The Laramee Filter: pseudorandom thoughts, subsequently put on the Internet.
Tom Laramee
Date Published:
September 10th, 2022
Word Count:
4,767 (25:00 read time)
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The Washington State Adolescent Mental Health System Is Very Broken

The WA State adolescent mental health system has some very broken parts. As my kids get older, and my peers kids get older, I have more interactions with this system. The more I experience, and hear about others' experiences, the more odd, confusing, and poorly conceived it becomes.

Now there's a lot to talk about here, and so I'd like to try to focus on two main areas to maintain some semblance of scope. Naturally, the two areas are those in which I've experienced the most conflict and confusion, as well as where I think we're most failing both our adolescents and their families:

  1. Why do we treat 13-year olds like complete adults when it comes to medical decisions?
  2. Why is there so much confusion around the 2019 WA State Adolescent Behavioral Health Care Access Act, and why does it make adolescent mental health counseling so problematic?
How Does Washington State Currently Rank In This Area?

Before I get too far, it's worth looking at how we're faring relative to how the rest of the country in terms of overall adolescent mental health. In looking at the national Mental Health America rankings, which rank individual states, Washington State has recently ranked as follows for Youth Mental Health:

Youth Rank

The criteria for their youth ranking includes some "canary in the coalmine" assessments such as (a) Youth with At Least One Major Depressive Episode in the Past Year and (b) Youth with Substance Use Disorder in the Past Year, so it's trying to gage the overall state of youth mental health on a state-by-state basis.

WA State is averaging a rank for 39 for the past three years, indicating we have an awfully long way to go before we can give ourselves a pat on the back and talk about what a great job we're doing on behalf of our youth and their families.

Topic #1: Are 13-Year-Olds Really Adults?

Here in Washington State, treat 13 year olds like complete adults when it comes to medical decisions, including mental health treatment. When someone turns 13, they're allowed to access essentially any medical care without the consent of a parent. It's like a switch is flipped, and they go from "dependent [for critical healthcare decisions]" to "independent [for critical healthcare decisions]".

What I find puzzling is how out of step with every other area of adolescent law/development. The state applies a countless number of restrictions in critical areas (smoking, drinking, driving, gambling, vaping, etc), presumably because from a developmental standpoint, the state believes 13 year olds are unable to make informed, beneficial decisions in these areas.

Additionally, it's clear that this sudden, age-based cut-off does not take into account the significant variance in ability/aptitude at this age (in proportion to an individuals level of neurodiversity). The law paints things with a very broad brush and doesn't take into account ASD, autism, maturity level, or developmental delays. It's a dangerous "one size fits all" based solely on biological age.

Things You're Not Allowed to Do When You're Thirteen

If you look at the big picture of rights & responsibilities for adolescents, you'll likely conclude that letting 13-year olds control their medical decisions is an odd outlier when you consider the restrictions we put on everything else for this age group.

For example, here in Washington State, when you're 13, you're not allowed to:

In looking at this set of laws as a whole, what's most puzzling is that we have either (a) decided 13-year olds are sufficiently wise, mature, and informed to make critical and important decisions or (b) we haven't. Having one major outlier, and such an important one, is extremely inconsistent.

The age 13 turns out to be fairly arbitrary. To quote Dr. Stacey Berg, professor of pediatrics and medical ethics at Baylor College of Medicine: "Not much happens right when you turn 18 13, but in the eyes of the law you're allowed to make really bad choices for yourself if you want to".

You might be thinking: "What's the big deal? Who cares if your 13-year old is free to make their own healthcare decisions?". Here's one example of how this could result in a big disconnect between an adolescent and their primary caregivers, and potentially a terrible outcome for everyone:

If an adolescent decides to being taking an SSRI, without informing their parents, there is some serious risk here. One adverse side effect of SSRIs is sometimes suicidal ideation and self harm, and the riskiest time period for this is the initial period (30-60 days). An adolescent is unlikely to receive the full/proper medical treatment, which involves a psychiatrist, who does an initial evaluation and then periodic dosage monitoring, but this is all logistically complex and adolescent psychiatrists are in extremely short supply, and so it's much more likely the primary care doctor will prescribe an SSRI without the involvement of a psychiatrist). If a parent doesn't know their adolescent has begun to take an SSRI, and they notice that maybe their young adult is feeling a little down, they might brush this off as "normal teenage emotional ups-and-downs", when what it might be is the onset of suicidal ideation. If they were informed, the parents might be inclined to ask the set of questions that gage the risk of self-harm, and then bring their kiddo to the ER for an emergency psych eval ... or, if left in the dark: they might just blow it off.

This scenario is incredibly real, and it's not just SSRIs, it's any pharmaceutical with side effects (which is all of them).

My difficulty with all of this is easy to articulate:

It seems unethical to ask parents to be both legally responsible for an adolescent as well as responsible for "the implementation and support services around their adolescents medical care" (e.g.: filling prescriptions, driving them to appointments, paying for surgery, therapy, etc) while keeping them in the dark on major healthcare decisions.
The Inconsistencies Involved are Revealing

As it turns out, there are some pretty interesting inconsistencies that parents will encounter as they try to navigate this mess. In some areas of medicine, we really do treat 13-year olds like adults, and in others, we definitely don't. What I find fascinating is that within some of these are tacit admissions that we don't believe our 13-year olds are ready to take control of their healthcare decisions.

Back to my original question: have we decided 13-year olds are sufficiently wise, mature, and informed to make critical and important decisions ... or have we not? (And why is biological age the only determinant?)

Things We Might Do With Our Adolescents If We Were Sane

A more rational approach might include a gradual step-up in terms of which healthcare-related decisions our adolescents can make. We already gradually grant adolescents more age-appropriate decision-making power over time in a number of key areas (e.g.: academic freedom, or socialization), so why don't we do something similar for healthcare?

It's well-understood that the teenage brain is still developing, and therefore can lack self-control, can be sensitive to rewards, and is sensitive to social evaluation. In short: it's still developing, and will not reach full maturity until approximately age 25. This implies that a teenager could make a permanent healthcare decision based on a brain chemistry that values instant gratification and where social pressure plays an outsized role. That seems like something that should be considered in the context of medical decisions.

If we already step-up the freedoms (and responsibilities) of our teens in other areas, why don't we do something along the lines of:

It would be helpful to allow our adolescents to begin to flex their decision-making skills on medical issues in areas that won't harm them (e.g.: permanent medical decisions that they might regret later), and gradually allow more freedom over time.

Suffice it to say: between the "one size fits all" biological-age criteria and the lack of any gradual/nuanced/step-based approach to allowing our adolescents to begin to make medical decisions, we're faced with a very broken system.

Topic #2: The House Bill Responsible For Endless Confusion About Parental Rights

In 2019, the Washington State legislature passed a bill called the Adolescent Behavioral Health Care Access Act. This bill contains impressively confusing and contradictory language. It is literally the case that no one understands how this law should work in practice (including the dozen or so attorneys I contacted to help explain it to me), and the WA State HCA, which is responsible for implementing the law for Apple Care recipients is largely, if not wholly, unresponsive to requests for clarification (as is the WSHA).

The simple question I attempted to find an answer for was: "Do parents have any rights to access any information pertaining to their adolescents mental health counseling?"

Before I Get Too Far: A Quick Clarification

Before I get too far, I'd like to clarify that I was seeking high-level parental-support information, e.g.: from a parenting strategy standpoint, how can I better support my adolescent as they face an increasing number of challenge.

I'm not looking for psychotherapy notes. I don't want to know what my adolescent talks about with their counselor. I don't want access to private medical information about my adolescent. I fully respect my kids right to privacy.

As you'll see, this bill contains text that suggests that exactly this kind of information is available to parents... and it could be wickedly helpful (e.g: "coaching on parenting or behavioral management strategies" for "crisis prevention planning and safety planning").

That's the kind of information that would be incredibly helpful, and the person who is arguably the best able to provide it is my kids counselor: after all, they're the one who is working to become a de facto expert on my kid and their risks, challenges, and strengths.


Here's one example: it would appear to be the case that mental health professionals should provide information to parents (the following excerpt is from the bill's digest):

Authorizes mental health professionals to provide certain treatment information to a parent or legal guardian who is involved in the treatment of the adolescent when the mental health professional believes that sharing this information would not be detrimental to the adolescent.

And then it turns right around and says this (from the bill itself):

It is also the purpose of this chapter to protect the rights of ((minors)) adolescents to confidentiality and to independently seek services for mental health and substance use disorders.

So there's a conflict right away, and it doesn't get less confusing if you continue to read more in your quest for clarity. This bill appears to have two mutually-exclusive, contradictory goals:

  1. protect adolescent privacy during treatment
  2. open up some adolescent treatment information to parents

And the bill states each goal explicitly, and this contradiction has been echoed in the various articles and presentations about the bill, which has lead to a sort of "amplification" of the confusion. Consider this slide, from a presentation on the bill by the WA State Hospital Association:

"** Notwithstanding the law, there was significant confusion around providers’ authority to disclose information to parents without the minor’s consent and information was rarely shared with them[3]."

Keep that "information was rarely shared with them" quote in mind, as it's likely the implicit thesis of this entire article.

They also have a slide that says (page 21 of the presentation):

Adolescents’ Privacy & Sharing Treatment Information
Hint: Parents have rights, too*
* For some information, sometimes, depending on the circumstances.

How awful is that slide?. It sort of says "Parents Have Rights Too / No They Don't" on the same slide. This is what I mean when I say the confusion has been amplified, instead of clarified.

So Which One Is It: Do We Have Access to Treatment Information Or Do We Not?

The run-up to House Bill 1874 pointed out the obvious problems with WA States adolescent treatment, particularly in the area of mental health:

“I couldn’t form a relationship with the child’s therapist because it was only allowed to be one way. Once my children said, no, they didn’t want me to know what was going on or have me participating in any way,” Dolane says[4].

That's good stuff. It's well-understood that adolescents do better with mental health counseling when the family is involved (at least at a high-level / no one is asking for the psychologist notes, we're just hoping to engage in a very high-level conversation to know how we can better support our teens at home).

A Crosscut article from 2020 appears to give parents much hope. Consider this tantalizing quote from Kathy Brewer, manager of psychiatry at Seattle Children's Hospital:

"Providers in WA State are still stuck on this idea that 13-year-olds have to sign a release of information for a therapist to talk with a parent, and it's just not true" Brewer says[4].

And the following verbiage, also from that article, needs to be examined quite closely, given it's restating the same contradictory goals:

Teens still have rights when it comes to their medical records. Those details aren’t freely given. In cases where health and safety are at risk, it is up to the discretion of the provider to share medication and treatment reviews. The teen will be notified of the disclosure ahead of time. Parents now have access to treatment plans, medication suggestions, psycho-education on the child's mental health and parenting strategies[4].

"Parents now have access" vs "Teens still have rights / aren’t freely given / up to the discretion / will be notified".

Confused? I certainly am. That paragraph also seems to say "Parents have no rights to information [access is constrained by a hopelessly narrow scenario]" / "Parents now have access to information".

In my experience, parents have access to zero information. As it turns out, everything is up to the provider (including when to violate HIPPA). You can request information all you'd like, but you have no rights whatsoever as a parent to any information regarding your adolescent's mental health treatment.

If you're the parent of an adolescent, and you contact your kids therapist with a question, the most likely response will be "I can't discuss this topic (nor any others) with you."

You'll get [literally] nothing.

But what about Kathy Brewer (?):

"Providers in WA State are still stuck on this idea that 13-year-olds have to sign a release of information for a therapist to talk with a parent, and it's just not true" Brewer says.

Who is right? Why so many words indicating parents have access to treatment information next to words that say they don't?

And why does nobody mention an ROI, which is a legal mechanism to disclose information between a patient and a medical provider?

As We Dig Deeper, The Saga Continues: Let's Look at the Bill Itself

We can source the information from a PAVE article[5] about the bill itself. Here's reference from that article, which looks pretty tantalizing to me:

Providers have discretion in determining what information about mental health diagnoses and treatment is clinically appropriate to share with parents of an adolescent 13-17. A provider retains discretion in withholding information from family/caregivers to protect an adolescent’s well-being. In general, the Adolescent Behavioral Healthcare Access Act encourages sharing information to support collaboration between the clinical setting and home. Specifically, providers and families are encouraged to discuss:

But don't be fooled for even one second! As a parent, you'll get none of this information. The key phrase is "A provider retains discretion in withholding information". It's so broad ("to protect an adolescent’s well-being") that it's used like a weapon, just like HIPPA.

The above quote is well-intended .. it comes directly from the text of the bill itself:

(2) When an adolescent receives a mental health evaluation
or treatment at the direction of a parent under RCW 71.34.600
through 71.34.670, the mental health professional is
encouraged to exercise his or her discretion under RCW
70.02.240 to proactively release to the parent such information
and records related to solely mental health services received
by the adolescent, excluding psychotherapy notes, that are
necessary to assist the parent in understanding the nature
of the evaluation or treatment and in supporting their child.
Such information includes:
(a) Diagnosis;
(b) Treatment plan and progress in treatment;
(c) Recommended medications, including risks, benefits, side effects, typical efficacy, dose, and schedule;
(d) Psychoeducation about the child's mental health;
(e) Referrals to community resources;
(f) Coaching on parenting or behavioral management strategies;
(g) Crisis prevention planning and safety planning.

(3) If, after receiving a request from a parent for release
of mental health treatment information relating to an adolescent,
the mental health professional determines that disclosure of
information or records related solely to mental health services
pursuant to RCW 70.02.240(3) would be detrimental to the
adolescent and declines to disclose such information or
records, the mental health professional shall document the
reasons for the lack of disclosure in the adolescent's medical

Looks great, right?! Totally expecting to be able to have conversations about "psychoeducation about the child's mental health" and "coaching on parenting or behavioral management strategies" .. that's great stuff, and would be wickedly helpful.

This would be ideal in the case where, your adolescent has threatened self-harm, or has expressed suicidal-ideation, and as a parent, you're looking for some "coaching on parenting or behavioral management strategies" to help with "crisis prevention planning and safety planning". Perfect! Let's talk!

After all: aren't we all in this together? Isn't a counselor who is invested in the health and well-being of an adolescent invested in this ALL OF THE TIME? Or does care end as soon as the kid steps out of the counselor's office?

Turns out: no. You'll get nothing.

Go ahead and ask your adolescent's counselor for any of that information, and feel free to include the house bill text itself. Send along the Kathy Brewer quote if you'd like. I guarantee you'll get nothing.

Want to get hopeful again? Check this out, from the bill itself:

Additionally, all mental health care and treatment providers shall assure that minors' parents are given an opportunity to participate in the treatment decisions for their minor children. The mental health care and treatment providers shall, to the extent possible, offer services that involve minors' parents or family.

You'd do best to forget you ever read that, as it's universally ignored by the mental health community.

Is There Any Clarification Here? Perhaps a Light At the End of the Tunnel?

I never got to the bottom of this one. I definitely tried. I tried to get clarification in the following ways:

Here's my understanding of what's going on:

The key is that any/all disclosures need to fall under Family Initiated Treatment (FIT), and outside of FIT, there are no disclosures. The bill as written caps FIT at 3 months or 12 visits, so, after that time, the information gates are automatically shut.

Even during FIT, medical providers can "run out the clock", knowing there is no recourse for a parent if the provider fails to comply with House Bill 1874 (and finding an attorney who is conversant in this bill is nearly impossible).

The bill also seems to tie release of information to (a) just the initial evaluation itself and (b) only when initiated by the parent. So, disclosure is effectively limited to a single instance of time, and that's right after a mental-health crisis.

Let's go back to Kathy Brewer:

"Knowledge is slow to get out in both providers and families say says. There are several aspect to the bill, but Brewer says the most misunderstood one is the release of information.

Am I misunderstanding? Or are other people? (Or are all of us misunderstanding?) It sure would be nice to know.

In the meantime, the "significant confusion" about providers’ authority to disclose information to parents without the minor’s consent is in full effect, and indeed, information is rarely never shared with them.

I'm Left With One Major Question

Why is it that I can't get a reasonably consistent and straightforward answer to my question?

It seems like an incredibly important question: so important that an entire piece of legislation was crafted to address/clarify it. It's well-understood that there's a lot of confusion here, so why hasn't anyone attempted to clarify it? And why does the mental health community seem to hostile to the idea of sharing information that will benefit the adolescent, the parents, and the families involved?

What's not helping is that the bill states, in multiple instances, that everything it up to the provider's discretion, which allows what I call "the weaponization of HIPPA", which is when a provider yields HIPPA like a weapon to separate "US from THEM" (parents from adolescents), much to the detriment of all involved.

One reference that I think is arguably the most clarifying is on page 23 of the WSHA presentation on House Bill 1874. It says, applying to "Release of treatment information or records", for "Adolescent initiated treatment" for "Solely mental health":

A mental health professional should not proactively release information to a parent unless the adolescent states a clear desire to do so unless:

Provider discretion. If a mental health professional (MHP) intends to disclose information to a parent, the MHP must:

  1. Give the adolescent advance notice
  2. Provide the adolescent a reasonably opportunity to express concern
  3. Document any objection by the adolescent in his or her medical record

So, this says a mental health professional should not disclose anything unless (a) the adolescent wants to (b) the adolescent has been given advance notice, and the default stance of the counselor to not share anything.

To me, this may not line up with either the text of the spirit of the law, but it's the closest to describing the current implementation of the law (as poorly implemented as it is).

Now you know why we're hovering around 39 (out of 51) for Youth Mental Health. We could be doing so much better, and part of that is to stop using HIPPA like a weapon, stop making the most negative possible assumptions about parents, and start to open up some conversations, instead of shutting them down.

Adolescent mental health isn't "US vs THEM".

Nor is it a zero-sum game.

Adolescent mental-health counselors are not attorneys representing their clients.

HIPPA was never intended to be weaponized for use against families trying to support their adolescents.

A good start would be making it so at least parents are able to understand their rights, and the next step would be to help facilitate conversations within families, instead of putting up barriers to any/all conversation.

[1] Washington state allows minors 16 and older to petition to court for emancipation. An emancipated minor is legally considered an adult and may enter into contracts ...
[2] In general, employees must stand years 14 of age or older to work in the State of Washington. Individuals thirteen years of age and younger may work for a family business, provided the minor does not perform prohibited duties.
[3] Understanding the Adolescent BehavioralHealth Care Access Act (E2SHB 1874)
[4] 'It affects the entire family': Washington parents now work alongside teens in mental health recovery
[5] Adolescent Health Care Act Provides Options for Families Seeking Mental Health and Substance Use Help for Young People Resistant to Treatment