A 15-year-old who asks you not to tell her parents
Amelia, 15, books a same-day appointment and comes alone after school. She is in Year 10, has been cutting her thighs for eight months, and three days ago took eight of her mother's 500 mg paracetamol tablets after an argument with her boyfriend. She told no one and has had no symptoms since. She asks you for 'something to help me sleep' and says: 'You can't tell my parents. My dad would go berserk - he'd kick me out. The school counsellor knows a bit but she's useless.' She is otherwise well, on no medication, and denies alcohol or other drugs. On direct questioning she says she sometimes thinks everyone would be better off without her, but denies current plan or intent and says she would not act on it. She is willing to see a psychologist 'if my parents don't find out'. The practice is open until 8 pm; a youth mental health walk-in service 20 minutes away is open until 7 pm.
1. How do you handle confidentiality - what can you keep, what must you share, and how do you explain this to her?
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Be honest from the start, before asking any questions. It is unfair and clinically counterproductive to promise secrecy and then break it. Say something like: 'What you tell me is private, and I will not tell your parents about most of it. The exception is if I think you are in danger, or someone else is. If that happens, I will tell you first who I need to speak to and why, and we will work out how.' That gives her some control and preserves the therapeutic alliance.
Specifically, the self-harm and suicidal thoughts are not things you can hold alone, and neither is a 15-year-old who has taken an overdose. Explain that her safety comes before her privacy, and that her father's reaction is itself something you can help manage.
Ask what she thinks would happen if her parents knew, and whether there is an adult she trusts - an aunt, a grandmother, a teacher, the school counsellor. Offer to make the disclosure with her, in a planned way, in your room, rather than by a phone call from you afterwards. If she refuses and you judge the risk to be high, you must still act, but tell her what you are doing and why.
Document the explanation you gave and her response.
2. How do you assess and manage the paracetamol ingestion three days later?
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Eight 500 mg tablets is 4 g. In a 50-55 kg adolescent that is roughly 70-80 mg/kg - below the 150 mg/kg treatment threshold, and a single early-presentation ingestion at that dose would usually not require acetylcysteine. But the presentation is three days late, so the nomogram cannot be applied; you must assess for hepatic injury instead.
Examine for right upper quadrant tenderness, jaundice and encephalopathy. Arrange today: liver function tests, INR, urea, creatinine and electrolytes, and a pregnancy test. If ALT and INR are normal at 72 hours or more after a single acute overdose, clinically significant hepatotoxicity is effectively excluded, no antidote is needed, and she can be reassured - the results also explain why you are not giving a treatment she may have read about.
If ALT is raised or the INR is prolonged, discuss with the poisons information service or hepatology the same day and arrange admission; acetylcysteine may still be considered outside the traditional 8-10 hour window, and that decision should be specialist-led.
Ask about other ingestions - alcohol, paracetamol-containing cold remedies - and about vomiting. Reassure her that her three days of silence has not necessarily harmed her; shame is a strong driver of further concealment.
3. How do you assess risk and construct a safe management plan for today?
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Assess risk properly rather than accepting 'I wouldn't act on it'. Ask directly about plans, means, previous attempts and rehearsal; ask about the cuts - function, depth, infection, whether she has ever needed stitches; screen for depression, bullying, abuse at home and substance use. Use a structured approach such as HEADSSS to cover home, education, activities, drugs, sexuality and mood.
Weigh the protective factors: she came to you, she is willing to see a psychologist, she has some insight, and she denies current intent. Against that: self-harm over eight months, an overdose, a passing suicidal statement, a frightening home environment, and an unreliable school counsellor.
Disposition: she needs a same-day mental health assessment, not a two-week referral. The youth walk-in service closes at 7 pm - arrange for her to be seen there today, with a written summary and a phone call ahead. If she will not go, or the risk is judged high, emergency department assessment is the alternative.
Safety plan: who she can call at night, means restriction (her mother's paracetamol must be moved or locked away), and a follow-up appointment within 48 hours regardless. Involving her parents is necessary for safety, but plan it with her; if her father is the greater risk, involve the safer parent first or use a trusted adult. Document the risk assessment, the reasoning, and the plan.