versus Reference
Males

Versus Reference
Females

All diagnoses of interest
Ever before index date 51 (31.7) 3.0 (2.3–3.9) 5.7 (4.2–7.7) 31 (34.4) 3.3 (2.3–4.6) 5.4 (3.7–7.8)
6 mo before index date 46 (28.6) 6.0 (4.3–8.4) 13.0 (8.7–19.6) 26 (28.9) 5.9 (3.8–9.0) 10.7 (6.4–17.8)
Anxiety disorders
Ever before index date 19 (11.8) 4.4 (2.6–7.4) 6.3 (3.6–10.9) 14 (15.6) 6.3 (3.3–11.9) 6.0 (3.2–11.3)
6 mo before index date 15 (9.3) 16.3 (6.7–41.4) 23.3 (8.8–68.5) 9 (10.0) 9.8 (3.4–27.6) 12.2 (4.0–37.3)
Attention deficit disorders
Ever before index date 24 (14.9) 3.3 (2.1–5.0) 6.1 (3.8–9.9) 14 (15.6) 2.8 (1.6–4.9) 6.9 (3.6–13.2)
6 mo before index date 22 (13.7) 5.0 (3.1–8.1) 10.9 (6.1–19.6) 14 (15.6) 4.2 (2.3–7.6) 12.6 (5.9–26.8)
Autism spectrum disorders
Ever before index date 8 (5.0) 2.2 (0.9–4.9) 11.8 (3.7–38.9) 0 NC NC
6 mo before index date 8 (5.0) 3.9 (1.5–9.5) 20.8 (5.5–95.3) 0 NC NC
Conduct and/or disruptive

disorders
Ever before index date 12 (7.5) 3.3 (1.5–6.7) 14.2 (5.4–38.8) 7 (7.8) 6.2 (2.0–17.5) 12.3 (3.5–45.5)
6 mo before index date 8 (5.0) 8.3 (2.8–23.8) 83.0 (11.0–3707.3) b 13.7 (2.3–95.1) 20.5 (2.9–229.2)
Depressive disorders
Ever before index date 9 (5.6) 6.7 (2.5–17.0) 7.8 (2.9–20.6) 10 (11.1) 27.5 (7.7–123.0) 12.3 (5.0–30.5)
6 mo before index date 6 (3.7) 8.8 (2.4–31.1) 12.3 (3.1–51.5) 8 (8.9) 43.0 (8.4–422.3) 28.5 (6.7–170.2)
Eating disorders
Ever before index date b 3.7 (0.8–12.6) 6.7 (1.4–28.8) 0 NC NC
6 mo before index date b 10.0 (0.1–787.4) 10.0 (0.1–784.0) 0 NC NC

NC, not calculated because there were 0 cases among transgender subjects.
a Logistic regression with exact 95% CIs for rare events (prevalence ≤10% in both the transgender and referent cohorts) or logistic regression with log link and approximate 95% CIs for
not-rare events (>10% prevalence in either the transgender or referent cohorts).
b Fewer than 5 cases were not reported.

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

PEDIATRICS Volume 141, number 5, May 2018 5

TA
B

LE
3

P
re

va
le

nc
e

of
M

en
ta

l H
ea

lt
h

D
ia

gn
os

es
in

T
G

N
C

Ad
ol

es
ce

nt
s

Ag
es

1
0–

17
Y

ea
rs

R
el

at
iv

e
to

T
ho

se
in

R
ef

er
en

t
G

ro
up

Ca
te

go
ri

es
o

f
M

en
ta
l H
ea
lt
h

D
is

or
de

rs
Pr

ev
al

en
ce

Tr
an

sf
em

in
in

e
Su

bj
ec

ts
, N

(
%

)

PR
(

95
%

C
I)

a
in

T
ra

ns
fe

m
in

in
e

Su
bj

ec
ts

Pr
ev

al
en

ce
in

an
sm

as
cu

lin
e

Su
bj
ec
ts

, N
(

%
)

PR
(
95
%
C
I)
a
in
T
ra

ns
m

as
cu
lin
e
Su
bj
ec
ts

Ve
rs

us
R

ef
er

en
ce

M
al

es
Ve

rs
us

R
ef
er
en

ce
F

em
al

es
Ve
rs
us
R
ef
er
en

ce
M

al
es

Ve
rs
us
R
ef
er
en
ce

F
em

al
es

Al
l d

ia
gn

os
es

o
f

in
te

re
st

er
b

ef
or

e
in

de
x

da
te

30
3

(7
1.

)
3.

0
(2

.8
–3

.3
)

3.
6

(3
.3

–3
.9

)
48

8
(7

4.
5)

3.
0

(2
.8

–3
.2

)
3.

7
(3

.4
–3

.9
)

m
o

be
fo

re
in

de
x
da
te

25
3

(5
9.

)
7.

8
(6

.8
–8

.9
)

8.
6

(7
.5

–9
.8

)
42

9
(6

5.
5)

7.
8

(7
.1

–8
.7

)
8.

7
(7

.8
–9

.6
)

An
xi

et
y

di
so

rd
er

Ev
er

b
ef

or
e

in
de

x
da

te
15

9
(3

7.
2)

5.
0

(4
.2

–5
.8

)
4.

2
(3

.6
–4

.9
)

25
5

(3
8.

9)
4.

9
(4

.3
–5

.6
)

4.
0

(3
.5

–4
.5

)

6
m

o
be

fo
re

in
de

x
da

te
10

6
(2

4.
8)

18
.0

(
13

.3
–2

4.
4)

9.
2

(7
.2

–1
1.

)
17

5
(2

6.
7)

15
.7

(
12

.5
–1

9.
6)

8.
7

(7
.2

–1
0.

5)
At

te
nt

io
n

de
fic

it
d

is
or

de
rs

Ev
er
b
ef
or
e
in
de
x
da
te

10
7

(2
5.

)
2.

0
(1

.7
–2

.4
)

5.
3

(4
.3

–6
.5

)
10

6
(1

6.
2)

1.
3

(1
.0

–1
.5

)
3.

3
(2

.7
–4

.1
)

6
m
o
be
fo
re
in
de
x
da
te

68
(

15
.9

)
3.

8
(2

.9
–4

.9
)

9.
0

(6
.6

–1
2.

4)
69

(
10

.5
)

2.
5

(1
.9

–3
.3

)
6.

4
(4

.6
–8

.8
)

Au
ti

sm
s

pe
ct

ru
m

d
is

or
de

Ev
er
b
ef
or
e
in
de
x
da

te
31

(
7.

3)
4.

1
(2

.6
–6

.4
)

25
.2

(
12

.7
–5

2.
9)

24
(

3.
7)

1.
8

(1
.1

–2
.8

)
7.

6
(4

.3
–1

3.
5)

6
m
o
be
fo
re
in
de
x
da
te

25
(

5.
9)

8.
1

(4
.6

–1
4.

)
26

0.
8

(4
2.

5–
10

73
3.

9)
17

(
2.

6)
3.

4
(1

.8
–6

.1
)

17
.2

(
7.

4–
42

.1
)

B
ip

ol
ar

d
is
or
de
rs

Ev
er
b
ef
or
e
in
de
x
da

te
23

(
5.

)
9.

9
(5

.3
–1

8.
5)

10
.3

(
5.

5–
19

.5
)

34
(

5.
2)

8.
6

(5
.2

–1
3.

9)
8.

0
(4

.9
–1

2.
9)

6
m
o
be
fo
re
in
de
x
da
te

16
(

3.
8)

18
.1

(
7.

5–
46

.9
)

14
.8

(
6.

4–
35

.6
)

19
(

2.
9)

11
.3

(
5.

5–
23

.3
)
14
.8
(
6.

9–
32

.8
)

Co
nd

uc
t

an
d/

or
d

is
ru

pt
iv

e
di

so
rd

er
s

Ev
er
b
ef
or
e
in
de
x
da
te

60
(

14
.1

)
2.
8
(2

.1
–3

.7
)

6.
6

(4
.8

–9
.0

)
59

(
9.

0)
1.

7
(1

.3
–2
.3
)

4.
5

(3
.2

–6
.2

)

6
m
o
be
fo
re
in
de
x
da

te
22

(
5.

)
5.

3
(3

.0
–9

.1
)

12
.6

(
6.

4–
25

.2
)

27
(

4.
1)

5.
5

(3
.3
–9
.0
)
10

.6
(

5.
9–

19
.1

)
D

ep
re

ss
iv

e
di
so
rd
er
s

Ev
er
b
ef
or
e
in
de
x
da
te

20
7

(4
8.

5)
5.

8
(5

.1
–6

.7
)

4.
4

(3
.9

–5
.0

)
40

3
(6

1.
5)

7.
0

(6
.4

–7
.8

)
5.

7
(5

.2
–6

.2
)

6
m
o
be
fo
re
in
de
x
da
te

17
2

(4
0.

3)
23

.5
(

18
.2

–3
0.

4)
10

.1
(

8.
4–

12
.2

)
32

6
(4

9.
8)

22
.8

(
19

.0
–2

7.
3)

13
.3

(
11

.5
–1

5.
4)

Ea
ti

ng
d

is
or
de
rs

Ev
er
b
ef
or
e
in
de
x
da
te

18
(

4.
2)

7.
7

(3
.9
–1
4.

9)
3.

3
(1

.8
–5

.7
)

28
(

4.
3)

6.
0

(3
.6

–9
.8
)
3.

2
(2

.0
–5

.0
)

6
m
o
be
fo
re
in
de
x
da
te

11
(

2.
6)

18
.5

(
6.

2–
61

.2
)

6.
1

(2
.6

–1
3.

8)
19

(
2.

9)
27

.5
(

11
.0

–7
7.

6)
8.

7
(4

.4
–1

7.
0)

Ps
yc

ho
se

Ev
er
b
ef
or
e
in
de
x
da

te
19

(
4.

5)
19

.5
(

8.
6 –

47
.3

)
12

.2
(

5.
9–

25
.5

)
32
(
4.

9)
12

.2
(

7.
0–

21
.3

)
14

.4
(

8.
1–

25
.9

)

6
m
o
be
fo
re
in
de
x
da
te
10
(
2.

)
20

.1
(

6.
2–

75
.4

)
10

0.
6

(1
4.

2–
43

75
.0

)
18

(
2.

8)
22

.7
(

9.
4–

60
.6

)
30

.4
(

11
.5

–9
3.

8)
Pe

rs
on

al
it

y
di

so
rd
er
s

Ev
er
b
ef
or
e
in
de
x
da
te

10
(

2.
3)

14
.4

(
4.

9 –
44

.7
)

11
.2

(
4.

1–
31

.2
)

15
(

2.
3)

11
.6

(
5.

1–
26

.6
)

7.
9

(3
.7

–1
6.

6
m
o
be
fo
re
in
de
x
da

te
b

19
.8

(
2.

8–
22

0.
0)

19
.8
(
2.

8–
21

9.
9)

9
(1

.4
)

29
.9

(
7.

4–
17

2.
1)

29
.9
(
7.
4–
17

2.
4)

Sc
hi

zo
ph

re
ni

a
sp

ec
tr

um
d

is
or
de
rs

Ev
er
b
ef
or
e
in
de
x
da
te

5
(1

.2
)

49
.7

(
5.
5–
23

57
.0

)
24

.9
(

4.
1–

26
1.

)
13

(
2.

)
21

.7
(

7.
7–

69
.9

)
32
.6
(

10
.0

–1
37

.8
)

6
m
o
be
fo
re
in
de
x
da
te

b
c

14
.8

(
1.

7–
17

8.
2)

10
(
1.
5)

99
.8

(
14

.2
–4

33
8.

3)
50

.0
(

10
.6

–4
70

.2
)

Se
lf

-in
fl

ic
te

d
in

ju
ri

Ev
er
b
ef
or
e
in
de
x
da

te
11

(
2.
6)
3.
9
(1
.8
–8
.2
)

4.
1

(1
.8

–8
.6

)
54

(
8.

2)
14

.0
(

9.
1–

21
.8

)
8.
7
(5
.9
–1

2.
8)

6
m
o
be
fo
re
in
de
x
da
te
7
(1
.6
)
69
.9
(
9.

0–
31

59
.2

)
17
.5
(

4.
4–

81
.7

)
28

(
4.

3)
14

3.
7

(3
6.

1–
12

47
.8

)
20
.5
(

10
.4

–4
2.

)
Su

bs
ta

nc
e

us
e

di
so
rd
er
s

Ev
er
b
ef
or
e
in
de
x
da

te
33

(
7.

7)
3.

0
(1
.9
–4
.5
)
3.
7

(2
.4

–5
.6

)
46

(
7.

0)
2.

4
(1

.7
–3

.4
)

3.
3

(2
.3

–4
.7

)

6
m
o
be
fo
re
in
de
x
da

te
24

(
5.

6)
5.

8
(3

.3
–9

.8
)

8.
9

(4
.9

–1
6.

0)
34

(
5.

2)
4.

5
(2

.9
–6

.9
)

8.
2

(5
.0

–1
3.

2)
Su

ic
id

al
id

ea
ti

Ev
er
b
ef
or
e
in
de
x
da

te
32

(
7.

5)
17

.8
(

9.
7–

33
.6

)
11

.3
(

6.
5–

19
.4

)
68

(
10
.4
)

21
.2

(
13
.8
–3

3.
2)

11
.0
(
7.

7–
15

.9
)

6
m
o
be
fo
re
in
de
x
da
te

21
(

4.
9)

54
.2

(
18

.2
–2

18
.3

)
31

.0
(
12
.6

–8
6.

7)
47

(
7.

2)
45

.2
(

22
.9

–9
7.

1)
24

.9
(

14
.3

–4
4.

6)
a

Lo
gi

st
ic

r
eg

re
ss

io
n

w
it

h
ex

ac
t

95
%

C
Is

fo
r

ra
re

e
ve

nt
s

(p
re

va
le
nc
e

≤
10

%
in

b
ot

h
th

e
tr

an
sg

en
de

r
an

d
re

fe
re

nt
c

oh
or

ts
)

or
lo

gi
st

ic
r

eg
re

ss
io

n
w

it
h

lo
g

lin
k

an
d

ap
pr

ox
im

at
e

95
%
C
Is
fo
r

no
t-

ra
re
e
ve
nt
s

(>
10

%
p

re
va

le
nc

e
in

e
it

he
r

th
e

tr
an

sg
en

de
r

or
r

ef
er

en
t

co
ho

rt
s)

.
b

Fe
w

er
t

ha
n

5
ca

se
s

w
er

e
no

t
re

po
rt

ed
.

c
N

ot
c

al
cu

la
te

d
be

ca
us

e
th

er
e

w
er

e
0

ca
se

s
am

on
g

re
fe

re
nt

s.
by guest on January 12, 2021www.aappublications.org/newsDownloaded from

BECERRA-CULQUI et al6

TA
B

LE
4

P
re
va
le
nc
e

of
H

os
pi

ta
liz

at
io

n
fo

r
M

en
ta
l H
ea
lt
h
D
ia
gn
os
es
in
T
G
N
C

Ch
ild

re
n

Ag
es
1
0–
17
Y
ea
rs
R
el
at
iv
e
to
T
ho
se
in
R
ef
er
en
t
G
ro
up
s
Ca
te
go
ri
es
o
f
M
en
ta
l H
ea
lt
h
D
is
or
de
rs
Pr
ev
al
en
ce
in

Tr
an
sf
em
in
in
e
Su
bj
ec
ts
, N
(
%
)
PR
(
95
%
C
I)
a
in
T
ra
ns
fe
m
in
in
e
Su
bj
ec
ts
Pr
ev
al
en
ce
in

Tr
an
sm
as
cu
lin
e
Su
bj
ec
ts
, N
(
%
)
PR
(
95
%
C
I)
a
in
T
ra
ns
m
as
cu
lin
e
Su
bj
ec
ts
Ve
rs
us
R
ef
er
en
ce
M
al
es
Ve
rs
us
R
ef
er
en
ce
F
em
al
es
Ve
rs
us
R
ef
er
en
ce
M
al
es
Ve
rs
us
R
ef
er
en
ce
F
em
al
es
Al
l d
ia
gn
os
es
o
f
in
te
re
st

Ev
er
b
ef
or
e
in
de
x
da
te

58
(

13
.6

)
9.
9
(6
.9
–1

4.
0)

8.
9

(6
.3

–1
2.

5)
99

(
15

.1
)

10
.2

(
7.

8–
13

.3
)
7.
8

(6
.1

–1
0.

6
m
o
be
fo
re
in
de
x
da
te
33
(
7.

7)
43

.9
(

19
.7

–1
10

.7
)

35
.1

(
16

.7
–8

0.
4)

59
(

9.
0)

35
.3

(
20

.4
–6

4.
1)

21
.9

(
13
.7
–3

5.
8)

An
xi
et
y
di
so
rd
er
s

Ev
er
b
ef
or
e
in
de
x
da

te
9

(2
.1

)
9.

0
(3

.2
–2
4.
9)
6.
0
(2
.3
–1
4.

8)
25

(
3.

)
15

.0
(
7.
7–

29
.8

)
13
.4
(

7.
1–

26
.0

)

6
m
o
be
fo
re
in
de
x
da

te
6

(1
.4

)
59
.8
(

7.
2–

27
57

.2
)
29
.9
(
5.

3–
30

3.
7)

13
(

2.
0)

43
.4

(
11

.9
–2

38
.3

)
32
.6
(
10
.0
–1
37
.8
)

At
te

nt
io

n
de

fic
it

d
is
or
de
rs

Ev
er
b
ef
or
e
in
de
x
da

te
20

(
4.

7)
9.

8
(5

.0
–1

9.
1)

14
.7

(
7.
0–
31
.7
)

14
(

2.
1)
4.
0

(2
.0

–7
.7

)
9.
4
(4
.2
–2

0.
9)

6
m
o
be
fo
re
in
de
x
da
te
6
(1
.4
)

19
.9

(
4.

2–
12

3.
6)

59
.8

(
7.

2–
27

55
.8

)
b

c
9.

9
(1

.3
–7

4.
0)
Au
ti
sm
s
pe
ct
ru
m
d
is
or
de
rs

Ev
er
b
ef
or
e
in
de
x
da
te
b
6.
6
(1
.4

–2
8.

0)
39

.7
(

3.
9–

19
57

.7
)

5
(0

.8
)
5.
0

(1
.3

–1
6.

0)
8.

3
(2

.0
–3

2.
6)

6
m
o
be
fo
re
in
de
x
da
te
b
c

c
b

3.
3

(0
.1

–4
1.

)
c

B
ip
ol
ar
d
is
or
de
rs

Ev
er
b
ef
or
e
in
de
x
da

te
12

(
2.

8)
30

.3
(
9.
1–

12
9.

6)
13

.5
(

5.
2–

36
.4

)
18
(
2.

8)
10

.1
(

4.
9–

20
.7

)
9.

1
(4

.5
–1
8.
2)

6
m
o
be
fo
re
in
de
x
da
te

b
39

.7
(
3.
9–

19
58

.7
)
19
.8
(
2.
8–
21
9.
9)

8
(1

.2
)
15
.9
(
4.

6–
62

.0
)
19
.9
(
5.

3–
90

.7
)
Co
nd
uc
t
an
d/
or
d
is
ru
pt
iv
e
di
so
rd
er
s

Ev
er
b
ef
or
e
in
de
x
da
te
10
(
2.
3)

16
.8

(
5.

5–
56

.4
)
16
.8
(
5.
5–
56
.4
)
10
(
1.
5)

5.
9

(2
.4
–1
3.

6)
6.

7
(2

.7
–1

5.
9)

6
m
o
be
fo
re
in
de
x
da
te
5
(1
.2
)
49
.7
(
5.
5–
23
57
.0
)
c
b
39
.6
(
3.
9–

19
51

.1
)

39
.6

(
3.

9–
19

54
.4

)
D
ep
re
ss
iv
e
di
so
rd
er
s

Ev
er
b
ef
or
e
in
de
x
da
te

41
(

9.
6)

21
.1

(
12
.1
–3

8.
1)

10
.3
(
6.

4–
16

.4
)

83
(

12
.7

)
17
.8
(

12
.5

–2
5.

2)
9.

1
(6

.8
–1

2.
1)

6
m
o
be
fo
re
in
de
x
da
te

26
(

6.
1)

68
.0

(
23

.4
–2

69
.3

)
54
.3
(

20
.4

–1
82

.2
)

49
(

7.
5)

10
4.

0
(4

1.
5–

33
5.

9)
21

.7
(

12
.9

–3
7.

2)
Ea

ti
ng

d
is
or
de
rs

Ev
er
b
ef
or
e
in
de
x
da
te
b
6.
6

(0
.5

–5
7.

7)
2.

8
(0

.3
–1
4.
9)

6
(0

.9
)
29
.8
(
5.
3–
30
2.
1)
4.
0
(1
.3
–1
0.

6
m
o
be
fo
re
in
de
x
da
te
b

c
3.

3
(0

.1
–4

1.
0)

b
29

.8
(

5.
3–

30
2.

1)
4.

0
(1
.3
–1
0.
9)
Ps
yc
ho
se
s

Ev
er
b
ef
or
e
in
de
x
da

te
8

(1
.9
)
26
.7
(

6.
4–

15
6.

9)
11

.4
(

3.
6–

37
.2

)
10
(
1.

5)
20

.0
(
6.
2–

74
.7

)
12
.5
(
4.
4–

36
.6

)

6
m
o
be
fo
re
in
de
x
da

te
5

(1
.2

)
49

.7
(

5.
5–

23
57

.0
)
49
.7
(
5.
5–
23
55
.8
)
b
19
.8
(
2.
8–
21
9.
1)

9.
9

(1
.8

–5
3.

3)
Pe

rs
on
al
it
y
di
so
rd
er
s

Ev
er
b
ef
or
e
in
de
x
da
te
b
39
.7
(
3.
9–
19
58
.7
)
19
.8
(
2.
8–
21
9.
9)
8
(1
.2
)

26
.5

(
6.

3–
15

5.
7)

8.
9

(3
.0

–2
6.

6
m
o
be
fo
re
in
de
x
da

te
0

(0
)

N
C

N
C
7
(1
.1
)

c
69

.7
(

8.
9–

31
44

.6
)
Sc
hi
zo
ph
re
ni
a
sp
ec
tr
um
d
is
or
de
rs

Ev
er
b
ef
or
e
in
de
x
da
te
b
c
14
.8
(
1.
7–
17
8.
2)

b
9.

9
(1
.8
–5
3.
2)

13
.2

(
2.

2–
90

.4
)

6
m
o
be
fo
re
in
de
x
da
te

0
(0

)
N

C
N

C
b

9.
9
(0
.1

–7
73

.9
)
9.
9
(0
.1

–7
75

.2
)
Se
lf
-in
fl
ic
te
d
in
ju
ri
es

Ev
er
b
ef
or
e
in
de
x
da
te
b
6.
6
(0
.5
–5
7.

7)
4.

9
(0

.4
–3

4.
6)

13
(
2.
0)

65
.2

(
14
.7
–5

96
.2

)
13
.0
(
5.
3–

33
.4

)

6
m
o
be
fo
re
in
de
x
da
te
b

c
c

7
(1
.1
)

c
34

.8
(

6.
6–

34
4.

4)
Su
bs
ta
nc
e
us
e
di
so
rd
er
s

Ev
er
b
ef
or
e
in
de
x
da
te
8
(1
.9
)
5.
7
(2

.1
–1

4.
7)

4.
2

(1
.6

–1
0.

1)
16

(
2.

4)
6.

2
(3

.1
– 1

2.
0)

6.
2

(3
.1

–1
2.

6
m
o
be
fo
re
in
de
x
da
te
6
(1
.4

)
29

.9
(
5.
3–

30
3.

9)
12
.0
(

3.
0–

49
.7

)
9

(1
.4
)
11
.2
(

3.
8–

33
.5

)
11
.2
(
3.
8–
33
.6
)
Su
ic
id
al
id
ea
ti
on

Ev
er
b
ef
or
e
in
de
x
da
te
9
(2
.1
)
15
.1
(

4.
8–

51
.7

)
5.
6
(2

.2
–1

3.
6)

29
(

4.
4)
19
.8
(
10
.2
–4

0.
1)

11
.5
(
6.

5–
20

.4
)

6
m
o
be
fo
re
in
de
x
da
te
7
(1
.6
)

c
23

.3
(
5.
3–

14
0.

2)
17

(
2.

6)
24

.5
(

9.
6–

70
.1

)
21
.5
(

8.
7–

57
.7

)

N
C,

n
ot

c
al

cu
la

te
d

be
ca

us
e

th
er

e
w

er
e

0
ca

se
s

am
on

g
tr

an
sg
en
de

r
su

bj
ec

ts
.

a
Lo

gi
st
ic
r
eg
re
ss
io
n
w
it
h

ex
ac

t
95

%
C

Is
fo

r
ra

re
e

ve
nt

s
(p

re
va
le
nc

e
≤

10
%

in
b

ot
h

th
e
tr
an
sg
en
de
r
an
d
re
fe
re
nt

c
oh

or
ts

)
or

lo
gi

st
ic
r
eg
re
ss
io
n
w
it

h
lo

g
lin

k
an

d
ap

pr
ox

im
at

e
95

%
C
Is
fo

r
no

t-
ra

re
e
ve
nt

s
(>

10
%

p
re

va
le
nc
e

in
e

it
he

r
th

e
tr
an
sg
en
de

r
or

r
ef

er
en

t
co

ho
rt

s)
.

b
Fe

w
er

t
ha

n
5

ca
se

s
w

er
e

no
t

re
po

rt
ed

.
c

N
ot

c
al
cu
la
te
d
be
ca
us
e
th
er
e
w
er
e
0
ca
se
s
am
on

g
re

fe
re

nt
s.

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

13 151 reference males and 13 149
reference females.

The cohort included 588 (44%)
transfeminine and 745 (56%)
transmasculine children and
adolescents (Table 1). Children
<10 years old represented 27% of the transfeminine cohort and 12% of the transmasculine cohort. Compared with TGNC children (n = 251), in which 36% (n = 90) were transfeminine, 61% (n = 655) of adolescents (n = 1082) were transmasculine. More than 45% of subjects in both groups were white; Hispanics represented 30% of transfeminine and 27% of transmasculine subjects, whereas the remainder of the study population was approximately equally distributed among African Americans, Asian Americans and/ or Pacific Islanders, and persons whose race and/or ethnicity was characterized as other or unknown. Health care use levels were much higher in both transfeminine and transmasculine subjects than in those in the corresponding reference groups.

The most common diagnostic
categories among TGNC children
3 to 9 years of age were attention
deficit disorders (15% transfeminine;
16% transmasculine) and anxiety
disorders (12% transfeminine; 16%
transmasculine; Table 2). The PR
(95% CI) estimates for attention
deficit disorders ranged from 2.8
(95% CI 1.6–4.9) to 13 (95% CI
5.9–27). The PR (95% CI) estimates
for anxiety disorders ranged from
4.4 (95% CI 2.6–7.4) to 23 (95%
CI 8.8–69) depending on the time
window before the index date
and the reference group. Among
transfeminine children, 5% had an
autism spectrum disorder diagnosis;
however, no cases were observed
in transmasculine children. For
all the diagnostic categories, the
most pronounced PR estimates
were observed within the 6-month

period before the index date.
Among transfeminine children,
the highest PR (95% CI) estimate
was for conduct and/or disruptive
disorders relative to reference
females (83 [95% CI 11–3707]).
Among transmasculine children, the
highest PR (95% CI) estimate was
for depressive disorders relative
to reference males (43 [95% CI
8.4–422]). Additional analyses of the
prevalence of hospitalizations by
mental health diagnostic category
were not possible in this age group
because of small sample sizes.

In the adolescent group (age 10–17
years), like in the younger age
group, attention deficit disorders
and anxiety disorders remained
common (“ever” prevalence:
25% transfeminine and 16%
transmasculine; 40% both
transfeminine and transmasculine,
respectively; Table 3). The
diagnostic category with the highest
prevalence in this age group was
depressive disorders, which were
found in 49% of transfeminine and
62% of transmasculine subjects.
For all diagnostic categories, PR
estimates used to compare STRONG
adolescents to matched reference
groups were highest within 6
months before the index date.
Compared with reference females,
transfeminine and transmasculine
adolescents experienced particularly
pronounced increased prevalence
in psychoses (PR 101 and 95% CI
14–4375; PR 30 and 95% CI 12–94,
respectively). Additionally, the PR
estimates among transfeminine
subjects were particularly elevated
for autism spectrum disorders
(PR 261; 95% CI 43–10 734) and
among transmasculine subjects for
schizophrenia spectrum disorders
(PR 50; 95% CI 11–470) compared
with reference females. Compared
with reference males, PR estimates
for suicidal ideation and self-inflicted
injuries for transfeminine subjects
were 54 (95% CI 18–218) and 70

(95% CI 9.0–159), respectively,
which were also high among
transmasculine subjects, (45 [95% CI
23–97] and 144 [95% CI 14–4338],
respectively).

When prevalence estimates were
limited to mental health conditions
recorded during hospitalizations,
the patterns among adolescents
generally remained the same. In
several instances, however, the PR
estimates could not be calculated
because of the absence of cases in the
reference groups (Table 4).

The median cutoff values used for
adjusted analyses were 3.2 average
visits per year for the “ever” analyses
and 0.2 average visits per month for
the 6-month analyses. The prevalence
estimates were slightly attenuated or
remained approximately the same for
most diagnostic categories. However,
some estimates changed appreciably.
For children 3 to 9 years, adjusting
for use 6 months before and
excluding the index date produced
the largest decrease in the PR (95%
CI) for anxiety disorders, from 23
(95% CI 8.8–69) to 9.0 (95% CI
2.9–29) when transfeminine children
were compared with reference males
(Supplemental Table 8). The PR
(95% CI) for suicidal ideation among
transfeminine adolescents compared
with reference males within 6
months of the index date decreased
from 54 (95% CI 18–218) to 38 (95%
CI 12–159; Supplemental Table 9).

DISCUSSION

The results of this study reveal that
among TGNC youth, mental health
conditions, specifically anxiety
and depression, are common and
often severe among adolescents, as
evidenced by diagnoses associated
with hospitalizations. Gender
nonconforming children (3–9 years
of age) have a higher prevalence
of anxiety and attention deficit
disorders compared with their
cisgender counterparts. In nearly all

PEDIATRICS Volume 141, number 5, May 2018 7
by guest on January 12, 2021www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/lookup/suppl/doi:10.1542/peds.2017-3845/-/DCSupplemental

instances, mental health diagnoses
were more common in the TGNC
youth than in referent children and
adolescents.

These results support findings
from previous research in which
the sample sizes were much
smaller.17, 19 –22, 37 – 42 Researchers in
a survey of 101 transfeminine and
transmasculine patients ages 12
to 24 years in a transgender youth
clinic in Los Angeles found that
35% had symptoms of depression
and >50% had suicidal thoughts.19
In comparison, we found that
adolescents had a higher prevalence
(40%–60%) of depression but a
lower prevalence of suicidal ideation
(5%–10%). In a medical record
abstraction study of 97 transfeminine
and transmasculine patients ages 4
to 20 years presenting to the Gender
Management Service Clinic at Boston
Children’s Hospital, 44% presented
with a significant psychiatric history,
21% had a history of self-mutilation,
and 9% had documentation of
suicide attempts.22 In a UK study, a
baseline chart review of children 5
to 11 years old referred to a national
specialty clinic revealed that 17%
had symptoms of anxiety, and 15%
had a history of suicidal ideation,
self-harm, and/or a diagnosis of
attention-deficit/hyperactivity
disorder recorded before entering
services.39 Our results for children
were similar for demonstrated
anxiety (9%–16%) and attention
deficit disorders (14%–16%). Direct
comparisons to the current study
are challenging because there are
methodological differences. Two
important differences are the way
in which mental health conditions
were ascertained and presentations
of age. In addition, we included a
broader population of children and
adolescents who were not necessarily
seeking treatment for gender-related
issues.

In recent years, researchers in
several studies have suggested that
gender dysphoria may be associated

with autism spectrum disorders.43 – 45
The most widely cited evidence
supporting this hypothesis comes
from a study of 204 children and/or
adolescents referred to the Gender
Identity Clinic in Amsterdam.46 The
presence of an autism spectrum
disorder was established via a
standardized diagnostic interview, 47
yielding a prevalence of 10%
among transfeminine patients and
4% among transmasculine patients,
which was reported by the authors
to be higher than the 1% estimate
reported in the general population.
The prevalence of autism spectrum
disorders in our study was somewhat
lower (7% in transfeminine and
3% in transmasculine subjects
across both age groups), but our
case ascertainment was based on
documented diagnostic codes, and
the denominator in our calculations
was not limited to children with
established gender dysphoria.
With these differences in mind,
our results are generally comparable
to those reported in the Dutch
study.

The gender ratio in this TGNC cohort
reveals that transfeminine youth
may present earlier in age than
transmasculine individuals, which
may pose a unique challenge to the
early identification of mental health
needs in transmasculine children and
adolescents. Historically, researchers
in studies of TGNC adolescents have
reported a greater proportion of
transfeminine than transmasculine
subjects, but in recent years, the
direction of the transmasculine:
transfeminine ratio appears to have
changed.48 For example, researchers
in 1 recent study observed that
transmasculine youth with gender
dysphoria (aged 12–24 years)
presented in significantly higher
numbers than their transfeminine
counterparts.19 Our data, which
were based on EMRs, were used to
confirm this observation. Therefore,
providers should also be aware of the
growing transmasculine population

needing timely and appropriate
medical and psychosocial services.

An important contribution of the
STRONG to the extant literature is
its relatively large cohort, which
allowed for focusing on previously
understudied groups (such as
young children), and an evaluation
of relatively rare events (such
as hospitalizations). In addition,
the current study was based on
children and adolescents who
were not necessarily in specialized
care and enrolled in a large health
care system; and we did not
require participant opt-in. The
availability of a well-defined source
population allowed for matching
transfeminine and transmasculine
study subjects to male and female
referents of the same age, race and/
or ethnicity, and geographic region.
This design feature permitted
direct comparisons of prevalence
estimates among transfeminine,
transmasculine, and cisgender
referent groups.

A limitation of this study is its cross-
sectional design. Although we were
able to retrospectively ascertain
mental health conditions before
the index date and we matched
on the basis of membership year,
a differential ascertainment of
diagnoses could have occurred. The
identification of the TGNC cohort was
based on health care use, which is
different from the matched referent
groups. Results from sensitivity
analyses adjusting for use and
excluding the index date revealed
a similar or slight attenuation of
the PR results for most diagnostic
categories. However, when adjusting
for use 6 months before the index
date, a more notable attenuation of
PRs was seen in anxiety disorders
in transfeminine children and
suicidal ideation in transfeminine
adolescents compared with reference
males, indicating possible higher
surveillance of mental health
conditions in the several months

BECERRA-CULQUI et al8
by guest on January 12, 2021www.aappublications.org/newsDownloaded from

before cohort identification.
Nevertheless, this baseline study
reveals that TGNC youth experience a
multitude of mental health problems
before initial presentation. However,
there is indication that TGNC
children who receive meaningful
gender identity support do not
necessarily experience elevated rates
of depression and anxiety.49 As the
STRONG cohort follow-up extends, it
will be possible to examine temporal
changes in the frequency and
severity of mental health problems,
particularly in relation to the age of
gender affirmation, which is an area
of considerable uncertainty, and
the impact of interventions to treat
gender dypshoria.50 –53

CONCLUSIONS
The most important finding is the
high frequency of mental health
conditions that TGNC children and
adolescents experience. Especially
worrisome are the results for
suicidal ideation and self-inflicted
injuries with prevalence estimates
orders of a magnitude that is higher
in TGNC children and adolescents
than in matched cisgender reference
groups. For nearly all mental
health disorders, the PRs increased
during the time window closest to
the index date. Overall, these data
reveal that children and adolescents
presenting as TGNC to health care
providers may require not only
thorough and immediate evaluation

of mental health needs but also
urgent implementation of social
and educational measures of gender
identity support.

PEDIATRICS Volume 141, number 5, May 2018 9

within their areas of expertise (such as epidemiologic methods, bias, health care access and health service use interpretation, and the broad messaging of the
manuscript), and revised the manuscript; Drs Liu, Flanders, and Nash provided substantial statistical analysis consultation, conducted the analyses, and critically
reviewed and revised the manuscript for important statistical interpretation of the data; Ms Cromwell substantially contributed to the design of multisite data
collection, critically reviewed the manuscript for appropriate interpretation of the data variables with respect to the results, and revised the manuscript; Ms
Millman and Ms Robinson conceptualized the study and substantially contributed to the acquisition of data by coordinating site data collection, critically reviewed
and revised the manuscript by providing and ensuring the interpretation of results with respect to site-specific patient populations, and revised the manuscript;
Drs Giammattei, Sandberg, and Tangpricha provided clinical consultation regarding the interpretation of results, revised the manuscript, and critically reviewed
the manuscript for important intellectual content specific to transgender and/or gender nonconforming youth, gender transitioning, and the mental health
outcomes discussed in the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

DOI: https:// doi. org/ 10. 1542/ peds. 2017- 3845

Accepted for publication Feb 22, 2018

Address correspondence to Michael Goodman, MD, MPH, Department of Epidemiology, Emory University School of Public Health, 1518 Clifton Rd, NE, CNR 3021,
Atlanta, GA 30322. E-mail: mgoodm2@emory.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Funded by contract AD-12-11-4532 from the Patient-Centered Outcomes Research Institute and grant R21HD076387 from the Eunice Kennedy Shriver
National Institute of Child Health and Human Development. Funded by the National Institutes of Health (NIH).

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

COMPANION PAPER: Companions to this article can be found online at www. pediatrics. org/ cgi/ doi/ 10. 1542/ peds. 2017- 3004 and www. pediatrics. org/ cgi/ doi/ 10.
1542/ peds. 2018- 0361.

ABBREVIATIONS

CI: confidence interval
EMR: electronic medical record
ICD-9: International Classification

of Diseases, Ninth Edition
KP: Kaiser Permanente
PR: prevalence ratio
STRONG: Study of Transition,

Outcomes, and Gender
TGNC: transgender and/or

gender nonconforming

REFERENCES

1. Lombardi E. Enhancing transgender
health care. Am J Public Health.
2001;91(6):869–872

2. Wallien MS, Cohen-Kettenis
PT. Psychosexual outcome of
gender-dysphoric children. J Am
Acad Child Adolesc Psychiatry.
2008;47(12):1413–1423

3. Steensma TD, van der Ende J,
Verhulst FC, Cohen-Kettenis PT.

Gender variance in childhood and
sexual orientation in adulthood:
a prospective study. J Sex Med.
2013;10(11):2723–2733

4. Leibowitz SF, Spack NP. The
development of a gender identity
psychosocial clinic: treatment
issues, logistical considerations,
interdisciplinary cooperation,
and future initiatives. Child

Adolesc Psychiatr Clin N Am.
2011;20(4):701–724

5. Chen D, Hidalgo MA, Leibowitz S,
et al. Multidisciplinary care for
gender-diverse youth: a narrative
review and unique model of gender-
affirming care. Transgend Health.
2016;1(1):117–123

6. Costa R, Carmichael P, Colizzi M.
To treat or not to treat: puberty

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

https://doi.org/10.1542/peds.2017-3845

mailto:

http://www.pediatrics.org/cgi/doi/10.1542/peds.2017-3004

http://www.pediatrics.org/cgi/doi/10.1542/peds.2018-0361

suppression in childhood-onset
gender dysphoria. Nat Rev Urol.
2016;13(8):456–462

7. Fast AA, Olson KR. Gender development
in transgender preschool children
[published online ahead of print April 25,
2017]. Child Dev. doi: 10. 1111/ cdev. 12758

8. Golombok S, Rust J, Zervoulis K,
Croudace T, Golding J, Hines M.
Developmental trajectories of sex-
typed behavior in boys and girls: a
longitudinal general population study
of children aged 2.5-8 years. Child Dev.
2008;79(5):1583–1593

9. Martin CL, Ruble DN. Patterns of
gender development. Annu Rev
Psychol. 2010;61:353–381

10. Rosenthal SM. Transgender youth:
current concepts. Ann Pediatr
Endocrinol Metab. 2016;21(4):185–192

11. Coleman E, Bockting WO, Botzer M, et al.
Standards of care for the health of
transsexual, transgender, and gender-
nonconforming people, version 7. Int
J Transgenderism. 2012;13(4):165–232

12. Wilczynski C, Emanuele MA. Treating
a transgender patient: overview
of the guidelines. Postgrad Med.
2014;126(7):121–128

13. Levine DA; Committee on Adolescence.
Office-based care for lesbian, gay,
bisexual, transgender, and questioning
youth. Pediatrics. 2013;132(1).
Available at: www. pediatrics. org/ cgi/
content/ full/ 132/ 1/ e297

14. Schneider C, Cerwenka S, Nieder TO,
et al. Measuring gender dysphoria:
a multicenter examination and
comparison of the Utrecht Gender
Dysphoria Scale and the Gender Identity/
Gender Dysphoria Questionnaire for
adolescents and adults. Arch Sex Behav.
2016;45(3):551–558

15. Grossman AH, D’Augelli AR.
Transgender youth and life-threatening
behaviors. Suicide Life Threat Behav.
2007;37(5):527–537

16. Cohen-Kettenis PT, Steensma TD, de
Vries AL. Treatment of adolescents with
gender dysphoria in the Netherlands.
Child Adolesc Psychiatr Clin N Am.
2011;20(4):689–700

17. de Vries AL, Doreleijers TA, Steensma
TD, Cohen-Kettenis PT. Psychiatric
comorbidity in gender dysphoric
adolescents. J Child Psychol
Psychiatry. 2011;52(11):1195–1202

18. Nahata L, Quinn GP, Caltabellotta NM,
Tishelman AC. Mental health concerns
and insurance denials among
transgender adolescents. LGBT Health.
2017;4(3):188–193

19. Olson J, Schrager SM, Belzer
M, Simons LK, Clark LF. Baseline
physiologic and psychosocial
characteristics of transgender youth
seeking care for gender dysphoria.
J Adolesc Health. 2015;57(4):374–380

20. Reisner SL, Biello KB, White Hughto
JM, et al. Psychiatric diagnoses and
comorbidities in a diverse, multicity
cohort of young transgender women:
baseline findings from project LifeSkills.
JAMA Pediatr. 2016;170(5):481–486

21. Reisner SL, Vetters R, Leclerc M, et al.
Mental health of transgender youth
in care at an adolescent urban
community health center: a matched
retrospective cohort study. J Adolesc
Health. 2015;56(3):274–279

22. Spack NP, Edwards-Leeper L, Feldman
HA, et al. Children and adolescents
with gender identity disorder
referred to a pediatric medical center.
Pediatrics. 2012;129(3):418–425

23. de Vries AL, Kreukels BP, Steensma
TD, Doreleijers TA, Cohen-Kettenis
PT. Comparing adult and adolescent
transsexuals: an MMPI-2 and
MMPI-A study. Psychiatry Res.
2011;186(2–3):414–418

24. Olson-Kennedy J, Cohen-Kettenis
PT, Kreukels BP, et al. Research
priorities for gender nonconforming/
transgender youth: gender identity
development and biopsychosocial
outcomes. Curr Opin Endocrinol
Diabetes Obes. 2016;23(2):172–179

25. Dekker MJ, Wierckx K, Van Caenegem
E, et al. A European network for the
investigation of gender incongruence:
endocrine part. J Sex Med.
2016;13(6):994–999

26. Kreukels BP, Haraldsen IR, De Cuypere
G, Richter-Appelt H, Gijs L, Cohen-
Kettenis PT. A European network for the
investigation of gender incongruence:
the ENIGI initiative. Eur Psychiatry.
2012;27(6):445–450

27. Reisner SL, Deutsch MB, Bhasin S, et al.
Advancing methods for US transgender
health research. Curr Opin Endocrinol
Diabetes Obes. 2016;23(2):198–207

28. Koebnick C, Langer-Gould AM,
Gould MK, et al. Sociodemographic
characteristics of members of a
large, integrated health care system:
comparison with US Census Bureau
data. Perm J. 2012;16(3):37–41

29. Gordon NP. How Does the Adult Kaiser
Permanente Membership in Northern
California Compare With the Larger
Community? Oakland, CA: Kaiser
Permanente Division of Research; 2006

30. American Academy of Pediatrics.
Periodicity schedule. 2017. Available
at: https:// www. aap. org/ en- us/
Documents/ periodicity_ schedule. pdf.
Accessed July 12, 2017

31. Roblin D, Barzilay J, Tolsma D, et al. A
novel method for estimating transgender
status using electronic medical records.
Ann Epidemiol. 2016;26(3):198–203

32. Quinn VP, Nash R, Hunkeler E, et al.
Cohort profile: Study of Transition,
Outcomes and Gender (STRONG) to
assess health status of transgender
people. BMJ Open. 2017;7(12):e018121

33. Lee PA, Houk CP, Ahmed SF, Hughes IA;
International Consensus Conference
on Intersex Organized by the Lawson
Wilkins Pediatric Endocrine Society and
the European Society for Paediatric
Endocrinology. Consensus statement
on management of intersex disorders.
International Consensus Conference
on Intersex. Pediatrics. 2006;118(2).
Available at: www. pediatrics. org/ cgi/
content/ full/ 118/ 2/ e488

34. Coleman KJ, Stewart C, Waitzfelder
BE, et al. Racial-ethnic differences in
psychiatric diagnoses and treatment
across 11 health care systems in
the mental health research network.
Psychiatr Serv. 2016;67(7):749–757

35. World Health Organization. Recognizing
adolescence. 2014. Available at: http://
apps. who. int/ adolescent/ second- decade/
section2/ page1/ recognizing- adolescence.
html. Accessed November 7, 2017

36. Nickleach D, Liu Y, Shrewsberry A,
Ogan K, Kim S, Wang Z. SAS macros
to conduct common biostatistical
analyses and generate reports. In:
SouthEast SAS User Group; October
20-23, 2013; St. Pete Beach, FL

37. Arcelus J, Claes L, Witcomb GL,
Marshall E, Bouman WP. Risk
factors for non-suicidal self-injury

BECERRA-CULQUI et al10
by guest on January 12, 2021www.aappublications.org/newsDownloaded from

www.pediatrics.org/cgi/content/full/132/1/e297

https://www.aap.org/en-us/Documents/periodicity_schedule

www.pediatrics.org/cgi/content/full/118/2/e488

http://apps.who.int/adolescent/second-decade/section2/page1/recognizing-adolescence.html

PEDIATRICS Volume 141, number 5, May 2018 11

among trans youth. J Sex Med.
2016;13(3):402–412

38. Kaltiala-Heino R, Sumia M, Työläjärvi
M, Lindberg N. Two years of
gender identity service for minors:
overrepresentation of natal girls
with severe problems in adolescent
development. Child Adolesc Psychiatry
Ment Health. 2015;9:9

39. Holt V, Skagerberg E, Dunsford
M. Young people with features of
gender dysphoria: demographics
and associated difficulties. Clin Child
Psychol Psychiatry. 2016;21(1):108–118

40. Shields JP, Cohen R, Glassman JR,
Whitaker K, Franks H, Bertolini I.
Estimating population size and
demographic characteristics of
lesbian, gay, bisexual, and transgender
youth in middle school. J Adolesc
Health. 2013;52(2):248–250

41. Diemer EW, Grant JD, Munn-Chernoff
MA, Patterson DA, Duncan AE. Gender
identity, sexual orientation, and eating-
related pathology in a national sample
of college students. J Adolesc Health.
2015;57(2):144–149

42. Chen M, Fuqua J, Eugster EA.
Characteristics of referrals for gender
dysphoria over a 13-year period. J
Adolesc Health. 2016;58(3):369–371

43. Glidden D, Bouman WP, Jones
BA, Arcelus J. Gender dysphoria
and autism spectrum disorder: a
systematic review of the literature. Sex
Med Rev. 2016;4(1):3–14

44. Jacobs LA, Rachlin K, Erickson-Schroth
L, Janssen A. Gender dysphoria
and co-occurring autism spectrum
disorders: review, case examples, and
treatment considerations. LGBT Health.
2014;1(4):277–282

45. Van Der Miesen AI, Hurley H, De
Vries AL. Gender dysphoria and
autism spectrum disorder: a
narrative review. Int Rev Psychiatry.
2016;28(1):70–80

46. de Vries AL, Noens IL, Cohen-
Kettenis PT, van Berckelaer-Onnes
IA, Doreleijers TA. Autism spectrum
disorders in gender dysphoric children
and adolescents. J Autism Dev Disord.
2010;40(8):930–936

47. Wing L, Leekam SR, Libby SJ, Gould J,
Larcombe M. The diagnostic interview
for social and communication
disorders: background, inter-rater
reliability and clinical use. J Child
Psychol Psychiatry. 2002;43(3):
307–325

48. Aitken M, Steensma TD, Blanchard
R, et al. Evidence for an altered sex

ratio in clinic-referred adolescents
with gender dysphoria. J Sex Med.
2015;12(3):756–763

49. Olson KR, Durwood L, DeMeules M,
McLaughlin KA. Mental health of
transgender children who
are supported in their identities.
Pediatrics. 2016;137(3):
e20153223

50. Hembree WC. Guidelines for pubertal
suspension and gender reassignment
for transgender adolescents.
Child Adolesc Psychiatr Clin N Am.
2011;20(4):725–732

51. Milrod C. How young is too young:
ethical concerns in genital surgery of
the transgender MTF adolescent. J Sex
Med. 2014;11(2):338–346

52. Milrod C, Karasic DH. Age is just a
number: WPATH-affiliated surgeons’
experiences and attitudes toward
vaginoplasty in transgender
females under 18 years of age
in the United States. J Sex Med.
2017;14(4):624–634

53. Shumer DE, Spack NP. Current
management of gender identity
disorder in childhood and adolescence:
guidelines, barriers and areas of
controversy. Curr Opin Endocrinol
Diabetes Obes. 2013;20(1):69–73

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

DOI: 10.1542/peds.2017-3845 originally published online April 16, 2018;
2018;141;Pediatrics

Michael J. Silverberg, Vin Tangpricha and Michael Goodman
Millman, Virginia P. Quinn, Brandi Robinson, Douglas Roblin, David E. Sandberg,

Darios Getahun, Shawn V. Giammattei, Enid M. Hunkeler, Timothy L. Lash, Andrea
Tracy A. Becerra-Culqui, Yuan Liu, Rebecca Nash, Lee Cromwell, W. Dana Flanders,

With Their Peers
Mental Health of Transgender and Gender Nonconforming Youth Compared

Services
Updated Information &

http://pediatrics.aappublications.org/content/141/5/e20173845
including high resolution figures, can be found at:

References
http://pediatrics.aappublications.org/content/141/5/e20173845#BIBL
This article cites 49 articles, 4 of which you can access for free at:

Subspecialty Collections

http://www.aappublications.org/cgi/collection/public_health_sub
Public Health
y_sub
http://www.aappublications.org/cgi/collection/psychiatry_psycholog
Psychiatry/Psychology
following collection(s):
This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml
in its entirety can be found online at:
Information about reproducing this article in parts (figures, tables) or

Reprints
http://www.aappublications.org/site/misc/reprints.xhtml
Information about ordering reprints can be found online:

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

http://http://pediatrics.aappublications.org/content/141/5/e20173845

http://pediatrics.aappublications.org/content/141/5/e20173845#BIBL

http://www.aappublications.org/cgi/collection/psychiatry_psychology_sub

http://www.aappublications.org/cgi/collection/public_health_sub

http://www.aappublications.org/site/misc/Permissions.xhtml

http://www.aappublications.org/site/misc/reprints.xhtml

DOI: 10.1542/peds.2017-3845 originally published online April 16, 2018;
2018;141;Pediatrics
Michael J. Silverberg, Vin Tangpricha and Michael Goodman
Millman, Virginia P. Quinn, Brandi Robinson, Douglas Roblin, David E. Sandberg,
Darios Getahun, Shawn V. Giammattei, Enid M. Hunkeler, Timothy L. Lash, Andrea
Tracy A. Becerra-Culqui, Yuan Liu, Rebecca Nash, Lee Cromwell, W. Dana Flanders,
With Their Peers
Mental Health of Transgender and Gender Nonconforming Youth Compared

http://pediatrics.aappublications.org/content/141/5/e20173845
located on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://pediatrics.aappublications.org/content/suppl/2018/04/12/peds.2017-3845.DCSupplemental
Data Supplement at:

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2018
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on January 12, 2021www.aappublications.org/newsDownloaded from

http://pediatrics.aappublications.org/content/141/5/e20173845

http://pediatrics.aappublications.org/content/suppl/2018/04/12/peds.2017-3845.DCSupplemental

What Will You Get?

We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

Premium Quality

Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

Experienced Writers

Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

On-Time Delivery

Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

24/7 Customer Support

Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

Complete Confidentiality

Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

Authentic Sources

We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

Moneyback Guarantee

Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

Order Tracking

You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.

Order Now Talk to Us

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Trusted Partner of 9650+ Students for Writing

From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

Preferred Writer

Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

Grammar Check Report

Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

One Page Summary

You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

Plagiarism Report

You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

Free Features $66FREE

Most Qualified Writer $10FREE
Plagiarism Scan Report $10FREE
Unlimited Revisions $08FREE
Paper Formatting $05FREE
Cover Page $05FREE
Referencing & Bibliography $10FREE
Dedicated User Area $08FREE
24/7 Order Tracking $05FREE
Periodic Email Alerts $05FREE

Our Services

Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

On-time Delivery
24/7 Order Tracking
Access to Authentic Sources

Academic Writing

We create perfect papers according to the guidelines.

Professional Editing

We seamlessly edit out errors from your papers.

Thorough Proofreading

We thoroughly read your final draft to identify errors.

Thorough Proofreading

We thoroughly read your final draft to identify errors.

Delegate Your Challenging Writing Tasks to Experienced Professionals

Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

Check Out Our Sample Work

Dedication. Quality. Commitment. Punctuality

It May Not Be Much, but It’s Honest Work!

Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.

0+

Happy Clients

0+

Words Written This Week

0+

Ongoing Orders

0%

Customer Satisfaction Rate

Process as Fine as Brewed Coffee

We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

Call Us +1 (877) 657-8180 Discuss Order Details Now

See How We Helped 9000+ Students Achieve Success

We Analyze Your Problem and Offer Customized Writing

We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

Clear elicitation of your requirements.
Customized writing as per your needs.

We Mirror Your Guidelines to Deliver Quality Services

We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

Proactive analysis of your writing.
Active communication to understand requirements.

We Handle Your Writing Tasks to Ensure Excellent Grades

We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

Thorough research and analysis for every order.
Deliverance of reliable writing service to improve your grades.

Place an Order Start Chat Now

Term Paper. Topic: Evidence Based Practices to Guide Clinical Practices

POWER POINT TO PRESENT THE TERM PAPER

What Will You Get?

Premium Quality

Experienced Writers

On-Time Delivery

24/7 Customer Support

Complete Confidentiality

Authentic Sources

Moneyback Guarantee

Order Tracking

Areas of Expertise

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Areas of Expertise

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Trusted Partner of 9650+ Students for Writing

Preferred Writer

Grammar Check Report

One Page Summary

Plagiarism Report

Free Features $66FREE

Our Services

Academic Writing

Professional Editing

Thorough Proofreading

Thorough Proofreading

Delegate Your Challenging Writing Tasks to Experienced Professionals

Check Out Our Sample Work

It May Not Be Much, but It’s Honest Work!

0+

Happy Clients

0+

Words Written This Week

0+

Ongoing Orders

0%

Customer Satisfaction Rate

Process as Fine as Brewed Coffee

Share Your Requirements

Place Order & Deposit Funds

Release Payment to Your Writer

See How We Helped 9000+ Students Achieve Success

We Analyze Your Problem and Offer Customized Writing

We Mirror Your Guidelines to Deliver Quality Services

We Handle Your Writing Tasks to Ensure Excellent Grades