Abstract
Purpose
This study aimed to assess adolescent and parent perspectives on parent notification after disclosure of adolescent relationship abuse (ARA) to a health care provider.
Methods
A computerized survey was administered to a convenience sample of adolescents aged 14–18 years and their parents presenting to three Midwestern pediatric emergency departments. The survey assessed the acceptability of parent notification after hypothetical adolescent disclosure of different forms of ARA (i.e., physical, cyber, psychological and sexual ARA, reproductive coercion, controlling behavior, and feeling unsafe) to a health care provider. Chi-square and Fisher's exact tests were used to examine possible relationships between acceptability of parent notification and prior ARA victimization, adolescent dating relationship status, and demographic factors.
Results
One-hundred fifty adolescent–parent dyads and 53 individual adolescents participated in this study. Most adolescents and parents found it acceptable to inform parents after disclosure of any type of ARA, although acceptability was higher among parents for all types of abuse assessed. Adolescent–parent dyads were more likely to both agree that parent notification was acceptable after disclosure of physical ARA, compared with other forms of ARA. Acceptability of parent notification after some types of ARA disclosure was less common among adolescents reporting previous sexual activity, prior ARA victimization, and adolescents currently in a dating relationship.
Conclusions
Most adolescents and parents found parent notification after ARA disclosure acceptable. However, adolescents most at risk, including those who reported previous sexual activity, prior ARA victimization, and those in a dating relationship, were less likely to find parent notification acceptable. Further study to assess barriers or concerns with parent involvement is crucial to optimizing provider response after ARA disclosure.
Keywords
Implications and Contribution
This study demonstrates that most adolescents and parents find parent notification after adolescent relationship abuse disclosure acceptable. However, further study is needed to evaluate decreased acceptability among at-risk groups, including adolescents reporting previous sexual activity, prior ARA victimization, and those in a dating relationship.
See Related Editorial on p.181
Adolescent relationship abuse (ARA) is highly prevalent and occurs among adolescents of all races, ethnicities, and socioeconomic levels [
[1]
]. One in five adolescent females report physical and/or sexual violence from a dating partner, and 32% of adolescent female homicides are committed by an intimate partner [[2]
,[3]
]. Although physical and sexual ARA are most commonly studied, ARA covers a wide spectrum of unhealthy behaviors where one partner seeks power and control over the other. Cyber ARA involves the use of technology to control a romantic partner [[1]
]. Psychological ARA refers to behavior that includes threatening a partner or harming his or her self-worth [[4]
]. Reproductive coercion, another form of ARA, is defined as any behavior to maintain control over a partner's decisions around reproductive health, including interfering with contraception [[1]
]. ARA is associated with significant negative health outcomes, including depression, suicidal ideation, eating disorders, substance abuse, sexually transmitted infections, adolescent pregnancy, and adult intimate partner violence (IPV) [5
, 6
, 7
, 8
, 9
]. Adolescents who experience ARA are more likely to be involved in abusive relationships as adults, continuing the cycle of violence [[6]
,[10]
].Given the prevalence and negative outcomes of ARA, addressing it in the health care setting is recommended as part of routine care for adolescents [
[1]
,[11]
,[12]
]. Existing recommendations provide some guidance around confidentiality after disclosure of ARA, recognizing mandatory reporting requirements and the limitations of confidentiality after disclosure of physical or sexual abuse [[1]
,[11]
]. Although mandatory reporting is not required after disclosure of psychological ARA, cyber ARA, or reproductive coercion, parent notification may enable parents to provide support for adolescents experiencing ARA and to mitigate associated negative health outcomes. Health care providers must balance the potential benefits of parent notification after ARA disclosure against the importance of recognizing adolescents' emerging autonomy and capacity for independent decision-making. Current practices around parent involvement after ARA disclosure are limited by a lack of understanding of adolescent and parent perspectives on confidentiality in this circumstance.The aim of this study was to assess adolescent and parent perspectives on parent notification after hypothetical adolescent disclosure of multiple forms of ARA to a health care provider. We hypothesized that there would be higher rates of agreement between parents and adolescents on acceptability of parent notification after physical and sexual ARA disclosure, compared with other forms of ARA.
Methods
This was a multisite, cross-sectional survey of a convenience sample of adolescents aged 14–18 years and their parents presenting to three emergency departments (EDs) at two Midwest tertiary care children's hospital systems. Hospital 1 includes two EDs, an urban Level I trauma center with 70,000 annual visits and a suburban community ED with 45,000 annual visits. Hospital 2 is an urban Level I trauma center with 70,000 annual visits. Both hospitals' institutional review boards approved this study.
Subject enrollment
English-speaking adolescents aged 14–18 years presenting to a study site ED were eligible when a research assistant was present. Adolescents were excluded if their chief complaint was sexual assault or psychiatric issues or if there was a significant impairment that would impede participation as determined by the ED provider (i.e., severe illness and developmental delay). Parents, if present, were eligible if their adolescent agreed to participate; parents were excluded if they did not speak or read English. Sampling was targeted to ensure that 50% of participants were aged 14–15 years and 50% were aged 16–18 years.
Trained study team members identified potential participants using computerized ED tracking boards, which display patients in real time. A study team member first obtained verbal permission from the parent to speak to the adolescent privately. Study team members were available to answer additional questions, and an information sheet about the purpose of the study was given. If an adolescent presented without a parent for a condition that did not require parental consent (i.e., reproductive health care and drug or alcohol use), the study team member approached the adolescent directly about participation. Participants were informed of mandatory notification to the ED provider and social worker if physical ARA, sexual ARA, or other ARA prompting significant safety concern was verbally disclosed to the study team. If nonphysical/nonsexual ARA was disclosed but safety was not a concern, adolescents were given the option to talk to a social worker. Social workers were available at each study site, if needed. Adolescent and parent participants completed a self-administered computerized survey either privately or were positioned to maintain privacy. Participants received either a $10 gift card or earbuds after survey completion (dependent on study site). All participants received a list of resources for general adolescent health that also included resources for ARA.
Survey instruments
Survey items were developed based on extant literature. Questions were pilot tested with 20 adolescents and amended as needed to ensure content was clear and understandable [
[1]
,13
, 14
, 15
, 16
]. Survey items assessed demographic factors (five items), current dating status (one item, adolescent only), history of ARA (eight items, adolescent only) or IPV (one item, parent only), prior sexual activity (one item, adolescent only), and acceptability of parent notification after ARA disclosure (seven items). The survey was administered online by tablet computer as an audio computer-assisted self-interview using REDCap [[17]
]. No personal identifying information was collected. Adolescents and parents could not see each other's answers, but dyad responses were linked in REDCap.Dating relationship status
We assessed adolescent dating relationship status with a single item, “Are you currently dating anyone (like a boyfriend or girlfriend)?” Dating was defined as, “having a boyfriend or girlfriend, like someone who you are currently going out or socializing with without being supervised, have hooked up with more than once, someone you like or love and spend time with, or a relationship that might involve sex” [
[16]
].History of ARA
We assessed for physical abuse (one item), psychological abuse (two items), sexual abuse (one item), cyber abuse (one item), feeling unsafe from past or current relationship (two items), and reproductive coercion (one item, female participants only; Table 1). We adapted these items based on previous work to capture ARA experiences broadly [
[15]
,[18]
]. Subjects with a “yes” answer to any item were defined as positive for prior ARA victimization.Table 1Assessment of history of adolescent relationship abuse
| 1. Do you feel unsafe in your current relationship? |
| 2. Is there someone you used to date who is making you feel unsafe now? |
| 3. Has someone you were dating ever hit, pushed, slapped, choked or otherwise physically hurts you (include things like being hit, slammed into something or injured with an object or weapon)? |
| 4. Has someone you were dating ever controlled what you do, like where you go, who you hang out with or what you wear? |
| 5. Has someone you were dating every pressured you to do things sexually that you did not want to do? |
| 6. Has someone you were dating every pressured you to get pregnant or not use a condom or other birth control? |
| 7. Has someone you were dating every used social media (like FaceBook, Twitter or Instagram) or technology (like texting or GPS location services) in a way that made you feel bad, nervous or uncomfortable? |
| 8. Has someone you were dating ever called you names or said things to make you feel bad? |
History of IPV
We assessed the parent history of IPV with a single item, “Have you ever personally experienced domestic violence?” Domestic violence was defined as, “any of the following behaviors used to hurt, scare or control a significant other: physically hurting you; forcing you to have sex; threatening to physically hurt you or force you to have sex; keeping you from getting or keeping a job, having access to money or seeing friends or family; stalking you; or saying things to hurt you or make you feel bad about yourself” [
[19]
].Sexual activity and orientation
We assessed prior sexual activity (adolescents only) with one item, “have you ever had any type of sex with a male or female (vaginal sex or anal sex or oral sex).” We assessed sexual orientation with one item, “who you prefer to date (boys, girls, both boys and girls)” [
[20]
].Acceptability of parent notification after ARA disclosure
Seven items assessed the acceptability of parent notification after hypothetical adolescent ARA disclosure using a 5-point Likert scale (1 = strongly agree, 5 = strongly disagree; Table 2). These items were developed by the study team and refined after pilot testing for readability.
Table 2Survey items assessing acceptability of parent notification
| Item stem: If I tell my doctor that my dating partner (like a boyfriend or girlfriend) ever [dating behavior], it is okay for the doctor to tell my parents. | |
|---|---|
| Dating behavior | ARA domain |
| Hit, pushed, slapped, choked or otherwise physically hurt me/them (includes being hit, slammed into something or injured with an object or weapon) | Physical abuse |
| Pressures me to do things sexually that I do not want to do | Sexual abuse |
| Controls what I do (like where I go, who I hang out with or what I wear) | Controlling behavior |
| Calls me names or says things to make me feel bad | Psychological abuse |
| Uses social media (like Facebook, Twitter or Instagram) or technology (like texting or GPS location services) in a way that makes me feel bad, nervous, or uncomfortable | Cyber abuse |
| Pressures me to not use a condom, to get pregnant or not to use other birth control | Reproductive coercion |
| Makes me feel unsafe | Feeling unsafe |
ARA = adolescent relationship abuse.
a Wording revised as needed for parent survey.
b Asked only for female adolescents.
Nonparticipants
Nonparticipants were asked to provide age, race, and a reason for nonparticipation (free text response) but could decline this request. Responses regarding reason the for declination were categorized as lack of interest, feeling unwell, and other/no response.
Statistical analyses
Acceptability of parent notification after ARA disclosure was dichotomized to “acceptable” (strongly agree/agree) or “not acceptable” (unsure/disagree/strongly disagree). Means with standard deviations and proportions were used to summarize the data. Ninety-five percent confidence intervals for proportions were also reported. Chi-square and Fisher's exact (used when expected cell counts were less than 5) tests were used to test for significant differences, and McNemar's tests were used to test for significant differences in paired proportions. When comparing the proportions of cases where the adolescent–parent dyads agreed on disclosure between each type of ARA, McNemar's tests were used, and because of the large number of pairwise comparisons, Bonferroni-corrected p values were reported. Potential differences based on age, race, ethnicity, insurance status, sexual orientation, history of sexual activity, current dating relationship status, education level, and history of ARA victimization or IPV were examined using chi-square and Fisher's exact tests.
Results
Participants
Subjects were enrolled from May 2016 to March 2017. Among 245 adolescents approached, 203 (82%) agreed to participate; of these, 150 adolescents participated as adolescent–parent dyads and 53 adolescents enrolled without a parent (N = 353). The mean age of the adolescent participants was 15.7 years (±1.4), and 43% were white. The most common reasons for refusal were lack of interest (n = 18) or patient feeling unwell (n = 18). We saw no differences in age among those who agreed to participate and those who did not. There were no significant differences in age, gender, race, or prior ARA/IPV history among adolescents and parents participating at either location. Adolescents who declined to participate were more likely to be nonwhite (74% vs. 57%; p = .04). All the parents approached agreed to participate.
Among adolescents, 38% reported they were currently in a dating relationship, 32% endorsed prior sexual activity, and 32% reported at least one form of ARA victimization. Among parents, 35% reported IPV. Fifty adolescents reporting ARA participated as part of an adolescent–parent dyad; 19 (38%) of these dyads included an adolescent reporting ARA and a parent reporting IPV. Additional participant characteristics are noted in Table 3.
Table 3Participant characteristics
| Adolescents (n = 203), n (%) | Parents (n = 150), n (%) | |
|---|---|---|
| Age, mean (SD) | 15.7 (1.4) | 42.6 (6.5) |
| Female | 133 (66) | 131 (87) |
| Race | ||
| African American | 69 (35) | 41 (28) |
| White | 86 (43) | 91 (63) |
| Other | 43 (22) | 13 (9) |
| Hispanic ethnicity | 41 (20) | 19 (13) |
| Sexual minority | 20 (14) | NA |
| Commercial insurance | 134 (67) | NA |
| Any ARA | 64 (32) | NA |
| Currently dating | 76 (38) | NA |
| Prior sexual activity | 63 (32) | NA |
| Married | NA | 71 (48) |
| Unemployed | NA | 30 (20) |
| High school degree or less | NA | 47 (23) |
| IPV | NA | 53 (35) |
ARA = adolescent relationship abuse; IPV = intimate partner violence; NA = not applicable.
a Homosexual/bisexual
Acceptability of parent notification after ARA disclosure
For each type of ARA assessed, most adolescents, parents, and adolescent–parent dyads found parent notification after ARA disclosure acceptable (Table 4). Parent notification was acceptable to the highest proportion of adolescents after disclosure of physical ARA (80%), reproductive coercion (74%), and sexual ARA (72%). When compared with adolescents as a whole, parents were more likely to report acceptability of parent notification for all ARA types assessed (Table 4).
Table 4Acceptability of parent notification after adolescent ARA disclosure
| Behavior disclosed | Adolescents (N = 203) versus parents (N = 150) | Agreement among adolescent–parent dyads (N = 150) | |||
|---|---|---|---|---|---|
| Adolescent, n (%) | Parent, n (%) | p | n (%) | 95% CI | |
| Feeling unsafe | 129 (66) | 130 (89) | <.001 | 85 (60) | (51.8%, 67.9%) |
| Physical ARA | 159 (80) | 134 (89) | .02 | 113 (76) | (69.5%, 83.2%) |
| Controlling behavior | 132 (67) | 127 (85) | <.001 | 87 (60) | (51.6%, 67.6%) |
| Sexual ARA | 142 (72) | 131 (89) | <.001 | 95 (66) | (58.2%, 73.7%) |
| Psychological ARA | 124 (63) | 128 (87) | <.001 | 84 (58) | (50.0%, 66.0%) |
| Cyber ARA | 132 (67) | 127 (85) | <.001 | 87 (60) | (51.6%, 67.6%) |
| Reproductive coercion | 145 (74) | 132 (89) | <.001 | 102 (70) | (62.4%, 77.3%) |
ARA = adolescent relationship abuse; CI = confidence interval.
There were significantly more dyads in which both the parent and adolescent agreed that parent notification was acceptable after disclosure of physical ARA (76%) compared with the disclosure of feeling unsafe in a relationship (60%; p = .002), controlling behavior (60%; p = .002), cyber ARA (60%; p = .002), and psychological ARA (58%; p = .002). We found no differences in the proportion of dyads who agreed with parent notification after disclosure of sexual ARA compared with disclosure of other ARA. Among dyads not in agreement about parent notification, most commonly for all types of ARA, the adolescent reported notification not acceptable, whereas the parent agreed with notification.
Adolescent factors associated with the acceptability of parent notification
Compared with those not currently in a dating relationship, adolescents in a dating relationship were less likely to find parent notification acceptable after disclosure of physical ARA (72% vs. 85%; p = .03), controlling behaviors (51% vs. 76%; p < .001), cyber abuse (56% vs. 74%; p = .01), reproductive coercion (61% vs. 82%; p = .01), and feeling unsafe (53% vs. 73%; p = .005). Compared with those not reporting sexual activity, adolescents reporting sexual activity were less likely to find parent notification acceptable after disclosure of cyber abuse (48% vs. 76%; p < .001) and feeling unsafe (53% vs. 71%; p = .02). Compared with adolescents without prior ARA victimization, adolescents reporting prior ARA victimization were less likely to find parent notification acceptable after disclosure of reproductive coercion (63% vs. 81%; p = .02), controlling behaviors (45% vs. 78%; p < .001), physical abuse (69% vs. 85%; p = .006), sexual abuse (62% vs. 77%; p = .02), psychological abuse (52% vs. 67%; p = .04), and feeling unsafe (49% vs. 74%; p = .001). Compared with white adolescents, nonwhite adolescents were less likely to find parent notification acceptable after disclosure of physical abuse (74% vs. 88%; p = .01) and reproductive coercion (66% vs. 87%; p = .008). Adolescents who found parent notification acceptable after disclosure of reproductive coercion or cyber ARA were younger than adolescents who disagreed with parent notification after disclosure of these two forms of ARA (reproductive coercion: 15.55 vs. 16 years, p = .04; cyber ARA: 15.47 vs. 16.11 years; p = .002). Sexual orientation, gender, insurance status, and ethnicity were not associated with the acceptability of parent notification after ARA disclosure.
Parent factors associated with the acceptability of parent notification
There were no parental factors (race, ethnicity, gender, education level, and personal history of IPV) that were associated with the acceptability of parent notification of ARA disclosure.
Discussion
Most adolescents and parents found parent notification acceptable after disclosure of ARA to the adolescent's health care provider, although acceptability was generally more commonly reported among parents. Consistent with our hypothesis, we found adolescent–parent dyads were more likely to be in agreement that parent notification is acceptable after disclosure of physical ARA when compared with disclosure of cyber or psychological ARA, feeling unsafe in a relationship, or controlling behaviors. We did not find any differences in dyad agreement that parent notification is acceptable after disclosure of sexual ARA compared with other forms of ARA.
Although state law requires mandatory health care provider reporting after patient disclosure of physical or sexual abuse, many forms of ARA fall outside these requirements, although they may still potentially be a source of patient harm. Guidelines for response to nonreportable ARA recommend providers distribute information about online/telephone resources, offer to refer patient to local domestic violence services, help identify a safe adult for additional support, and make a follow-up plan that can include a visit or phone call [
[1]
]. It is important that providers are aware of their individual state guidelines for mandated reporting of physical and sexual abuse and to be cognizant of these guidelines when caring for patients who are legally adults. Our study findings suggest certain adolescents may consider their parent as a safe adult resource after ARA disclosure. However, discussion with the individual adolescent before parent involvement is warranted, given we found significant differences in adolescents' preferences.The proportion of adolescents who found parent notification after ARA disclosure acceptable was decreased among adolescents with previous sexual activity, prior ARA victimization, and adolescents in a dating relationship. Reasons these groups of adolescents found parent notification less acceptable are unknown but could include fear of punishment, shame, and lack of parental support. In addition, fewer nonwhite adolescents found parent notification acceptable after disclosure of some types of ARA. Although these exploratory analyses were conducted with a small sample, our findings suggest that practice around parent notification is nuanced. Clarification around why adolescents may disagree with parent notification after ARA would be helpful in future research. Further assessment of factors influencing acceptability of parent notification after ARA disclosure might identify barriers that can be addressed through additional interventions (e.g., education and resources to the parent that may aid them to serve as a resource). Ultimately, providers must balance potential benefit of parent involvement with potential harm of parent notification while considering an adolescent's preference. Provision of confidential care is associated with increased health care utilization and the number of topics adolescents discuss with providers [
21
, 22
, 23
, 24
, 25
, 26
]. When confidential care is not available, more than one third of adolescents report they would avoid seeking services to prevent disclosure of sensitive information to their parents [[25]
].The importance of parent–adolescent communication even in the context of provision of confidential care [
[22]
] and the role of health care providers to facilitate such conversations, including limitations of confidentiality, is well-recognized [[11]
,[22]
]. Further research should examine how providers can best equip parents to serve as a resource for adolescents experiencing ARA, as notifying the parent about abuse is likely not sufficient to support effective intervention. Parents may benefit from education regarding the types and impact of ARA, adolescent–parent communication, and parenting behaviors that may decrease relationship abuse victimization and perpetration [27
, 28
, 29
]. In addition, providers should be mindful that relationship abuse is often transgenerational, with IPV more common among adults exposed to IPV as children [[30]
]. History of IPV was reported by approximately one in three parent participants in our study, mirroring the national prevalence of IPV [[31]
]. Among these parents with IPV history, 36% of adolescents reported ARA or reproductive coercion, highlighting the need for additional resources or interventions for this vulnerable group.Our findings may have limited generalizability, as all participants were recruited from pediatric EDs in the Midwest and surveys were only conducted in English, although recruitment in both urban and suburban EDs increased the diversity of our sample. Acceptability may vary in the primary care setting where there are established provider–patient relationships. Self-selection may also have introduced sampling bias; we found that those who declined to participate were more likely to be nonwhite. Established relationship and communication patterns between adolescent–parent dyads may have impacted responses; we did not assess these factors. In addition, participants may have been hesitant to disclose prior ARA or IPV because of concerns about confidentiality or social desirability bias. We minimized these concerns by ensuring adolescents and parents could not see each other's response and using a computerized survey to allow participants to directly enter responses. Finally, ARA encompasses a spectrum of behaviors that evolve over time, so future research may need to expand on the categories of ARA studied here.
In conclusion, parent notification after disclosure of various types of ARA is acceptable to the majority of adolescents and parents. However, a decreased proportion of adolescents at higher risk for ARA, including those with previous sexual activity, prior ARA victimization, and those currently in a dating relationship, considered parent notification acceptable. Age may also impact adolescent confidentiality preferences. Although health care providers may encourage parent involvement after ARA disclosure, a one-size-fits-all approach is unlikely to be appropriate. Thoughtful communication with adolescents will be needed to facilitate parent involvement and empower parents to serve as a resource for adolescents experiencing ARA. Further study should examine preferences for parent notification after ARA disclosure among adolescents at increased risk for ARA, including barriers and facilitators of such interventions.
Acknowledgments
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors whose names are listed earlier certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this article.
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Article info
Publication history
Published online: November 09, 2020
Accepted:
September 27,
2020
Received:
March 28,
2020
Footnotes
Conflicts of interest: The authors have no conflicts of interest to disclose.
Identification
Copyright
© 2020 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine.
