Right Words, Wrong Moment: A Clinician-Grounded Analysis of Distress in 19,930 Conversations between Young People and ChatGPT

Youth increasingly turn to AI chatbots for social and emotional support, raising concerns about how these systems respond, especially in high-stakes situations. However, existing child safety evaluations of AI lack grounding in real-world harms that youth experience, rely on unvalidated assumptions about what counts as an appropriate output (e.g., refusal), and typically focus on detecting adversarial prompts or surface-level harms in outputs only. Thus, these evaluations can fail to detect responses that pose harm to youth in practice. To better understand the limitations of current evaluation practices, we conducted interviews with 19 practitioners working directly with youth in vulnerable situations, including social workers, therapists, and psychologists, asking them to reflect on chatbots' responses to risky situations commonly faced by youth, as established in prior empirical work. Practitioners identified chatbot behaviors likely to cause harm as well as those that could meaningfully support youth in difficult moments, discussed the role that chatbots should (and should not) play in these interactions, and offered concrete recommendations for improving chatbot responses. Based on these findings, we provide recommendations for AI child safety evaluation and infrastructure, and highlight the need for incorporating practitioners' perspectives into safety work.

Large language models are increasingly used as private, always-available conversational systems, but little is known about how people with depressive symptoms use them. Building on CSCW work on disclosure and peer support, we examine ChatGPT as an emerging informal support infrastructure: private, persistent, responsive, and available outside ordinary hours. We analyze 187,093 ChatGPT conversations from 766 participants who completed the PHQ-8, comparing those below the moderate-symptom threshold (score of 10) with those at or above it. Higher-PHQ participants used ChatGPT more for mental-health, interpersonal, loneliness, self-focused, and support-seeking conversations, with pronounced late-night and recurring month-level patterns. Their language contained more first-person singular pronouns and absolutist terms. They more often engaged ChatGPT in high-disclosure contexts, but professional redirection was not higher. Language-based prediction was modest and insufficient for screening (AUROC 0.591). We argue these histories should not be treated as clinical screening data but as evidence LLMs are increasingly used as informal support infrastructure.

LLM chatbots increasingly serve as a first source of support for people in psychological distress, including those whose distress is entangled with delusional beliefs. Prior work on LLM mental-health safety largely evaluates general therapeutic quality or single-turn crisis detection, leaving unclear how models behave when distress is intertwined with delusion over sustained conversations. We address this gap with matched multi-turn simulations, across clinically grounded personas and six LLMs, that pair each delusional conversation with a distress-only control to isolate the effect of delusional framing. This reveals a recognition-intervention gap: models detect distress at comparable rates regardless of framing, yet sharply fail to act on it once distress is embedded in delusion, with safety interventions suppressed by up to 4.5x. The failure tracks accumulated acceptance of the user's premises rather than emotional validation. Worse, the intuitive fix of prompting models to assess user distress backfires under delusional framing; only delusion-aware prompting with explicit response guidance closes the gap, and even this depends on a delusion classifier that is itself unreliable on the most vulnerable models. Safe deployment therefore requires treating delusional framing as a distinct risk signal that overrides conversational accommodation.