Eye on Ethics
When to Break Confidentiality With Minors
Ronnie was a 16-year-old high school student who was struggling academically. He had always been a strong student, but his grades had recently begun to decline. Ronnie told his guidance counselor that he was distracted by his parents’ recent separation and pending divorce. With the guidance counselor’s encouragement, Ronnie began therapy with a social worker, Martha, who was employed by a nearby family service agency that has a counseling program for adolescents.
Ronnie and Martha spent considerable time talking about how distressed Ronnie was about his parents’ marital conflict and separation. Ronnie also focused on his longstanding conflicts with his father and his concern about his mother’s psychiatric problems.
Almost two months after they started working together, Ronnie told Martha that he had something important to tell her. He said that he was concerned he had developed a drug problem. “I’ve been doing a fair amount of ecstasy and amphetamines with my friends on weekends,” he said. “I didn’t think I’d have a problem, but now I’m really worried that I might have an addiction.” Ronnie asked Martha to help him with his substance abuse, but he insisted that she not tell his parents about his drug use. “You’ve met my dad, and you know how afraid I am of him, and I can’t bear the thought of adding to my mom’s worries. I just don’t want you to say anything to them. All I want is some help,” he pleaded.
Martha faced a common ethical challenge encountered by social workers who provide services to minors: whether or not to disclose confidential information to the minor’s parents (or guardians), particularly when the minor client has explicitly asked the social worker not to share the information. Nearly every social worker who serves minors can think of times when he or she had to decide whether or not to share sensitive information with a client’s parents over the client’s objections. Usually, these situations involve confidential information that minors have shared with their social workers about drug and alcohol use, sexual activity, contraception, pregnancy, abortion decisions, and mental health treatment.
There is no simple answer to questions about social workers’ ethical obligations in these circumstances. On one hand, minors typically have a right (albeit somewhat limited) to confidentiality. Social workers understand that minor clients need to be able to trust their therapists and counselors; otherwise, minors may be reluctant to share clinically relevant information. Social workers also understand that many parents believe they have a right to know about major risks their children face and believe that their children’s clinicians have a duty to share critical information involving their children’s safety.
Social workers who encounter difficult ethical choices about minor clients’ right to confidentiality—and social workers’ corresponding duty to share information with parents—should always keep the following guidelines in mind:
• Ethical standards — The National Association of Social Workers (NASW) Code of Ethics includes a number of key standards on client confidentiality. The most pertinent highlight social workers’ obligation to “protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons” (standard 1.07[c]). Also, social workers should “discuss with clients and other interested parties the nature of confidentiality and limitations of clients’ right to confidentiality … as soon as possible in the social worker-client relationship and as needed throughout the course of the relationship” (standard 1.07[e]). It is helpful to become acquainted with the extensive confidentiality guidelines in the NASW Code of Ethics and other relevant ethics standards (e.g., guidelines promulgated by the Clinical Social Work Federation, the American Board of Examiners in Clinical Social Work, and the American Association for Marriage and Family Therapy).
• Federal laws and regulations — Social workers should be aware of diverse federal laws and regulations that may be relevant in their work setting. For example, social workers employed in agencies that receive federal funds and that assess, treat, or refer clients for alcohol or drug problems must follow the strict confidentiality guidelines regarding minors in Confidentiality of Alcohol and Drug Abuse Patient Records (42 Code of Federal Regulations, 2-1 ff). School-based social workers need to comply with confidentiality guidelines contained in the Family Educational Rights and Privacy Act (20 United States Code Section 1232g), which spell out the ways in which confidential information in minors’ educational records should be protected. The new Health Insurance Portability and Accountability Act regulations also contain many relevant guidelines concerning the disclosure of electronically stored and transmitted confidential information.
• State laws and regulations — Perhaps the greatest challenge for social workers is becoming familiar with state laws and regulations that focus directly or indirectly on minors’ confidentiality rights. State laws and regulations vary considerably as a function of local history, culture, public attitudes, court opinions, political climate, and legislative debate. For example, some states have laws permitting social workers to use their professional judgment when deciding whether or not to inform parents about their children’s drug or alcohol problems and requests for treatment. In these states, social workers are permitted to exercise their professional discretion when determining whether disclosure to parents is in the minor’s best interest or would be deleterious to the client’s efforts to get help for his or her problems. However, in other states, the law prohibits social workers’ disclosure of confidential information to parents without the minor’s explicit consent in an effort to encourage minors with substance abuse problems to seek treatment. Some state laws require involvement of one or both parents in minors’ abortion decisions. Many states permit minors of a certain age (e.g., 16) to consent to routine medical care. Social workers should always review pertinent state laws and regulations and check for recent changes.
• Agency policy — In addition to consulting relevant ethics standards, laws, and regulations, social workers employed in agencies should also contact supervisors and administrators to review internal policies regarding disclosures of confidential information to parents. Some agencies have drafted extensive policies concerning disclosure of confidential information to parents that are based on relevant ethics standards, laws, and regulations.
Confidentiality issues involving minors can be particularly challenging. Ethics guidelines, laws, regulations, agency policies, and clinical judgment sometimes conflict, thus creating a daunting ethical dilemma. Social workers who find themselves on the horns of such a dilemma should consult appropriate colleagues and guidelines. Social workers should always document their consultations and decisions carefully to protect their clients, as well as themselves and their agencies, in the event that outside parties raise questions about their judgment.
— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work, Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, healthcare, criminal justice, and professional ethics.