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Section 2
Kentucky Administrative Regulations: 201 KAR 23:080
Client Relationships

Question 2 | Test | Table of Contents

     Section 2. Client Relationships. (1) A legal guardian of a minor or legally incompetent adult shall be considered the client for the purposes of making decisions relative to the provision of services for the minor or legally incompetent adult.
     (2) The minor or legally incompetent adult shall be considered the client for an issue that:
     (a) Directly affects the physical or emotional safety of the individual, including a prohibited relationship; or
     (b) Is specifically reserved to the individual and agreed to by the guardian prior to the rendering of the service.
     (3) A client who directly receives the social work service shall be deemed to continue to be a client for a period of five (5) years following the last date of service actually rendered.

- Kentucky Legislature. Title 201, Chapter 23: 080 Board of Social Work. 2018 Kentucky Administrative Regulations. Section 2. Client Relationships.

Since legal guardians are legally responsible for minors or legally incompetent adults, it seems appropriate to discuss the confidentiality areas raised by this situation.

In this section, we will examine three concepts regarding confidentiality boundaries with very young children. These three concepts regarding confidentiality boundaries related to children include: maximizing communication; wary parents; and treatment in the classroom.

3 Concepts for Confidentiality Boundaries with Very Young Children

♦ Boundary #1 - Maximizing Communication
The first concept regarding confidentiality boundaries related to children is maximizing communication. Children that have been traumatized and that are under the age of seven obviously do not understand the idea of confidentiality. They cannot know their own rights and how disclosure of their information to another party could be detrimental to their social development. Because of this, communication with those adults who come into close contact with the child becomes crucial. However, who needs to know about the child’s disorder and who does not? 

The first step is to discuss with the parents who they feel comfortable sharing this delicate information with in the first place. Many times, this includes the child’s teacher, who spends more time with the client during the day than the working parents. I always request the parents to authorize the exchange of child-oriented information between the school and myself to allow for communication at case conferences. Personal information shared by the parent in the treatment format should not be shared unless the parent grants permission to do so. 

It is ethically important that the parents understand the confidentiality rights they do have and those that the child has as well. In addition, I also try to explain to the client in as simple terms as possible the concept of confidentiality. 

Brooke, age 6, was autistic.  Because of her low level of consciousness, it seemed impossible to get the concept of confidentiality across.  However, to be in line with ethical guidelines, I stated to Brooke, "No one needs to know about what you tell me or what you do here. I won’t tell the other children and you don’t need to tell the other children. Also, Mommy and Daddy won’t tell anybody except teacher." Although this conversation may not have registered completely in Brooke’s mind, I have found that it has been successful with other children. Think of your very young clients. How could you explain the concept of confidentiality to him or her?

♦ Boundary #2 - Wary Parents
The second concept regarding confidentiality boundaries related to children is wary parents. Agency affiliation may become clear to parents as they fill out intake and financial information forms for the mental health agency.  Many parents who are not familiar with the role the agency affiliation plays can become hesitant in sharing the child’s information. Some of the most common concerns fall under the category of future effects of treatment. If it is permanently documented that the child had a disorder early on in life, would that affect his or her chances for a higher education, career, or marriage? 

In these circumstances, many parents would almost prefer to "wait-it-out" and hope that their son or daughter grows out of his or her troubles.  Obviously, this poses a great risk to the child client. To facilitate parental understanding of the confidentiality and privacy notice, I familiarize them with HIPAA guidelines and exactly how these guidelines are utilized. I make sure to make it clear to them that any information placed into the data base is strictly confidential and cannot be used against their son or daughter.  Secondly, I emphasize that pulling the child out of crucial treatment will most likely worsen his or her chances for a healthy, normal life later on. 

Gracie, age 8, had been sexually abused by her uncle. Since then, she speaks very little, and in monotones. Essentially, Gracie had mentally regressed to the age of a two-year old as a defense mechanism.  Her parents, Stephen and Jill, were worried that her information would be leaked, and she would never be able to escape the stigma of an abused child. Jill stated, "This regression thing is probably a phase. She’ll grow out of it. I just don’t want anyone finding out about this. It could ruin her life!" 

After giving Jill a crash course on HIPAA regulations and the proper usage of information, I explained to her the risks of pulling Gracie out of therapy so soon. I stated, "If Gracie does not find a different way to cope with her trauma, regression will become her permanent coping mechanism. When another trauma comes along, she will want to regress to an earlier age in order to feel protected. Also, unresolved sexual abuse issues can become extremely detrimental to her mental health in the future. A client does not just grow out of a trauma such as this. It could affect her sexual identity, relationships, and her own self-worth." 

Think of your Jill.  How would you explain to him or her the risks involved in denying treatment?

♦ Boundary #3 - Treatment in the Classroom
In addition to maximizing communication and wary parents, the third concept regarding confidentiality boundaries related to children is treatment in the classroom. When treatment includes issues of socialization, poor self-esteem, and oppositional or negativistic behaviors, as you have most likely experienced, it becomes extremely beneficial to observe a child within a regular setting such as a classroom. 

However, confidentiality becomes an issue with the many dozens of other classmates that could unintentionally overhear delicate information about a client’s case. To avoid this, I work with the client’s teacher in finding a "safe space." This safe space is an area such as another room or corridor which is isolated from others. If the client’s play indicates he or she needs to communicate something vital, he or she is taken to the safe space where he or she can communicate his or her needs. 

Jason, age 5, was playing with G.I. Joes. When another boy came to Jason and began to take part in the play, Jason left the area. When I noticed this, I asked Jason why he didn’t want to play with that boy. However, Jason didn’t say anything. I asked him again, and he said, "I don’t want to say. I don’t want him to hear me." Even at this young age, Jason had already begun to understand the concept of privacy. I realized that Jason wanted to share something important, so I asked his teacher, Melanie, where we could talk so the other children could not overhear. 

She suggested the classroom across the hall. After we had sat down and closed the door, Jason stated, "I didn’t want him to hit me. I thought he was going to hit me." I asked Jason why he thought anyone was going to hit him. He stated, "Because Jake always hits me when we play." Jake, Jason’s older brother, had instilled in Jason a fear of playing with others. I could not have discovered this information had it not been for the safe space. Think of your Jason. Where could you take him or her in order to maintain confidentiality?
- Remer, Frederic. Update on confidentiality issues in practice with children: Ethics risk management. Children & Schools. Apr 2005. Vol. 27; Issue 2.

In this section, we discussed three concepts regarding confidentiality boundaries related to very young children. These three concepts regarding confidentiality boundaries related to children include: maximizing communication; wary parents; and treatment in the classroom.

Peer-Reviewed Journal Article References:
Borelli, J. L., Sohn, L., Wang, B. A., Hong, K., DeCoste, C., & Suchman, N. E. (2019). Therapist–client language matching: Initial promise as a measure of therapist–client relationship quality. Psychoanalytic Psychology, 36(1), 9–18. 

Conlin, W. E., & Boness, C. L. (2019). Ethical considerations for addressing distorted beliefs in psychotherapy. Psychotherapy, 56(4), 449–458.

Conrad, M. (2019). Moving upstream in the post-Hoffman era: When ethical responsibilities conflict with the law. Professional Psychology: Research and Practice, 50(6), 407–418.

Marmarosh, C. L., & Kivlighan, D. M., Jr. (2012). Relationships among client and counselor agreement about the working alliance, session evaluations, and change in client symptoms using response surface analysis. Journal of Counseling Psychology, 59(3), 352–367.

Olivera, J., Challú, L., Gómez Penedo, J. M., & Roussos, A. (2017). Client–therapist agreement in the termination process and its association with therapeutic relationship. Psychotherapy, 54(1), 88–101.

QUESTION 2
What are three concepts regarding confidentiality boundaries related to very young children? To select and enter your answer go to Test.

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