Confidential Care For Adolescents

1. Confidential Care For Adolescents Division of Adolescent and Young Adult Medicine

2. AYA Medicine of CHP Care for patients up until age 26 Complex Primary Care Specialty Care Gynecology & Menstrual disorders Eating disorders and chronic PH/MH management Gender identity and sexual development Family Planning Contraception STI testing and treatment

3. AYA Medicine of CHP Main location is in Oakland Additional sites: Children’s Pine Center Children’s South Lawrenceville Services also provided at Shuman Detention Center 412 Youth Zone Carlow University Homewood-Brushton Clinic Hilltop Clinic Caremobile

4. Self-Determination Theory Deci and Vansteenkiste 2004

5. Self-Determination • Motivation for participation • Balance and understanding of internal and external influences and motives Independence Dependence

6. Shared Decision-Making

7. Shared Decision-Making Most adults, provider-patient confidentiality assumed, equally comfortable adult or children’s hospital Most teens, confidentiality and parent proxy negotiated, move in direction of driving process, supported by transition practices Older children, teens, special reasons for confidential interview, documentation

8. Standards of Care • By age 13 introduce concept and purpose of confidential interview in conjunction with introduction of patient portal • If necessary, consider plan for implementing confidential visits, consistent with parent proxy • Well before 18th birthday, confidential discussions and proxy removed unless serious concerns of competency

9. Purpose of Consent and Confidentiality • Respect and support autonomy of individual • Support development towards self-determination in health care decision making • Provide for safe and effective risk assessment and triage • Support therapeutic relationship between continuity providers and individuals with complex needs • Other reasons….

10. Why is this essential? • Improve quality of care for AYA • Consistent continuum of care supporting emerging rights, abilities, and responsibilities of individuals we serve • Minimize problems with transition and transfer to adult systems • Compliance with state, federal law

11. Confidential services for teens: • Increases disclosure of information and access to care • >25% of adolescents would forgo care if confidentiality not assured • Of patients who reported they did not obtain needed medical care, 35% said it was because they did not want parents to know

12. Confidential services for teens, safety, and mandatory reporting: • Always disclose the limits of confidentiality up front • Provide clinical care first prior to discussing need to report • Involve the youth in the reporting process

13. Practice in Pairs • What do you say to minor about confidentiality and its limits? • What do you say to parent/guardian?

14. Limits of Confidentiality • https://www.youtube.com/watch?v=hSO-nudEbcg&list=PLaS4Etq3IFrWgqgcKstcBwNiP_j8ZoBYK

15. Minors’ Access to Confidential CareIn Pennsylvania Pennsylvania law requires the consent of a parent of guardian for the medical treatment of anyone less than 18 years of age (a “minor”) There are exceptions……

16. Medical treatment of minors Exceptions to parental consent Emergency care if obtaining parental consent would result in delay of treatment likely to increase the risk to the minor’s health or life Emancipated minors High school graduates Ever been married Ever been pregnant

17. PA law permits minors to consent to certain medical services: Contraceptives Testing and treatment for pregnancy Testing and treatment for STDs Drug and alcohol treatment Mental health out-patient care When a minor consents for services, his/her confidentiality is protected

18. Age of Consent to Sexual Activity • “In Pennsylvania: • Children less than 13 years old cannot grant consent to sexual activity. • Teens between the ages of 13 and 15 cannot consent to sexual activity with anyone who is four or more years older than them. • People ages 16 and older can legally consent to sexual activity with anyone they choose, as long as the other person does not have authority over them as defined in Pennsylvania’s institutional sexual assault statute.” • “Statutory Sexual Assault • It is considered a felony statutory sexual assault when: • one person is 13 and the other is 17 or older • one person is 14 and the other is 18 or older • one person is 15 and the other is 19 or older” (PCAR.org)

19. What happens when a minor discloses? • Highlight strengths: thank patient for their honestly • Remind patient of limits of confidentiality previously discussed • Examples of language you would use? • Review role as mandated reported • Explain purpose of report • Invite patient to participate • CHP Child Advocacy Center: (412) 692-8664 • www.compass.state.pa.us

20. What happens when there is no disclosure? • Remember standards of care for all minors regardless of age: • Universal education about healthy relationships • Assess meaning of relationship and current safety • Provide resources for patient or a friend • Resources: • Crisis Text Line: 741741 • Futures without Violence • PAAR • Women’s Center and Shelter • Center for Victims

21. Please contact us with questions: • Adolescent and Young Adult Medicine • Main phone number: 412-692-6677