4/29/24, 12:27 AM AACAP Code of Ethical Principles

AACAP Code of Ethical Principles

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.

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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

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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

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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.]
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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.

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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

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4/29/24, 12:27 AM AACAP Code of Ethical Principles

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.

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