Rula's clinical quality practice guidelines: minors in treatment

Definitions

Minor: any child or adolescent who is between the ages of 5 and 17 who is not legally responsible for themselves

Emancipated Minor: a person who is not of legal age who has been identified, usually by court action, that they are self-sufficient and their own legal guardian.

Legal Guardian: person(s) or entity responsible for minors who are able to consent to treatment services

 

Rula’s Position on Minor Consent

It is recognized that there are varying state laws regarding a minor’s ability to consent to mental health and/or substance use treatment. While some states recognize that certain minors can seek treatment without parental consent, it is the practice pattern of Rula and the Group not to accept minors into treatment without parental consent. There may be exceptions to this upon review by the Head of Clinical Care. Currently, assessments and treatment to minors aged 5-17 can be provided with parental consent.

We require the consenting parent/guardian to be present at the first appointment with a minor child between the age of 5-12 to confirm medical decision making authority. While Rula has notified parents/guardians of children of this requirement, providers should consider contacting the guardian of a minor client prior to a scheduled appointment to inform them of this expectation and if necessary, to confirm consent.

If a parent/guardian is not present for the first visit with a child, providers should: 

  • Ask the child if their parent/guardian is present in the home and able to join; 
  • If a parent/guardian is not able to join, end the session with the child and 
  • Contact the parent/guardian to see if they are able to join the session within the next 10 minutes. If yes, you may continue (90791 sessions are a minimum of 16 minutes). If not, a no-show fee may be applied.

It is recommended and considered best practice to have the parent of a 13-17 y.o. present during the first session, although this is not required. 

 

Informed Consent and Medical Decision-Making Authority

It is the legal responsibility of the consenting parent to ensure that the appropriate parties have agreed for a minor to receive treatment at Rula. We specify in our registration process that the parent must address if a custody arrangement is present.

Intact Family

Generally, in an intact family (two biological/adopted parents) only one parent needs to provide consent prior to or at the minor’s first session. It is recommended that the therapist seek the consent of the other parent and ensure that the other parent is aware of treatment; however, it is not required. Both parents can attend individual and/or family therapy sessions of the minor.

Separated/Divorced Family

Reasonable steps should be taken to determine which parent has the legal authority to consent to mental health and/or substance use treatment of the minor. It is the responsibility of the parent entering the minor into treatment to notify the other parent of the treatment. Rula includes the following language during the consent process, as determined by our legal counsel: if parents are divorced, parents need to follow custodial arrangements on who is permitted to consent to medical care for the minor. The parent has attested to this statement at the time of consent, prior to the appointment.

Consent is usually determined in the divorce decree or custody court paperwork. Many times court paperwork does not specify “mental health” or “substance use treatment,” but it is assumed under “medical treatment.”

If the parents share joint legal custody, usually they share the right to make healthcare decisions for the minor. Either parent alone may consent to the minor’s treatment (unless specified as above). In rare cases, the custody court order may specify that both parents must consent to treatment.

If one parent has sole custody, they alone have the right to make healthcare decisions for the minor and can consent to treatment without the other parent’s consent.

If the provider learns through the course of treatment or otherwise that the non-medical decision making parent consented to treatment, the provider will pause treatment until the parent who has medical decision making authority can consent to continued treatment.

Non-Biological Parents/Other Legal Guardians

At this time, non-biological parents (stepparents) may not consent to treatment of a minor unless they have legally adopted the minor, or become the minor’s legal guardian, or are acting in loco parentis. If permitted by the client and biological parent, the non-biological parent may attend the client’s individual or family therapy sessions.

Foster parents, in most cases, are not considered legal guardians of a minor. However, they are responsible for the health, wellness, and care of the minors in their custody. Foster parents may have the legal right to seek treatment for the minor; however, this should be confirmed via court order paperwork and/or seeking permission from the state Department of Human Services.

Other Situations

Emancipated minors may seek and consent to treatment as long as they provide court documentation of their emancipation prior to or during the first scheduled session. Other types of minors may consent to their own treatment in special circumstances. Any special circumstances that arise need to be addressed with the Head of Clinical Care.

Legal Guardianship

A legal guardian has the same authority to consent to medical treatment for a minor as a parent would have. A provider would need to obtain documentation (court paperwork) that identifies the legal guardian of the minor and verify the identified legal guardian is consenting to the minor’s treatment.

State Law

State laws may vary on who can consent to a minor’s treatment. If there are questions about state specific laws regarding consent that are not addressed specifically in this guideline, the Rula Compliance Officer should be consulted at privacy@rula.com.

 

Medical Records Access

Generally, HIPAA offers no protection to minors and requires healthcare providers to release a minor patient’s medical records to the child’s parent or guardian upon request. The Privacy Rule generally allows a parent to have access to the medical records about his or her child, as his or her minor child's personal representative when such access is not inconsistent with State or other law.

Unless a biological parent’s rights have been terminated or there is information in the minor client’s record that could reasonably be harmful to the minor child if the information was released, both biological parents will have the right to access the minor client’s medical records regardless of who signed consent for the minor.

Anyone who is not the legal guardian or biological parent of the minor is not permitted access to the minor’s medical records and is not to be given information regarding the minor’s treatment, unless an authorization form is signed by the parent or legal guardian is obtained. If a minor is in foster care, the State Department of Human Services is the identified legal guardian of the minor and can have access to the minor’s medical record.

 

Confidentiality

The right to confidentiality in treatment sessions is oftentimes connected to the right to consent to treatment. Providers should have a discussion with the parent and the minor regarding confidentiality and limits of confidentiality during the first session and periodically throughout treatment.

Providers and Rula team members are able to share appointment information and billing information with either parent who has medical decision-making authority, as described in the previous section. A release of information is not required to share this information with the parent or guardian.

One of a therapist’s most important ethical duties when treating minors is to discuss and address confidentiality concerns with both the parent(s) and the child. The therapist should be clear about the law, Rula’s policy, and their own confidentiality practices. Some important aspects of confidentiality to cover with the minor and consenting parent (and others involved in the patient’s care):

  • The steps the therapist takes to protect the minor’s privacy. This includes information from the Notice of Privacy Practices and internal HIPAA privacy policies. 
  • The circumstances under which a therapist would disclose information to the parent(s) that the minor shared in therapy.
  • The importance of confidentiality in therapeutic settings. When parents understand that confidentiality is key to effective treatment, they may be more willing to respect their child’s need for privacy. This includes allowing the minor a confidential space to engage in the treatment session with the provider.
  • The benefits of open communication between a parent and the minor. When parents understand the importance of open communication and confidentiality of their child’s sessions, it can encourage better parent-child relationships.

Minor Assent

The purpose of obtaining a minor's assent is to inform them of what will happen during therapy sessions and what information may need to be shared with the minor’s parents during the course of treatment. Assent is not legally required in any state of practice or when practicing through Rula. Providers may obtain verbal assent from an adolescent or teenage minor, as it can be used as an opportunity to discuss Rula obligations and ensure the minor understands the potential for disclosure of some information with others. You may elect to review this process with a younger child, but will need to adapt the level of understanding.

As part of the assent process (typically conducted in the first session), the provider should also obtain agreement from the parent/guardian to respect privacy. Please use this minor/adolescent assent and parent/guardian agreement. The assent form is available as a web link in the EHR. You can copy that link and email it or share in the chat feature of the telehealth visit.

If you use this process, please acknowledge this in the initial assessment. However, it is not required.

 

Parental Involvement In Treatment

We require the consenting parent/guardian to be present at the first appointment with a minor under the age of 13. It is recommended for adolescents ages 13-17.

It is the expectation that parents/guardians and families be involved in the minor’s treatment unless otherwise contraindicated. Families of clients are collaborative partners in all aspects of planning, development, implementation, and evaluation of the minor’s behavioral health treatment.

 

Parental Notification of Appointments & No-Shows

The parent or parent(s) or legal guardian who consented to the minor’s treatment will be notified by the provider of the minor’s scheduled appointments. Providers are expected to reach out to the parent/legal guardian when a minor no-shows an appointment and will be responsible for payment of the no-show fee.

 

Children Under Age 13

Providing telehealth with children is different than with adolescents or adults. You will need to explain telehealth and confidentiality to a young child in a developmentally appropriate manner. You may want to consider offering shorter, more frequent, appointments with children who may have trouble participating for a full hour (i.e., 90832 for 16-37 minutes). Be sure to proactively manage expectations with parents and the child around technology issues that may arise. Have a plan for what you will do if the connection is lost during the session.

Tips for providing services to children in a telehealth environment:

  1. 1. Work with parents in advance to create a suitable environment for sessions. Make sure activities or materials for play therapy are available before starting the visit with young children. Be sure a child’s privacy is respected.
  2. Keep safety in mind and watch for signs of abuse. Noticing signs of abuse can be more difficult in a telehealth environment. For example, it may be more difficult for children to disclose abuse or neglect on a telehealth session if they are in the same environment with the individual who is abusing them, or if they are worried about disclosing on a telehealth session where they could be overheard by someone in the home.
  3. Incorporate movement such as stretching, yoga, shaking like a wet dog, or dance breaks to give antsy young clients a break.
  4. Give parents guidance on how to help their children manage emotions. Since you cannot be physically present if the child has a tantrum, you’ll need to prepare parents in advance with a plan on how you and the parent will support a child client when they experience difficult emotions during the session.

Training resources for working with minors:

  • For a comprehensive 46 min video on working with children via telehealth
    00:00
    46:39
  • Tips on telehealth with children can be found here

Creative ways to build rapport with children via telehealth:

  • Consider asking the child to share their favorite things and show you items from home or drawings.
  • Use activities that require minimal supplies from home
  • Many techniques for trauma-informed therapy with children — such as drawing a story to describe an event, asking them where they feel sensations or emotions in their bodies, using a thermometer to discuss their feelings, or playing games — work well in a telehealth environment.
  • “Play through the camera” by using play-based activities such as puppets and drawings.
  • Use interactive online features such as:
  • A resource guide on this topic is available for purchase here.

Note: Rula did not create any of these resources and does not endorse any particular site mentioned in this document. Most recommendations were provided by Rula providers who work with minors. These are listed here as an option for you to explore.

 

Appropriateness for Telehealth

Your initial assessment is the first place to assess if you believe the child is appropriate for telehealth. You will also need to reassess this once the child is engaged in care. A few situations that may present challenges to this mode of delivery include:

  • The child is unable to sit still to participate in the session. For example, if a client has Attention Deficit Hyperactivity Disorder (ADHD), and/or is hypervigilant they may be too distracted by various aspects of the video platform.
  • The child is not verbally engaging during sessions.
  • There is no one on-site to assist with the technology.
  • The provider has difficulties managing or containing the child’s intense client emotions during remote sessions and a parent is unable to support the child

Rula providers have the option of providing in-person care, although this is not always feasible due to the geographical spread of clients throughout one’s state of practice. To refer a child for in-person services, complete the HLOC request form (available as a web link in the EHR). Please speak with the parent/guardian about this recommendation prior to making a referral request.

 

Cultural Differences in Telehealth with Minors

Carefully pay attention to the verbal and nonverbal communication clues with minor clients, especially if technical challenges arise. Be aware that different speech patterns and communication styles may come across differently over a telehealth platform. Be aware that different cultural backgrounds will have different experiences accessing and responding to this technology; be respectful and patient as you and your client learn the best way to optimize treatment in a telehealth setting.

Be flexible and give children agency. Older children may sometimes find it easier to talk about difficult subjects with the camera turned off or by using the chat feature. Providing clients with options allows them to choose which method of communication feels best for them.

Most importantly, be mindful of your own unconscious bias with clients who are different from your background, especially if you have children of your own. Pay attention to how your own value and belief system may impact your work in making diagnoses, talking with parents, and your expectations of minor clients.

Note: See our Mandated Reporting Policy for additional information on this topic

 

Additional Resources

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