Approach to assessing adolescents on serious or sensitive issues and confidentiality

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Introduction

Adolescence is a time of rapid change in both physically and emotionally. Young people may be overwhelmed with conflicting and confusing feelings regarding changes in their bodies, sexuality, as well as their place in family, friends and society. Most adolescents have few serious medical problems, however it can be a dangerous time of experimentation with high-risk behaviors, while lacking the maturity to make sound, safe decisions. To work toward a healthier adolescent population, health care providers must address sensitive issues that impact the physical and emotional health of modern youth. It is important for health care providers to be comfortable discussing sensitive issues with adolescents. Issues pertinent to facilitating such discussions are confidentiality and consent. 

 

Confidentiality

Clinicians who care for adolescent patients should discuss confidentiality with the patient and his or her parents or guardians at the beginning of the adolescent-provider relationship.  The provider should make it clear that teen patient confidentiality is necessary to provide optimal medical care.

Although it is important for clinicians to respect their adolescent patients' privacy and the confidentiality of their patients' information, it is also important to encourage the adolescent, when appropriate, to talk with his or her parents about these personal and sensitive issues that affect health even if doing so may be uncomfortable.  Parental support can help to ensure that the adolescent's health needs are met.

It is also important for the patient to understand that the established confidentiality is not absolute or unqualified.  In circumstances where there is imminent harm to the patient or others, confidentiality may be forsaken to obtain help for the patient.  In these circumstances the patient should be informed of what information needs to be disclosed and to whom.  The patient should also be given the opportunity to make disclosure to their parents or others on their own.

Confidentiality provisions are found in both state and federal law.  In the following situations, physicians are universally required to forsake confidentiality:

  • Suicidal ideation
  • Homicidal ideation
  • Physical abuse
  • Sexual abuse
  • Behaviors that put one at risk of physical harm

 

Consent

In general, parental consent is required to provide medical treatment to minors.  However, there are several types of services for which minors are frequently authorized to give their own consent:

  • Emergency care
  • Pregnancy related care (sometimes including abortion)
  • Contraceptive services
  • Diagnosis and treatment of STIs
  • HIV/AIDS testing and treatment
  • Treatment and counseling for drug and alcohol problems
  • Inpatient and out patient mental health services
  • Immunizations

The laws governing consent and confidentiality in adolescent health care vary from state to state.  For state specific laws regarding adolescent consent and confidentiality, follow the link below:

http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf

 

Abortion controversy

Although the controversy surrounding abortion is long-standing and not limited to the questions related to the minor's access to abortion. Some states have enacted a parental consent law.

 

Potential Threats to Confidentiality

Medical Records:  Many health-care providers do not distinguish information that is confidential when they document.  The ability to redact information and to segregate confidential from other information in a medical chart depends upon the policies of a particular institution or practice setting.  Confidentiality of adolescent patients may be inadvertently breached when parents request copies of the medical record.  Providers should be wary of this fact before the medical record is released to the parent.  

Payment for services:

  • Private insurance – To receive payment for services, clinicians are required to share medical information with third-party payers.  Even though certain health care services can be performed without parental consent or notification, confidentiality may be breached when the bill or a detailed insurance statement is sent to the patient's parents.
  • Medicaid – If a patient is funded by Medicaid, billing is confidential and sent directly to Medicaid, and statements generally are not sent to the parents, although there may be exceptions to this in some states, and clinicians should be familiar with policy and practice in their own state.

 

Some approaches to working with adolescent patients

  • Time MUST be spend alone talking to the adolescent
  • It is often useful to talk to the patient individually, then speak to the parent individually, and then both together
  • On issues that are confidential, encourage adolescents to discuss the issue with parents, or disclose the issue
  • Follow the HEADSS interview format: Home, Education/Employment, Activities, Drugs, Sexuality, Suicide
  • It can be useful to ask patients about their friend's involvements in risky behavior: ex. Do your any of your friends smoke or drink alcohol?;
  • Encourage adolescents to share their knowledge with you before giving them information: ex: Have you thought of what kind of birth control method you might want to use?" Allow them to tell you if they have been thinking about the pill versus Depo, then explain the various methods.
  • Open-ended questions are helpful in directing further questioning.

 

References:

1)   Levine, SB. Adolescent Consent and Confidentiality. Pediatr Rev. 2009; 30:457.

2)   An Overview of Minor’ Consent Law. Guttmacher Institute State Policies in Brief. New York, NY: Guttmacher Institute. 2008. Available at: http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf

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