What patient disclosure during an annual sports physical would require a healthcare provider to break confidentiality?

Recurrent Suicidal Feelings Require Breaking Confidentiality

Among the disclosures listed, recurrent suicidal feelings would require the provider to break confidentiality to ensure patient safety. 1

Clear Circumstances Requiring Confidentiality Breach

The 2024 American Academy of Pediatrics guidelines explicitly state that if a patient reports active suicidal ideation, the pediatrician and other mandated reporters must break confidentiality and inform other responsible individuals (e.g., parents, other health care professionals, relevant authorities). 1 This supersedes confidentiality considerations because clinical circumstances that entail mandated reporting of risks to the patient or others take precedence. 1

Why Suicidal Feelings Mandate Disclosure

• Recurrent suicidal feelings represent an acute safety compromise where managing the minor adolescent's risk to self is incompatible with preserving confidentiality. 1
• The provider must address safety risks proactively to prevent mortality, even though this may increase the adolescent's distress and strain the patient-provider relationship. 1
• Skilled assessment and careful decision-making are required, but the priority is always patient safety when suicide risk is present. 1

Disclosures That Generally Maintain Confidentiality

Gender Dysphoria

• Long-standing gender dysphoria does not require breaking confidentiality. This is a mental health concern that should be addressed supportively but does not represent an acute safety risk requiring parental notification. 1

Cannabis Use

• Daily cannabis use typically remains confidential unless it meets criteria for subacute safety compromise. 1
• Confidentiality may be broken only if the substance use shows escalating patterns associated with severe impairment, life disruption, or dangerous behaviors such as driving. 1
• Simple daily use without these aggravating factors should remain confidential to maintain the therapeutic relationship. 1

Consensual Sexual Activity

• Engaging in consensual sex generally remains confidential and does not require breaking confidentiality. 1
• The exception would be if the sexual activity involves abuse, neglect, or human trafficking, which fall under mandated reporting requirements. 1

Psilocybin Use at Parties

• Weekend psilocybin use at parties typically remains confidential unless it meets the threshold for subacute safety compromise with dangerous associated behaviors. 1

Critical Process for Breaking Confidentiality

When breaking confidentiality for suicidal feelings is necessary:

• Inform the adolescent before disclosure whenever possible, explaining the need to break confidentiality. 1
• Give the patient as much control as possible over the disclosure process, including when, how, and with whom information is shared. 1
• Consider whether disclosure might increase safety risks depending on the parent's potential response, though this rarely outweighs the immediate suicide risk. 1
• Work in partnership with the adolescent when feasible, as many youth may agree with the need for parental involvement but simply need support navigating these conversations. 1

Common Pitfalls to Avoid

• Failing to establish confidentiality limits upfront: Pediatricians should discuss the limits of confidentiality before starting confidential portions of clinical encounters to ensure youth understand when essential disclosures may occur. 1
• Making unilateral disclosures without patient involvement: This can increase distress and disrupt the treatment alliance, potentially worsening outcomes. 1
• Underestimating suicide risk: Even passive suicidal thoughts require careful assessment, as they can progress rapidly in adolescents. 1
• Delaying action due to relationship concerns: While the therapeutic relationship is important, immediate safety always takes precedence over confidentiality when suicide risk is present. 1