Reply from Kelly Thompson
NUR 630 Discussion Module Two
One common dilemma faced by psychiatric nurse practitioners is determining who the
“client” is. Given that children are typically brought for treatment by their parents,
describe how the psychiatric nurse practitioner would respond to a child who discloses they
are indulging in illicit behavior and asks you not to tell his or her parents.
This clinical situation depicts an important ethical and legal consideration that must be
contemplated when taking care of children and adolescents, the balance between confidentiality
of a minor and the duty to involve their parents or caregivers. The research has consistently been
demonstrating that concerns about confidentiality entail significant consequences for mental
health behaviors in adolescent patients (Kafka et al., 2024.) In caring for the pediatric population,
the patient/client is viewed as both the child and the parent. Morally, ethically and clinically the
focus and treatment plan is centered on the child, but the parents or caregivers have the legal
decision-making authority for the child. Each state defines a different age, and Florida Statue
349.4784 defines the age of consent for mental health treatment without parental involvement at
age thirteen during an emotional crisis (Florida Senate, 2012.) Although, the limitations of the
statue are glaringly obvious in that when the emotional crisis has calmed, the child will have to
involve the parent/guardian/caregiver in the treatment plan in order for effective care to be
administered. Parental consent is still required prior to any interventions, medications, treatments
or referrals.
Minors articulate fear regarding their physician informing the parents about the reason of
their consultation, particularly if sensitive issues are involved. This leads to an increased
reluctance to seek medical care and may result in foregoing treatment all together (Kakfa et al.,
2024.) I feel like the most proactive way to address this issue is clearly define the parameters of
confidentiality at the initial consultation with the child and parent. Explaining in age-appropriate
language to the child and their parent the boundaries of confidentiality will help establish rapport
and aid in building trust in the relationship. Also, outlining concepts such as HIPAA and
mandatory reporting should be included in this review. If a child was to reveal illicit behavior
after the initial interview, I feel that the best approach would be to validate the child/adolescent’s
feelings by acknowledging their statement. After assessing the severity and risk implications
together with the child/adolescent, explain to them that we would need to share this information
with their parent to protect their safety, health, legality, etc. It would be important to engage the
child/adolescent in formulating and creating a plan in sharing that information with the parent/
caregiver. Another integral facet would be reinforcing the fact that the psychiatric mental health
nurse practitioner (PMHNP) is not in a role of judgement but rather protection and safety for the
child/adolescent. The PMHNP should remain honest in their communication and continue to
advocate for the child/adolescent’s role in the treatment plan by respecting their autonomy but
balancing the other roles of safety and legal considerations. A recent systematic review
demonstrated that adolescents perceive trust and confidentiality in therapeutic relationships as a
significant facilitator or barrier in the case of a lack thereof, to consulting mental health care
services (Rowan, 2024.) Perhaps by addressing this salient concern in the very beginning of a
child or adolescents’ treatment plan will help keep the lines of communication open and safe.
Revisiting the concept briefly as treatment progresses would be helpful as well so that
communication remains flowing. Even more concerning, Zucker and colleagues found that most
adolescents have never had a conversation about confidentiality with their mental health provider
at all (Kafka et al., 2024.)
Reply from Darya Valoshyna
Ethical Challenges in Caring for Pediatric Patients
When caring for patients under 18, a common dilemma is determining who the client truly
is. Providing psychiatric care to children and adolescents raises a distinct set of ethical issues,
challenges, and interests that may include patient autonomy, parental values and preferences, and
the collective welfare and safety of the patient and family (Barican et al., 2022). If a child
confided in me about illicit behavior and asked me not to tell their parents, this must be handled
carefully and appropriately.
Confidentiality and Safety
Although ensuring confidentiality is at the forefront of the nurse practitioner’s role in
providing patient care, another essential priority is promoting safety. These two issues can
conflict at times, similar to when someone threatens violence against another, and then the
provider must warn that person and temporarily break that confidentiality. Children and
adolescents can be impulsive and take risks due to the nature of their developing brains and
bodies. The prefrontal cortex is not fully developed until age 25, and this is a key area of the
brain that helps someone say no and override impulses. This fact highlights the need for adults to
monitor them closely and intervene when potentially dangerous decisions and behaviors occur.
Adolescents’ engagement in risky behavior results in substantial mortality and morbidity, and
studies reveal that in the U.S., approximately ten thousand 15- to 19-year-olds die every year,
mostly from preventable causes related to risky behavior (Walter et al., 2020). Upholding
confidentiality is vital to ensure the patient feels safe and trusts the provider; however, safety
risks override confidentiality. In mental health care, confidentiality must be balanced against
safety and policy considerations that might justify a breach (Barican et al., 2022).
Beneficence, Malfeasance, and Consent
Considering the role of a nurse practitioner also includes the ethical principles of doing
good and doing no harm and risk-taking behavior such as casual sex, driving too fast, or drug use
can significantly negatively impact a person’s safety and mental well-being than not addressing
these risks will lead to poor outcomes for the patient. Even though the child is the patient and the
focus of the care because they are not 18 yet, they do not have full rights to make their own
medical decisions yet and fully decide who is given information about their health. Although
minor patients usually cannot provide legal consent, they should be involved in treatment-related
choices to the degree possible, following their ability to understand options and express coherent
preferences (Barican et al., 2022). For the child in this situation, their parents are their legal
guardians and should have full access to their records and what they disclose to the provider.
Handling the Situation
Ultimately, I would disagree with the child withholding information about their illicit
behaviors from their parents. Instead, I would first focus the interview closely on those behaviors
to assess the thoughts and feelings behind these behaviors and develop an effective treatment
plan. I would also educate them on the risks of these behaviors to their health and well-being.
Common strategies to mitigate risk-taking behaviors are teaching refusal skills and providing
information about a given behavior’s risks (Walter et al., 2020). Next, I would ensure I let the
child know that I must disclose that information to the parents and explain why. My hope in
doing this is that although, from their immediate perspective, I might be breaking their trust, I
hope they can understand I am doing it in their best interest. This hopefully will retain the
therapeutic relationship between them and I. Lastly, I would involve the parents in a plan to help
safeguard the child and prevent these behaviors, such as close monitoring of their phone,
implementing a curfew, not being around certain friends, etc. based on what the behaviors are.
Because the child does not want me to tell their parents, it makes me believe that they inherently
know the parents would disapprove, so that potentially is a good sign because not only does the
child recognize these behaviors are wrong, but the parents most likely will not be accepting of it
and rather be more apt to engage in a parenting plan to reduce these behaviors.
