Confidentiality and Involvement of Parents in Mental
Health Services for Children and Adolescents
Involvement of parents is often a key factor in engaging children and adolescents in psychotherapy (Dailor &
Jacob, 2011; Oetzel & Scherer, 2003; Weisz & Hawley, 2002). At the same time, establishing the boundaries of
client/patient confidentiality is critical to establishing a trusting relationship among psychologist, child client/
patient, and parents (Principle B, Fidelity and Responsibility; Standard 4.01, Maintaining Confidentiality). While
federal and state laws grant minors limited access to mental health services without guardian consent, they
often permit (and sometimes require) parents to be involved in their child’s treatment plan, provide parental
access to treatment records, and permit disclosure of information to protect the child or others from harm
(English & Kenney, 2003; Weithorn, 2006).
In making confidentiality and disclosure decisions, psychologists should be aware that parent’s perceptions
of confidentiality may differ from those of their children (Byczkowski, Kollar, & Britto, 2010). Psychologists must
also consider practical issues such as the parent withdrawing the child from therapy for lack of access to
information or children’s misuse of confidentiality as a weapon in their conflict with parents. Psychologists
working with children and adolescents thus need to anticipate and consistently reevaluate how they will
balance confidentiality considerations with parental involvement in the child’s best interests.
Establishing Confidentiality Limits at the Outset of Therapy
The nature of information that will be shared with parents should begin with a consideration of the child’s
cognitive and emotional maturity, presenting problem, treatment goals, and age-appropriate expectations
regarding the role parents can play in facilitating treatment (D. J. Cohen & Cicchetti, 2006; Morris & Mather, 2007).
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Chapter 7 Standards on Privacy and Confidentiality——159
For example, younger children’s cognitive limitations and dependence on significant adults suggest that
maintenance of strict confidentiality procedures may hinder treatment by failing to reflect the actual contexts
in which children grow and develop. By contrast, increasing protection of private thoughts and feelings may
facilitate treatment by demonstrating respect for older children’s developing autonomy, comprehension of the
nature and purpose of therapy, and ability to take a self-reflective perspective on their own thoughts and
feelings (Hennan, Dornbusch, Herron, & Herting, 1997).
The Consent Conference
Engaging parents and children in discussion about the nature and rationale for confidentiality and disclosure
policies is the first step to creating a trusting relationship. This can be accomplished during the consent
conference when psychologists
• explain their ethical and legal responsibilities, describe the benefits of confidentiality or information
sharing relevant to the child’s developmental status and treatment plan, and provide age-appropriate
examples of the type of information that will and will not be confidential;
• obtain feedback from and address client’s/patient’s and parent’s concerns; and
• tailor a confidentiality policy to the cultural and familial context in which information sharing is viewed
by parent and child.
Parental Requests for Information
There will be times when parents request information the psychologist had not previously considered
appropriate for disclosure. The first response should be to determine whether the parents’ request relates to an
issue that does not require confidentiality consideration. While parental demands should never supersede
ethical, legal, and professional responsibilities to protect client/patient confidentiality, they should always be
given the following respectful considerations (Fisher et al., 1999; Mitchell, Disque, & Robertson, 2002; L. Taylor &
Adelman, 1989):
• Employ empathic listening skills and convey respect for parental concerns.
• Assume, unless there is information to the contrary, that parents’ queries reflect a genuine concern
about their child’s welfare.
• Avoid turning parental requests for information into a power struggle among psychologist, parent, and
client/patient.
• Guard against taking on the role of therapist or counselor to the parent (Standard 3.05, Multiple
Relationships).
• Help the parent reframe confidentiality in terms of (a) the child’s developing autonomy, (b) encouraging
the child to share information with parents by choice rather than requirement, and (c) maintaining
therapeutic trust.
• If appropriate, suggest that the parent ask the child about the desired information or, with the parent’s
knowledge, explore with the child about clinically indicated ways in which information might
be shared.
Disclosing Confidential Information
in Response to Client/Patient Risk Behavior
Psychologists working with children and adolescents often become aware of behaviors hidden from parents
that place the child at some physical, psychological, or legal risk. Sexual activity, alcohol and drug use, gang
involvement, truancy, and vandalism or theft are some of the “secret” activities that require consideration for
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160——PART II ENFORCEABLE STANDARDS
the protection of others or whether confidentiality or disclosure is in the best therapeutic interests of the child
(Standard 4.05, Disclosures).
For example, disclosures can lead to physical protections for a child who is beginning to show signs
of an eating disorder or involvement in gang behavior through increased parental monitoring of
behaviors in and outside the home. Alternatively, sharing such information with parents may damage the
therapeutic alliance or place the child at greater risk if parental reactions can be predicted to be
physically violent or emotionally abusive. For example, the consequences of disclosing to parents highrisk
sexual activity of lesbian, gay, bisexual, transgendered, and questioning youth (LGBTQ) who have not
discussed their sexual orientation with their parents are more complex and potentially more hazardous
than would occur when disclosing information regarding a minor’s heterosexual activities (Ginsberg et al.,
2002; Lemoire & Chen, 2005).
Psychologists must also consider how entering into a secrecy pact with a minor client can adversely affect
the therapeutic alliance and be wary when assuming that minor clients expect and desire confidentiality when
they reveal during therapy that they are engaging in high-risk behaviors (Fisher, 2003a).
Steps to consider in deciding whether and how to disclose confidential information when clients/patients
are engaging in high-risk behaviors include the following.
Step 1: Assess and Clinically Address Risk Behaviors
• Confirm that the child is actually engaging in the risk behavior and whether it is an isolated incident or
a continuing pattern.
• Evaluate the danger of the behavior to the client/patient or others.
• Assess developmental, psychological, and situational factors that might impair the child’s ability to
terminate or reduce behaviors.
• Conduct intervention strategies to help the client/patient terminate or reduce risk levels of behavior.
• Monitor whether the client/patient has terminated or limited the behavior.
Step 2: Consider Options if Client/Patient Is Unable or Unwilling to Terminate or Reduce Behaviors
• Know federal and state laws on reporting requirements regarding prior or planned self-harming, illegal,
or violent client/patient behavior.
• Weigh legal, therapeutic, social, and health consequences of confidentiality and disclosure for the client/
patient.
• Anticipate, to the extent possible, parents’ ability to appropriately respond to disclosure.
• Consult with other professionals regarding alternatives to disclosure (Standard 3.09, Cooperation With
Other Professionals).
Step 3: Prepare Client/Patient for Disclosure
• Frame the current need to disclose information in terms of the limits of confidentiality discussed during
informed consent and the psychologist’s responsibility to protect the welfare of the client/patient
and others.
• Respond to the child’s feelings and concerns while focusing discussion on the process of disclosure and
not on ways to avoid it.
• Evaluate the client’s/patient’s willingness and ability to disclose information to parents.
• When appropriate, go over the steps that will be taken to share the information with parents and
involve the client/patient as much as possible.
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Chapter 7 Standards on Privacy and Confidentiality——161
Step 4: Disclosing Information to Parents
• Involve the client/patient as much as clinically appropriate in the disclosure discussion.
• Focus on the positive actions parents can take to help their child and, whenever feasible, to place the
child’s actions within the context of continued treatment progress.
• Discuss additional treatment options such as joint parent–child or more frequent goal-setting sessions.
• Identify appropriate referral sources for parents to help them address their child’s behaviors following
disclosure.
• Empathize with and respond to the parent’s feelings and concerns, and refer the parent to individual
counseling if it appears necessary.
• Schedule one or more follow-up meetings with parents and clients/patients to monitor their reactions
to the disclosure and the steps taken to reduce the risk behaviors and provide additional recommendations
if necessary.
• If the risk increases or remains at dangerous levels, consider other therapeutic, community, and legal
options.
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