Informed consent lays the foundation for the psychotherapy relationship and treatment to come in respecting the client’s legal rights and offering her or him the opportunity to make an informed decision about participating in the treatment to be offered. Barnett, Wise, Johnson-Greene, & Bucky (2007) have highlighted the potential benefits of an appropriately implemented informed consent process:
- It is a collaborative process that sets the tone for the psychotherapy relationship, promoting an enhanced therapeutic alliance.
- It promotes shared decision-making power in the relationship.
- It promotes the client’s autonomy and empowers the client to play an active role in her or his treatment.
- It minimizes the risk of exploitation of, and harm to, the client through this information sharing and collaborative decision-making process.
The informed consent process also is required by the ethics code and in the licensing laws and regulations of each of the mental health professions. Licensing laws and regulations make clear the legal requirements and obligations for informed consent.
One such requirement is the age of majority for that jurisdiction and the various circumstances under which minors have the same rights as adults to give their own consent. In each jurisdiction’s licensing law and regulations there are multiple exceptions to the requirement to be legally an adult to give consent to treatment. Each of these must be known and understood prior to beginning clinical work with minors.
Snyder and Barnett (2006) assert that for informed consent to be valid, four criteria must be met:
- Consent must be given voluntarily.
- The client must be competent (legally as well as cognitively/emotionally) to give consent.
- We must actively ensure the client’s understanding of what she or he is agreeing to.
- The information shared and all that is agreed to must be documented.
The first three of these criteria are of special significance when seeking to obtain informed consent in the treatment of minors.
Who is the Client?
Children and adolescents may come to treatment under a number of circumstances. They may be brought to treatment by their parent(s), they may be brought to treatment by a guardian (an individual or a representative of an agency such as Child Protective Services or Department of Social Services, for example), or they may seek out treatment on their own. An important first step is to determine what obligations the psychotherapist owes to each party (Fisher, 2009). Who we typically consider the client is the individual receiving the psychotherapy. But, this is not always the case. The Ethical Principles of Psychologists and Code of Conduct (APA Ethics Code; APA, 2010) addresses this issue in Standard 3.07, Third Party Requests for Services. As is stated in this standard “psychologists attempt to clarify at the outset of the service the nature of the relationship with all individuals or organizations involved” (p. 6).
In these situations “the client” may in fact be an organization or individual other than the child or adolescent who is to receive the treatment. Thus, the informed consent process is of great importance for clarifying roles, responsibilities, and expectations with agreements being reached at the outset, before treatment is provided. These agreements would include decisions on confidentiality and its limits, the role third parties may play in the child or adolescent’s treatment, if any; who will participate in setting treatment goals, and who will agree to the treatment plan.
Informed Consent and Assent
Except in situations consistent with certain exceptions allowed under the laws in one’s jurisdiction (e.g., when the minor is married or in the military, an emancipated minor) minors are not typically allowed to consent to their own treatment. But, that does not mean they should not play any role in the informed consent process. Depending on the minor’s age and developmental level, minors may have varied levels of participation in the informed consent process.
Even in situations where the parent or guardian legally is “the client” it is important for clinical and ethical reasons to include the minor (the direct recipient of our services) in this information sharing and decision-making process. For very young children it will be important to obtain their assent to treatment.
Assent is different from informed consent in that assent involves sharing information to the child so that she or he will understand the services to be provided, the nature of the process, the psychotherapist’s role and the child’s role, and other relevant information. The goal is to share basic information with the child at a level that she or he may understand. Doing so may help encourage the minor’s participation in the proposed course of treatment and to promote a more collaborative and effective treatment relationship.
As the minors’ age and developmental level increase their ability to comprehend the nature and vicissitudes of the psychotherapy process and each party’s role, responsibilities, and obligations typically increases as well. Thus, as McCabe (2006) illustrates, it is helpful to think of assent and informed consent as being on a continuum. As the minor develops an increased ability to participate in the information sharing and decision-making process, with the parents’ agreement, she or he should be afforded an increased role in this process.
Including the Minor in the Informed Consent Process
Even when they do not yet have the legal right to give their own consent to treatment, research has demonstrated that many minors possess the cognitive and emotional abilities to understand the consequences of their decisions, to include health care decisions. In fact, minors as young as 12 years of age frequently possess this ability (Redding, 1993). While they may not have the legal right to provide informed consent to their own treatment, many minors may be able to be active partners in the decision-making process. Further, as their developmental level increases over time, the information sharing and decision-making processes should be revisited to afford minor clients the opportunity to participate in this process as fully as is feasible.
Further, there are a host of clinical reasons for including the more developmentally advanced minor in this process:
- Demonstrates respect of the minor and of her or his autonomy,
- It helps to promote the therapeutic alliance and relationship,
- It helps to empower the minor on her or his own behalf, and
- It communicates the message that the minor will be an active participant in her or his own treatment (Lind, Anderson, & Oberle, 2003).
Negotiating Parents’ Rights in This Process
Parents or guardians have the legal right to consent to their minor child’s or adolescent’s treatment, to decide on the parameters of the course of treatment and potentially have complete access to all information from the psychotherapy process; however, one must consider the appropriateness of this on a practical level.
Psychotherapists should consider if clinically, this is a viable way to proceed with psychotherapy.
Psychotherapists should carefully consider the minor’s wishes and preferences in light of the presenting clinical situation. Additionally, we should consider what would be most appropriate for achieving the goals of psychotherapy. For example, how effective would psychotherapy be with a 15 year-old if she or he knows that everything shared and discussed in treatment is disclosed in detail to her or his parents each week? What impact would this arrangement have on the degree of sharing that takes place as well as on the level of trust the minor has for the psychotherapist?
Thus, while parents and guardians do have certain legal rights with regard to their minor children, these rights can be negotiated during the informed consent process. A parent could be informed that for treatment to be effective, the minor must be afforded some degree of confidentiality. As Koocher explains: “Parents can often be persuaded to agree to respect the privacy of the treatment relationship, particularly if they feel that the psychotherapist shares their interest and values with respect to their child’s safety” (In Barnett, Behnke, Rosenthal, & Koocher, 2007, p. 12).
It can be explained to all parties that certain topics and issues will be addressed within the confines of the psychotherapy relationship and that only if certain thresholds are crossed will this confidential information be shared with the parent or guardian. Examples of these circumstances can be shared to illustrate when this will happen, such as a significant risk to the safety of the minor or to others.
Recommendations for Practice
- Know the laws in your jurisdiction with regard to age of consent as well as for when minors have the legal right to consent to their own treatment.
- Clarify legal obligations from the outset. Determine who has the legal right to provide consent to treatment.
- Determine each party’s desire, and capacity to participate in the informed consent process.
- When the minor client is not legally authorized to provide her or his own informed consent, seek their assent, explaining treatment-related information to them in a manner consistent with their intellectual and developmental level.
- When the parent(s) or guardian(s) and the minor client’s needs and or desires diverge, negotiate the parameters of the treatment to be provided with each party prior to initiating treatment.
- Provide representative examples of situations and circumstances when you may take certain actions such breeching confidentiality, keeping certain information from the parent(s) or guardian(s) and addressing them in treatment, and the like.
- Determine the minor client’s ability to participate in informed consent/assent discussions and in treatment-related decision-making. With the parent(s)’ or guardian(s)’ permission include the minor in this decision-making to the extend possible based on her or his developmental and intellectual level. Repeat this process over time as the minor’s developmental level and ability to participate in this process more fully increases.
- Keep in mind that informed consent is a process that should continue to be readdressed throughout the course of treatment, especially if any substantive changes to treatment are being considered.
- If, over the course of treatment, a minor client who did not have the legal right to give her or his own consent becomes of the age where they now have this legal right, the informed consent agreement should then be renegotiated to ensure compliance with the client’s legal rights.
Cite This Article
Coffman, C., & Barnett, J. E. (2015, October). Informed consent with children and adolescents. [Web article]. Retrieved from: http://www.societyforpsychotherapy.org/informed-consent-with-children-and-adolescents
American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics
Barnett, J. E., Behnke, S. H., Rosenthal, S. L., & Koocher, G. P. (2007). In case of ethical dilemma, break glass: Commentary on ethical decision making in practice. Professional Psychology: Research and Practice, 38, 7-12.
Barnett, J. E., Wise, E. H., Johnson-Greene, D., & Bucky, S. F. (2007). Informed consent: Too much of a good thing or not enough? Professional Psychology: Research and Practice, 38, 179-186.
Fisher, M. A. (2009). Replacing “who is the client?” with a different ethical question. Professional Psychology: Research and Practice, 40, 1-7.
Lind, C., Anderson, B., & Oberle, K. (2003). Ethical issues in adolescent consent for research. Nursing Ethics, 10, 504-511.
McCabe, M. (2006). Involving children and adolescents in decisions about medical and mental health treatment. The Register Report, 32, 20-23.
Redding, R. E. (1993). Children’s competence to provide informed consent for mental health treatment. Washington and Lee Law Review, 50, 695-753.
Snyder, T. A., & Barnett, J. E. (2006). Informed consent and the psychotherapy process. Psychotherapy Bulletin, 41, 37-42.