A 15-year-old girl comes to the office for a routine examination. Over the past few months, her parents have been in a high-conflict divorce proceeding during which she has been living with her paternal aunt. The patient was diagnosed with type 1 diabetes mellitus at age 12 and prescribed insulin therapy. She also has attention-deficit hyperactivity disorder for which she takes methylphenidate. The patient is currently a sophomore in high school and has won awards in competitive gymnastics and dance. Her BMI is 16.5 kg/m²; her weight is 9.1 kg (20 lb) less than at her last visit 6 months ago. She initially says that she has no concerns but then begins to cry, saying, "I am under so much stress. I have to look perfect to fit in with the other dancers and I can't talk to my parents about it at all. They don't even know I exist." The patient discloses that she has been avoiding insulin to lose weight and frequently doubles the dose of the methylphenidate to decrease her appetite. She has no symptoms of depression, suicidal ideation, or homicidal ideation. She says, "I promise I will stop misusing my medication. You can talk to my aunt; she is much more understanding. Just don't tell my parents. They will freak out and it will just make my life worse than it already is." Which of the following is the most appropriate course of action?

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Explanation: Confidential medical care is critical for enhancing a patient's willingness to both provide an honest history and seek future health care. Most states have laws that enable physicians to care for adolescents without parental consent. These laws protecting confidentiality are typically limited to the diagnosis and management of pregnancy, contraception, sexually transmitted diseases, substance use, and mental health issues. However, adolescents should be informed that confidentiality is conditional on their individual safety and the safety of others. Disclosure to parents or appropriate authorities takes precedence over confidentiality in situations involving self-injurious behavior, homicidal ideation, abuse, and neglect. This patient is in acute danger as the misuse of insulin and methylphenidate places her at high risk for diabetic ketoacidosis and methylphenidate toxicity. In such cases, the patient should be informed that parental notification is mandatory to recruit help in addressing endangering behaviors. Ideally, the patient should participate in the decision regarding the manner in which the information is disclosed. (Choice A) This patient is a danger to herself; in this case, confidentiality should not be maintained. (Choice B) Although the patient's aunt might be able to help monitor and support the patient, she is not the child's guardian and cannot make medical decisions for her. Due to the acute safety concerns, her parents must be contacted. (Choice C) Parental consent is required to prescribe psychotropic medications; however, the reason for contacting the parents now is due to safety concerns. Once safety is established and the misuse of the patient's current medications is addressed, the need for further treatment, both psychotherapeutic and/or pharmacological, can be assessed. (Choice E) Confidentiality regarding adolescent mental health issues should be maintained provided there are no concerns regarding self-harm or harm to others. In this case, the reason to notify the parents is the patient's risk for self-harm, not that she has a mental health issue. Educational objective: In most states, confidentiality is upheld for adolescents seeking care related to pregnancy, contraception, sexually transmitted disease, substance abuse, and mental health issues. However, physicians must break confidentiality and alert parents when the adolescent is at risk for self-harm. References: Improving communication with adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/22611123) Confidentiality, consent, and caring for the adolescent patient. (http://www.ncbi.nlm.nih.gov/pubmed/19474734)

A 15-Year-Old Girl Comes to the Office for a Routine