Question: I’m counseling a 14-year-old girl, Ann, in a residential substance abuse treatment program. Today she revealed that she’s been getting her drug supply from her parents. What do I do? Report the parents to Child Protective Services and lose the family? Or ignore the information and focus on Ann’s treatment?

It makes sense why you’re asking for a consult. Most of our professional organizations don’t address adolescents as a special population with unique standards of care (Corey, Corey, & Callahan, 1993). And your situation raises several key issues in the treatment of adolescents: the rights of minors to consent to treatment, the rights of parents to be involved in their children’s care, the adherence to legal mandates for reporting suspected child abuse and neglect, and your desire to work with these realities in weaving together a successful treatment program for a child in need. At first the legal mandate to report child abuse and neglect seems like a major obstacle. Mandatory breaches of confidentiality are often in conflict with other ethical concerns. But this is one of those times when your legal mandate and ethical obligations might work together.

Your responsibility is to Ann’s welfare, her freedom from substance abuse, and ongoing wellness. When suspicions of child abuse and neglect are raised in therapy, they can seem to derail the treatment plan. Suddenly sobriety and the development of resilience take a backseat to fulfilling your obligation to make a report to your local Department of Social Services. I think it’s clear that you should make the report. Parents who supply their children with drugs are abusing their children, creating an environment that will promote, if not create, illness and long-term suffering. What if you sat on the information in the hopes of helping Ann into recovery without the interference of legal issues, social service agencies and reactive parents? Well-intentioned ... but misguided. All of the treatment gains could be lost if Ann returns to a home that actively encourages her to abuse drugs. The treatment plan will become a thing of the past, overwhelmed by the power of the family system. For Ann’s treatment to be successful, her parents must either support her treatment or at the very least stand out of the way.

How you make the report, like all breaches of confidentiality, is best done with the client’s understanding and, ideally, participation. Including adolescents in treatment planning, especially around crucial issues like this one will help treatment succeed (Winter, 1999). And Ann’s cooperation is key. She might know best how her parents should be informed and might react. The report shouldn’t be a major surprise. If her parents originally provided consent for her treatment, they should have been informed about these limits to confidentiality (Nagy, 2000).
Ann’s parents could respond in many different ways. If they are not impaired by their own substance abuse, they may be able to develop a new way of parenting that will preserve the unity of their family, and support Ann in her efforts to avoid substance abuse and develop healthy behaviors and attitudes. Enlisting Ann’s parents in her treatment is a crucial element at this point. They will have to make some changes; family therapy might become a new focus (Winter, 1999). When Ann leaves the treatment facility, and re-enters her family home, she’ll need a lot of positive support from her parents.

Is it sounding far-fetched? Will her parents, deep in their own denial and shame, respond to the report of abuse with hostility and attempts to re-establish control? This is the harsher possibility. Your agency should be prepared to respond if they attempt to remove Ann from the facility. And the first ethical/legal consideration is her right to seek treatment without parental consent. The federal regulations leave it up to state law to decide at what age a person can consent to treatment (Confidentiality of Alcohol and Drug Abuse Patient Records, 1997). And states differ. Generally, the legal and ethical trend is toward granting more medical consent rights to adolescents (Corey et al., 1993). About half of the 50 states allow adolescents under 18 to consent to substance abuse treatment without parental consent (Brooks, 1999). Your agency may already be prepared with policies about how to assist adolescents seeking treatment. Agencies may also have concerns over how it will be paid for its services if parents pull out. Discharging an adolescent in this type of crisis seems an unethical dereliction of responsibility. At the least, careful and zealous efforts to place Ann in another facility are ethically required.

The family may seek legal action. However, each state provides some type of immunity from civil suit arising from reporting suspected child abuse and neglect (Brooks, 1999). This isn’t to say they might not struggle to remove Ann from the residential facility. They most likely will. Your skill at working in a system will be crucial. Do you already have a friend at the Department of Social Services who can work collaboratively with you (and Ann) to negotiate the Child Protective Services system, any confrontations with her parents, and the efforts to preserve her family in a new healthy pattern? In this situation, skills in case-management and referral might become more critical than other core functions of the substance abuse counselor. Ann will have to consent to that information sharing, because once the initial report of suspected abuse is made, the facility is no longer empowered to share her information with DSS without her consent (Brooks, 1999; Confidentiality of Alcohol and Drug Abuse Patient Records, 1997).

In short, you can’t ignore Ann’s revelation. You have a clear legal mandate to make a report of suspected child abuse. But I understand the reluctance to breach confidentiality and alienate your client and her parents. However, in this case ignoring the environment she’ll return to is a recipe for relapse and failed treatment. It will have to be addressed for legal, ethical, and clinical reasons. Legal pressures arising from the report of suspected abuse might motivate Ann’s parents to change, to create a new home for her that might not be ideal but might be good enough. In this case, adhering to your legal obligations might allow you to live out your ethical obligations more effectively.

Adam Robinson, MA, CSAPC ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it ) is associate director of Program Services at Wake AHEC in Raleigh, NC, and former chair of the NC Substance Abuse Professional Certification Board Ethics Committee.

References
Brooks, M. K. (1999). Legal and Ethical Issues. In Winter, K. C. (Ed.), Treatment of Adolescents with Substance Abuse Use Disorders, Treatment Improvement Protocol (TIP) Series 32. Rockville, MD: USDHHS.
Confidentiality of Alcohol and Drug Abuse Patient Records. 42 C.F.R. Ch. 1, Part 2 (1997).
Corey, G., Corey, M. S., & Callanan, P. (1993). Issues and Ethics in the Helping Professions. (4th ed.). Pacific Grove: Brooks/Cole Publishing Company.
Nagy, F. T. (2000). Ethics in Plain English: An illustrative casebook for psychologists. Washington DC: American Psychological Association.
Winter, K. C. (Ed.). (1999). Treatment of Adolescents with Substance Abuse Use Disorders, Treatment Improvement Protocol (TIP) Series 32. Rockville, MD: USDHHS.

This article is published in Counselor,The Magazine for Addiction Professionals, April 2004, v.5, n.2, pp. 22-23.

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