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Adolescent Relationship Abuse: Challenges in Confidentiality, Disclosure, and Protection

      See Related Article on p.242
      Adolescent relationship abuse (ARA) occurs in a wide range of interactions among adolescents. Most young people victimized by ARA would benefit from the support of a trusted adult. The disclosure of ARA victimization presents important clinical and legal questions as well as ethical dilemmas. Healthcare providers caring for adolescents are increasingly likely to confront these questions as awareness of ARA increases and in light of the widespread prevalence of ARA [
      • Wolitzky-Taylor K.B.
      • Ruggiero K.J.
      • Danielson C.K.
      • et al.
      Prevalence and correlates of dating violence in a national sample of adolescents.
      ].
      A recent study by Jennifer Wiebelhaus et al. [
      • Wiebelhaus J.N.
      • Miller M.K.
      • Sherman A.K.
      • et al.
      Adolescent and parent perspectives on confidentiality after adolescent relationship abuse disclosure.
      ] explored the perspectives of adolescents and parents about parental notification after an adolescent discloses ARA to a healthcare provider. The types of abuse in their study were physical, cyber, psychological, and sexual ARA; reproductive coercion; controlling behavior; and feeling unsafe. As Wiebelhaus et al. [
      • Wiebelhaus J.N.
      • Miller M.K.
      • Sherman A.K.
      • et al.
      Adolescent and parent perspectives on confidentiality after adolescent relationship abuse disclosure.
      ] explain, ARA is multifaceted and complex. It includes some behaviors that are criminal, others that are legally considered child abuse, and many that are associated with serious short- and long-term adverse physical and psychological outcomes [
      • Exner-Cortens D.
      • Eckenrode J.
      • Rothman E.
      Longitudinal associations between teen dating violence victimization and adverse health outcomes.
      ]. For this reason, along with appropriate health care, adult support may be needed by a young person experiencing ARA.
      A healthcare provider treating an adolescent who discloses ARA must address not only the immediate concern of what health care is needed but also a range of legal and ethical questions: Is the adolescent willing to disclose the ARA to a parent or other trusted adult? Does the adolescent insist that confidentiality protection is essential? Is the adolescent in continuing danger? Is the ARA experienced by the adolescent reportable as child abuse? Do legal requirements and ethical principles require, permit, or preclude disclosure? Are there ways that the ARA may be inadvertently disclosed? These questions require understanding the importance of confidentiality in adolescent health care, the significance of child abuse reporting and other disclosure mechanisms, the role of parents and other trusted adults, and evolving confidentiality challenges.

      The Role of Confidentiality

      Long-standing legal protections and ethical principles have provided some assurance to adolescents that when they disclose sensitive information to their healthcare provider, that information will not be disclosed without their agreement. These protections increase the likelihood that young people will receive needed care because privacy concerns influence whether, where, and when adolescents seek care and what they disclose when they do so [
      • Ford C.
      • English A.
      • Sigman G.
      Confidential health care for adolescents: Position paper of the Society for adolescent medicine.
      ]. Past research on the role of confidentiality in adolescent care often has focused on sexual health–related services [
      • Reddy D.M.
      • Fleming R.
      • Swain C.
      Effect of mandatory parental notification on adolescent girls' use of sexual health care services.
      ,
      • Jones R.K.
      • Purcell A.
      • Singh S.
      • Finer L.B.
      Adolescents' reports of parental knowledge of adolescents' use of sexual health services and their reactions to mandated parental notification for prescription contraception.
      ]. Clearly, some adolescents will be discouraged from seeking care, will delay doing so, or will withhold important information if their privacy will be compromised [
      • Ford C.A.
      • Bearman P.S.
      • Moody J.
      Foregone health care among adolescents.
      ,
      • Ford C.A.
      • Millstein S.G.
      • Halpern-Felsher B.L.
      • Irwin C.E.
      Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care: A randomized controlled trial.
      ]. Nevertheless, limits to confidentiality exist when the adolescent is at risk for hurting themself or others or when disclosure is required by law [
      • Ford C.
      • English A.
      • Sigman G.
      Confidential health care for adolescents: Position paper of the Society for adolescent medicine.
      ]. The primary principles underlying these exceptions are protection of health and safety.

      Disclosure Requirements

      Confidentiality protection is essential but not absolute. Overriding it may be necessary to comply with legal requirements or in situations where the health or safety of an adolescent patient is at stake. At the same time, breaching confidentiality may not be permissible unless there is a law that requires or allows disclosure. Such laws include child abuse reporting laws as well as provisions in some states' minor consent and federal or state medical privacy laws.
      Every state has a child abuse reporting law and most healthcare professionals are mandated reporters who are required to disclose to child protective services or law enforcement otherwise confidential information. [
      Child Welfare Information Gateway
      State Statutes Search.
      ,
      Reproductive Health National Training Center
      Mandatory child abuse reporting state Summaries.
      ] Child abuse requirements generally apply to minors younger than the age of 18 years, although the age for reporting specific forms of abuse varies among states. [
      Child Welfare Information Gateway
      State Statutes Search.
      ,
      Reproductive Health National Training Center
      Mandatory child abuse reporting state Summaries.
      ] The scope of child abuse reporting laws is specific and often does not include many forms of ARA [
      Child Welfare Information Gateway
      State Statutes Search.
      ,
      Reproductive Health National Training Center
      Mandatory child abuse reporting state Summaries.
      ]. Similarly, some state minor consent laws require or permit disclosure of confidential information about care, while others disallow it without the permission of the minor [
      • English A.
      • Bass L.
      • Boyle A.
      • Eshragh F.
      State minor consent laws: A summary.
      ]. Under the state law, when a minor is allowed to consent to their own care based on their status or the services they are seeking, the confidentiality of information about that care often is protected. Special considerations are needed when an adolescent is cognitively impaired and not able to provide consent for their own care. Even so, if the health of the minor is threatened, some of these laws either require the healthcare provider to disclose the information to a parent or grant the provider discretion to do so [
      • English A.
      • Bass L.
      • Boyle A.
      • Eshragh F.
      State minor consent laws: A summary.
      ].

      Beyond Mandatory Reporting and Disclosure

      In the context of ARA, many areas of uncertainty exist owing to the scope of child abuse reporting mandates and the patchwork nature of confidentiality protections in state minor consent and federal and state medical privacy laws [
      Child Welfare Information Gateway
      State Statutes Search.
      ,
      Reproductive Health National Training Center
      Mandatory child abuse reporting state Summaries.
      ,
      • English A.
      • Bass L.
      • Boyle A.
      • Eshragh F.
      State minor consent laws: A summary.
      ,
      • English A.
      • Ford C.
      The HIPAA Privacy Rule and adolescents: Legal questions and clinical challenges.
      ]. Although expanding the scope of child abuse reporting laws to include more forms of ARA is an option, it is far from ideal: child protective services are already overwhelmed and challenged in dealing with abuse of both younger children and adolescents. Moreover, child abuse reporting mandates create ethical dilemmas by requiring healthcare providers to breach confidentiality. To ensure that adolescents victimized by ARA receive the support they need, one strategy for addressing this uncertainty may be to focus greater attention—beyond child abuse reporting or parental notification—on helping the young person voluntarily involve other trusted adults. Focusing on voluntary engagement with trusted adults could enhance protective options for adolescents and minimize ethical dilemmas for healthcare providers.
      While some adolescents require confidentiality protection to seek care, others voluntarily share information with their parents, do not object to disclosure, or disclose with the help of their healthcare provider [
      • Jones R.K.
      • Purcell A.
      • Singh S.
      • Finer L.B.
      Adolescents' reports of parental knowledge of adolescents' use of sexual health services and their reactions to mandated parental notification for prescription contraception.
      ,
      • Song X.
      • Klein J.D.
      • Yan H.
      • et al.
      Parent and adolescent attitudes towards preventive care and confidentiality.
      ]. The support of a parent or another trusted adult is especially important when an adolescent is experiencing harmful interactions such as ARA. Noteworthy in the study by Weibelhaus et al. is that even though a majority of both adolescents and parents did find parental notification acceptable, adolescents who were most at risk were the least likely to find it acceptable: adolescents with prior sexual activity or prior ARA victimization or those in current dating relationships [
      • Wiebelhaus J.N.
      • Miller M.K.
      • Sherman A.K.
      • et al.
      Adolescent and parent perspectives on confidentiality after adolescent relationship abuse disclosure.
      ]. Unfortunately, although most adolescents have supportive parents, not all do and, among the parents reported in the study by Wiebelhaus et al., 35% of the participating parents had themselves experienced intimate partner violence, which might complicate their capacity to support a victimized adolescent child [
      • Wiebelhaus J.N.
      • Miller M.K.
      • Sherman A.K.
      • et al.
      Adolescent and parent perspectives on confidentiality after adolescent relationship abuse disclosure.
      ]. Consideration of alternatives to parental notification may be necessary to ensure that adolescents experiencing ARA victimization have the support they need to navigate a difficult situation with potentially long-term adverse effects on their health and well-being.

      Evolving Confidentiality Challenges

      Any strategy to improve support for adolescents experiencing ARA must consider evolving confidentiality challenges. The question of confidentiality protection in adolescent health care is not a binary one: will the information be protected or disclosed? Rather, it involves the interaction of an increasingly complex web of health information technology systems, digital health apps, electronic health information, and legal requirements. Each of these has its own implications for the confidentiality of adolescents' health information [
      AAP Committee on Adolescence
      Policy statement for health information technology to ensure adolescent privacy.
      ,
      • Anoshiravani A.
      • Gaskin G.L.
      • Groshek M.R.
      • et al.
      Special requirements for electronic medical records in adolescent medicine.
      ,
      • Gray S.H.
      • Paskernak R.H.
      • Hawkins K.
      • et al.
      Recommendations for electronic health record use for delivery of adolescent health care: Position paper of the Society for Adolescent Health and Medicine.
      ]. A salient example is the recent regulation issued by the Office of National Coordinator for Health Information Technology to implement the 21st Century Cures Act (ONC Rule) [
      21st Century Cures Act: Interoperability, information Blocking, and the ONC health IT Certification Program, 85 fed. Reg. 25642, May 1, 2020.
      ,
      Office of National Coordinator for Health Information Technology
      ONC Cures Act final Rule.
      ]. The ONC Rule will have a major impact on adolescent confidentiality by requiring that clinical notes be shared with patients and sometimes with their parents directly or as proxies, usually via Web portals, which could inadvertently result in disclosure of ARA and other sensitive information [
      • Carlson J.
      • Goldstein R.
      • Hoover K.
      • Tyson N.
      NASPAG/SAHM statement: The 21st Century Cures Act and adolescent confidentiality.
      ,
      • Pageler N.M.
      • Webber E.C.
      • Lund D.P.
      Implications of the 21st Century Cures Act in Pediatrics.
      ]. Against this broad backdrop, the preferences and behaviors of adolescents with respect to privacy protection and disclosure of their confidential information are evolving as well. Wiebelhaus et al. have presented important findings about the current perspectives of adolescents and parents regarding a particularly troubling dimension of adolescent relationships—the myriad forms of abuse that all too often characterize their interactions.

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