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Chair of Child and Adolescent Psychiatry Professor Mina Fazel outlines her recent paper on building and promoting trust with adolescents to share information about their mental health. It was published in the British Journal of Psychiatry.
Take a typical 14 year old who decides to share something personal with an adult outside the family home - maybe with an adult at school - perhaps about low mood, self-harm, or worries about home. What might happen next with the information they share?
The pathway is often uncertain. Because they are under 16, they step into a kind of grey area: they may not know who will be told about what they have said or where that information will go next.
Professionals, quite rightly, have safeguarding duties. They usually begin any conversation by explaining the limits of confidentiality – in other words, that what’s shared will be kept private unless there are concerns about the young person’s safety or the safety of others.
That caveat is essential for protection but its also the moment when trust can start to wobble. For some adolescents, the message is entirely appropriate and reassuring. For others, it is enough to close the conversation before it even begins.
This grey area - between the promise of confidentiality and the duty to protect - is where we focused our research.
In my early work with refugee children we set up school-based mental-health services because we knew that families were struggling but not presenting to clinics and formal services. We hoped that working in schools could democratise access to care - to make the step of walking into an unfamiliar clinic, to talk to strangers, a little less daunting by bringing services into the school environment where children and their families already felt some familiarity.
Research interviews with asylum-seeking and refugee adolescents opened my eyes to their experiences of school and specifically about receiving school-based mental-health support. They described profound isolation - both those who had arrived unaccompanied and those who came with families - experiencing their schools and neighbourhoods as unfriendly and distant.
The interviews revealed two additional insights. First, what was their understanding of confidentiality: they could clearly recall that their therapists had explained confidentiality to them - but when I asked, “And did you believe it?” most said NO. They did not actually trust the therapist and that confidentiality would apply to them.
The second was about parental involvement. When I asked about involving parents there were mixed responses, most did not want this. One boy quietly said: “… you don’t really want anyone else to get involved - especially me, I know my mum, she gets upset.”
It leads to this central question: How do we design services, especially for those at the margins, that young people can trust enough to speak honestly.
Roughly one in eight (13%) said they wanted help but hadn’t accessed it.
Over the past seven years I have led the OxWell Student Survey and, with an incredible team, have run a repeated whole-school self-report survey that over 100,000 students have participated in, mainly across Oxfordshire, Berkshire, and Liverpool. The survey asks about a range of factors relevant to mental health and well-being. In the 2023 survey, more than 20,000 adolescents answered questions about whether they have accessed mental health supports and of particular relevance to this issue of trust, we asked about barriers to accessing additional mental health support.
Roughly one in eight (13%) said they wanted help but hadn’t accessed it. We asked them why they hadn’t accessed more support and most raised privacy concerns with 50% saying that they had not accessed more support because they did not want their parents to know. That figure rises to 62% among students who reported self-harm.
So those adolescents who feel most in need of support are the ones most likely to be deterred by the fear that information will be shared, especially with their primary caregivers. So the question becomes not only how to make the support available, but how to make it trusted and safe, for all concerned.
Parents matter enormously and our data is clear, they are the most commonly accessed form of support. They carry enormous love, responsibility and worry. They are experts on their children in a way professionals will never be. When parents are engaged and supportive, they can be the cornerstone of any effective system of care. It is natural for parents to feel anxious at the idea of not being told about their children seeking external support.
But it is also true that in adolescence, even in warm families, young people need space that is theirs. Privacy, exploration, even secrecy - these are ordinary parts of growing up.
And then there are those for whom their home is not safe: adolescents living under and experiencing coercive control, abuse, or neglect. For them, parental involvement is not just unhelpful - it may be dangerous.
I believe we need to design our services specifically with these adolescents in mind. If our systems are deliberately designed to serve those at the margins - those most in need and least safe - we will also design systems that I think will serve everyone else better.
So we need to hold two truths at once:
- Parents are essential partners in most adolescents’ mental health.
- But some adolescents can only seek help if they trust that the system allows them privacy – possibly from those same parents.
This is not an attack on parenting. It’s a recognition of the diversity of family realities, and the importance of designing a system that can adapt to them.
It comes down to rebuilding trust, and how to better design and provide services for our current generation of adolescents.
Understanding this balance - between dependence and independence, between safety and privacy - matters more now than ever, because the young people growing up today inhabit a very different world to the one in which the current health service was designed for.
It comes down to rebuilding trust, and how to better design and provide services for our current generation of adolescents. In particular Generation Alpha – the largest generation of youth in history are born from 2010 to 2025. They are becoming adolescents and have grown up in an era where information has been more readily available than ever before, and often one click away. It is with these adolescents in mind that we need to design services that are transparent, responsive and respectful of their autonomy. Ambiguity, in particular, is the enemy of trust and it is clear that adolescents seeking mental health support are currently experiencing substantial ambiguity regarding their rights to privacy and confidentiality.
In this year’s survey, we asked whether students needed parental consent to access school-based mental health provision. Only 7% said yes, around a third said no but what is most striking, 54% - over half of young people - did not actually know. We then asked about the future and whether adolescents, should need parental consent to access school based support in the context of self harm. The current students are clear, even in the context of risk, they believed that parental consent should not be required to access support – with over half saying no.
We therefore owe adolescents and parents plain language about confidentiality: what it means, what triggers sharing, what the process is.
We suggest that adolescents could nominate a trusted adult - someone they choose - to be involved if disclosure becomes necessary, rather than professionals assuming to know who that should be (usually a parent).
Legal and ethical frameworks, such as the widely used Gillick competence, already recognise that many adolescents have the capacity to make autonomous decisions about their own health.
Yet practice has not kept pace with the law. Confidentiality is applied inconsistently - not only within institutions, but also between sectors like health and education, and even between countries. Young people, if they are competent, have the right to confidentiality if they seek mental health support at school, for example. Yet it can be difficult to actually provide this in practice and it is this area that I believe we need to change - to clarify when information is shared, to provide information to young people that they understand that is not inconsistent with what other statutory agencies and institutions practice, and through these changes hopefully better earn their trust.
If we design systems that young people can truly trust, perhaps no child will be worried to speak of their struggles, as they will have better appreciation and control over what is done with their information and with whom it is shared. And that, I think, is the measure of a just health system, fit for this next generation.