Adolescent Health Care Act Provides Options for Families Seeking Mental Health and Substance Use Help for Young People Resistant to Treatment

A Brief Overview

  • The Adolescent Behavioral Health Care Access Act, passed into law by the Washington Legislature in 2019, gives parents and providers more leverage in treating a young person who will not or cannot independently seek medical help for mental illness and/or substance use disorder.
  • The Washington State Health Care Authority (HCA) hosts website links with information about the new law, which allows Family Initiated Treatment (FIT). The landing page includes an email address: hcafamilyinitiatedtreatment@hca.wa.gov.
  • Enactment of FIT is a project of the state’s Children and Youth Behavioral Health Work Group. CYBHWG supports several sub-work groups, including one focused on school-based services and suicide prevention. Information group membership, public meetings, resources, events and training is available through a dedicated HCA website page.
  • A place to connect with other families concerned about these topics is a Facebook group called Youth Behavioral Healthcare Advocates (YBHA-WA).
  • If a person ages 15-40 is newly experiencing psychosis, Washington offers a wraparound-style program called New Journeys. This website link includes access to a referral form.

Full Article

Getting mental health help for a youth in crisis can be complicated, frustrating, and frightening.

Mental Health America ranks states based on the incidence of mental illness and access to services. The 2021 youth rankings list Washington 35th in the nation. Various measures indicate a high prevalence of major depression, substance use disorder, and/or emotional disturbance as a category of disability on the Individualized Education Program (IEP). Barriers to treatment consider insurance as well as availability of services.  

The 2021 indicators show Washington has risen since 2020, when the youth ranking was 43rd nationally. However, overall statistics are dire, indicating the COVID-19 pandemic has worsened mental healthcare conditions and treatment access across all age groups and states. “Youth mental health is worsening,” the data shows. “Even in states with the greatest access, over 38 percent are not receiving the mental health services they need. Among youth with severe depression, only 27.3 percent received consistent treatment.”

Sometimes a barrier to treatment involves a complicated balance of youth autonomy and parental responsibility. The most severe psychiatric conditions often include a symptom called anosognosia, which blocks the brain’s ability to see the impairment or understand why professional help could be of benefit. In youth whose brains are still forming, symptoms that impact insight and choice-making are particularly problematic.

New Journeys is an option when psychosis is present

Sometimes anosognosia co-occurs with psychosis, which indicates a person has lost touch with reality. Delusions and hallucinations may be present. If a person is newly experiencing psychosis, Washington offers a wraparound-style program called New Journeys: This link provides access to information for clients and families and includes an online referral form.

Causes of psychosis are the subject of ongoing research, but some theories suspect the brain is trying to make sense out of a world that does not make sense. Synapses fire errantly, and the brain tries to organize them into stories to calm itself. Synaptic loops get built during these firestorms of neural activity, and the stories that emerge become reality to the person whose brain is narrating the experience, even if they are untrue or grounded in false perceptions. Choice-making in the empirical world is often compromised.

Family education about psychosis is an aspect of New Journeys, which is for youth and adults ages 15-40 who have experienced psychotic symptoms for more than or equal to 1 week and less than or equal to 2 years. Staff from the University of the Washington contribute support to the state’s New Journeys program, which is offered in various but not all regions of the state.

UW staff also support a program called Psychosis REACH, which provides evidence-based skill-building for relatives and friends of individuals with psychotic disorders. The practices are based in cognitive behavioral therapy (CBT). The program’s website includes information about training opportunities and resources.

Age of Consent in Washington is 13

In Washington State, the age of medical consent is 13. That means that a person 13-17 years old can independently seek medical treatment, without the consent or knowledge of parents.

Age of consent laws also have meant that Washington youth could say no to behavioral health treatment, regardless of whether parents and providers agreed that such treatment was necessary to protect the safety and well-being of the adolescent. Exceptions are made when there is a threat of imminent danger or grave disability due to psychiatric deterioration. Read on for more information about involuntary treatment/commitment.

The Adolescent Behavioral Health Care Access Act, passed by the Washington legislature in 2019, gives parents and providers more leverage when a young person is struggling with behavioral health and does not independently engage with treatment. The law allows parents/caregivers to bring a youth, ages 13-17, to a provider for evaluation without requiring consent from the youth. The law includes elements introduced by the state Senate and House of Representatives, which originally titled the bill as HB 1874. In 2020, passage of HB 2883 added residential treatment as an additional option under Family Initiated Treatment (FIT).

The law does not limit an adolescent’s ability to initiate treatment on their own.

Parents have felt shut out of their teenager’s care

January 8, 2020, article in Crosscut profiles several families impacted by the new law. “Until the new law,” the article states, “parents often were shut out of their teenager’s care and treatment plans and couldn’t push a teen toward necessary outpatient or inpatient care without their consent.”

Passage of FIT marks a win for the Children and Youth Behavioral Health Work Group, which studied and reviewed recommendations from a stakeholder advisory group authorized by the 2018 legislature. Final language in the law was impacted by family members, youth, clinicians, hospital staff and many others who met dozens of times.

“Parent” is broadly defined, and information sharing is more open

Under the law, the definition of parent is expanded to include a wide range of family caregivers, guardians and others who have authority to initiate treatment. The Revised Code of Washington (RCW 9A.72.085) provides standards for “subscribing to an unsworn statement” that can apply to a caregiver initiating treatment. 

The law enables providers to share information with parents without an adolescent’s consent, if the provider determines that information sharing with family is in the best interests of the adolescent patient. A list of information-sharing guidelines is included below.

Note that parents retain the right to make medical decisions for children younger than 13, and adults 18 and older are responsible for medical decision-making if there is no guardianship.

In accordance with RCW 71.34.375, providers are required to provide notice to parents of all available treatment options, including Family Initiated Treatment. The state Health Care Authority provides a fact sheet to clarify those requirements.

Family-Initiated Treatment (FIT)

The FIT law allows a parent/caregiver to escort their adolescent child to certain licensed behavioral health facilities and request that a professional person examine the adolescent to determine whether treatment is medically necessary. That treatment might include outpatient, inpatient, or residential care.

According to the Health Care Authority (HCA), FIT is not a guarantee of immediate services and no provider is obligated to provide services under FIT. Each provider has processes, procedures, and requirements pertaining to evaluation and admission to services. However, the only reason for not providing services cannot be the youth’s lack of consent (RCW 71.34.600).

If a facility covered by this law does not have a professional person available to perform the examination, the facility is not required to make staff available on demand. Additionally, if the professional determines the adolescent needs in-patient treatment but the facility does not have a bed available, the facility is not required to make a bed available. Included are those facilities that house children and youth under the Children’s Long-term Inpatient Program (CLIP). CLIP beds are generally subject to a waiting list and a multi-step referral process.

According to staff at Washington’s Health Care Authority, the COVID-19 pandemic and capacity limitations within the behavioral health system have hindered many providers from fully developing processes to implement the law. Families are encouraged to contact providers before taking an adolescent to a facility to determine if the provider has the capacity or ability to perform an assessment.

FIT in a community setting

If medical necessity is found by an outpatient provider who evaluates a young person brought into care through FIT, the provider is limited to 12 sessions over 3 months to attempt to work with the adolescent. If the young person still refuses to engage with treatment, then the period of Family-Initiated Treatment with that provider ends. The family at that point could seek treatment elsewhere.

State laws continue to encourage autonomy for young people, despite recognition that family involvement is important. According to the Revised Code of Washington (RCW 71.34.010):

 “Mental health and chemical dependency professionals shall guard against needless hospitalization and deprivations of liberty, enable treatment decisions to be made in response to clinical needs in accordance with sound professional judgment, and encourage the use of voluntary services. Mental health and chemical dependency professionals shall, whenever clinically appropriate, offer less restrictive alternatives to inpatient treatment. 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.”

For children and youth with Medicaid, the Wraparound with Intensive Services (WISe) program is Washington’s most intensive option for outpatient care. The Health Care Authority (HCA) maintains a website page with information about WISe in multiple languages. Families can discuss their options for FIT with WISe staff and leadership at HCA.

FIT in a hospital setting

An inpatient or residential facility can detain the adolescent under Family-Initiated Treatment (FIT) if medically necessary for a mental health condition. In these settings, FIT may last up to 30 days. Then the adolescent must be discharged, unless:

  • they agree to stay voluntarily, or
  • a designated crisis responder (DCR) initiates involuntary commitment proceedings

The Involuntary Treatment Act (ITA) can apply to persons of any age who are determined to be gravely disabled or at imminent risk of harm to self, others, or property. Under Ricky’s Law, community members of any age who are a danger or gravely disabled due to a drug or alcohol problem may beinvoluntary detained to a secure withdrawal management and stabilization facility—also known as secure detox.

For substance use disorder treatment, due to Federal Privacy Laws, a parent/caregiver can only provide consent for an assessment. The youth would have to consent to the results of the assessment being shared with their parent/caregiver and volunteer for ongoing treatment if it is deemed medically necessary.

Guidance for Information Sharing

Federal law, 42 CFR Part 2, restricts information sharing related to substance use, and clinicians cannot share that information without a patient’s written consent, regardless of whether the substance use co-occurs with mental illness.

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, however, 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:

  • Diagnosis
  • Treatment Plan and Progress
  • Recommended medications, including risks, benefits, side effects, typical efficacy, dosages, and schedule
  • Education about the child’s mental health condition
  • Referrals to community resources
  • Coaching on parenting or behavioral management strategies
  • Crisis prevention planning and safety planning

To support family caregiving for individuals of all ages, the Washington State Hospital Association provides general guidance about exceptions to federal confidentiality laws (HIPAA): Permitted disclosures of mental health information and substance use disorder information without patient consent.

Resources

The  Health Care Authority (HCA) provides a range of information about behavioral health services for children and youth, including this downloadable resource: Parent’s Guide to Family Initiated Treatment.

Families can direct specific questions to: hcafamilyinitiatedtreatment@hca.wa.gov. Please note that this business email is not intended for crisis response.

An agency called CaseText organizes links related to Family Initiated Treatment for direct access to various statutes.

Adolescent Health Care Act Provides Options for Families Seeking Mental Health and Substance Use Help for Young People Resistant to Treatment

A Brief Overview

  • The Adolescent Behavioral Health Care Access Act, passed into law by the Washington Legislature in 2019, gives parents and providers more leverage in treating a young person who won’t or can’t independently seek medical help for mental illness and/or substance use disorder.
  • The Washington State Health Care Authority (HCA) in March 2020 launched several website links with information about the new law, which includes an option for Family Initiated Treatment (FIT).
  • The Washington State Hospital Association on July 9, 2019, provided a slide presentation describing the law’s history and its primary features.
  • A place to connect with other families concerned about adolescent mental healthcare access in Washington State is a group called Youth Behavioral Healthcare Advocates (YBHA-WA) on Facebook. Included on the page are handouts that summarize key aspects of the new law. 

Full Article

Getting mental health help for a youth in crisis can be complicated, frustrating and frightening.

Mental Health America ranks states based on the incidence of mental illness and access to services. The agency’s 2020 rankings list Washington in the 43rd position, based on various measures that indicate a higher prevalence of mental illness and lower rates of access to care.

Often a barrier to treatment is the youth, who may not be able to see a problem or want to get professional help. Parents often struggle to navigate systems that must balance a young person’s autonomy with concern that they may not be able to make good decisions because of their development, specific illness circumstances or symptoms that impact the brain.

In Washington State, the age of medical consent is 13. That means that a person 13-17 years old can independently seek medical treatment, without the consent or knowledge of parents.

Age of consent laws also have meant that Washington youth could say no to mental health or substance use treatment, regardless of whether parents and providers agreed that such treatment was necessary to protect the safety and well-being of the adolescent.

A law passed by the Washington legislature in 2019 gives parents and providers more leverage when a young person is struggling with a mental illness or substance use disorder and won’t independently engage with treatment. The law does not limit an adolescent’s ability to initiate treatment on their own.

A January 8, 2020, article in Crosscut profiles several families impacted by the new law. “Until the new law,” the article states, “parents often were shut out of their teenager’s care and treatment plans and couldn’t push a teen toward necessary outpatient or inpatient care without their consent.”

The Adolescent Behavioral Health Care Access Act enables parents/caregivers to bring a child for inpatient or outpatient treatment without requiring consent from the child, ages 13-17. The law includes elements introduced by the state Senate and House of Representatives, which originally titled the bill as HB 1874.

Passage of the law was a win for the Children’s Mental Health Work Group, which studied and reviewed recommendations from a stakeholder advisory group authorized by the 2018 legislature. The final version of the law included input from family members, youth, clinicians, hospital staff and many others who met dozens of times. A June 13, 2019, slide presentation available online provides additional history and detail about the work group and its recommendations: Family Initiated Treatment and Engaging Families in Treatment of Youth. The webinar with sound is available on YouTube.

The 2020 legislature is considering amendments to the law, and the Children’s Mental Health Work Group continues to meet to consider proposals to clarify provisions that relate to residential treatment and referrals for Wraparound with Intensive Services (WISe).

“Parent” is broadly defined

The 2019 law expands the definition of parent to include a wide range of family caregivers, guardians and others who have authority to initiate treatment. The Revised Code of Washington (RCW 9A.72.085) provides standards for “subscribing to an unsworn statement” that can apply to a caregiver initiating treatment. 

Note that parents retain the right to make medical decisions for children younger than 13, and adults 18 and older are responsible for medical decision-making if there is no guardianship.

A substantive change with the 2019 law is that providers may share mental health information with parents without an adolescent’s consent, if the provider determines that information sharing with family is in the best interests of the adolescent patient. A list of information-sharing guidelines is included below.

How Family-Initiated Treatment Works

If a parent/caregiver believes that an adolescent requires mental health or substance use disorder treatment, the adult can escort the young person to an inpatient or outpatient treatment facility even if the adolescent doesn’t readily agree to go.

A provider will assess the adolescent and consider information from the family to determine whether treatment is medically necessary. An adolescent’s refusal to engage with the provider cannot be the sole basis for refusing to treat.

An inpatient facility can detain the adolescent under Family-Initiated Treatment (FIT) if medically necessary. Note: another option could be detention under the Involuntary Treatment Act (ITA), if the adolescent is determined to be gravely disabled or at imminent risk of self-harm or harm to others.

If medical necessity is found by an outpatient provider, a counselor is limited to 12 sessions over 3 months to attempt to work with the adolescent. If the young person still refuses to engage with treatment, then the period of Family-Initiated Treatment with that provider ends.

State laws continue to encourage autonomy for young people, but family engagement is encouraged. According to the Revised Code of Washington (RCW 71.34.010):

 “Mental health and chemical dependency professionals shall guard against needless hospitalization and deprivations of liberty, enable treatment decisions to be made in response to clinical needs in accordance with sound professional judgment, and encourage the use of voluntary services. Mental health and chemical dependency professionals shall, whenever clinically appropriate, offer less restrictive alternatives to inpatient treatment. 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.”

Guidance for Information Sharing

Federal law, 42 CFR Part 2, restricts information sharing related to substance use, and clinicians cannot share that information without a patient’s written consent, regardless of whether the substance use co-occurs with mental illness.

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:

  • Diagnosis
  • Treatment Plan and Progress
  • Recommended medications, including risks, benefits, side effects, typical efficacy, dosages and schedule
  • Education about the child’s mental health condition
  • Referrals to community resources
  • Coaching on parenting or behavioral management strategies
  • Crisis prevention planning and safety planning

Information about state laws related to Behavioral Health Services for Minors is available through the Washington State Legislature website under RCW 71.34.

Information about child and youth behavioral health services in Washington State is available from the Health Care Authority (HCA).

Children’s Long-Term Inpatient Program (CLIP) Provides Residential Psychiatric Treatment

A Brief Overview

  • CLIP serves children ages 5-18 by providing residential mental-health treatment for a long-term stay that usually lasts 6-12 months. Read on for more information about CLIP eligibility and how to initiate a referral.
  • Governor Jay Inslee in December recommended $675 million in new funding for behavioral health improvements statewide, and policymakers are working on a variety of bills during the 2019 legislative session. Families can contact lawmakers to participate in advocacy.
  • The state has a Stakeholder Advisory Group discussing issues related to Parent-Initiated Treatment. A group of engaged parents participates in a conversation on a Facebook page called Support SB 5706.
  • Studies show that 1 in 5 children will suffer from mental illness. PAVE has additional articles and webinars about mental health education in school, suicide and Social Emotional Learning.

Full Article

Families have few options to help a child with a psychiatric illness that makes in-home, community-based care unworkable. Local hospitals are designed to provide crisis care and generally do not keep a patient for mental health treatment and recovery beyond a few days or weeks. Sometimes those short hospitalizations are not long enough to offer true stability that allows a child to return to school and life with successful outcomes.

One choice is to apply for the Children’s Long-Term Inpatient Program (CLIP), a state program that manages 89 beds in five locations throughout Washington. Most CLIP referrals are for children with Medicaid—public health insurance. Families with private health insurance have access to CLIP but may be referred first to private facilities for long-term, inpatient care. Medicaid is the payer of last resort.

Who is Eligible for CLIP?

  • Youth ages 5 to 18
  • Legal residents of Washington State
  • Youth diagnosed with a severe psychiatric disorder
  • Youth possessing a risk to themselves or others
  • Youth who warrant care under the supervision of a psychiatrist because of grave disability due to psychiatric illness
  • Youth who are not successfully treated through community-based mental health resources

CLIP serves children ages 5-18 by providing residential mental-health treatment for a long-term stay that usually lasts 6-12 months. Please note that eligibility for CLIP ends on the child’s 18th birthday.

Parents/legal guardians engage with the treatment team while the child is at the CLIP facility. The goal is to help the child stabilize and provide the family with the tools needed for a successful return to the home, school and community. Children attend school while at CLIP, and teachers manage any Individualized Education Program (IEP) or Section 504 plan that travels with the student from the local district.

Parents and legal guardians can refer children to CLIP by applying through one of the regional committees positioned throughout the state. Contact information for regional committee leadership is available through the CLIP website. The regional committee meets with the family to discuss the case and determine whether to refer the case to the CLIP Administration for review. The state committee then determines whether to approve the case for CLIP. Sometimes a child is put on a waiting list for an available bed.

Please note that families need an organized set of medical and school paperwork to complete CLIP applications. Refer to PAVE’s article about document management for guidance about how to create a care notebook or other filing system for this and other purposes.

The regional CLIP committee includes care providers from managed care organizations and other agencies that may provide additional support and resources to the family, regardless of whether a CLIP referral is recommended. Generally, the committee determines that all community-care options have been exhausted before recommending a more restrictive placement through CLIP. The team will also make a recommendation based on whether the child is likely to benefit from the therapeutic program, which is mental-health based and may not be a good fit for an individual with a severe form of developmental or intellectual disability.

The largest CLIP facility is the Child Study and Treatment Center (CSTC) in Lakewood, adjacent to Western State Hospital. CSTC provides 47 beds in cottages that house children in groups by age. Additional options include:

  • Burien, Sunstone Youth Treatment Center: 10 beds
  • Tacoma, The Pearl Street Center: 12 beds
  • Spokane, the Tamarack Center: 16 beds
  • Yakima, Two Rivers Landing: 4 CLIP beds in a facility with 16 total youth beds

Parents can initiate a referral, but children over Washington’s Age of Consent (13) must volunteer to go to a CLIP facility unless a county Designated Crisis Responder (DCR) determines the child meets the state’s criteria for a 180-day commitment under the Involuntary Treatment Act (ITA). Any persons over the age of 13 in Washington must be imminently threatening to harm themselves or others or be severely gravely disabled, in a state of extreme psychiatric deterioration, to receive an ITA admission to any inpatient facility.

Wording from Washington’s gravely disabled statute is as follows: “Manifests severe deterioration in routine functioning evidenced by repeated and escalating loss of cognitive or volitional control over his or her actions and is not receiving such care as is essential for his or her health or safety.”

State lawmakers are engaged in work to consider changes to the ITA law, and families are invited to contact policymakers if they have thoughts or concerns to share about this initiative or other activities related to treatment access, Age of Consent laws or Parent-Initiated Treatment. Governor Jay Inslee in December recommended $675 million in new funding for behavioral health improvements statewide.

CLIP is funded with state and federal dollars. A child’s Medicaid case manager through a Managed Care Organization (Molina, Community Health Plan of Washington, Coordinated Care, Amerigroup or United Healthcare) can provide guidance about CLIP applications. Families also can request further information from a care management team through the Wraparound with Intensive Services (WISe) program, which provides outpatient care coordination for children with intensive psychiatric needs in various Washington communities. A CLIP referral often happens because WISe was unable to help the child stabilize in the home.

WISe is managed through the state’s Health Care Authority, and HCA is another source for information about various options for mental healthcare for Medicaid-eligible children, youth and families. Families can reach out to the HCA for further information.