“Wouldn’t you want to know what medications your child is on?” a mother implored. It was my first week working in an addiction medicine clinic for justice-involved youth and I had recently started a young person on an antidepressant. The young person, over the age of 14, could consent confidentially for mental health services, and I was not permitted to discuss his mental health diagnosis or medications with his mother. Unbeknownst to the mother, though, it was my second week back from maternity leave, and her question gave me some pause.
Parental choice has quickly become politicized by a kind of demagoguery across domains. In education, it has been the justification for parents to protest books in libraries; in health care, it has been used to restrict access to abortion for minors. In fact, the requirement of judicial bypass in many states where a minor must stand before a set of justices to advocate for their right to obtain an abortion is predicated on the notion that the court serves as a parental figure for a minor wishing to obtain an abortion. Simultaneously, parental choice is seemingly sparse in discussions around care for gender non-conforming youth, where individual states have recently attempted to leverage authority over the wishes of parents regarding health care decisions for their children.
In my pediatric residency, most of my patients were well under the legal age of consent and my medical care was directed through the intermediary of parental advocacy. The history, physical, assessment, and plan were all guided by parents for my youngest patients. And I was grateful — parents who spent nearly every day in close proximity to their children were quick to detect when something was “off”: an underlying sepsis, excessive sleepiness from the buildup of a metabolic product, or something else. They vocalized what their young children could not. But that started to change when I became a fellow in adolescent medicine. The provisions of care I was delivering — reproductive care, mental health services — were protected by law for those over the age of 14. And I quickly became privy to histories that my patients would never share with their parents.
Adolescent medicine, which has only been recognized as a formal academic subspecialty since the end of the 1960s, has had its own evolution negotiating the influence of parents. In its earliest iterations, the field could resemble a “parent-ectomy” where “high risk” behavior was best managed by clinicians who were trusted confidants. This mentality, similar to changes in educational paradigms that governed paternalistic approaches to removing young people from their environment, has since evolved to see parents as an integral part of a young person’s health care. In fact, data delineates that the involvement of parents in a young person’s life reduces more risky health behaviors including reduced risk of cigarette smoking, alcohol use, and becoming sexually active.
But where does that leave physicians who are navigating the delicate territory between confidentiality and not cutting parents out of the picture?
One of the more demoralizing aspects of political partisanship has been the equally binary notion of choice as something that is either belonging to the adolescent or the parent, and leaves little room for those choices being harmonious. What we have the opportunity to do is to change that narrative as shared decision-making. American culture prides itself on choice as power, which may mean that shifting the narrative away from the language of choice. Reconceptualizing a framework as shared decision-making means that parents may instead consult with their young person regarding the ability to seek confidential care. A young person and a parent may have a discussion about the young person learning to navigate the health care system at an adolescent medicine clinic, for example, which would allow the actual substance of their conversations with clinicians to remain more confidential without coming as a surprise to parents. Furthermore, teens often want parents to be part of conversations that are thought to be sensitive — such as reproductive health — and also want them to be a source of information. Asking a young person at a visit when they are alone whether they want a parent to be part of a conversation about a new medication for mental health, long-acting reproductive contraception placement, or whether they feel comfortable discussing their sexuality with a parent can produce surprising answers about the desire for parental involvement. And if biological parents/guardians are not trusted by the young person, they can often name a trusted adult, known to have protective impacts.
Our role as clinicians is to help navigate the stigma and opposition that has characterized open communication between parents and their adolescent children. Health care ought to be a site onto which we can grow parental-child communication — one of the few sacred spaces we have left. My daughter, now just two, seems far from her adolescent years. But at a recent dinner with my husband’s 16-year-old cousin, I asked a dangerous question: “What percentage would you give to how much you tell your mother?” “Forty percent,” he said without hesitating. And at that moment I realized I only had a decade to help her foster a network of teachers, clinicians, peers, coaches, and community to catch the other 60%.
How do you approach conversations with parents with respect while maintaining trust with adolescents?
Megana Dwarakanath is a third year adolescent medicine fellow in Pittsburgh where she lives with her husband, Rahul, their young daughter, Meera, and their dog, Milo. When she is not spending time with friends and family, she likes to run, swim, and bike as well as read for as long as she can in one go. Dr. Dwarakanath is a 2022–2023 Doximity Op-Med Fellow.
Collage by Jennifer Bogartz / Shutterstock