As Reference JellinekJellinek (2010) notes, where judgment must play a role [] is in dissecting different degrees of danger. When a state offers a child more privacy rights than the child has under federal law, a therapist must follow state law. Until that time, the law will normally give the parent access to the child's treatment. Emergency care Care for independent minors An evidence-based tool such as the Structured Assessment of Violence Risk in Youth (SAVRY) could be particularly useful. Nevertheless, children in their preteen years and younger do not and cannot fully understand the nature of sexual activity. If it is felt that legally Ahmed is competent, that clinically the benefits outweigh the risks, and that practically access is feasible, then the treatment should arguably proceed in confidence. Select the single best option for each question stem. On the other hand, it could be argued that the short-term risk is low, and that breaching confidentiality might have a negative impact on his rights, his healthcare engagement and perhaps his social situation, any of which could exacerbate risk. Ultimately, clinicians want to do the right thing. r1Z^82R 4 Ethical principles (both deontological and consequentialist) and legal and regulatory frameworks (relating to human rights, case law and General Medical Council guidance) are outlined. This may include a childs diagnosis, symptoms, and treatment plan. The development of autonomy is also an important task of adolescent maturity, and the opportunity to engage with services in a confidential, supportive manner can be an empowering experience in its own right. This situation echoes that of Gillick, assuming that Ahmed is Gillick-competent. For example, If your weight drops below the xth percentile or I feel you are in danger, I will need to raise the issue with your parents (Reference JellinekJellinek 2010). Counselors will encounter ethical dilemmas throughout their careers that may test their personal moral beliefs. What are the Legal Rights of Children? - FindLaw She feels distressed at what happened and blames herself. One could argue that the potential outcome is so serious, one should have a low threshold, so that confidentiality should be breached even if the likelihood of him acting on his thoughts is low. The term "minor" is used to refer to a person who is under the age at which one legally assumes adulthood and is legally granted rights afforded to adults in society. Ultimately, there are various reasons why a child may wish for information to be kept confidential. 11 During the 1970s, many states established laws that allowed minors to consent to treatment for sexually transmitted diseases, 12 after it became clear that adolesc. Justice Silber's High Court judgment noted that the ECHR and the UNCRC: show why the duty of confidence owed by a medical professional to a competent young person is a high one and which therefore should not be overridden except for a very powerful reason. What if a child instead wanted to keep confidential information that would indicate that they, or others, were in danger: would it still be in the public interest to keep this type of information confidential? 67 0 obj <> endobj e However, the Courts have never declared this to be part of the . R8u But often, the information they dont want disclosed is the information that is most important for them to discuss in therapy. Children and Consent: What You Need to Know - The Innocent Lives Foundation However, some therapists ask parents to agree to the therapists confidentiality rules before they will treat the client. In contrast, research shows that parents value being told important information about their child. Mirza, Hassan For example, a teenager whose weight is dropping and who confides early signs of an eating disorder may agree to gain weight on a prescribed schedule and attend regular visits until you are assured that he or she has the problem under control. %PDF-1.7 % He is not overly distressed by these thoughts, but recognises that others might be concerned if they knew about them. There are also situations where confidentiality needs to be breached in accordance with legal or regulatory statutes (Box 2). }]4|zz0?dY7?vHqW>_}E>N&5(z;xWMt[z$j| cN3pRb. (Respect for Confidentiality), B.2.d. to mental health review tribunals) for statutory purposes under the Mental Health Act 1983. First, young people frequently present to child and adolescent mental health services (CAMHS) with sensitive and risk-related situations, including self-harm, suicidality, sexual behaviour, and alcohol and substance use. One occasion on which information is sometimes unwittingly shared is when letters to GPs are copied to parents. Some parents may worry that secrets will undermine their relationship with their child. Confidentiality/Minor Consent Laws For Educational Purposes Only PARENT/GUARDIAN CONSENT EXCEPTIONS A parent or legal guardian must provide consent on behalf of a minor (under age 18) before health care services are provided, with several important exceptions. In fact, research has convincingly shown that protecting confidentiality can improve, and restricting confidentiality can diminish, the likelihood that adolescents access healthcare (Reference Cheng, Savageau and SattlerCheng 1993; Reference Ford, Millstein and Halpern-FelsherFord 1997, Reference Ford, Bearman and Moody1999; Reference Kapphahn, Wilson and KleinKlein 1999; Reference Carlisle, Shickle and CorkCarlisle 2006). 'Shhh! Releasing Records In The Age of Adolescent Consent The threshold issue surrounding minors' privacy rights is who gets to make decisions about the privacy and disclosure of the minor's mental health information. Does a parent have a right to receive a copy of psychotherapy notes about a child's mental health treatment? For example, if a therapist fears a child may be planning a school shooting, the therapist may be required to notify police or school authorities. 7 0 obj <> endobj Various factors would indicate abuse (Box 3): the significant age difference, the use of alcohol, and Katie being an age where her maturity to consent is questionable. Please don't tell Confidentiality in child https://doi.org/10.1192/apt.bp.114.013854, Reference Ford, Millstein and Halpern-Felsher, Medical confidentiality versus disclosure: ethical and legal dilemmas, Confidentiality: issues in working with self-harming adolescents, Concerns over confidentiality may deter adolescents from consulting their doctors: a qualitative exploration, Adolescent consent and confidentiality in the UK, Confidentiality in health care: a survey of knowledge, perceptions, and attitudes among high school students, The Victoria Climbi Inquiry: Report of an Inquiry by Lord Laming (Cm5730), Working together to Safeguard Children: A Guide to Inter-Agency Working to Safeguard and Promote the Welfare of Children. The notes are for personal use rather than official documentation. Furthermore, it would still be useful to encourage Frank to have information shared with his parents, who may be well positioned to more closely monitor and support him. The law regarding a minor's right to confidentiality in most states' rests on a simple foundation: Minors generally cannot consent to treatment, a parent or guardian consents on the minor's behalf. 'Shhh! Please don't tell' Confidentiality in child and adolescent Some important topics to discuss include: When a therapist believes a child is in danger, they typically have a legal duty to disclose certain information, even when the child otherwise has a right to confidentiality. English, A., & Ford, C. A. However, the GMC would generally advise the clinician still to encourage Ahmed to involve his parents, even if ultimately his confidentiality is respected (GMC 2007). Additionally, most legal jurisdictions R (Axon) v Secretary of State for Health [2006] (subsequently referred to as Axon) (Table 1). Eighteen ethical dilemmas in three domains were presented to respondents in a questionnaire. Be found at the exact moment they are searching. Such transparency makes it easier if confidentiality has to be breached in the future and may help protect longer-term therapeutic rapport and engagement (Reference Ford, English and SigmanFord 2004). The right of minors to confidentiality and informed consent The GMC guidance states that disclosure without consent may be justified in the public interest if failure to disclose may expose others to a risk of death or serious harm (GMC 2009: p. 21). Answer: When working with minors, confidentiality can be a tricky situation. Knowledge about ones responsibilities can make decisions easier during a crisis. =H rUT%9`&8K MF)lc6a]dl Q.j=8?`N[R "-$4`Vi/du]S:oL74(}@+neXV^3&6DW RPFwN(Y} y(P7h Fu@OU U+m5& ! Furthermore, protecting confidentiality may enhance both the therapeutic relationship and service engagement, with potentially long-term benefits to health and risk (Reference Guedj, Sastre and MulletGuedj 2009). They may worry parents will intervene in a seemingly unhelpful way. Has data issue: false (Child emancipation is when a minor becomes legally responsible for their own care before the age of 18.). Sometimes it is useful to set up an agreed if, then scenario. C%61 TX[:b9m tXxdhA)d?ZHUS?L ~\pzXeO"g(y_#xtz7`5 %{:{+45vPE(#,x6x )|!t +oqPvH'kvcP[p_ g,k>|7A!a)hA#&Q$zzl|k >)7ed- .R,DC9-6Oi\5$w G?B'NVL7Nv riro#/'O>}v9= !V9cu ;h miW{&4*me;Zm]C}sT>;ny.j3%1[ETu:S>.8\Sc~!vN&4A*\Z@.o5u. ~H(w6s1q)StU-7txN':=^^k]w;?Orb4.5y>Q)zE>u| S:89u;Pd^9c*||EE$:O]dDtEWKG}*1=tL#NA>I1NE Specific ethical principles have also been proposed for medical practice (Reference Beauchamp and ChildressBeauchamp 2001). Adult patients' confidentiality is subject to few restrictions. On the other hand, the lack of empathy associated with autism spectrum disorder may increase risk. Evidence supports such a model. Now let us turn to Adele, the 15-year-old with depression, self-harm and suicidal ideation, but no firm suicidal intent or plan, who does not wish her parents to know. GMC guidance advises that information can be disclosed if there is an overriding public interest in the disclosure in order to protect the child from risk of death or serious harm, including through self-harm (GMC 2007). The status of minority ends at the age of majority. When parents understand that confidentiality is key to effective treatment, they may be more willing to respect their childs need for privacy. This paper explores the ethical scenario related to confidentiality rights of a minor when his/her parents seek information from the counseling session, in this case related to exploration of sexuality. It also gives an opportunity to create a safe, supported space to encourage communication between the young person and the parents (Reference FordFord 2007). For under-16-year-olds, case law on consent generally derives from Gillick v West Norfolk and Wisbech Area Health Authority. If Adele's clinician decides to breach confidentiality, they would need to explain to her why they think it necessary, as well as monitoring her for any negative consequences and supporting her and her family so as to minimise any exacerbation of risk. "useRatesEcommerce": true Confidentiality in child and adolescent mental health is a complex and often challenging matter. Even if confidentiality is maintained, the GMC advises that you should not refuse to listen to a patient's [] carers or others on the basis of confidentiality. PDF Confidentiality/Minor Consent Laws - Adolescent Health Initiative Applewhite & Joseph meanwhile argue for a hierarchy of principles: safety and security, then autonomy, then parental autonomy and privacy (Reference Applewhite and JosephApplewhite 1994). In contrast, consequentialist or teleological ethics, such as utilitarianism proposed by Bentham and Mill, argues that the morality of an action is based solely on all the good and all the harm that consequentially arises (Reference MillMill 1863). View all Google Scholar citations Their views or the information they provide might be helpful in your care of the patient. Finally, let us consider Katie, the 14-year-old who discloses that a 19-year-old man had sent her sexually related messages and then had sex with her while she was drunk. And what about parents rights should they not be given information to enable them to protect their child? The HIPAA privacy rule and adolescents: Legal questions and clinical challenges. A Minor's Right to Confidentiality - FAMCare One model consists of breaking the session into distinct components: time with the young person alone, time with parents (or carers) alone and time with the family together. For example, he states that once a child is competent, then parental rights yield to the child's right, and this has since been interpreted to encompass rights to confidentiality. One of a therapists most important ethical duties when treating minors is to discuss confidentiality concerns with the parent(s) and the child. Article 8(1) could therefore be applied either way in a confidentiality dilemma, although many would generally prioritise a child's right to privacy over parental rights to know information about their child (Reference Applewhite and JosephApplewhite 1994). The steps the therapist takes to protect the childs privacy. endstream endobj startxref School counseling and confidentiality - University of Northern Iowa This article explores confidentiality in the context of child and adolescent mental health services (CAMHS), particularly when the clinician is having to make decisions on whether to maintain or to breach it. On the other hand, breaching confidentiality would allow services (e.g. Disclosure may therefore result in distress or other negative feelings that actually lead to an exacerbation of risk. Mental health professionals who meet our membership requirements can take advantage of benefits such as: Copyright 2007 - 2023 GoodTherapy, LLC. Palmer v Tees Health Authority [1999] a mother claimed that the health authority had been negligent by discharging a man with personality disorder who subsequently killed her child. Therapists, parents, and others who have specific concerns about confidentiality may wish to talk to an attorney knowledgeable about the laws in their state. Confidentiality is another issue that lacks clarity when counseling with minors. Outline some relevant ethical principles and legal/regulatory frameworks, and apply them when weighing up the pros and cons of maintaining or breaching confidentiality, Apply strategies for breaching confidentiality that balance the need to share information appropriately against the need to preserve therapeutic rapport and engagement, Judge how one's own ethical perspectives might influence decision-making in confidentiality dilemmas. Is it acceptable for a psychiatrist to break confidentiality to prevent spousal violence? It is useful to bear in mind deontological positions and individuals rights, as well as analysing the consequential benefits and harms of disclosure versus maintaining confidentiality. } Minors - Rights and Obligations | Stimmel Law 0 On one hand, there is the consideration of preserving engagement and therapeutic rapport, particularly important given Katie's eating disorder and the associated risks. She also has occasional suicidal ideation, although has never had any firm intent or plan. She remembers little, although reports that the man, who was vaguely connected to her wider peer group, had been sending her sexually related messages online. Because I work with many high-conflict divorce families, many of the children and teens I see in therapy have their own minor's counsel. Ahmed is a 15-year-old boy who presents with anxiety disorder. Behnke, S. H., & Warner, E. (2002). However, who decides what is in their best interests the child, their parents or the State is perhaps ambiguous, as is what happens when rights to autonomy conflict with rights to protection (Reference IltisIltis 2010). For minors, however, the right to privacy in therapy is limited. This consequentialist position is shared by Gillon (Reference Williams, Hari Singh and NaishWilliams 1987), whereas Roche argues more deontologically that information-sharing [] carries the risk of overwhelming any concern for children's rights and family privacy [] in a way that so clearly ignores the complex reality of children's lives and their voices (Reference RocheRoche 2008). So even when a minor has no right to confidentiality from a parent, they still have a right to privacy from third parties. The risk that young people will not disclose sensitive issues such as substance use, mental illness and sexual behaviours (Reference Hawton, Saunders and O'ConnorCarlisle 2006) and that they might disengage from services altogether (Reference Ford, Millstein and Halpern-FelsherFord 1997; Reference Thrall, McCloskey and EttnerThrall 2000) is significant if they feel that their confidentiality may be breached. Youth under the age of 18 can consent to all medical care if they are emancipated or living separately and without support from their parents, are/were legally married, or a member of the Armed Forces. The therapist's disclosure policies. Even in cases of potential child abuse, the GMC still notes the relative value of confidentiality: although it may seem that parents would be the obvious people to disclose to in these circumstances, doctors should consider the potential adverse consequences. If a child cannot safely disclose whatever they want, the therapist may not have enough information to know what kind of help the child needs. But what if the process of breaching confidentiality could exacerbate the risk? One needs to decide whether Adele's cutting and suicidal ideation, without suicidal intent, would constitute a risk of serious harm. A survey of clinical child psychologists found a significant lack of consensus in attitudes but the authors reflected that ethical codes and guidelines allow for (and result in) individual differences in decision making (Reference Rae, Sullivan and Pena RazoRae 2002). Confidentiality in the treatment of adolescents However, both common law and Article 8(2) of the ECHR indicate that this duty is not absolute and disclosure can be justified when there is overriding public interest (Reference Robshaw and SmithRobshaw 2004). Police and children's services might even offer support, which could attenuate risk. But when a child can openly discuss their feelings in therapy, their relationship with others, including their parents, may improve. First, young people frequently present to child and adolescent mental health services (CAMHS) with sensitive and risk-related situations, including self-harm, suicidality, sexual behaviour, and alcohol and substance use. However, he is clear that he does not wish his family to know anything: they have other stresses and he does not wish to worry them further. For therapy to be optimally effective, a person must be able to disclose their thoughts, feelings, experiences, and behaviors without fear of judgment. Article 8(1) of the European Convention on Human Rights specifies that: a everyone has the right to have their private and family life respected, b everyone has the right to freedom of thought, conscience and religion, c everyone has the right to liberty and security, d everyone has the right to freedom of expression. Not all societies share autonomy as a fundamental right. Teen Pregnancy and Confidentiality | Journal of Ethics | American Now what? (2017, September 12). This is particularly important given the evidence that many girls who cite concerns about confidentiality as a reason for future nonattendance reported unsatisfactory communication with their parents (Reference Lehrer, Pantell and TebbLehrer 2007). A parent who consents on the minor's behalf generally has the right to know the content of the child's treatment. a a young person's belief that information will invariably be shared with parents does not affect the likelihood that they will disclose risky behaviours or attend healthcare services, b parents generally believe that they do not have a right to know about risks relating to their adolescent children, c aspects of confidentiality are rarely discussed with adolescent patients and their families in primary care, d when deciding whether to breach confidentiality, clinicians prioritise the risk of patient disengagement more than the seriousness, frequency, intensity and duration of the risky behavior. In fact, it is often through seemingly adverse outcomes that individuals learn from their mistakes and develop as human beings. All these judgements need to be made in terms of calculating beneficence and non-maleficence. The therapist should be clear about the law and their own confidentiality policies. A parent or legal guardian must provide consent on behalf of a minor (under age 18) before health care services are provided, with several important exceptions. Hanson, K. (2018, October 12). The circumstances under which a therapist would disclose information the child shared in therapy. The following factors concerning possible sexual abuse would indicate the need for reporting: the young person is too immature to understand or consent, children under 13 years old are legally considered to be unable to consent to sexual activity, significant differences in age, maturity or power between the young person and the sexual partner, the young person's sexual partner having a position of trust or having a history of abusive relationships with children, the use of force or the threat of force, pressure, bribery or payment, the use of drugs or alcohol to influence a young person. The Health Insurance Portability and Accountability Act (HIPAA) is the primary federal law governing medical privacy. Therefore, in Katie's case, where child abuse and criminal behaviour are implicated, GMC guidance would advise breaching confidentiality to children's services, and ultimately the police, to help ensure protection for her and, potentially, others. Ensuring a child gets effective treatment, Protecting the child from risk of abuse or homelessness, Practice Management Software for Therapists, Rules and Ethics of Online Therapy for Therapists, How to Send Appointment Reminders that Work, Health Insurance Portability and Accountability Act (HIPAA), Dialectical Dilemmas and How ACT Models Can Help Guide Treatment, How Emotionally Intelligent People Use Negative Emotions to Their Advantage, Political Differences May Shorten Thanksgiving Visits. other people's rights to be protected from the 19-year-old man, either victims currently being abused, or potential victims at risk in the future. Confidentiality brings these tensions to the forefront: Reference TebbTebb (2011) notes the important role that clinicians can play both in helping young people in the transition to adulthood, encouraging them to take greater responsibility for making decisions about their own health, and in supporting parents accept the increasing independence of their children. PDF The Case of Liam: Ethical Counseling of Minors police and children's services) to intervene and thus hopefully reduce the risk to both Katie and, potentially, others now and in the future. The presence of autism spectrum disorder could work either way. is a counselor for two minor male children who are experiencing difficulties as a result of their parents' divorce. When a minor has their own attorney, this lawyer holds the privilege for the child's therapy, and they often work with me to help keep emotional safety a priority for the child's counseling. case law that becomes accepted as legal). There is currently no specific target in mind, but Frank thinks it is possible he might do something sometime in the future. She does not wish anyone to know; she feels embarrassed and does not want to cause trouble. (207) 922-3222 | mainefamilyplanning.org The UNCRC stipulates that, for any action relating to a child, their best interests must be considered. The case law that most explicitly relates to children's rights to confidentiality is Minors' Rights to Confidentiality, When Parents Want to Know An Ethical The ethical and legal concerns of counseling the minors and completing custody evaluations are discussed. Let us now consider Frank, the 16-year-old with autism spectrum disorder and repetitive thoughts of killing people, but no specific intent or target. His school counsellor remains concerned despite a package of cognitivebehavioural therapy; Ahmed's anxiety is significantly affecting his work. Minors' Rights to Confidentiality, When Parents Want to Know An Ethical Time with the young person and their parents together allows information to be shared both ways, as well as enabling psychoeducation and discussions about the care plan. Confidentiality should be one of the first issues raised when initially meeting a young person and their parents; this helps them understand the principles from the start (Reference Lehrer, Pantell and TebbLehrer 2007; Reference TebbTebb 2011). Published online by Cambridge University Press: Confidentiality represents an opportunity to engage a young person in developing a trustful engagement with services, with long-term positive consequences for their mental health. This state of affairs changes when the minor reaches the age of majority. The murderous thoughts may represent a concrete black or white internal response to peer problems and consequent difficulty in emotional regulation, but little actual risk of carrying out violent acts. You must make this judgement case by case, by weighing up the various interests involved [] You should consider the benefits and possible harms that may arise from disclosure [] You should disclose information [] to protect the child, or someone else, from risk of death or serious harm (GMC 2007: pp. Furthermore, there are also the rights of others to consider: first, those of her parents, who have an important role in safeguarding; second, there is the issue of public interest, i.e. If parents do not need to know, but the GP does, consider writing the GP a separate letter or contacting them by phone. GMC, Clinical conversations about health: the impact of confidentiality in preventive adolescent care. "coreDisableSocialShare": false, Ahmed has read information online about medication with selective serotonin reuptake inhibitors and wants to give it a go.
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