The partnership between parents and pediatrician evolves as a child grows. “In the beginning, obviously everything is between the parent and the doctor. They’re babies, and they’re toddlers, and gradually at school age, they can begin to tell us how they’re feeling,” said Linda Goldstein, a pediatrician with Friendship Pediatrics in Chevy Chase. By adolescence, the expectation is that the child will begin to do most of the talking.
Once their child enters puberty, parents are encouraged to leave the exam room to allow the patient time alone with the pediatrician. Elizabeth Alderman and her colleagues at Children’s Hospital at Montefiore in New York introduce this idea with a conversation and handout when the child is 11 years old. Pediatricians recommend annual well-child exams, and at the next year’s visit, she said, the pediatrician will tell parents, “I want to talk to your child about some behaviors that hopefully he or she isn’t doing — and that I hope you discuss with your child, too — but would like to talk about it in private.”
Pediatricians reassure parents that they will be informed of dangerous situations. If children or adolescents reveal they are homicidal or suicidal, the parent must be told, Alderman said. If they tell the doctor they are being abused, child protection services must also be informed. It would be up to the doctor to determine what to do if an adolescent reports taking drugs or drinking, she said.
Exactly when a child is ready to spend time alone with the doctor varies, Goldstein said. While some are ready quite young, others “look like they’re scared out of their minds” to be alone with a doctor, she said. If time alone with the doctor hasn’t happened by a child’s 14th birthday, Goldstein will be fairly blunt and ask the parent to leave the room.
An adolescent’s private time in the exam room could include frank talk about mental health, substance abuse and sexual activity. A 1977 Supreme Court decision established a minor’s right to privacy regarding contraception, and details vary by state. In addition to contraception, minors, in general, have some legal rights to seek sexually transmitted disease treatment and prenatal care. Minors may also be able to consent to some types of outpatient mental health, drug or alcohol treatment.
“States have adopted policies to allow minors to consent to certain services because it has been recognized that minors need this care and sometimes they can’t talk to their parents about it,” said Elizabeth Nash, state issues manager for the Guttmacher Institute.
Pediatricians should try to bring families in on important matters. When she is particularly concerned about an issue, Goldstein will tell the patient that he or she needs more help and make a referral.
Alderman will also encourage parental involvement, especially in the case of suspected depression. “I definitely try to talk to them about disclosing to the parents, because how are they going to get the proper help? Kids have to use their parents’ insurance to get better mental health services,” Alderman said. “I rarely get pushback, particularly on mental health.”
Once teens reach age 18, doctors cannot share their health information with parents without the patient’s permission, according to the federal Health Insurance Portability and Accountability Act. But when faced with serious illness or hospitalization, young people may need parental help. It’s therefore a good idea for them to sign documents such as a health-care proxy authorizing parents to intervene in an emergency, Goldstein said. Copies of such documents can often be kept on file with college health services.
Many young adults begin to transition to adult-care providers around age 21. College students used to leave their pediatricians as soon as they left home, Goldstein said. But today, it’s more often the case that college students who are comfortable with their pediatric practice remain there, touching base if they have a medical problem, until they graduate.