Imagine you are a school counselor, principle, etc. at a public school. You are given the file for a middle school student, age 13, on her teacher’s suggestion that she may be depressed and at risk of self harm. It is also suggested that her relationship with her parents may be partially responsible for her state of mind. The teacher who referred the student to you bases this off direct observations, overheard conversations, and rumor.
Ignoring legal considerations - what are the ethics in play when it comes to evaluation and treatment, and the decision to let the parents know what’s going on? In loco parentis, should you offer mental health care services to children without parental consent?
As to more specific details, which you wouldn’t necessarily know until after interviewing the student (is it ethical to do so without parental consent?) - take your pick. Maybe the student is anxious about her body weight. Maybe she has high expectations and low grades, or was rejected from a club or team. Maybe she lives in a broken family and doesn’t feel like she’s wanted at home. Maybe it’s a drug problem. Maybe it’s a sex problem. Maybe it’s a traumatic disorder. Maybe it’s a case of gender dysphoria. Possibly a combination of any of these, or other things. But in each case the student is uncomfortable opening up to her parents… a fear of shame, or even retaliation. I would say sexual abuse by the parent is off-topic, but milder forms of physical (no marks) or emotional/psychological abuse are not.
One thing I will say, even if you personally don’t give two cahoots about the parent’s “right” to be a bad/horrible parent, if you don’t have a case strong enough for CPS there is always the chance that if you go too far, the parents may simply remove the child from your school. So you have to give that at least some consideration.
I will add as a given in this debate, that you don’t have a case strong enough for CPS to get involved.
What are the benefits of allowing such treatment without parental consent, versus the benefits of requiring parental consent?
Now that you’ve made that list: to whom do the benefits accrue?
I am concerned that the benefits of requiring parental consent accrue mostly to the parents, whereas the benefits of allowing treatment without parent consent accrue mostly to the child.
That said, I think the default should be to contact parents prior to any decision being made. There are certainly times not to go with the default (e.g., suspicion of parental abuse, and sometimes a child’s request for initial consultation without parental notification)–but absent a reason not to default, call the guardians.
The student will ask that you not involve the parents, at least at first, and may be reluctant to open up to anyone without such a guarantee.
But before we even get to the benefits of telling the parents what the school wants to do about her mental health, we have to decide about the initial interview between you (the counselor) and the student. Just going off the teacher’s referral - should the parents be there when you talk to the student? Should they know that a teacher thinks the student is at risk of self harm?
A child’s relationship with their parents is more often than not the reason for any mental health issues they might have. The more outside sources of support a child has the better, even if that means providing that support without parental involvement or parental consent.
My wife has been playing Fortnite with a young lady in England who is struggling with mental health, largely because her family and social support systems have failed her. My wife is literally one of the only positive influences in her life, and is trying to expand that positive influence to more people by streaming online. If my own kids were struggling the way she is and I have failed her the way her parents have, then I would want my kids to seek better support too.
As to the question of informing parents, in the case of the 13 year old I would defer to their preference. If they don’t want their parents to know they sought help, I wouldn’t tell them. I may encourage them to let me talk to their parents, or seek to meet with the parents independently without tipping them off as to why. Much younger than 13, say grade school age or younger, I would be more inclined to meet with both student and parents together and less inclined to keep parents out of the loop. The younger a kid is, the less you can rely on them being able to accurately communicate their situation.
Supposing you went through with the evaluation without parental consent. When it comes to mental health treatment you have a whole new set of concerns.
If we’re talking psychotherapy, the student needs to find time to attend the appointments. At 13 she can’t drive. Sessions could conceivably be worked into her school schedule, but don’t the parents have access to that? And other kids would talk. I personally struggle with what to tell the student if she has to come before or after school hours but doesn’t know what excuse to give her parents. Declining to tell the parents about mental health care is one thing, actively lying to them is another.
If we’re talking medications, how do you approach that? I don’t know where to start. I don’t want the kid hiding unmarked pills in her bathroom.
I don’t think we have to worry about surgeries or electric shock therapy for 13 year olds, and even if that was recommended by a licensed psychiatrist for a severe condition I think it would be strongly unethical without parental consent.
If we are talking about something like bipolar or major depressive, you also have to consider whether the parents would change their behavior if they knew about the diagnosis. If the evaluation shows that she’s at risk of suicide or self harm, is it really ethical to send her home without telling the parents? To me that seems to cross a line…
This seems to be a shortcoming of @Left_Hand_of_Dorkness’s framework, above. Aside from the question of parental consent for treatment, there is also the question of telling the parents about the diagnosis. I think most people would take a severe diagnosis of their child as a wake up call, but there are some, no doubt, who would deny the legitimacy of the diagnosis and become very angry with the school. How do you navigate that minefield, counselor?
I’m neither a parent nor a mental health worker nor a social worker, so all that follows is may be totally wrong, but my gut instinct is as follows.
If it just involves regular sessions with the school counselor, then I don’t think the parents need to be informed. But if it goes into a clinical level of mental health treatment then the parents need to be informed, both for the reasons outlined by Max_S above, and for the more logistical reason of who’s going to pay for it.
If the relationship with the parents is such that informing them would be harmful to the student, then I think a call to child protective services might be in order. Not that the child necessarily needs to be taken away, but so that the relationship can be properly evaluated and the parent can be informed of the situation by an authority figure that the parents will need to listen to.
I think it is reasonable to let this child — and all the others — know that they are welcome to drop in or make an appointment for counseling if they so choose. And it should not require parental permission to access that service.
But if the child in question does not indicate any interest, it is unethical to impose, require, or repeatedly suggest services.
First, I’d be really surprised if most schools could provide mental health evaluation or treatment on-site. There are certainly some places where schools host various sorts of health clinics sponsored and staffed by a community-based clinic or hospital and I’m sure some of those include mental health services but that’s different from school staff providing the evaluation and treatment. Most schools are probably going to be limited to giving the student information about a community resource.
Second - consent may not be an issue. Some states allow minors to consent to their own treatment in some situations and outpatient mental health treatment tends to be one of those situations.
To the OP, at least in Washington State the teacher and/or counselor would need to inform the parents regarding the risk of self harm. I am not certain but I believe would also need to involve CPS.
A red flag raised at school (or at therapy for that matter), leaves zero discretion to the school.
Not sure how many times I was contacted by the school regarding my son “joking” about suicide. It was dozens. (I engaged therapists, and from starting gender affirming hormones the suicidal ideation went away. BTW, fuck any of these right wing bigots supporting bathroom bills and trying to criminalize gender affirming care.)
Supposing who goes through what evaluation? What do you imagine schools have the ability and resources to do in a situation like you’re describing?
You appear to be envisioning a scenario where a school spends money to hire a professional for the purpose of clandestine psychotherapy sessions behind the parents’ back. Do you think that’s happening now? Is anybody seriously advocating that schools be allowed to?
More to the point, what do you think happens when a teacher refers a potentially at-risk child to a school counselor?
You, the school counselor, go through with a mental health evaluation. For risk of depression, for risk of self harm, etc. In your office or something. I assume the school has forms for this, like in a drawer or something. But it could also be pure discretion… I suppose.
Well, I do know for a fact that some public schools employ psychiatrists. I do not think the purpose is to hold clandestine psychotherapy sessions - AFAIK parental consent is required as a matter of federal law, and those school psychiatrists are a limited resource mostly for special ed or to train teachers, with one per cluster of schools. But this thread is supposed to be about what should be done, not what is being done.
But that’s not the scenario I had in mind when I wrote what you quoted. I’m not really imagining psychotherapy on-campus, but rather some sort of arrangement where the student walks to a nearby psychiatrist’s office during school hours. If there is one.
What would Federal law have to do with whether parental consent was needed? There may be special HIPAA provisions regarding the release of mental health information , but consent would be a matter of state law. According to this, minors over 13 in Florida can consent to outpatient mental health evaluation and treatment under some circumstances.
This explains the circumstances when a minor’s consent is enough in New York - and while it seems somewhat restrictive ,
(ii) requiring parental or guardian consent or involvement would have
a detrimental effect on the course of outpatient treatment
would include situations where the minor would refuse treatment if the parent was notified.
Did you mean to say the school has access to Psychologists? That is true. Most also have some access to social work services.
These however, are usually reserved for more serious student mental health/learning issues and do require parent permission to access services.
School counselors are able to meet with students without consent, by student or teacher referral. More ongoing contact or concerns about serious problems may require parent involvement.
Well, not only release of health information but retention and use as well - something as simple as keeping notes between sessions would be covered. I admit to ignorance of the specific provisions of law but, for example, at my workplace (medical, not mental health) we don’t allow minors to receive treatment on their own cognizance and I always assumed it was a federal law.
One important fact is that teenagers are very unreliable narrators about their parents. This goes in all directions. They will say they have supportive parents that turn out to beat them, but they will also say “never call my mom, she’s a conservative Christian who will send me to conversion camp” and it turns out mom is a Unitarian minister and kid has a therapist and whole mental health team.
I find this very disturbing, and disagree strongly.
In the area I am familiar with - IL/IN/WI - it is not at all uncommon for mental health treatment to be offered at schools. I am unfamiliar with the specific legal aspects, but I will often see records of counseling and medication prescription that I assume was provided in a “traditional” healthcare environment - a doctor’s office or such. Upon questioning, however, I learn that the services are provided AT THE SCHOOL during school hours.
As folk have mentioned, this seems to greatly help the issues of access, getting the child to appointments, getting the parent/guardian’s assistance… But this entire thread goes to the incredible burden we are imposing on our schools, to go FAR beyond what has traditionally been considered to be “education.” I’m not at all saying this is a bad thing - just observing the incredible burden it places on educators.
Are these cases usually kids in special education programs? Because as far as I know school psychologists are a limited resource. They’re mostly used for special ed. and to train teachers and administrators.
You say that as tho you think “special ed” to be a limited thing. I often wonder what percentage of kids in grade/middle/high school have some sort of IEP or accomodation plan (504 plan in IL).
I work with claims for disability benefits. Nearly every child applying for such benefits has an IEP and is receiving SOME services/accommodations. This source offers the number of 14% in 19-20. That is not a small number of “special” children - and I strongly suspect the number is higher post-COVID.
The case I reviewed yesterday was from Indianapolis. The child received treatment from this provider. This impresses me as something considerably different - and more involved - than what I was aware of as “school counselors/psychologists” when my kids were in school in the 90s. From my review of the records, they looked essentially identical to what I expect from non-school based mental health care providers.
And this is far from the only such school-based provider I encounter regularly.
I often wonder what percentage of kids in grade/middle/high school have some sort of IEP or accomodation plan (504 plan in IL).