Chapter 2 Adam L. Fried and Celia B. Fisher Psychological treatments hold enormous benefit for children and adolescents and have been found to be effective across a variety of mental health conditions and disorders. Responsible professional practice with children and adolescents may differ in important ways from treatment with adults and requires an understanding of important population-specific factors that critically inform psychologists’ ethical decision-making processes. Such factors include children and adolescents’ evolving cognitive, social, and emotional developmental processes, differential symptom presentation and treatment response, legal status, and special ethical responsibilities when conducting treatment with minors. Drawing on the relevant empirical and theoretical literature, laws and regulations, and principles and enforceable standards detailed in the American Psychological Association’s Code of Ethics and Ethical Principles (APA Ethics Code) (American Psychological Association [APA], 2010), this chapter explores several important ethical and legal topics related to psychological treatment with school-age children and adolescents. Consistent with the goal of this volume, the chapter focuses on four areas: As professionals committed to promoting the welfare of clients, pediatric psychologists and other mental health clinicians have a special responsibility to identify, develop, and disseminate treatments for children and adolescents that reflect empirical and other types of scholarly knowledge in the field. In recent years, psychology and other mental health professions have increasingly drawn on scientific findings and established professional knowledge to empirically inform treatment and practice. Within such a model, research and practice are seen as complementary activities, each representing benefit to individual clients and society at large rather than opposing or unrelated activities (APA, 2002). Such a relationship is often bidirectional; practicing psychologists not only benefit from the fruits of scientific research, but investigators are called on to draw from real-world clinical problems and experiences often informed by practice and applied psychological activities in order to develop and empirically examine appropriate psychological questions and constructs (APA Presidential Task Force, 2006; Fisher, 2013a; Fisher, Busch-Rossnagel, Jopp, & Brown, 2012). Consistent with the APA Ethics Code General Principle A, Beneficence and Nonmaleficence, psychologists and other mental health clinicians are called on to engage in professional activities that provide benefit and do no harm. To accomplish this requires selection of treatments that have been scientifically or professionally demonstrated to show effectiveness with a particular problem and population (Standard 2.04, “Bases for Scientific and Professional Judgments”) (APA, 2010). Competence is the linchpin enabling mental health professionals to fulfill these ethical obligations (Fisher, 2013a). In the field of children’s mental health, professional competence requires ongoing learning and consideration of the dynamic and changing science of the field to best address the needs of their clients (Kinscherff, 1999). As evidenced throughout this volume, a growing body of research demonstrates effective treatments for children and adolescents and should form the basis of competency to treat them (Falzon, Davidson, & Bruns, 2010; Ollendick & Davis, 2004; Ollendick & King, 2004; Weisz & Hawley, 2002). Similarly, growing evidence-based ethics and best practice resources in many important areas (including competence, consent, and confidentiality) may inform practice with children and adolescents. By definition, all professional psychological activities require some degree of competence both in terms of the focus of the activity (e.g., disorder) and the applicable population, whether it is the assessment of dementia in older adults, interventions with college-age substance users, or depression research with developmentally disabled adults. Working with child and adolescent populations requires a special competence that may well exceed one’s own personal experience (either as a child/adolescent or as the parent of a child/adolescent) (Koocher, 2003) and that includes specialized training, education, experience, and/or consultation to acquire the skills necessary to provide effective professional psychological services for specific disorders or conditions (Standard 2.01, “Boundaries of Competence”) (APA, 2010). Clinicians who are not appropriately trained or who cannot otherwise demonstrate necessary competencies risk providing ineffective or, in some cases, harmful services. One important area of competence required for professional work with children and adolescents is specialized knowledge of child and adolescent development, including an understanding of the complex and evolving cognitive, social, and emotional processes, as well as related clinical knowledge to evaluate the implications of development on symptom presentation, treatment selection and implementation, and response. For example, pediatric clinicians treating mood disorders should be aware that children and adolescents may display certain depressive symptoms (such as irritability and mild antisocial behaviors) that may not be associated with depression disorders commonly diagnosed in adults (American Psychiatric Association, 2013). Interventions with child and adolescent populations also must be assessed for their developmental validity, or the extent to which the treatments have been assessed and shown to be effective across various age populations (Fisher, Hatashita-Wong, & Isman, 1999; Prout, DeMartino, & Prout, 1999). Treatment approaches that have not been adequately researched with children and adolescent populations may lack effectiveness or unintentionally worsen symptoms. As reflected in the profession’s ethical principles and standards (APA, 2010), discerning mental health professionals also understand the importance that cultural factors may play not only in symptom presentation and response to interventions but in other important facets of the child/adolescent’s experience (including important values and relationships with peers and family members) that may have implications for therapeutic outcome (Arredondo & Toporek, 2004; Ponterrotto, Casas, Suzuki, & Alexander, 2001; Sue & Sue, 2003). Rather than assuming that clinicians have expertise in all types of cultural, racial, ethnic, religious, and other types of identity, the critical factor required for competent practice is a type of sensitivity to these issues, or what Fisher (2013a, 2013b) and others have described as a multicultural ethical awareness, which includes both a critical self-reflection of one’s own beliefs, biases, and prejudices as well as an understanding of the ways in which cultural factors, both at the immediate and broader political levels, may affect professional work with the child/adolescent and his/her family (APA, 1993, 2003; Arredeondo & Toporek, 2004; Fowers & Davidov, 2006; Ridley, Liddle, Hill, & Li, 2001; Salter & Salter, 2012). These may include examination of broader themes, such as the basis and appropriateness of particular values, treatment goals, and determinations of deviance and psychopathology (Fisher, 2013a; Prilleltensky, 1997). A full discussion of these topics is beyond the scope of this chapter, but several authors provide excellent discussions of these topics, including Fisher (2013a, 2013b), Lemoire and Chen (2005), Ponterrotto et al. (2001), and Sue and Sue (2003). Competence also requires an honest and critical self-evaluation and analysis of skills, knowledge training and experience, as well as any personal limitations or barriers to effective treatment; the prudent mental health professional may determine that, at times, the best way to address the clinical needs of a client adequately is to make a referral to a professional with the appropriate competencies or who may be better suited to provide the required professional services (Fisher, 2013a; Kinscherff, 1999). Referrals also may be highly appropriate for specific interventions (such as exposure therapies or behavior modification programs) that are considered highly effective but may be outside the skill repertoire of the therapist. Finally, clinicians working with school-age children and adolescents should be aware of the specific laws, rules, and regulations governing professional interventions with minors. For example, as discussed later in the chapter, in most cases, minors are not deemed legally competent to provide informed consent to treatment; in most jurisdictions, consent must be provided by a parent or guardian. It also should be noted that rules and regulations may differ by setting or duties, and clinicians should not assume that all interventions and treatments with children and adolescents are subject to the same regulations across settings. For example, school-based interventions may be governed by additional or differing ethical standards and laws, such as the National Association of School Psychologists’ Principles for Professional Ethics (2010) and the Family Educational Rights and Privacy Act of 1974. Reflecting the values of respect for individual dignity and right to self-determination, informed consent procedures in professional practice provide clients and/or their appropriate decision makers with an opportunity to receive, consider, and make an informed, rational, and voluntary decision about participation in professional treatment (Standards 3.10, “Informed Consent,” 10.01, “Informed Consent for Therapy”) (APA, 2010). While most children and adolescents lack the legal competence to make consent decisions, their involvement in the consent process often is ethically indicated and considered essential for collaborative and productive therapeutic relationships. Parents are assumed to be in the best position to make informed decisions for their children and are given the legal responsibility to consent to services on their behalf. In legal contexts, children and adolescents are considered incapable of providing informed consent for treatment, except in limited circumstances in which certain adolescents may be deemed competent to consent. For example, an emancipated minor is a state-determined legal status that describes an individual who has not reached the age of legal majority but who is considered (most often by law or court) competent through the assumption of adult responsibilities, such as self-support or marriage, to engage in certain types of decision making. As another example, the mature minor is a category defined by state law and refers to an individual who has not reached the age of legal competency but who has been deemed competent to make limited decisions about activities, such as engagement in treatment or assessment. Finally, court-ordered treatments may not require informed consent from parents, but ethical standards and professional guidelines recommend that both the child or adolescent client and parents/guardians be provided with pertinent consent information, such as the purpose of the treatments, limits to confidentiality, and the reporting responsibilities of the mental health professional and record keeping. Notwithstanding the aforementioned categories, when a referral of a child or adolescent is made, it is important to ensure that the referring party (often the parent/guardian) has the legal authority to do so, especially in cases in which there may be legal action (Fisher et al., 1999; Koocher, 2008). For example, a therapist who receives a referral from the local child welfare office to provide treatment for a 10-year-old child for issues related to neglect and trauma may be well advised to request a copy of court documentation confirming that the agency has the legal authority to make such a referral and consent to treatment. It is helpful to view informed consent as an ongoing process rather than a singular event conducted at the onset of a professional relationship. Additional discussion about important consent components, including limits to confidentiality (such as mandatory disclosures) and relevant treatment information, often are necessary as treatment progresses, as the exact techniques, overall therapeutic goals, and estimated duration of therapy may change from the initial consent consultation (Fisher, 2013a; Fisher & Oransky, 2008). In addition, children and adolescents (as well as parents) may benefit especially from periodic review and discussion of these important topics. As many point out (e.g., Fisher, 2013a; Kunin, 1997; Kuther, 2003; Melton, 1999), respect for children’s and adolescents’ dignity and self-determination does not necessarily imply a capacity for autonomous decision making. On the contrary, reliance on such a conclusion may lead to harm and neglects the legal and ethical responsibilities of mental health professionals. Respectful and appropriate consent procedures with child and adolescent clients take into account the developmental and other important contextual details of the decision-making process to appropriately frame the consent process and offer an opportunity to voice assent or dissent (Fisher, 2013a; Fisher, Cea, Davidson, & Fried, 2006; Masty & Fisher, 2008). For example, an advanced understanding of developmental levels and age milestones may inform methods for explaining critical consent information, such as treatment procedures, duration and frequency, and limits to confidentiality. In most cases, it is recommended that the child/adolescent and the parents or guardians or those responsible for the care of the child/adolescent be involved in consent discussions (Fisher et al., 1999; Molin & Palmer, 2005). Such an approach reflects respect for personhood and promotes responsibility and active participation in the therapeutic process (Byckowski, Kollar, & Britto, 2010; Kunin, 1997; Melton, 1999). In fact, recent research suggests that adolescents may expect to be involved in consent discussions. For example, Paul, Berriman, and Evans (2008) found that a majority of 14- to 16-year-olds in their study expected to be asked their opinions about participating in treatment, saw themselves (rather than parents or guardians) as primary decision maker, and believed that they had the right to terminate treatment without parental approval. Throughout the consent process, mental health professionals also may find it helpful to solicit client attitudes toward and perceptions about mental health treatment. Rather than assume that minors or their parents/guardians accurately and adequately understand the nature and purpose of the psychotherapy (Fisher, 2013a; Fisher et al., 1999; Fisher & Oransky, 2008), providing clear explanations about the purpose, goals, and process of the therapy may help to address possible misconceptions about the purpose of treatment, offer a space to discuss feelings and values associated with mental health treatment (including possible stigma), and promote child/adolescent participation in decision-making processes in a responsible manner that reflects the principles of beneficence, nonmaleficence, integrity, and respect. Such discussions may be especially helpful in situations with families who are largely unfamiliar with the nature or purpose of psychological treatments. Including both parents and minors in developmentally appropriate ways may hold several additional benefits, including opportunities to ensure that all parties have similar understandings about consent information and resolve any possible misconceptions regarding treatment goals, methods, and confidentiality, such as when the goals of therapy between child/adolescent and parent/guardian differ markedly. For example, research suggests that children/adolescents and parents may disagree about what types of situations therapists should report to parents (Byczkowski et al., 2010). In addition, such interactions early in the therapeutic relationship may promote a collaborative approach to treatment that may benefit the therapy process (Fisher & Oransky, 2008), and research suggests that including children and adolescents in the consent process may improve participation in and effectiveness of treatments (Redding, 1993; Sales, DeKraai, Hall, & Duvall, 2008). Identification of the particular individual(s) who will be the primary client is a critical component of informed consent discussions. The identified client may be the child or adolescent, parents or guardian, or sometimes the entire family (Standard 10.02, “Therapy Involving Couples or Families”) (APA, 2010). Often, therapy with children and adolescents may involve other family members in one capacity or another. Indeed, relevant collateral individuals can contribute to a more complete clinical picture, provide multiple perspectives on behaviors, and contract and enlist the assistance of family members in meeting treatment goals (Weisz & Hawley, 2002). These interactions, however, require special planning by professionals to ensure that the client is clearly identified and to delineate the nature of the participation of the collateral individuals. For example, unless clearly described during informed consent, parents may incorrectly believe that the therapist is supposed to treat not only the child/adolescent, but also address unrelated parental or family mental health concerns (Koocher & Henderson Daniel, 2012). Such situations may jeopardize the trust of the child/adolescent and lead to complex confidentiality dilemmas. Respect for the self-determination of clients requires that psychologists explain necessary components of the procedures that would be reasonably be expected to affect one’s decision to participate in language that is reasonably understandable to the individual (Standard 3.10, “Informed Consent to Treatment”; Standard 10.01, “Informed Consent to Therapy”) (APA, 2010). Important components include (but are not limited to) risks and benefits of the procedures, the estimated course of treatment and recommended frequency of appointments, costs and fees, and confidentiality, disclosure, and mandatory reporting procedures (see below for an extended discussion of confidentiality with children and adolescents). In addition, psychologists should also explain relevant details about suggested interventions that may affect one’s decision to participate in treatment (Fisher, 2013a). For example, interventions that are new or have not yet been supported by scientific or professional data or knowledge also require the psychologist to provide information about the experimental nature of the intervention, available alternative treatments, and the client’s right to end participation at any time (Standard 10.01(b), “Informed Consent to Therapy”). As new and emerging technologies develop that allow practitioners to work with clients from wide geographic areas in a variety mediums, mental health professionals must consider important ethical, legal, and technological concerns to ensure that their work adheres to ethical standards and relevant laws (Baker & Bufka, 2011; Fisher, 2013a; Fisher & Fried, 2003; Maheu & Gordon, 2000). As described, consent should include relevant information about the nature of the treatment and professional interaction. Due to the relatively recent development and adoption of telehealth methods, consent may include available data on the effectiveness of such methods for mental health treatment as well as the unique risks to confidentiality and privacy associated with particular methods.
Ethical Considerations in Mental Health Treatment and Interventions With School-Age Children and Adolescents
INTRODUCTION
COMPETENCE AND THE SCIENTIFIC BASES FOR CLINICAL JUDGMENT
Treatment Selection and Empirically Based Interventions
Clinical, Developmental, and Multicultural Competence
INFORMED CONSENT FOR TREATMENT
Consent as an Ongoing and Developmentally Appropriate Process
Identification of the Client and Involvement of Family Members
Informed Nature of Consent
Distance and Internet-Based Therapies
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