Confidentiality with children and adolescents — branching viva

Stem

The examiner will test whether you can run a confidentiality-competent adolescent consultation under pressure and make a defensible override decision. [1] [6]

Branch 1 — The opening statement

Examiner: A 15-year-old asks, "If I tell you something, will you tell my parents?" Give me your opening line. [2]

Strong answer: Deliver a conditional-confidentiality script: private unless serious risk of harm to self or others, abuse or neglect, or a legal duty; and if an override is ever needed you will tell the young person first and plan it together. Never promise absolute secrecy. [2] [1]

Examiner: Why not just say "of course I won't tell anyone"? [6]

Strong answer: Because that promise cannot be kept. An inevitable override would make it a lie and collapse trust. Conditional framing is the safeguard that lets the clinician honour the promise actually made. [6]

Branch 2 — Capacity

Examiner: How do you assess this young person's capacity, and is the same capacity test used everywhere? [9]

Strong answer: Gillick or Fraser competence in the UK asks whether the young person understands the condition, the proposed care, the alternatives and the risks, and can weigh them rationally. Fraser applies specifically to contraceptive advice under 16. The mature-minor doctrine carries the equivalent logic in common-law Australasia and parts of North America. Capacity is decision-specific and fluctuates with illness and distress. [9] [13]

Branch 3 — The override

Examiner: The young person privately discloses an active suicide plan for tonight and begs secrecy. Walk me through your actions. [6]

Strong answer: This meets the serious-harm threshold. Secure immediate safety. Override to the minimum necessary: crisis team and parent as part of the safety plan. Tell the young person what must be shared and why. Document the clinical and legal basis, what was shared and with whom. Do not leave a high-risk young person unsupported, and do not maintain a secrecy promise that endangers them. [6] [1]

Examiner: And if it had been occasional vaping instead? [1]

Strong answer: Keep it private. Occasional vaping without dependence, escalation or other harm does not meet the serious-harm threshold. Offer brief advice, explore context and arrange follow-up. Over-riding for low-grade risk erodes trust and suppresses future disclosure. [1]

Branch 4 — The parental request

Examiner: The parent phones demanding the full portal notes of the confidential mental-health visit. The young person does not want them shared. [5]

Strong answer: Acknowledge the parent respectfully, then explain that a competent young person controls their own information and parental responsibility does not automatically override that right. Offer to facilitate a shared conversation with the young person's agreement. Do not hand over the record against their wishes. Document the request, response and preference. [5] [6]

Branch 5 — The portal breach

Examiner: A billing statement revealed a contraception visit to the parent. What went wrong and how do you fix it? [4]

Strong answer: A structural auto-disclosure through billing, portals or open-notes not configured for sensitive encounters. The 21st Century Cures Act illustrates how default-open-notes rules threaten adolescent confidentiality. Fix: apply sensitive-note flags, route sensitive results through an alternative channel, confirm local portal and billing configuration, and tell young people how the system handles their encounters. Support the young person after the breach. [4]

Examiner extras

• Confidentiality is conditional, never absolute. [1]
• Capacity is decision-specific — assess, do not assume by age. [9] [13]
• Time alone is clinical quality, not a courtesy. [3]
• After an override, tell the young person what was shared and why. [6]
• Portals and billing are the modern trapdoor — configure sensitive-note workflows. [4]