1. Chapter 2: Ethical Considerations in Mental Health Treatment and Interventions with School-Age Children and Adolescents Adam L. Fried Celia B. Fisher

2. Competence Psychologists and mental health clinicians have a responsibility to identify, develop, and disseminate treatments Research and practice are complementary Benefit to individual clients and society at large (APA, 2002); relationship is bidirectional Psychologists benefit from scientific research Researchers called to draw from “real-world” clinical problems

3. Treatment Selection and Empirically Based Interventions APA Ethics Code General Principle A: beneficence and nonmaleficence Psychologists 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)

4. 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

5. Clinical, Developmental, and Multicultural Competence Specialized knowledge in development is important for working with children and adolescents Knowledge of evolving cognitive, social, and emotional processes Clinical 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 validity Developmental validity: extent to which treatments have been assessed to show effectiveness across various ages (e.g., Fisher et al., 1999)

6. Clinical, Developmental, and Multicultural Competence Cultural factors play important role in: Symptom presentation Response to interventions Child/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 prejudices 2) Understanding of the ways cultural factors may affect professional work

7. 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

8. 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 decisions Involvement, 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

9. 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

10. 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 confidentiality Research suggests that including children/adolescents in the consent process may improve participation in and effectiveness of treatments (Sales et al., 2008)

11. 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)

12. Distance and Internet-Based Therapies New technologies allow practitioners to work with clients from wide geographic areas in a variety of mediums Need 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)

13. 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 client Ensure the referral question is clear Perspectives of all parties are discussed Clinical goals between parent and client are congruent and participants’ rights are understood

14. Rational Nature of Consent Four essential components to psycho-legal consent (Grisso et al., 1995) 1) Understand the key points conveyed in the consent information 2) Risk-benefit analysis about the decision to participant 3) Communicating a decision about participation 4) 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)

15. Children/Adolescents With Mental Health Conditions Children/adolescents may be limited in their understanding of consent information if diagnosed with a mental health condition Research 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

16. 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)

17. 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

18. Limits to Confidentiality Limits to confidentiality should occur at the beginning of a professional relationship (APA, 2010) Discussed with both parents and children/adolescents Topic 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.

19. 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)

20. Disclosures Mandated Reporting: Providers should be aware of relevant laws in their jurisdiction that require psychologist to report without consent. This typically includes: Child abuse Elder abuse Domestic abuse Abuse of individuals who are disabled If client represents a danger

21. 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)