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:
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:
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.
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.
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:
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:
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?)
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.
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, 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):
And then it turns right around and says this (from the bill itself):
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:
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:
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):
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.
The run-up to House Bill 1874 pointed out the obvious problems with WA States adolescent treatment, particularly in the area of mental health:
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:
And the following verbiage, also from that article, needs to be examined quite closely, given it's restating the same contradictory goals:
"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 (?):
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?
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:
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:
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:
You'd do best to forget you ever read that, as it's universally ignored by the mental health community.
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:
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.
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:
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.
