Chapter 2: Ethical Considerations in

Mental Health Treatment and Interventions with School-

Age Children and Adolescents

Adam L. Fried

Celia B. Fisher

Competence

Psychologists and mental health clinicians have a responsibility to identify, develop, and disseminate treatments

Research and practice are complementaryBenefit to individual clients and society at large (APA,

2002); relationship is bidirectionalPsychologists benefit from scientific researchResearchers called to draw from “real-world” clinical

problems

Treatment Selection and Empirically Based Interventions

APA Ethics Code General Principle A: beneficence and nonmaleficencePsychologists and other mental health clinicians are

called upon to engage in professional activities that provide benefit and do no harm

To accomplish this, need to select treatments that have been scientifically or professionally demonstrated to show effectiveness with a particular problem and population (APA, 2010)

Requires ongoing training to best address needs of clients (Kinscherff, 1999)

Clinical, Developmental, and Multicultural Competence

Working with child and adolescent populations requires a special clinical competence that exceeds one’s own personal experience (e.g., being a parent; Koocher 2003)

Professionals need: specialized training, education, experience, and/or consultation

Clinicians not properly trained risk providing ineffective or even harmful services

Clinical, Developmental, and Multicultural Competence

Specialized knowledge in development is important for working with children and adolescentsKnowledge of evolving cognitive, social, and emotional

processesClinical knowledge to evaluate implications of development on

symptom presentation, treatment selection and implementation, and response

Interventions with children need to be assessed for their developmental validityDevelopmental validity: extent to which treatments have been

assessed to show effectiveness across various ages (e.g., Fisher et al., 1999)

Clinical, Developmental, and Multicultural Competence

Cultural factors play important role in: Symptom presentationResponse to interventionsChild/adolescent’s experience (e.g., important values and

relationships with peers and family members)

These factors may have implications for therapeutic outcome (e.g., Sue & Sue, 2003)

Multicultural awareness (Fisher, 2013): 1) Critical self-reflection of one’s own beliefs, biases, and

prejudices2) Understanding of the ways cultural factors may affect

professional work

Clinical, Developmental, and Multicultural Competence

Professionals should know the limitations of their skills, knowledge, and experience in order to best address the clinical needs of a client

Referrals might be highly appropriate for specific interventions (e.g., exposure therapies or behavior modification programs)

Professionals should also be aware of the specific laws, rules, and regulations governing professional interventions with minors

Informed Consent for Treatment

Informed consent: gives the opportunity to receive, consider, and make an informed, rational, and voluntary decision about participation in professional treatment

Most children and adolescents lack the legal competence to make consent decisionsInvolvement, however, is often ethically indicated and considered

essential

Parents are assumed to be in the best position for consent

Limited circumstances where certain adolescents may be deemed competent to consent

Informed Consent for Treatment

Parents do not need to consent when…

Emancipated minor: state-determined legal status that describes an individual who has not reach the age of legal majority but who is considered (most often by law or court) competent through the assumption of adult responsibilities

Mature minor: individual who has not reached age of legal competency but who has been deemed competent to make limited decisions about activities (e.g., engagement in therapy)

Court ordered treatments: may not require consent from parents

Consent: An Ongoing and Developmentally Appropriate Process

Consent is an ongoing process not a singular event

Children and adolescents (and parent) may benefit from periodic review and discussion of consent and limitations to consent

It is recommended that the child/adolescent and parents/guardians be involved in the consent discussions (e.g., Molin & Palmer, 2005)

Including both parents and children ensures that both parties have similar understandings about consent information and resolve any possible misconceptions regarding treatment goals, methods, and confidentialityResearch suggests that including children/adolescents in the consent

process may improve participation in and effectiveness of treatments (Sales et al., 2008)

Identification of Client

Identifying the primary client is a critical component of the informed consent process

Client can be: child/adolescent, parent or guardian, or even the entire family (APA, 2010)

Often therapy with children includes the family due to their ability to help provide a more complete clinical picture (Weisz & Hawley, 2002)If the whole family is included, need to clarify the boundaries of

therapy (e.g., will not include unrelated parental or family mental health concerns; Koocher et al., 2012)

Distance and Internet-Based Therapies

New technologies allow practitioners to work with clients from wide geographic areas in a variety of mediumsNeed to consider ethical, legal, and technological concerns (Fisher

(2013)

Consent should include information relevant to telehealth treatment (e.g., effectiveness of this treatment)

Due to difficulties assessing age of client via some electronic means (e.g., instant messaging), experts suggest initial in-person meetings, videoconferencing, or exchange of identifying documentation (Fisher & Fried, 2003)

Voluntary Nature of Consent

A child’s decision to enter treatment is likely made by other individuals with greater power and experience (Campbell, 2003)

If a child is reluctant to participate, the clinician should: Spend time with both the parent and minor clientEnsure the referral question is clearPerspectives of all parties are discussedClinical goals between parent and client are congruent

and participants’ rights are understood

Rational Nature of Consent

Four essential components to psycho-legal consent (Grisso et al., 1995)1) Understand the key points conveyed in the consent

information2) Risk-benefit analysis about the decision to participant3) Communicating a decision about participation4) Demonstration of adequate reasoning about a decision

Minors age 14 and older are considered likely to possess the cognitive skills necessary to make independent decisions about treatment (Paul et al., 2008)

Children/Adolescents With Mental Health Conditions

Children/adolescents may be limited in their understanding of consent information if diagnosed with a mental health conditionResearch suggests that certain children/adolescents who

are diagnosed with a mental health disorder have a poor understanding and difficulty appreciating their condition and subsequent treatment needs (Turrell et al., 2011)

Informed assent: Children/adolescents may be incapable of providing legal consent, but they should be afforded the opportunity to provide their approval (“assent”) to participate in treatment

Consent Context

Characteristics related to the child/adolescent: age, developmental level, legal status

Self-referring clients: adolescents seeking to directly initiate services with a provider without parental knowledge (e.g., in school setting)In many cases, initiating treatment with minors without parental

consent is not ethically advisable and may conflict with state and local laws

Best Interests: There may be situations in which soliciting consent from parents/guardians may potentially result in risk of harm to the child/adolescent and therefore it is not in his or her best interests (APA, 2010)

Privacy and Confidentiality

Confidentiality: core ethical commitment in health care settings and in mental health professions, –often is viewed as critical to the success of the therapeutic process (Koocher, 2008)

Privacy: significant concern among adolescents considering treatment because there often is an expectation that clinicians will maintain privacy about information disclosed (e.g., Condie et al., 2008)

Mental health professionals struggle with knowing what information should be provided to parents/guardians about potentially risky behaviors disclosed during therapy

Limits to Confidentiality

Limits to confidentiality should occur at the beginning of a professional relationship (APA, 2010)Discussed with both parents and children/adolescentsTopic should be revisited throughout therapy

Important to discuss specific situations that may warrant disclosure at the outset of therapy (Rae et al., 2002)

Health Insurance Portability and Accountability Act (HIPAA) of 1996: allows parents, in most cases, to request and view the contents of their child’s health care records.

Privacy Assurances

“Secrecy Pact”: therapist assurance of absolute privacy May be ethically irresponsible, lead to harm to the client,

and place the psychologist at serious legal and professional risk (Fisher, 2013; Jacob & Hartshorne, 2007)

Research suggests that many adolescents expect and prefer that health care providers disclose information about high-risk behavior or harm to parents/guardians (e.g., Ford et al., 1997)

Disclosures

Mandated Reporting: Providers should be aware of relevant laws in their jurisdiction that require psychologist to report without consent. This typically includes: Child abuseElder abuseDomestic abuseAbuse of individuals who are disabledIf client represents a danger

Best Disclosure Practices

Disclosures of private information attempt to protect and promote the well-being and welfare of the child/adolescent, while minimizing possible damage to the therapeutic relationship

Disclosures conducted in a sensitive and thoughtful manner may serve to strengthen the therapeutic bond, enhance parent-child relationships, enhance treatment effectiveness, and serve as a model for effective and respectful methods of communication (Mitchell et al., 2002)