A 16-year-old's request for confidentiality after disclosing abuse
A 16-year-old girl presents alone to your urban family practice requesting help with low mood. She reports 3 months of sadness, sleep disturbance, poor appetite and falling grades. She has cut her forearms several times in the past month, most recently 4 days ago, using a blade; the cuts are superficial and healing. She denies suicidal thoughts, plans or intent, has no access to firearms at home, and says her parents 'would not understand' and must not be told. On further questioning she describes her father as physically abusive when drunk and says she is afraid to go home. She is tearful but calm, with intact judgment. PHQ-A score 18. Physical examination is unremarkable apart from healing linear scars. She asks you to promise not to tell anyone.
1. How do you respond to her request for confidentiality? What are the limits?
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I would not promise absolute confidentiality. I would explain, in a way she can understand, that what she tells me is usually private, but that I must share information if she is at risk of serious harm, if someone is hurting her, or if a court orders it. I would say that I want to work with her on how and when to involve her parents rather than going behind her back.
She is 16 and has disclosed physical abuse by her father. That triggers a child-protection duty in most jurisdictions, regardless of her wishes. I would tell her clearly what I must report and why, and involve her in the process as far as is safe. I would also assess whether she is at immediate risk if she goes home tonight. Her request for secrecy is understandable, but it cannot override the duty to protect her.
2. What is your risk assessment and immediate safety plan?
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Assess suicide risk directly: thoughts, intent, plan, access to means, previous attempts and protective factors. She denies suicidal ideation and has no firearm access, but self-harm is a strong risk marker, especially with a PHQ-A of 18. Ask about the function of the cutting, precipitating triggers, and whether cuts have needed medical attention. Assess the abuse: who, when, how often, whether she has injuries, whether siblings are at risk, and whether she feels able to go home.
If there is immediate danger, arrange emergency police or child-protection involvement and do not send her home alone. Otherwise, make a same-day child-protection report, identify a trusted adult she can stay with, give crisis numbers, and arrange review within 24–72 hours. Discuss means restriction - removing blades and locking away medicines. Document the risk assessment and safety plan in detail.
3. How would you discuss this with her and her family, and what would you document?
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I would tell her what I am required to share, with whom, and what will happen next, and offer to be with her when her parents are told if that is safe. If the father is the alleged abuser, I would not inform him directly without child-protection advice, because that could increase her danger. I would explore whether her mother or another relative can be a protective adult.
Treatment should not be delayed: talking therapy is first-line for moderate depression, and if an SSRI is started, fluoxetine is the best-studied option in adolescents. Explain the small increase in suicidal thinking early in treatment and arrange close follow-up. Document her words, the risk assessment, the report time, the agency and person contacted, and the safety plan. Record that she assented to the parts of the plan she could, and that her confidentiality was explained at the outset.