Journal of Pediatric Psychology, Vol. 27, No. 6, 2002, pp. 541-549
© 2002 Society of Pediatric Psychology
Adolescent Health Risk Behavior: When Do Pediatric Psychologists Break Confidentiality?
Texas A&M University
All correspondence should be sent to William A. Rae, Department of Educational Psychology, MS 4225, Texas A&M University, College Station, Texas 77843-4225. E-mail: warae{at}tamu.edu.
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Abstract |
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Objective: To determine the circumstances under which pediatric psychologists believe it is ethical to break confidentiality when presented with adolescent health risk behavior.
Method: Members of the Society of Pediatric Psychology (N = 92) responded to a survey containing a vignette about an adolescent patient engaging in health-compromising behaviors. Participants rated the degree to which it is ethical to break confidentiality for health risk behaviors of varying frequency, intensity, and duration.
Results: Respondents generally find it ethical to break confidentiality when health risk behaviors are more intense, more frequent, and of longer duration. Respondents also find it more ethical to break confidentiality for female smoking than for male smoking. Similarly, they find it more ethical to break confidentiality for female sexual behavior than for male sexual behavior, but only as the frequency/duration increases.
Conclusions: At a certain point, maintaining the adolescent's health is more important for pediatric psychologists than maintaining confidentiality.
Key words: health behavior; professional ethics; adolescence; confidentiality of information; risk taking.
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Introduction |
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Adolescent health risk behaviors are becoming a serious health care problem (DiClemente, Hansen, & Ponton, 1996
) as adolescents engage in health-compromising behaviors at a
high frequency in several crucial domains
(Resnick et al., 1997;
U. S. Department of Health and Human
Services [DHHS], 2000). One domain involves tobacco, alcohol, and
illicit drug use. In 1999, for example, 35% of adolescents were current
cigarette smokers (DHHS, 2000). Similarly, more than 81% of high school
seniors admitted to alcohol use during their lifetime; nearly 75% admitted to
alcohol use during the last year, and 53% admitted to getting drunk during the
last year. Drug use also is common, with over 54% of high school seniors
reporting illicit drug use during their lifetime and over 42% reporting drug
use during the last year. The modal drug used is marijuana or hashish, with
over 38% of the adolescents admitting using it within the last year
(National Institute on Drug Abuse [NIDA],
1998).
Sexuality is another area of adolescent health risk behavior; sexual
activity among adolescents has increased dramatically since the 1970s
(Sells & Blum, 1996). For
unmarried women, 21% have had sexual intercourse by age 15, increasing to 63%
by age 18; for males, the onset of sexual behavior is even younger
(Centers for Disease Control and Prevention
[CDC], 1997). Fortunately, there is a recent trend for adolescents
to abstain from sexual intercourse or use condoms if they are sexually active
(DHHS, 2000). At the same time, adolescents continue to represent a high-risk
group for acquired immunodeficiency syndrome or other health problems because
of their inclination to ignore the dangers of potentially risky situations
(Olson, Huszti, Mason, & Seibert,
1989). Suicidal and self-destructive ideation is another health
risk area for adolescents. Resnick et al.
(1997) report that about 18%
of adolescents experience emotional distress and nearly 4% have attempted
suicide. In a recent survey of high school students, over 12% thought about
killing or hurting themselves (Lewinsohn,
Rohde, & Seeley, 1996). Unfortunately, parents do not always
recognize their adolescent's underlying emotional distress, as these feelings
are much harder to detect than overt behaviors.
Pediatric psychologists often face an ethical dilemma when confronted with
adolescent health risk behavior. Psychologists have a longstanding ethical
mandate to break confidentiality to protect patients from harm to self or
others (American Psychological Association
[APA], 1992), but in doing so the therapeutic relationship can be
severely disrupted. Pediatric psychologists must break confidentiality and
tell parents or other adults about risky adolescent behaviors when, in their
professional judgment, the adolescent's risky behaviors would result in
harmful outcomes. Tobacco use, alcohol use, drug use, sexual behaviors, and
suicidal behaviors can clearly have untoward effects on adolescents
(Kann et al., 2000). When all
is said and done, pediatric psychologists have to make a binary decision about
breaking confidentiality, a decision influenced by the pediatric
psychologist's own value system and the assessment of the degree of danger to
the patient (Tarvydas, 1998).
In this process the frequency, intensity, duration, and type of the risky
behavior are evaluated, but the exact mechanism of how these specific factors
influence the decision process is unknown. Moreover, pediatric psychologists
do not always agree when a particular adolescent behavior represents a
substantial risk of imminent danger or harm to the adolescent
(Rae & Worchel, 1991).
The purpose of this study is to determine under what circumstances pediatric psychologists believe it is ethical to break confidentiality and report health-compromising, risky adolescent behaviors. It is also of interest to determine the relative contribution of intensity, frequency/duration, and type of risky behavior on the perceived ethicality of breaking confidentiality. We hypothesized that as the intensity and frequency/duration of the health-compromising behaviors increased, so would the likelihood that respondents would find it ethical to break confidentiality. We also hypothesized that gender of the patient might present differential responses from the participants.
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Method |
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Participants
Two hundred randomly selected members of the Society of Pediatric Psychology (Division 54 of the American Psychological Association) were mailed a survey designed to assess their attitudes and beliefs about psychological treatment of risk-taking adolescents. This survey was developed, in part, as a follow-up to a 1991 survey of ethical beliefs of pediatric psychologists (Rae & Worchel, 1991
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Specifically, the current questionnaire examined six domains of adolescent
risk-taking behavior; five of these could directly affect adolescent health.
Overall, 92 participants returned the survey, yielding a 46% response rate. Of
the 92 participants responding to the survey, 12 chose not to complete it or
completed it only partially, resulting in 80 useable surveys. All participants
were full members of the American Psychological Association with 95%
(n = 76) having a doctoral degree; 96% (n = 77) were also
licensed psychologists. The sample was 51% male (n = 41) and 96% were
Caucasian/white (n = 77). The mean age was 49.4 years (SD =
10.45). These demographics appear to be representative of the members of the
Society of Pediatric Psychology, who are 49% male, 96% have a doctoral degree,
are 93% Caucasian/white (for those reporting), and have a mean age of 49.6
years (APA, 1999).
Measure
The survey was divided into two sections. In the first section,
participants were asked to rate the degree to which they believed it was
ethical to break confidentiality under several circumstances. The vignette and
questions were developed initially by the senior author, and after
consultation with colleagues, consensus about the plausibility and suitability
of the items to practicing pediatric psychologists was obtained. The specific
circumstances involved potentially risky health behaviors for five behavioral
domains (i.e., smoking, alcohol use, drug use, sexual behavior, and suicidal
behavior) with an adolescent patient. Participants were randomly assigned
either a male form or a female form of the questionnaire; the forms differed
only in the gender of the adolescent patient identified in the vignette.
Respondents returned nearly equal male and female forms: 39 male forms and 41
female forms were returned. The following vignette is from the male form:
Chris is a 15-year-old male who was referred by his parents for disrespectful, acting out, and oppositional behavior that has gotten much worse in the last few months. Chris is an only child of working parents who describe themselves as middle class. His parents have brought Chris to treatment and he is not enthusiastic about therapy since he does not believe that he has a "problem." Chris is also very concerned about confidentiality, but his parents have agreed that they will not ask you for details about the content of the therapy sessions. You assure Chris that you will only break confidentiality to his parents (or others) if he presents a danger to himself or others. During the sixth therapy session, Chris begins admitting to risk-taking behaviors.
Each question varied on the intensity (e.g., number of cigarettes smoked) and frequency/duration (e.g., weekly for several months) of risky behavior under each of the five health-related behavioral domains (i.e., smoking, alcohol use, drug use, sexual behavior, and suicidal behavior). Participants rated their response about the degree it was ethical to break confidentiality on a 6-point scale from (1) unquestionably not ethical to (6) unquestionably ethical. A Likert scale was used instead of a binary choice format (i.e., "yes" or "no") in order to obtain information about strength of the participants' beliefs. In the second section of the survey, participants were asked to provide background information about personal characteristics (e.g., age, gender) and professional characteristics (e.g., theoretical orientation, primary work setting, years of clinical experience). Finally participants were asked to rate the extent to which certain factors influenced their decision to break confidentiality, but the results of this inquiry are not reported here due to space limitations.
Procedure
Following approval by the institutional review board, participants were
mailed a pamphlet containing the questionnaire and a cover letter explaining
the purpose of the study. Questionnaire packets also included a
self-addressed, stamped return envelope and a postcard for participants who
wished to obtain a copy of the results. Two mailings were conducted in order
to maximize the response rate. All responses were anonymous.
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Results |
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Table I provides the mean rating of ethicality for each item within the five health domains along with the questionnaire items (see Table I). Questions 1 and 2 comprised the smoking domain; questions 3 and 4 the alcohol domain; questions 5 through 8 the drug use domain; questions 9 through 11 the sexual behavior domain; and questions 12 through 14 the suicidal behavior domain. For the suicidal behavior domain, only items 13 and 14 were analyzed because the levels of frequency/duration for item 12 were different.
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A two-way repeated measures ANOVA was conducted for each of the five
behavioral domains of our survey. As Mauchly's Test of Sphericity
(Mauchly, 1940) was
significant across all domains, the Huynh-Feldt correction
(Huynh & Feldt, 1976) was
used to interpret all of the results. The Sidak post-hoc test
(
idák, 1967)
was used to determine main effect differences among dependent variables when
there were more than two levels. Across each behavioral domain (e.g.,
smoking), the form type (i.e., male or female vignette) was the
between-participants factor. The intensity and frequency/duration of the
behavior were the within-participants factors. For each domain, the intensity
consisted of an increase in the amount of a particular substance (i.e.,
cigarettes and alcohol) or an increased risk of harm to self (i.e., drug use,
sexual behavior, and suicidal behavior).
Table II provides overall means
and standard errors of measurement for each of the five domains.
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Across all domains (smoking, alcohol use, drug use, sexual behavior, and suicidal behavior), the increased intensity within each domain significantly affected pediatric psychologists' belief that it is more ethical to break confidentiality: F(1) = 28.101, p < .001; F(1) = 134.250, p < .001; F(2.325) = 64.567, p < .001; F(1.573) = 138.824, p < .001; and F(1) = 36.644, p < .001, respectively. Frequency/duration (ranging from once a month ago to nearly daily) was also statistically significant across all domains: F(1.354)=57.357, p<.001; F(1.690)=123.991, p<.001; F(1.681) = 170.568, p < .001; F(1.632) = 70.784, p<.001; and F(1.701)=98.716, p<.001, respectively. The form type (i.e., male or female vignette) was found to be significant for only the smoking domain, F(1) = 10.271, p = .002. Figure 1 provides a graph showing the likelihood that pediatric psychologists would find it ethical to break confidentiality (response means) depending upon intensity (e.g., number of cigarettes smoked) and frequency/duration for three domains (i.e., smoking, alcohol use, and drug use). As these three domains could all be categorized as substance use, this graph illustrates the relationship among the three domains.
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In general, respondents were unlikely to find it ethical to report smoking, although the likelihood that they found it ethical to break confidentiality increased somewhat as did the frequency/duration and amount of smoking. Respondents indicated that breaking confidentiality was rarely ethical when the patient admitted to smoking only one cigarette, regardless of frequency/duration. The results are very similar when the patient admitted to smoking more than a pack of cigarettes. Respondents found reporting to be rarely ethical even when the patient admitted to smoking more than a pack of cigarettes nearly daily for the last year. When the patient was female, respondents were more likely to find it ethical to report smoking than when the patient was male.
With regard to both alcohol and drug use, respondents were more likely to find it ethical to break confidentiality as intensity and frequency/duration increased. Respondents found it ethical to break confidentiality in many circumstances when the patient admitted to using a large amount of alcohol (four or more drinks) nearly daily for the last year. With this exception, however, respondents rarely found it ethical to report alcohol use in either small or large amounts under most circumstances. Interestingly, respondents were more likely to find it ethical to break confidentiality when the patient admitted to using a large amount of alcohol than when the patient admitted to using marijuana. With regard to amphetamines, inhalants, and hallucinogens, the patterns were very similar across drugs; the likelihood that respondents found it ethical to break confidentiality increased as frequency/duration increased. Respondents found it most ethical to break confidentiality when the patient admitted to using inhalants, followed by hallucinogens and amphetamines. When any of these three substances was used nearly daily for the last year, respondents found it ethical to report under many circumstances, indicating that when any of these substances is abused regularly, pediatric psychologists are likely to break confidentiality.
Respondents generally did not find it ethical to report sexual behavior when the adolescent engaged in sex with either a steady partner or multiple partners, though breaking confidentiality became more acceptable as frequency/duration of the behavior increased. This perception changed, however, when the patient was reported to be HIV-positive and admitted to engaging in sexual behavior without using condoms. In this case, respondents found it ethical to report under many circumstances even when the behavior occurred only once several months ago and found it more ethical to report as the frequency/duration increased up to nearly daily for the last year.
As suicidal ideation increased in frequency/duration, the likelihood that pediatric psychologists found it ethical to report increased as well. Furthermore, the more recently and frequently a suicide gesture or attempt had occurred, the more ethical they believed breaking confidentiality. Thus, respondents were very likely to find it ethical to report either a suicide gesture or attempt that occurred more than once during the last month. These findings are not surprising given the potential severity of these behaviors, which may reflect a true desire to die or a cry for help (either of which should be taken very seriously).
Across the smoking, alcohol use, drug use, and suicidal behavior domains, the interaction between the intensity and the frequency/duration were found to be significant: F(1.983) = 12.049, p < .001; F(2.326) = 14.604, p < .001; F(5.153) = 9.891, p < .001; and F(2.129) = 10.213, p < .001, respectively. For these domains, there is a greater spread among the levels of intensity as the frequency/duration increases. Therefore, as the intensity and frequency/duration increase together, there is greater likelihood that pediatric psychologists will find it ethical to break confidentiality. This is not the case for the sexual behavior domain. For this domain, the interaction between form type (i.e., male or female vignette) and the frequency/duration was significant, F(1.632) = 5.545, p = .008. In this situation, pediatric psychologists were more likely to believe that it was ethical to report adolescent females with increased intensity and frequency/duration of sexual behavior as compared to adolescent males. There were no significant three-way interactions.
The Sidak post-hoc test showed that within each domain each
frequency/duration was found to be statistically different from one another
(p 
.001). In addition, the Sidak post-hoc test also determined
that there were significant differences between each of the four types of
drugs and each of the three types of sexual behavior (p <
.001).
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Discussion |
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The purpose of this study was to determine the extent to which pediatric psychologists find it ethical to break confidentiality and report adolescent health risk behaviors. In addition, the study examined the influences of intensity, frequency/duration, and type of risky health behavior on the perceived ethicality of breaking confidentiality. While engaging in risk-taking and health-compromising behaviors is often seen as developmentally normal or typical during adolescence, these behaviors have the potential to cause adolescents (or others) harm. It is the responsibility of pediatric psychologists who have developed a therapeutic relationship with adolescents to determine whether the intensity and frequency/duration of their behaviors constitutes a genuine and immediate threat and therefore warrants breaking confidentiality to protect the adolescent patient or others from harm. The results of this study indicate that as the intensity and frequency/duration of certain self-reported risk-taking behaviors increase, pediatric psychologists believe that it is increasingly ethical to break confidentiality to report the behaviors. Further, while between-domain differences were not tested for statistically due to the lack of relation and cohesion (i.e., parallelism) among domains, qualitative analysis of mean differences among domains indicates that respondents were least likely to find it ethical to report smoking and most likely to find it ethical to report suicidal behavior; mean scores for the remaining domains fell somewhere in between (see Table II).
Respondents generally were unlikely to find it ethical to break confidentiality when the behaviors were of low intensity (e.g., one cigarette, small amount of alcohol) and low frequency/duration (e.g., once several months ago, monthly for several months). Notable exceptions to this trend were observed when the adolescent was reported to be HIV-positive and admitted to engaging in sexual activity without using condoms and when the adolescent admitted to attempting suicide. Respondents were likely to find it ethical to report these behaviors even when they were of relatively low levels of frequency/duration (once several months ago and once over a year ago, respectively). Conversely, for some of the risky behavior domains, respondents were unlikely to find it ethical to break confidentiality even when the adolescent reported engaging in certain levels of the behavior with high intensity and frequency/duration. For example, even at high rates of frequency/duration (i.e., weekly for several months, nearly daily for the last year), respondents tended to be unlikely to find it ethical to report the adolescents' smoking more than a pack of cigarettes, using marijuana, and engaging in sexual activity with either a steady partner or with multiple partners.
There appears to be no consensus in the literature with regard to whether
psychologists should report sexual behavior by HIV-positive patients. An
examination of relevant court cases suggests that the extent to which duty to
warn principles have been applied to patients who are HIV-positive has been
inconsistent (Chenneville,
2000). In these cases, the psychologist faces the same issue that
arises when patients engage in any potentially harmful behavior: protecting
the patient's rights to confidentiality versus protecting the patient and
others from harm (Olson et al.,
1989). As noted by Olson et al., "There is no clear
definition of what constitutes an imminent or serious danger that requires the
therapist to warn the sexual partner" (p. 15). Chenneville offered a
model for psychologists working with sexually active, HIV-positive patients
that considers predictability of harm, identifiability of the victim,
professional ethical codes, and state guidelines and laws. The American
Psychological Association
(2001) offers similar
guidelines, yet maintains that the decision to break confidentiality must be
made on a case-by-case basis after multiple factors have been considered.
Previous research has shown that psychologists support the ethicality of
breaking confidentiality if a patient is suicidal
(Pomerantz, Ross, Gfeller, & Hughes,
1998); this finding was supported by our results indicating
respondents' willingness to report chronic ideation and frequent gestures or
attempts. It appears that frequent and chronic suicidal ideation may be
considered pathological even by itself, with no accompanying action; such
persistent ideation may be considered dangerous enough to warrant disclosure
in many circumstances.
The results revealed a significant gender difference within the smoking
domain; respondents were statistically significantly more likely to find it
ethical to report cigarette smoking when the patient was female. Further, the
statistically significant interaction between gender and frequency/duration on
the sexual behavior domain indicates that while the gender main effect was not
statistically significant, the gender distinction became more prominent as
frequency/duration increased. Thus, respondents were more likely to state that
it was ethical to break confidentiality for certain kinds of sexual activity
if the patient in the vignette was female, and this tendency increased along
with frequency/duration. Respondents were not significantly more
likely to break confidentiality with a female patient who admitted to using
alcohol or drugs, and no gender differences were detected for the suicidal
behavior domain. The observed gender differences suggest that respondents were
more cautious or protective of adolescent females (at least regarding smoking
and sexual behavior). With regard to sexual behavior, females may cause
particular concern among respondents given the potential negative impact of
teenage pregnancy; females also may be seen as more vulnerable to sexually
transmitted diseases. It also is possible that because males tend to engage in
risk-taking behaviors at a higher rate than females
(Jelalian et al., 1997;
Morrongiello & Rennie,
1998), psychologists are less inclined to report this behavior
with male patients, as it is seen as more normative. Conversely, psychologists
may be more inclined to report health risk behavior with female patients,
simply because females tend to engage in these behaviors at a lower rate, so
that any degree of involvement is seen as abnormal or atypical and therefore
worth reporting. Psychologists must recognize their own biases when making
ethical decisions and must seek to understand how these biases influence their
beliefs, perceptions, and decisions.
The lack of consensus among respondents on many issues does not indicate a
failure to teach ethics effectively. While laws are prescriptive, ethical
codes and guidelines allow for (and result in) individual differences in
decision making. Thus, disparate opinions across respondents were expected,
given the difficult nature of the decisions they were asked to make. Indeed,
the purpose of this study was to examine these individual differences, to
determine how psychologists would respond to what may be considered
"gray areas" in ethical decision making. These decisions are
multifactored, likely depending on pediatric psychologists' perceptions,
beliefs, training, and previous experience with adolescent patients. Recent
research points to the importance of such factors as the negative nature of
the risk-taking behavior (e.g., frequency, intensity, duration) and
maintaining the therapeutic process in psychologists' decision of whether to
break confidentiality with adolescent patients
(Sullivan, Rae, George, Razo, &
Ramirez, 2001). Further, many psychologists may attempt to
maintain confidentiality while encouraging the patient to take responsibility
and disclose the health risk behavior himself or herself, thereby maintaining
the therapeutic relationship while also addressing ethical obligations. With
the less intense (and therefore less potentially dangerous) behaviors for
which respondents did not find it ethical to break confidentiality, it may be
that psychologists are more likely to try to address these issues within
therapy rather than immediately reporting.
The propensity to report extreme levels of risk-taking behavior points to the importance of a thorough discussion of the limits of confidentiality at the initial stages of therapy. Rather than speaking in abstract terms, the pediatric psychologist should delineate specific behaviors that would warrant breaking confidentiality in order to make the discussion concrete. This is especially true for therapy involving adolescent patients and for cases involving risk-taking or health-compromising behaviors.
This study has several limitations. First, the survey included no assessment of whether the respondents would break confidentiality in actual practice with adolescents. Rather, the survey only assessed the pediatric psychologists' beliefs about whether it was ethical to break confidentiality when the patient in the vignette admitted to engaging in risk-taking behaviors. While we hope that ethical beliefs will lead to consistently ethical actions, the results tell us nothing about actual behaviors. Second, the way in which the survey questions were posed makes it impossible to reach separate or unique conclusions with regard to the relative influences of frequency and duration on pediatric psychologists' decision to break confidentiality. Frequency and duration were combined on each item (e.g., "weekly for several months"), making it impossible to discern the unique influence of each. Third, the vignette format made it impossible for the respondent to obtain additional information about the patient or the patient's behaviors. In clinical practice, the pediatric psychologist would likely ask follow-up questions to gain a more comprehensive perspective of the presented ethical dilemma and would then make a decision based on this more thorough information. Fourth, the age of the adolescent in the vignette was not varied, and the extent to which the health risk behaviors included in the survey are perceived as developmentally normal or typical likely varies depending on the adolescent's age. For example, it is likely that respondents would have found it more ethical to break confidentiality and report high levels of cigarette and alcohol use had the patient been younger, and perhaps even less ethical to report had the patient been older. Fifth, the survey items regarding sexual behaviors assumed a heterosexual orientation. Though this is the modal orientation among adolescents, a more gender-neutral term (e.g., "partner") could have been used in place of "boyfriend" or "girlfriend" in order to reflect the full range of potential sexual preferences. Sixth, the levels of intensity for some of the behavioral domains (e.g., sexual behavior) were not equally spaced. Finally, although our response rate is adequate, we would have preferred a higher rate of response.
Previous research suggests that issues surrounding confidentiality are
among the most serious and frequently encountered by psychologists
(Pope & Vetter, 1992), yet
little is known about the relationship between frequency, intensity, and
duration of risk-taking behaviors and the decision to break confidentiality.
This study has added some knowledge to this area, yet there is much more
territory ripe for investigation.
After gathering all relevant information and determining whether the patient's behavior truly has potential to harm himself or herself or others, pediatric psychologists ultimately are forced to decide to break or not to break confidentiality. Further survey research that presents pediatric psychologists with detailed vignettes similar to that we used but forces them to make a "yes" or "no" decision about whether they would break confidentiality in their own practice, rather than assessing their beliefs of ethicality on a Likert-type scale, would be useful. Respondents likely would request additional information about the context or situation in order to make an informed decision. It would be interesting to ask respondents to provide additional information that they need to make an informed decision.
Another fruitful area of inquiry is the exploration of the factors that contribute to the decision of whether to break confidentiality. That is, we not only need to ask psychologists what they would do in these situations; we also need to ask why they would do it. Such information would further delineate the complex and multidimensional process of ethical decision making.
Finally, similar research should be conducted with different professional groups (e.g., clinical child psychologists, school psychologists, counseling psychologists, child psychiatrists, social workers) to determine whether these groups would perceive and handle these ethical dilemmas differently. Such research could elucidate the influence of variables such as training and work setting on ethical decision making.
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Acknowledgments |
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We thank Dr. Victor L. Willson for help with the statistical analysis for this study.
Received January 16, 2001; revision received June 6, 2001; accepted October 9, 2001
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