The 16-year-old with self-harm and a parent who refuses consent
A 16-year-old girl is brought to the paediatric emergency department after cutting her left forearm. The wounds are superficial and do not need suturing. She is calm, answers questions, and says she cut herself 'to feel something' after a fight with her mother. She denies suicidal intent but says she has thought about 'not being here'. She has missed three months of school and has lost weight. Her mother, who is present, insists that 'it is just attention-seeking' and refuses consent for a psychiatric assessment, saying she will take her home. The girl says she does not want her mother to know what she tells the doctor. The department has a child and adolescent mental health team available by phone but not on site.
1. How do you assess risk and capacity in this 16-year-old, and what does confidentiality mean here?
Read the worked answer
Assess suicide risk directly: ask about plans, methods, access to means, previous attempts, hopelessness, and whether the 'not being here' thoughts include intent or a plan. Superficial wounds do not mean low risk; the school absence, weight loss and withdrawal add concern. Use a structured approach such as a brief risk assessment tool, but the clinical formulation matters more than the score. Capacity in a 16-year-old is assessed developmentally: can she understand, retain, weigh and communicate the decision to be assessed and to go home? Many 16-year-olds can. Confidentiality is not absolute: explain at the outset that most of what she says will remain private, but that if there is a risk to her life or serious harm, information must be shared with those who need to know. Her wish that her mother not know is understandable and should be respected where possible, but her safety overrides it. Explore why she does not want her mother to know - fear of punishment, or of being dismissed - because that shapes how to involve the mother.
2. The mother refuses consent. What are your options, and how do you handle the disagreement?
Read the worked answer
First, distinguish consent for the assessment from consent for treatment. A psychiatric assessment and risk evaluation are part of emergency care and can proceed; refusing consent to assessment does not remove the duty to keep her safe. If the mother takes her home against advice, document the risks discussed and the advice given, and consider whether the child is at risk of significant harm, which triggers a safeguarding referral. If the girl has capacity and wants help, her views carry weight; a 16-year-old can often consent to her own treatment, though this depends on the jurisdiction and on her capacity. Where the mother's refusal is unreasonable and the child's health is at serious risk, escalate: involve the on-call child and adolescent psychiatrist, the safeguarding lead, and if necessary the legal route for treatment without parental consent. Try to engage the mother: acknowledge her view, explain that self-harm is a sign of distress rather than attention-seeking, and offer family work. Do not frame this as a battle; a cooperative parent is the best protective factor. Arrange a follow-up appointment before she leaves, and give a crisis number.