Forging Partnerships with Parents While Delivering Adolescent Confidential Health Services: A Clinical Paradox

Confidentiality between adolescents and clinicians has long been established to ensure that adolescents receive necessary health information and services. A confidential clinical encounter increases adolescents' willingness to seek health care, improves access to care, enhances disclosure of health risk behaviors and increases the likelihood they return for care.^1-3 Adolescents, especially those at greatest risk for negative health consequences, will forego health care services they know are needed, if they fear their parent may find out.^4-7 A number of professional medical associations recommend that clinicians discuss sensitive health issues with adolescents in private and provide adolescents access to an array of confidential health services without parental knowledge or consent.^8-16 To support families in their efforts to improve health care for their adolescent children, clinical guidelines also recommend that clinicians educate parents about the need for confidentiality and encourage communication between adolescents and their families.^8,9,11.^7,17-19 Given the complexity of assuring that adolescents receive high quality care, the provision of confidentiality becomes a dual and often conflicting responsibility for clinicians.

Clinicians face challenges both in terms of their own capacity to provide counseling for sensitive services and the current reimbursement structure for providing needed care. ^20-23 They often do not want to query patients about confidential-care related topics because they are concerned with the potential negative reactions from parents. ^20-22 This partially explains why clinical preventive services, which often overlap with confidential types of services, are not routinely included in the health care delivery of adolescents. Mechanisms to improve partnerships with parents, while delivering adolescent confidential health services, are extremely limited. Some evidence suggests that the use of clinic services can encourage parent-child communication without compromising confidentiality. ²⁶ Others have found it is possible to improve parental attitudes about adolescent confidentiality.²⁴ Yet, we still know little about the attitudes that parents have about confidentiality and how to inform interventions to improve clinician-teen-parent partnerships.

In the current issue of Journal of Adolescent Health. Duncan et al. takes an important step in addressing this research void by including parental perspectives on confidential health services for adolescents.²⁵ The study provides an important contribution to our growing understanding of the complex and conflicting feelings parents have toward confidential health services for their adolescents.^26,27 In particular, Duncan and her colleagues have captured the discordance between parents' awareness of the importance of confidentiality with difficulties parents have in relinquishing control to a health professional. In this Australian sample, parents perceived many benefits to adolescent confidentiality including: providing an opportunity for teens to talk about sensitive matters, improving their adolescent's communication with the clinician, and supporting adolescents' growing need to take responsibility for their own health. At the same time, their greatest concern was being left out of important decisions that affect the health of their adolescent.

Adolescence marks the transition between childhood and adulthood. Parents are also transitioning in their role as their child grows in maturity and autonomy. Confidentiality brings these tensions to the forefront at the same time it provides an important opportunity for adolescents to obtain accurate information, support and services from a trained medical professional. Clinicians can play an important role in facilitating adolescents' transition into adulthood where they encourage adolescents to assume responsibility for making decisions about their own health and for navigating the health care system more independently. Clinicians can also support parents' own transitions as they begin to witness the eventual independence of their children. If we are to improve our partnerships with parents, while simultaneously respecting adolescent's rights to confidential health services, we need more research to better understand the range of parental attitudes in other populations, how these attitudes vary, and examine what influences parental attitudes in order to improve our communication with parents. Building on what parents identify as the benefits of adolescent confidentiality and normalizing confidentiality as the standard of quality health care, as Duncan et al. suggests, are important starting points. The findings also imply a need for parents to understand the mutual benefit of confidentiality as a transitional step towards the adolescent's growing self-sufficiency and responsibility.

While our efforts to improve health partnerships with parents need greater attention, public health policies that promote access to confidential care and protect teens from having to disclose information to parents remains critical. Far too many teens do not have recommended time alone with a clinician²⁸, a proxy measure that helps to identify whether such confidential health opportunities are built in as part of the adolescent health care visit, and access to confidential services is far from equitable.²⁹ The debate over minors' access to confidentiality continues^30,31 and has resulted in a complex array of international^30,32,33, federal^34,35 and U.S. state policies³⁶ that are not always consistent. Mandatory parental notification policies appear to have adverse consequences on adolescent health. Such policies do not change adolescent health risk behaviors; rather they drive them under the radar of clinical detection, prevention and treatment placing adolescents at greater risk for negative health outcomes.^5,6,36-39 Efforts on all fronts (research, policy, advocacy) are needed to address this chasm in health care quality for our adolescents and parents are an important part of this approach.