Children Are Different: Liability Issues in Working With Suicidal and Dangerous Youths

Even in jurisdictions where a minor patient can consent for his or her treatment, it is quite unusual for parents not to know about the treatment, even if that knowledge comes only when the bill arrives. When a parent consents for a child, the parent can generally consent to release of records or other information about treatment until the child reaches the age of majority (typically age 18). In most jurisdictions, when treating a child, the therapist can discuss the child’s treatment with the parent at the therapist’s discretion. Therefore, the usual discussion about confidentiality one has with adult patients needs to be modified: Many therapists who treat adolescents tell their patients that they will endeavor to keep their communications confidential unless there is an urgent need to disclose information, such as to protect the patient or someone else, to hospitalize the patient, or to discuss issues that are relevant to obtaining consent for medication. Some clinicians make more limited claims—that they will try to protect the confidentiality of the treatment but will reveal information to the parent(s) if they think it necessary. With younger children, where parent guidance may be a larger part of the treatment, less confidentiality may be promised. In family treatment, where the youth is also seen individually, other guidelines might be justified. Since a treating clinician can discuss treatment issues with a parent, a failure to inform the parent about risks to the youth can be a source of liability. Particularly after an adverse event, parents who were not informed of relevant information are likely to feel angry at the clinician for being left out of the loop and argue that, had they known, they would have acted to prevent the bad outcome.

Regardless of what degree of confidentiality is promised, parents can generally release the child’s records to themselves until the child turns 18. At 18, the authority to release records shifts to the now-adult child. As the administrative head of two child psychiatry training clinics, I have reviewed patient record requests in cases where the trainee therapist and supervisor had left the clinic. Although quantifiable data on the subject are lacking, it was surprising how many young adults wanted to see records of their childhood treatment, often because they had limited memory of the treatment and wanted insights into their past. It is, generally, a good idea to write chart notes with the assumption that the patient may someday read them; however, many clinicians, not unsurprisingly, focus their notes on psychopathology. For a person reading about treatment that took place many years ago and who has little memory of the emotional bond to the therapist, it is helpful if the chart discussions of psychopathology are leavened by some comments that show that the clinician appreciated the strengths and humanity of the patient, perhaps also including statements that even the psychopathology had some positive underlying motivation (“Johnny suffers from low self-esteem and is trying to show others he’s not always weak. Unfortunately, he does this by bullying and beating up others”).