Adolescent Confidentiality: Where Are the Boundaries?

A MOTHER ASKS:

The angry mother of a 15-year-old girl has called the office multiple times asking for the laboratory results from her daughter’s office visit last week and demanding to know whether the teen was “put on the pill.” Along with other lab work, tests for sexually transmitted infections (STIs) and pregnancy were performed, and the patient was given a prescription for a hormonal contraceptive. In addition, the girl had confided that she is intentionally vomiting after every meal but doesn’t want her mother to know about it.
What information about the patient’s recent visit should be shared with the mother?

THE PARENT COACH ADVISES:

The degree to which a teenaged patient’s confidentiality should be protected by his or her health care provider is a question that pediatricians and adolescent medicine providers frequently
find challenging. Striking the right balance between maintaining patient confidentiality and providing optimal medical care is not always easy.

The importance of confidentiality in adolescent medicine. In its position paper on this subject, the Society for Adolescent Medicine emphasizes that confidentiality is an essential part of adolescent health care and helpful in promoting adolescent autonomy.¹ During clinic visits, parents can be asked to step out of the room temporarily to encourage the teenager’s independence and to allow for discussion of private matters. Also, a social history is best obtained without a parent present, using a screening tool such as the Perkins Adolescent Risk Screen,² which poses questions about high-risk behaviors, such as sexual activity, drug and alcohol use, abuse in the home or outside the home, mood disorders, and other high-risk problems. Also useful is the HEADSS system for taking an adolescent's psychosocial history.³ This assessment tool guides the clinician in eliciting pertinent information from a teen about various aspects of home, education, activities, drugs, sex, and suicidality. While a teenaged patient should be strongly encouraged to discuss with his parents any high-risk behaviors that are uncovered, whenever possible the clinician should obtain the patient’s permission to discuss sensitive issues with the parents.

When confidentiality poses a challenge. The case of this girl and her mother involves several areas in which determining the boundaries of adolescent confidentiality can be particularly difficult: contraceptive care, STI and pregnancy testing, and eating disorders. Other such areas
include homicidal or suicidal ideation, drug or alcohol use, cutting and other self-injurious behavior, physical or sexual abuse, and mental health treatment. Keep in mind that statutes relating to the confidentiality of an adolescent’s health care vary from state to state and also according to the issue involved. In addition, while laws may be clear about the extent of confidentiality allowed patients who are considered to be in “middle adolescence” (ages 14 to 16 years) or “late adolescence” (ages 17 to 21 years), the status of those in “early adolescence” (ages 10 to 13 years) is more of a gray area. With “tweens,” there may be a greater need
to involve parents or social services, depending on the specific concern.

Confidentiality and adolescent sexual activity. Confidentiality regarding contraceptive care is frequently a controversial issue. Most states in the United States provide specific directives that allow adolescents to receive contraceptive care without parental consent; however, in other states, parental consent is required. It is important for providers to be familiar with the laws in
their area of practice. Studies have shown that sexually active adolescents who fear parental discovery and disapproval will not seek medical guidance regarding pregnancy prevention
if they do not feel assured of confidentiality from their health care provider.^4-6 For this reason, I
would strongly recommend not disclosing information about contraceptive care unless specifically given permission by the adolescent to do so-at least in states where this is legal.
With regard to the mother’s questions about her daughter’s laboratory test results, the pediatrician might simply state that as a general policy, the adolescent must explicitly grant permission to discuss her results with another. (Note, however, that in some states, health care providers may disclose medical information to a minor’s parents without his consent.)

Life-threatening problems and the limits of confidentiality. This patient’s eating disorder is another issue altogether because of its potentially life-threatening consequences. Other situations in which the breaking of confidentiality would be justified on similar grounds include
those in which a teenaged patient is suicidal or homicidal. Moreover, in the case of eating disorders, treatment optimally involves both the patient and the family participating in therapy with a behavioral medicine specialist; inclusion of the whole family would increase the chances that
the adolescent would be successful in breaking the pattern of disordered eating.

What to tell teens about confidentiality. When explaining the limits of confidentiality to adolescent patients, it is helpful to state up front that confidentiality cannot be ensured regarding conditions that could be lethal to the patient or to others. Also mention other legal limits to confidentiality, such as the mandated reporting of certain sexually transmitted diseases or of
physical or sexual abuse.

Tips for keeping the peace with parents. Pediatricians can minimize angry phone calls from parents by taking a proactive approach-establishing good rapport with the parents and fostering an understanding of the importance of confidentiality and adolescent autonomy. Also helpful are efforts to anticipate parental questions in advance, followed by getting input from the teenager
regarding how to handle these questions.

References:

REFERENCES:

1.

Ford C, English A, Sigman G. Confidential health care for adolescents: position paper of the Society for Adolescent Medicine.

J Adolesc Health.

2004;35:160-167.

2.

Adams CD, Perkins KC, Lumley V, et al. Validation of the Perkins Adolescent Risk Screen (PARS).

J Adolesc Health.

2003;33:462-470.

3.

Cohen E, MacKenzie RG, Yates GL. HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth.

J Adolesc Health.

1991;12:539-544.

4.

Klein JD, Wilson KM, McNulty M, et al. Access to medical care for adolescents:results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls [published correction appears in

J Adolesc Health.

1999;25:312].

J Adolesc Health.

1999;25:120-130.

5.

Ford CA, Bearman PS, Moody J. Foregone health care among adolescents.

JAMA.

1999;282:2227-2234.

6.

Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health care services.

JAMA.

2002;288:710-714.