AACAP Code of Ethics

Principle I, Developmental Perspective is an aspect of ethics unique to our profession, emphasizing the obligation to understand the developmental context of children and adolescents when providing clinical care, conducting research studies or making consultation recommendations. All aspects of development should be considered and optimal development should always be facilitated.

Brief Overview
Understanding and working effectively with children, adolescents and families relies on an appreciation of their developmental characteristics and context. Awareness and knowledge of about the child's developmental stage and cognitive abilities is of priority when considering ethical issues. Children can participate in treatment decisions in a meaningful way once they have acquired sufficient cognitive functioning consistent with the ability to understand the world based on reality, and a capacity for logical reasoning. Assessing the child's understanding of any situation and the relevant options is an essential component of psychiatric care, especially when ethical concerns are paramount. However, it is essential to consider that physical, cognitive, social and emotional aspects of development interact and impact each other. For example, children who have an adequate cognitive capability to understand the dilemmas and choices for a particular situation may not be able to effectively use such capability due to emotional or social developmental factors.

Knowledge of the capabilities of the child's family or caretakers is highly relevant to the developmental understanding of any child. Due to their developmental and legal status, children rely on others for the care and protection that ensures their well being and safety. A family's developmental level influences their abilities to care for and make reasonable decisions for their children. Likewise, children in the care of those who are not family members are significantly impacted by the qualities and characteristics of those responsible for them.

• Davies D. Child Development: A Practitioner's Guide, 3rd edition, The Guilford Press, New York, 2010.
• Gemelli R. Normal Child and Adolescent Development, American Psychiatric Press, Inc, Washington DC, 1996.

Principle II, Promoting the Welfare of Children and Adolescents (Beneficence) focuses on the obligation to promote the optimal wellbeing, functioning and development of youth, both as individuals and as a group. This commitment should be prioritized over familial or societal pressures. The actions of the child and adolescent psychiatrist should be based on solid scientific knowledge, including properly conducted research, clinical experience and sound judgment, and an understanding of the significant relationships between the child, adults, and agencies. In situations in which the practitioner has obligations to entities other than the child or adolescent, these responsibilities should be clear to all. The welfare and needs of the child should be paramount.

Brief Overview
Child and adolescent psychiatrists consistently should examine their reasoning behind decisions and recommendations, asking themselves who benefits and why. Determining which course of action will best promote the welfare of a given child can be complicated. Considerable differences in social, economic and cultural environments for children add to the complexity to such decisions. In addition, what is considered best for children and adolescents has changed significantly over time. Taking the time and devoting the resources to obtaining the most comprehensive and accurate understanding of the child, family and environment increases the likelihood that subsequent decisions will be the most appropriate for any given child.

• Sondheimer A, Jensen P. Ethics and child and adolescent psychiatry. In: Bloch S, Green SA, editors. Psychiatric Ethics. London: Oxford Publishing; 2010. p. 385-407.

Principle III, Minimizing Harmful Effects (Non-maleficence) focuses on the importance of "do no harm". Practitioners should strive to avoid any and all actions that may be detrimental to the optimal development of children and adolescents. They should also strive to minimize the harmful impact of the behaviors of others on children at the individual, family, local community, and societal levels. The vulnerability of youth and their families should never be exploited for personal gain. Relationships outside of professional interactions should be carefully considered prioritizing the responsibility to prevent any adverse impact on patient care. Some types of relationships, such as sexual interactions with current or former patients are never appropriate.

Brief Overview
Ethical concerns can arise when the therapist, patient and guardian(s) do not agree about the goals of treatment. This can happen when the psychiatrist's goals are in conflict with the patient's or family cultural or religious beliefs such as when a child is brought to treatment to "fix" his or her homosexuality. It can also occur when the clinicians' reactions (countertransference), personal issues or beliefs interfered with their ability to objectively conduct treatment (such as a perceived need to protect or save a child). Boundaries between the therapist and family always demand vigilance. Whether to give or accept gifts, attend various activities (e.g. graduations, baseball games, religious events) or whether to treat relatives or friends of the patient should always be carefully considered. Factors such as the location and type of practice (e.g. a small town) are relevant. Sexual relationships between physicians and patients are always unethical and unprofessional, and usually illegal. Sexual and non sexual boundaries between the clinician and a child's caretakers also always demand vigilance. Potential non sexual boundary concerns include other professional relationships, gifts, and social relationships. Other relevant areas impacting on education and patient care include the integrity of boundaries between residents and faculty, and residents and staff.

• Koocher GP. Ethics in child psychotherapy. Child and Adolescent Psychiatric Clinics of North America. 1995;4(4):779-91.
• Schetky D. Boundaries in child and adolescent psychiatry. Child and Adolescent Psychiatric Clinics of North America. 1995;4(4):769-78.

Principle IV, Assent and Consent (Autonomy) focuses on respecting the rights of patients and caregivers to make their own informed decisions without pressure. Youth under the age of 18 years should be involved in the decision making about their care and assent should be obtained. Guardians must always consent to treatment except in emergencies. Practitioners should always provide full communication about all relevant issues for informed decisions to be made. Particular care should be taken when youth and guardian disagree.

Brief Overview
Informed consent requires that adequate information is provided, the decision is voluntary and the individual making the decision is competent. The legal age of consent for medical and psychiatric care varies by state in the United States. Research suggests indicates that 14 year olds have the same ability to make complicated decisions that adults do. Under certain circumstances, such as family planning or drug treatment, some states allow adolescents to consent for treatment at a younger age. Adolescents may also become legally emancipated, making them legally able to make decisions like competent adults. Criteria to become an emancipated minor differ between states but usually require marriage or the ability to care for oneself financially. For most children and adolescents, competence to give consent is related to the assessment of the patient's decision-making abilities specific to the choice at hand (capability). Factors to consider include the patient's developmental status, the medical or psychiatric diagnosis, and their understanding of the benefits and risks of treatment, no treatment and alternative treatments, consequences of possible decisions, and their ability to make and express a decision. Contextual variables include cultural and community background, health care literacy, family involvement and resources, and possible clinician biases.

Informed consent has been defined as having three elements: information sharing, decision-making capacity and voluntariness. Information must include the purpose, involved procedures, possible risks, potential benefits, standard of care and alternatives. Decisional capacity consists of being able to communicate a preference, to comprehend the information necessary for the decision, to appreciate the significance of the decision for one's life, and to be able to reason. Voluntarism is the ability to make a free, uncoerced decision. This ability is influenced by factors related to development, illness, culture, psychological status, spiritual beliefs, and environmental factors.

Complicating the ethical consideration is the fact that the minor is often not the one initiating the evaluation or treatment. Also, many of the psychopharmacological treatments lack rigorous data supporting their efficacy and effectiveness for children and adolescents or information on their potential neurodevelopmental impact. In situations in which parental consent is required for an intervention, children and adolescents are expected to be able to give assent. There is considerable variation between jurisdictions as to whether youth are legally allowed to refuse treatment despite parental consent to the treatment and whether they can consent to treatment against their parents' wishes. Finally, some children and adolescents may have restrictions on their ability to assent or consent depending on their circumstances. For example, children and adolescents in state custody often cannot decide with whom they live and those incarcerated may not be able to make decisions about treatment.

When minors are included in research protocols the issues of permission, consent and assent take on more complex meanings. Investigators conducting such research along with research sponsors and Review Boards (Ethics Committees) must fully understand ethical obligations to insure that when minors are incorporated into such protocols their rights are fully protected.

• AACAP Policy Statement: Family and Youth Participation in Clinical Decision-Making
• Hoop JG, Smith AC, Roberts LW. Ethical issues in psychiatric research on children and adolescents. Child and Adolescent Psychiatric Clinics of North America. 2008;17(1):127-48.
• Ratner RA. Ethics in child and adolescent forensic psychiatry. Child and Adolescent Psychiatric Clinics of North America. 2002;11:887-904.
• Sondheimer A, Jensen P. Ethics and child and adolescent psychiatry. In: Bloch S, Green SA, editors. Psychiatric Ethics. London: Oxford Publishing; 2010. p. 385-407.
• Unguru Y, Coppes MJ, Kamani N. Rethinking pediatric assent: from requirement to ideal. Pediatric Clinics of North America. 2008;55:211-22.

Principle V, Confidentiality (Autonomy/ Fidelity) focuses on the patient's right to have information kept private and confidential. Practitioners should inform children and adolescents about confidentiality and any known limits to their confidentiality at the beginning of the treatment relationship. Patients and their families should always be told, preferably in advance, about possible disclosures of information, such as the reporting of abuse. Release of information to outside parties must involve the guardian's consent and the patient's assent as capable.

Brief Overview
Confidentiality and privacy are essential aspects of medical care, especially in psychiatry. When providing care for children and adolescents, providers must balance the patient's desires to keep information between themselves and the physician and their caretakers' requests to be informed. Many children and adolescents are unaware of what information their legal guardians can access. In addition to respecting the patient's decision making, consideration of the child's privacy is integral to trust and the therapeutic alliance. Often, children and adolescents fail to realize the amount and type of information that may be shared to facilitate heath care, billing and insurance coverage. Federal regulations as set forth in the Health Insurance Portability and Accountability Act (HIPAA) also govern what information may be disclosed. State laws vary on what providers are permitted to keep confidential and private. All states mandate the disclosure of imminent serious harm to self or others. Child and adolescent psychiatrists also can face the challenge of deciding whether the patient's revelations constitute a serious problem such as abuse warranting unilateral breach of confidentiality. Even in these situations openness with the child and their caretaker about the obligation to report and involving them in the reporting process is usually optimal.

• Campbell AT. Consent, competence, and confidentiality related to psychiatric conditions in adolescent medicine practice. Adolescent Medicine Clinics. 2006;11:25-47.
• Koocher GP. Ethics in child psychotherapy. Child and Adolescent Psychiatric Clinics of North America. 1995;4(4):779-91.
• Racusin R, Felsman JK. Reporting child abuse: The ethical obligation to inform parents. Journal of American Academy of Child Psychiatry. 1986;25(4):485-9.
• Sondheimer A, Jensen P. Ethics and child and adolescent psychiatry. In: Bloch S, Green SA, editors. Psychiatric Ethics. London: Oxford Publishing; 2010. p. 385-407.

Principle VI, Third Party Influence (Fidelity) focuses on issues related to the influences of outside entities. Practitioners should always place the welfare of the patient above competing interests. Monitoring to keep professional judgments and opinions regarding the interests of children and adolescents above improper influence by competing interests is paramount. Child and adolescent psychiatrists should fully disclose and describe all possible conflicts to all involved parties. [These concerns also are addressed in the separate COI documents on CAP practice and CAP research.]

Brief Overview
Child and adolescent psychiatrists may have conflicts of interest related to their responsibilities to their patients and their responsibilities to other agencies such as schools, courts, child protective services, managed care organizations or their employers (i.e. hospitals, clinics). Other situations that may produce conflict of interests are child custody disputes or research goals. In such cases the primacy of the patient's interests can be threatened by the other role and responsibilities of the child and adolescent psychiatrist. Practitioners must be vigilant to potential conflicts of interest related to their various roles and responsibilities and the potential impact of such competing interests.

• AACAP Guidelines on Conflict of Interest for Child and Adolescent Psychiatrists
• Belitz J, Bailey RA. Clinical ethics for treatment of children and adolescents: a guide for general psychiatrists. Psychiatric Clinics of North America. 2009;32:244-57.
• Sondheimer A, Jensen P. Ethics and child and adolescent psychiatry. In: Bloch S, Green SA, editors. Psychiatric Ethics. London: Oxford Publishing; 2010. p. 385-407.
• Soulier MF: Ethics of child and adolescent forensic psychiatry, in Principles and Practice of Child and Adolescent Forensic Mental Health. Edited by Benedek EP, Ash P, Scott CL. Washington DC, American Psychiatric Publishing Inc, 2010, pp 13-27.
• Walter G, Rey JM, Thomas CR, Martin A. Conflict of interest. In: Martin A, Scahill L, Kratochvil CJ, editors. Pediatric Psychopharmacology Principles and Practices. 2nd ed. New York: Oxford University Press; 2011. p. 738-51.

Principle VII, Research Activities focuses on the value of research with emphasis on the importance of minimizing risk. While scientific advancement of the field is essential, the priority of researchers must be to protect the child or adolescent from risks. The safety and well being of the participating youth is always paramount. The level of risk should always be fully disclosed. A child should never be forced to participate against their will and assent should always be obtained; Children and adolescents always have the right to rescind assent and parents and guardians always have the right to rescind consent. Research should always be conducted in accordance with all ethical standards. All investigator and organizational conflicts of interest should be clear and thoroughly discussed.

Brief Overview
Children and adolescents are recognized as vulnerable research subjects. They may not always be competent to voluntarily participate, their guardians may have reasons other than the child's best interests for consenting, and they may have institutional or state guardians who may have less than an optimal investment in the child's best interests. There is historical precedent for youth not being treated well as research subjects. Current federal regulations on a child's participation in research require a delineation of the risk and benefit involved with most research projects falling into the category of minimal risk or potential benefit to the individual participant. Parents must give permission and, when appropriate, children and adolescents must assent. Most discussion on research related to children and adolescents has concentrated on safety or welfare issues rather than children's rights.

• CITI (University of Miami) internet module on research ethics.
• Glantz LH. Conducting research with children: legal and ethical issues. Journal of American Academy of Child and Adolescent Psychiatry. 1996;34(10):1283-91.
• Hoop JG, Smith AC, Roberts LW. Ethical issues in psychiatric research on children and adolescents. Child and Adolescent Psychiatric Clinics of North America. 2008;17(1):127-48.
• Levine R. Children as research subjects: ethical and legal considerations. Child and Adolescent Psychiatric Clinics of North America. 1995;4(4):853-68.

Principle VIII, Advocacy and Equity (Justice), focuses on the importance of the availability of competent mental health care for all children, adolescents and families. Practitioners should support efforts to improve access to care for all children. Practitioners should also attempt to minimize youth's exposure to injustice. Research risk should not be borne disproportionately by vulnerable groups and its benefits should be shared equally.

Brief Overview
Children's' unobstructed access to care, and particularly unobstructed access to mental health care, continues to be a major challenge. Obstacles include a lack of parity of insurance coverage for psychiatric illness; managed care restrictions, uninsured youth, poverty, poor awareness and recognition of mental illness in children and adolescents, inadequate private and public funding for a continuum of services, and a shortage of child and adolescent psychiatrists. A number of regions of the country do not have any child and adolescent psychiatrists, and a number of child and adolescent psychiatrists in private practice do not accept any form of insurance.

• Ptakowski KK. Advocating for Children and Adolescents with Mental Illnesses. Child and Adolescent Psychiatric Clinics of North America. 2010;19(1):131-8.

Principle IX, Professional Rewards focuses on issues relevant to the tangible and intangible reinforcements of aspects of CAP practice. Practitioners should be aware of the possible influence of rewards on their judgments and actions. Child and adolescent psychiatrists should not exploit their influence or relationships for improper personal aggrandizement. The pursuit of personal rewards must not interfere with or negatively impact youth, families or communities. When such rewards compromise the integrity of the child and adolescent psychiatrist the public trust in the CAP profession is damaged.

Brief Overview
Child and adolescent psychiatrists must keep in mind that self monitoring and self awareness are crucial to safe and ethical practice. It is normal to seek positive responses and benefits from activities and interactions. Given the intimacy and nuances of psychiatric relationships with children, adolescents and families, child and adolescent psychiatrists must constantly examine their behavior and priorities to ensure that the best interest of the child remains center. There are many forms of exploitation, some subtle, which can occur and cause harm.

• Sondheimer A, Jensen P. Ethics and child and adolescent psychiatry. In: Bloch S, Green SA, editors. Psychiatric Ethics. London: Oxford Publishing; 2010. p. 385-407.
• Schetky D. Boundaries in child and adolescent psychiatry. Child and Adolescent Psychiatric Clinics of North America. 1995;4(4):769-78.

Principle X, Legal Considerations focuses on the importance of understanding the local, state and federal laws that impact CAP practice. For example, in some circumstances, adolescents manage consent and confidentiality, not their parents or guardians. However, legal standards do not replace ethical ones. Practitioners should be knowledgeable in both areas, striving to integrate them effectively in practice.

Brief Overview
Ethical and legal principles are related. Both are important. Depending on the situation, the ethical and legal standards may be identical, complementary or antagonistic. However, they have different purposes. Laws define minimally acceptable behavior in society. Ethics aims to identify the optimal action or plan. Laws often do not accommodate the subtlety and complexity to medical situations which ethical approaches grapple with. Child and adolescent psychiatrists engaged in forensic work often prioritize the principle of justice over that of beneficence.

• Soulier MF: Ethics of child and adolescent forensic psychiatry, in Principles and Practice of Child and Adolescent Forensic Mental Health. Edited by Benedek EP, Ash P, Scott CL. Washington DC, American Psychiatric Publishing Inc, 2010, pp 13-27.