Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Consent, confidentiality and family involvement
Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Immediate danger changes the timescale, not the duty to reason
Imminent death, serious deterioration, suicide, violence, severe intoxication or medical collapse may require immediately necessary assessment or treatment before ordinary consent arrangements can be completed. If valid consent is absent or treatment is refused, do not relabel refusal as incapacity: identify the applicable emergency, court, mental-health or other lawful authority and obtain urgent senior advice.
Action: Protect life using only the immediately necessary and least restrictive intervention, obtain senior clinical and legal or safeguarding support as soon as possible, identify the applicable national law, and record the urgency, decision-making assessment, authority and alternatives. Explain what occurred afterwards and review whether continuing intervention needs a different lawful basis.
Purpose and principles
Make lawful, developmentally supported mental-health decisions with children and young people, preserve confidentiality without promising secrecy, involve families constructively, and recognise when emergency, safeguarding, mental-health or court authority requires senior advice.
Begin with the actual decision: an interview, physical examination, blood test, medicine, admission, disclosure, family meeting or longer-term plan. Explain purpose, material benefits, likely burdens, reasonable alternatives and consequences of refusal in language suited to age, development, communication and culture. Check understanding by asking the young person to explain the choice and consequences, not by asking whether they understand. Offer interpreters, communication aids, time, breaks and a trusted supporter, while ensuring that another person's presence does not create coercion.
Decision-making ability is time-specific and decision-specific. A young person may consent to routine therapy yet be unable to decide about a complex treatment carrying immediate fatal risk; ability may improve after sleep, treatment of intoxication, communication support or relief of overwhelming distress. Apply the age- and nation-specific test. In England and Wales, a sixteen- or seventeen-year-old lacks Mental Capacity Act capacity only when an impairment of or disturbance in mind or brain causes inability to understand, retain, use or weigh the relevant information or communicate the decision. Diagnosis, distress, disagreement, unusual values or an unwise choice is not enough. Record the information, support, reasoning, applicable test and conclusion.
Practice
Two practice questions
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PsychiatryOriginal SBA
Under-sixteen consent assessment
A 15-year-old requests psychological therapy, describes its purpose and alternatives, weighs likely benefits and burdens, communicates a stable voluntary choice, and asks that parents are not told the session content. What is the best response?
Sources and review status18 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Across the UK, GMC guidance says sixteen- and seventeen-year-olds should be presumed able to consent unless evidence shows otherwise, but the legal routes differ. England and Wales use the Mental Capacity Act 2005 for this age group. Scotland treats a person aged sixteen or over under the adult Adults with Incapacity framework when capacity is absent. In Northern Ireland, a sixteen- or seventeen-year-old can consent under the Age of Majority Act (Northern Ireland) 1969, while the Mental Capacity Act (Northern Ireland) 2016 remains only partly commenced and is not yet a general routine-treatment authority. For under-sixteens, England, Wales and Northern Ireland use decision-specific Gillick competence; Scotland instead applies section 2(4) of the Age of Legal Capacity (Scotland) Act 1991. Fraser guidelines are contraception-specific, and competence is never a permanent badge.
When a young person can consent, their consent is sufficient and a parent cannot veto it. Encourage supportive family involvement, because carers often hold developmental history, help implement treatment and notice deterioration, but do not make family attendance the price of care. Offer some private time when appropriate and explore reluctance: the concern may be ordinary embarrassment, fear of conflict, coercion, identity disclosure or a safeguarding risk. A negotiated plan can share practical warning signs or medication support without revealing every private detail.
If an under-sixteen lacks the relevant competence, a person with parental responsibility, or Scottish parental rights and responsibilities, may usually consent within the lawful scope of that authority and the child's best interests or welfare; the child must still be involved. For sixteen- and seventeen-year-olds, identify the national route. In England and Wales, a parent may consent, but proportionate best-interests treatment may also proceed under the Mental Capacity Act without parental consent when its conditions are met. In Northern Ireland, a parent may consent; if unavailable, ordinary treatment may proceed under common-law best interests, with legal advice for significant non-emergency intervention. In Scotland, a parent cannot consent merely as parent: treatment ordinarily needs Adults with Incapacity (Scotland) Act 2000 Part 5 authority, usually a section 47 certificate. Parental authority does not authorise deprivation of liberty for a sixteen- or seventeen-year-old.
Confidentiality applies to children and young people. At the start of a sensitive consultation, explain that information is private but may need to be shared under a lawful basis. Never promise secrecy before hearing the concern. Consent to treatment does not automatically authorise disclosure to family, school or another service. Ask what can be shared and why, identify the smallest useful information set, and check how the young person would prefer the conversation to happen.
The right to access a child's records belongs to the child, not automatically to a parent. A competent or capacitous child or young person can authorise or refuse parental access. If the child cannot exercise the right, a holder of parental responsibility may usually act only when access is consistent with the child's best interests; protect information given in confidence, third-party information and exempt material. Scotland usually presumes a child aged twelve or over mature enough to exercise data-access rights unless evidence shows otherwise; England, Wales and Northern Ireland have no fixed-age presumption.
Disclosure without consent may be justified or required by law, for the proper care or best interests of a child who lacks sufficient maturity and understanding to decide about that disclosure, or by an overriding public interest such as preventing death or serious harm. Assess the disclosure decision separately from treatment consent. Respect a competent or capacitous objection unless another basis applies. Normally tell the young person what will be shared and why, but not if warning them would increase danger or undermine protection. Share only relevant information, verify the recipient and document the basis, reasoning and follow-up.
Confidentiality does not require refusing to hear a carer. Listen, clarify whether the information may be used in care and explain that information materially affecting treatment may need to be discussed with the patient. Patient-specific disclosure normally needs consent or another lawful basis, but clinicians may provide non-confidential general information, service processes, crisis contacts and risk-response advice without confirming or denying the patient's diagnosis or account. Where sharing is limited, acknowledge carers' distress and explain the boundary without making them responsible for unknown hazards.
Refusal demands jurisdiction-specific caution. In Scotland, a parent cannot authorise treatment refused by a competent young person. In England, Wales and Northern Ireland the law concerning override of refusal is complex and should not be reduced to a rule that parents can always consent. For serious or contested treatment, obtain urgent legal advice and consider court authority. Emergency necessity may permit immediately life-saving treatment, while mental-health legislation may provide a separate route for qualifying psychiatric assessment or treatment; neither route authorises unrelated physical treatment automatically.
Mental-health law and capacity law are not interchangeable or uniform across the UK. Name the nation, check the statute and code in force, and seek the organisation's legal or mental-health-act team. Do not apply the Mental Capacity Act 2005 as though it covers every UK nation or every child under sixteen. In England and Wales, the Mental Health Act 2025 is enacted, but as at 31 August 2026 most clinically relevant reforms remain uncommenced; apply only provisions actually in force and otherwise continue to use the Mental Health Act 1983 and current codes. Northern Ireland's revised Mental Health Order code takes effect on 1 September 2026 and is therefore not yet operative on 31 August 2026.
Deprivation of liberty has a new UK-wide definition after the Supreme Court's 2 June 2026 judgment. Do not use the former Cheshire West single acid test. Assess the type, duration, effects and manner of restrictions, objection, relative normality and purpose; no one factor is decisive. A person may sometimes validly accept the arrangements for Article 5 purposes despite lacking domestic-law capacity for care and residence, but compliance alone is not consent and serious doubt prevents that conclusion. When restrictions may amount to deprivation of liberty, obtain legal advice and identify the applicable court, mental-health or other authority; neither ordinary parental agreement nor Mental Capacity Act section 5 alone authorises it.
Good family involvement is relational rather than binary. Ask the young person who counts as family, include foster carers or other trusted adults when appropriate, and avoid assumptions based on biology, gender or household. Agree how results, appointments, medicine changes and crisis signs will be communicated. Revisit the plan as risk, capacity, age and relationships change. When confidentiality limits detail, teams can still explain general service processes, invite observations and provide emergency advice without disclosing the clinical record.
Key points
Valid consent is voluntary, informed and specific to the decision at the time. The familiar understand, retain, use-or-weigh and communicate abilities are useful professional checks, but they are not one UK-wide statutory test; in England and Wales a sixteen- or seventeen-year-old lacks Mental Capacity Act capacity only when impairment or disturbance of mind or brain causes inability in one of those functions.
At sixteen and seventeen, presume capacity unless there is evidence otherwise. A child under sixteen may be able to consent when maturity and understanding are sufficient for that particular decision.
For an under-sixteen, Gillick is the common-law competence test in England, Wales and Northern Ireland. Scotland instead uses section 2(4) of the Age of Legal Capacity (Scotland) Act 1991: the attending qualified medical practitioner decides whether the child understands the nature and possible consequences of the proposed procedure or treatment.
Diagnosis, autism, learning disability, psychosis, self-harm, distress, family disagreement or an apparently unwise choice does not by itself establish incapacity or incompetence.
A competent child's or capacitous young person's valid consent is sufficient; a parent cannot veto it. If decision-making ability is absent, parental authority is limited by best interests and the scope of parental responsibility.
Indications, selection and cautions
Capacitous or competent agreement
The young person voluntarily makes the decision after appropriate developmental support and meets the applicable age- and nation-specific legal test; the four functional abilities are not one UK-wide statutory formula.
Supported decision needed
Language, sensory, cognitive, emotional or situational barriers may be remediable and should prompt communication support before a negative conclusion.
Possible impaired decision-making
Intoxication, delirium, acute psychosis, overwhelming distress or severe nutritional illness may impede one decision at that time; in England and Wales, Mental Capacity Act incapacity at sixteen or seventeen still requires a causal impairment or disturbance of mind or brain.
Confidential disclosure dilemma
A request for secrecy involving serious harm, abuse or threat requires proportionate information-sharing analysis rather than an automatic promise or breach.
Family involvement opportunity
A trusted adult can provide history, practical support and safety monitoring without being given unrestricted access to confidential clinical information.
Contested legal decision
Refusal, restraint, parental conflict, liberty restriction or high-burden treatment signals a need for senior jurisdiction-specific legal advice.
Red flags requiring action
Never rely on parental agreement alone for an objecting young person who is restrained, confined, sedated or subjected to invasive treatment; obtain senior legal advice on authority and liberty.
Assessment before treatment
01Decision-specific competence or capacity assessmentFirst step
Why
Identify age and jurisdiction, then apply the correct test: under-sixteen maturity and understanding under Gillick or Scotland's statutory rule; for sixteen- and seventeen-year-olds, the applicable national capacity framework, including the causal impairment requirement in England and Wales.
Interpretation and limitations
Record the information, support, reasoning, test and conclusion; diagnosis, distress or an unwise decision cannot substitute for the required assessment.
02Consent information check
Why
Confirm that material benefits, burdens, alternatives, uncertainties and consequences of refusal were explained accessibly.
Interpretation and limitations
A signature or yes answer does not cure missing information, coercion or failure to check meaningful understanding.
03Confidentiality and risk formulation
Why
Clarify requested secrecy, serious-harm likelihood, safeguarding duties, potential recipients and consequences of sharing or not sharing.
Interpretation and limitations
Choose the minimum justified disclosure and document purpose, rationale, recipients and what the young person was told.
04Parental-responsibility and relationship check
Why
Establish who has lawful responsibility, who the young person trusts and whether control, conflict or abuse affects involvement.
Treatment approach
01Planned decisionSupport and assess the exact choiceFirst stepA child or young person is considering a non-emergency mental-health assessment, treatment or disclosure decision.+
1Explain options, material consequences and uncertainty in an accessible format, offer private time and remove avoidable coercion.
2Identify the age, UK nation and exact decision, apply the relevant competence or capacity test with all practicable support, and record the test, reasoning and outcome.
3If consent is valid, proceed within it and agree family and information-sharing boundaries that can be revisited.
02Serious confidential riskShare proportionately for protectionInformation suggests death, serious harm, abuse, neglect or a credible threat while consent to disclosure is absent.+
1Assess immediacy and severity, seek consent when safe, and obtain senior or safeguarding advice without delaying urgent protection.
Complications, monitoring and follow-up
Reassess consent and decision-making ability when the treatment, risk, understanding, communication support or mental state materially changes.
Review the family-sharing plan after crises, new safeguarding concerns, age transitions, relationship changes and every major care decision.
Audit non-consensual disclosures for purpose, minimum necessary content, verified recipient, explanation, documentation and planned follow-up.
Track whether advocacy, interpreter, accessible information, sensory adjustments and private consultation time were offered and effective.
Review any restraint, confinement or emergency intervention promptly for ongoing legal authority, proportionality, trauma impact and less restrictive alternatives; apply the post-June-2026 multifactorial deprivation-of-liberty definition rather than the former single acid test.
Ensure carers receive permitted practical guidance and a route to report deterioration even when the young person limits clinical disclosure.
Special situations
Ability is not obedience
A young person can make a valid decision clinicians dislike if the functional decision-making requirements are met voluntarily.
Two separate permissions
Agreeing to therapy does not automatically mean agreeing that the therapist may disclose its content to parents or school.
Listening is not disclosure
A clinician can receive a carer's concern while protecting the young person's confidential diagnosis, account and treatment details.
Private time can reveal context
A short supported conversation alone may uncover coercion, identity concerns, abuse or an explanation for apparently irrational refusal.
Authority must be named
Emergency necessity, parental responsibility, court order and mental-health legislation are distinct bases with different scope and safeguards.
Common pitfalls
01
Saying that children under sixteen cannot consent or that every sixteen-year-old automatically has capacity for every decision.
02
Using Gillick competence as a permanent diagnosis, as a UK-wide statutory formula or as another name for the contraception-specific Fraser guidelines.
03
Assuming self-harm, autism, psychosis, learning disability or refusal proves incapacity without supported functional assessment.
04
Promising absolute confidentiality, automatically informing parents or confusing treatment consent with consent to disclosure.
05
Refusing to listen to carers because the young person has restricted information sharing.
06
Teaching that a parent can routinely override a competent refusal or authorise any restraint, detention or invasive treatment.
07
Applying the Mental Capacity Act, its functional limbs or one nation's mental-health code throughout the UK without checking age, causal requirements, jurisdiction and commencement.
08
Using the former Cheshire West single acid test after the June 2026 Supreme Court judgment or assuming ordinary parental consent authorises deprivation of liberty.
Confidentiality duties towards children and young people are as strong as for adults. Explain limits before sensitive discussion and do not promise absolute secrecy.
Consent to healthcare and decisions about disclosure are separate. Relevant information for direct care may ordinarily be shared on implied consent when the patient is informed, has not objected and the recipient owes confidence; otherwise identify and record the applicable basis.
If a child lacks sufficient maturity and understanding to decide about disclosure, necessary information may be shared for proper care or best interests. Respect a competent or capacitous objection unless law or overriding public interest justifies disclosure; information needed to protect anyone from death or serious harm should be shared promptly and proportionately.
Clinicians may listen to parents and carers without disclosing confidential information; receiving a concern is different from confirming the young person's diagnosis or account.
A competent refusal is handled differently across UK jurisdictions: never teach routine parental override, and obtain urgent legal advice for serious contested treatment.
A request to keep suicidal intent, serious self-harm, abuse, exploitation or a threat to another person completely secret requires an immediate safety and information-sharing decision.
Fluctuating consciousness, intoxication, psychosis, severe malnutrition, communication difficulty or acute distress may affect one decision now but must not be treated as proof of global incapacity.
A parent who controls the consultation, demands records, interprets inaccurately, threatens the young person or may be the source of danger requires private assessment and safeguarding planning before disclosure.
Disagreement about life-preserving treatment, sterilisation, abortion, prolonged restraint, deprivation of liberty or a competent refusal is not resolved by informal family consensus and needs specialist legal input.
Interpretation and limitations
Biological relationship does not automatically prove parental responsibility, safe involvement or authority for the proposed intervention.
05Jurisdiction and legal-authority check
Why
Identify the UK nation, age, current statute, commencement status, mental-health status, liberty restrictions and any court involvement.
Interpretation and limitations
Use the applicable law and code; do not transfer England-specific capacity or mental-health rules across borders or treat an enacted but uncommenced reform as operative.
06Liberty-restriction review
Why
Assess the type, duration, effect and manner of restrictions, objection, relative normality, purpose and the person's supported wishes under the post-June-2026 multifactorial approach.
Interpretation and limitations
No single acid test decides deprivation of liberty; doubt, significant restriction or objection requires prompt jurisdiction-specific legal review and an identified lawful authority.
07Communication-needs assessment
Why
Identify interpreter, advocacy, sensory, literacy, neurodevelopmental and augmentative communication support needed for participation.
Interpretation and limitations
Failure to communicate using the clinician's preferred format is not evidence that the young person cannot decide.
2
Share only the relevant minimum with a capable recipient, explaining the disclosure beforehand unless that would increase risk or undermine protection.
3Document facts, reasoning, recipients and follow-up, then preserve as much therapeutic privacy and trust as safety permits.
03Refusal or conflictIdentify lawful authority before coercionA young person refuses important treatment, carers disagree, or force, confinement or serious burden is contemplated.+
1Recheck information, communication, voluntariness and the applicable decision-specific test, and treat reversible impairment where clinically appropriate.
2Name the jurisdiction and obtain senior legal advice on parental responsibility, court, emergency or mental-health authority; never assume routine parental override.
3If liberty may be restricted, use the current multifactorial definition, then choose the least restrictive lawful option, involve the young person, record authority and review promptly.
09
Giving emergency treatment and failing to document the authority, explain afterwards or reassess the need for continuing intervention.