David Baxter PhD
Late Founder
18 and Under: What to Do When the Patient Says, ?Please Don?t Tell Mom?
By PERRI KLASS, M.D., New York Times
December 9, 2008
Some years ago, in the candor of the exam room, a seventh-grade boy told me that he didn?t really have friends at school, and that he sometimes found himself being picked on. I gave him the pediatric line on bullying: it shouldn?t be tolerated, and there are things schools can do about it. Let?s talk to your parents, let?s have your parents talk to the school; adult interventions can change the equation.
And he was horrified. He shook his head vehemently and asked me please not to interfere, and above all not to say a word to his mother, who was out in the waiting room because I had asked her to give us some privacy.
He wouldn?t have told me this at all, he said, except he thought our conversation was private. The situation at school wasn?t all that bad; he could handle it. He wasn?t in any danger, wasn?t getting hurt, he was just a little lonely. His parents, he said, thought that he was fine, that he had lots of friends, and he wanted to keep it that way.
When treating older adolescents, pediatricians routinely offer confidentiality on many issues, starting with sex and substances. But middle-schoolers are on the border ? old enough to be asked some of the same questions, but young enough that it can be less clear what should stay confidential.
At my own eighth-grade son?s pediatric checkup last year, I of course left the room, because I didn?t want to embarrass him or inhibit him, and because I wanted his pediatrician to have the opportunity to hear anything he wanted to say. (I am reporting this with my son?s explicit permission.) But as I waited, I thought of that seventh grader, and of the other middle-schoolers who have told me things that left me agonizing about the ethics and the wisdom of confidentiality in this age group.
I?m not talking about the child who tells you something that makes it clear he?s in danger. Those are the ?easy? ones (though in another sense they can be tremendously difficult), and I?ve had my share: The 13-year-old girl who is frightened of a much older guy who sometimes seems to follow her home. The 14-year-old boy who has been thinking about dying a lot ever since his grandmother died. The seventh grader who is being beaten up on the playground. No matter the age, when I feel the child is actually in danger, I explain that I have to let the parents know.
But as I talked to my colleagues ? including my son?s pediatrician, Dr. Herbert Lazarus ? we all kept coming up with ambiguous cases. Because you do value the child?s trust, and you don?t want to lose it.
I?m not talking about the child who tells you he shared a beer with his friends one day after school. Most sensible parents, I think, know that once they?re out of the exam room we?re going to review sex, drugs and rock ?n? roll with their children, and most sensible parents, I think, are grateful. And many middle-school children seem grateful for the opportunity to mention that yes, they have been in situations where people are drinking.
?They?ll preface it with ?My mom?s not going to know about this, right?? ? said Dr. Lazarus, who is also a clinical associate professor of pediatrics at New York University. ?I?m going to talk as much as I can about why this is not good, and all we know about alcohol and marijuana. There are enough studies out there that show how bad this is for brain development.?
But what about if it?s more than a beer? One of my colleagues had a story: a 13-year-old girl who was drinking and stealing from her parents? liquor cabinet. ?She did admit that to me,? the pediatrician said. ?She was doing it by herself, not a good sign, not social drinking.?
The child did not want her mother to know, and the pediatrician, who had known her since infancy, negotiated a compromise: the doctor would advise the mother that the girl needed counseling, and as long as she went to counseling, and discussed the drinking and her underlying issues with the counselor, the pediatrician would not tell her mother about the liquor.
But even though it worked out, even though she continued seeing the patient regularly, the pediatrician still felt less than completely comfortable. ?I did personally feel bad,? she said, ?because if I were the mother, I would want to know, and I actually did tell the mother just to keep a closer eye on her without going into the details.? So what about the child who trusts you with the information that he?s being picked on, or that all is not well at home? You want to keep that child?s trust ? all the more so if the child isn?t talking to the parents, because you want to be available for more confidences if things grow worse.
?The balance changes in part based on what the level of the health risks are, how mature that young person is, how much parental oversight they?re receiving,? said Dr. S. Jean Emans, chief of adolescent medicine at Children?s Hospital Boston.
Experts say the middle-school years are particularly challenging. ?It?s a fine balance because it?s developmentally appropriate for kids to want to develop some autonomy and it?s the time when they should be developing at least in part a private and confidential relationship with a physician,? said Dr. Carol A. Ford, director of the adolescent medicine program at the University of North Carolina, Chapel Hill.
?Middle school is really when you see a lot of variation in pubertal development and cognitive development and social development,? Dr. Ford went on. ?A 12-year-old who looks like an 18-year-old ? you can?t assume they think like an 18-year-old. You can?t assume their skills of negotiating the world are related to their physical maturity.?
Or as Dr. Emans put it: ?You do have to make tough choices. There isn?t a little book where you look up, ?O.K., this can stay confidential and this can?t.? ?
So what did I do with the seventh grader who had told me he didn?t have friends at school? Well, I asked him a bunch of questions, and I decided that he wasn?t feeling suicidal (or homicidal) and that the situation in his school didn?t threaten his physical safety. I urged him to talk to his parents, especially if things grew worse ? and I scheduled an appointment for him to come back and check in with me.
But with his mother, I limited myself to one of those ?generic? comments: this is an age when he really needs you to be involved in his life, to talk about how things are going at school.
?Your role as a physician is different than your role as a mother,? Dr. Ford said. ?If you lose the trust of the kid, you?ve lost a lot; they won?t tell you what?s going on in the future, and that?s not in the best interests of the kid or the parent.?
If I had been his mother, I would have wanted to know. But I was his doctor, and he wanted it kept confidential.
Perri Klass is a professor of journalism and pediatrics at New York University. Her most recent book is the novel The Mercy Rule.
By PERRI KLASS, M.D., New York Times
December 9, 2008
Some years ago, in the candor of the exam room, a seventh-grade boy told me that he didn?t really have friends at school, and that he sometimes found himself being picked on. I gave him the pediatric line on bullying: it shouldn?t be tolerated, and there are things schools can do about it. Let?s talk to your parents, let?s have your parents talk to the school; adult interventions can change the equation.
And he was horrified. He shook his head vehemently and asked me please not to interfere, and above all not to say a word to his mother, who was out in the waiting room because I had asked her to give us some privacy.
He wouldn?t have told me this at all, he said, except he thought our conversation was private. The situation at school wasn?t all that bad; he could handle it. He wasn?t in any danger, wasn?t getting hurt, he was just a little lonely. His parents, he said, thought that he was fine, that he had lots of friends, and he wanted to keep it that way.
When treating older adolescents, pediatricians routinely offer confidentiality on many issues, starting with sex and substances. But middle-schoolers are on the border ? old enough to be asked some of the same questions, but young enough that it can be less clear what should stay confidential.
At my own eighth-grade son?s pediatric checkup last year, I of course left the room, because I didn?t want to embarrass him or inhibit him, and because I wanted his pediatrician to have the opportunity to hear anything he wanted to say. (I am reporting this with my son?s explicit permission.) But as I waited, I thought of that seventh grader, and of the other middle-schoolers who have told me things that left me agonizing about the ethics and the wisdom of confidentiality in this age group.
I?m not talking about the child who tells you something that makes it clear he?s in danger. Those are the ?easy? ones (though in another sense they can be tremendously difficult), and I?ve had my share: The 13-year-old girl who is frightened of a much older guy who sometimes seems to follow her home. The 14-year-old boy who has been thinking about dying a lot ever since his grandmother died. The seventh grader who is being beaten up on the playground. No matter the age, when I feel the child is actually in danger, I explain that I have to let the parents know.
But as I talked to my colleagues ? including my son?s pediatrician, Dr. Herbert Lazarus ? we all kept coming up with ambiguous cases. Because you do value the child?s trust, and you don?t want to lose it.
I?m not talking about the child who tells you he shared a beer with his friends one day after school. Most sensible parents, I think, know that once they?re out of the exam room we?re going to review sex, drugs and rock ?n? roll with their children, and most sensible parents, I think, are grateful. And many middle-school children seem grateful for the opportunity to mention that yes, they have been in situations where people are drinking.
?They?ll preface it with ?My mom?s not going to know about this, right?? ? said Dr. Lazarus, who is also a clinical associate professor of pediatrics at New York University. ?I?m going to talk as much as I can about why this is not good, and all we know about alcohol and marijuana. There are enough studies out there that show how bad this is for brain development.?
But what about if it?s more than a beer? One of my colleagues had a story: a 13-year-old girl who was drinking and stealing from her parents? liquor cabinet. ?She did admit that to me,? the pediatrician said. ?She was doing it by herself, not a good sign, not social drinking.?
The child did not want her mother to know, and the pediatrician, who had known her since infancy, negotiated a compromise: the doctor would advise the mother that the girl needed counseling, and as long as she went to counseling, and discussed the drinking and her underlying issues with the counselor, the pediatrician would not tell her mother about the liquor.
But even though it worked out, even though she continued seeing the patient regularly, the pediatrician still felt less than completely comfortable. ?I did personally feel bad,? she said, ?because if I were the mother, I would want to know, and I actually did tell the mother just to keep a closer eye on her without going into the details.? So what about the child who trusts you with the information that he?s being picked on, or that all is not well at home? You want to keep that child?s trust ? all the more so if the child isn?t talking to the parents, because you want to be available for more confidences if things grow worse.
?The balance changes in part based on what the level of the health risks are, how mature that young person is, how much parental oversight they?re receiving,? said Dr. S. Jean Emans, chief of adolescent medicine at Children?s Hospital Boston.
Experts say the middle-school years are particularly challenging. ?It?s a fine balance because it?s developmentally appropriate for kids to want to develop some autonomy and it?s the time when they should be developing at least in part a private and confidential relationship with a physician,? said Dr. Carol A. Ford, director of the adolescent medicine program at the University of North Carolina, Chapel Hill.
?Middle school is really when you see a lot of variation in pubertal development and cognitive development and social development,? Dr. Ford went on. ?A 12-year-old who looks like an 18-year-old ? you can?t assume they think like an 18-year-old. You can?t assume their skills of negotiating the world are related to their physical maturity.?
Or as Dr. Emans put it: ?You do have to make tough choices. There isn?t a little book where you look up, ?O.K., this can stay confidential and this can?t.? ?
So what did I do with the seventh grader who had told me he didn?t have friends at school? Well, I asked him a bunch of questions, and I decided that he wasn?t feeling suicidal (or homicidal) and that the situation in his school didn?t threaten his physical safety. I urged him to talk to his parents, especially if things grew worse ? and I scheduled an appointment for him to come back and check in with me.
But with his mother, I limited myself to one of those ?generic? comments: this is an age when he really needs you to be involved in his life, to talk about how things are going at school.
?Your role as a physician is different than your role as a mother,? Dr. Ford said. ?If you lose the trust of the kid, you?ve lost a lot; they won?t tell you what?s going on in the future, and that?s not in the best interests of the kid or the parent.?
If I had been his mother, I would have wanted to know. But I was his doctor, and he wanted it kept confidential.
Perri Klass is a professor of journalism and pediatrics at New York University. Her most recent book is the novel The Mercy Rule.
