The Catch 22 And Your Mentally Ill Teen

Parents of children with mental illness have it hard, really hard.  Diagnosing, treating and managing a mental illness in a youg child is one of the most difficult responsibilities a parent can encounter.  Parents and families are thrown into a world of confusion, chaos and often despair.  Unraveling what you have is a daunting task.  These disorders of the brain are often met with much comorbidity but are also very dimensional each on their own.  Over time many of the presentations change and it could take years to see what you are truly dealing with.  With maturity of communication and self awareness some of these children eventually are able to participate in targeting the origin of the symptoms and become collaborative in their treatment.

For some, despite all efforts, the teen years pass by in a blurred flurry of  disregulation, outbursts, suicidal thoughts or attempts, self harm, dangerous or promiscuous behaviors, treatment resistant mania, psychotic features,  phobias, panic attacks, impulsive or reckless actions and most significantly unbearable pain. 

Multiple hospitalizations are not uncommon.  Multiple psychiatrists, therapists and residential treatment programs are not uncommon.  Navigating a children’s mental healthcare system that is broken leaves these families is financial and emotional ruin.

Even parents who have been fortunate enough to find a treatment to manage the disorder often find as the teen becomes more independent that noncompliance can undo years of progress.  As the child reaches his latter teen years, noncompliance with medications and therapies becomes a source of concern.  

In addition, teens that may have had minor levels of impairment with depression or anxiety find as the pressures of impending independence and often the use of street drugs or alcohol come into play, the disorders worsen dramatically leaving parents scrambling for control.  Instead of now dealing with trying to manage a mental illness they are now in the world of duel diagnosis and the walls are closing in on them.  

Some parents simply cannot take the pressure.  They are hopeless and as I mentioned earlier, are trying to fix a child or teen with a broken system.  The years of abuse by the teen, the years of chronic stress, worry and exhaustion take hold and they throw their hands in the air and give up.  Many of these teens wind up in the hands of the state and in state run facilities, it is a horrific situation for all.

“The mental-health-care ‘system’ in America is a broken system,” says Michael Fitzpatrick, executive director of the National Alliance on Mental Illness (NAMI). “The system was already in crisis, and has become even less accessible over the last three years as state budgets for mental health—psychiatric beds [in hospitals], counseling, and other services—have been cut by $2 billion. States have eliminated 4,000 in-patient psychiatric beds.” NAMI’s Katrina Gay adds, “In many cases you can’t even get an evaluation for two to three months—and that’s assuming you know how to get one in the first place.”

Some parents hope and pray as the teen matures they will outgrow the behaviors.  They put their faith in the day that the teen will finally break down and accept the help they need.   As they wait for that day they take every measure to keep the teen safe, walk on egg shells to keep the peace, construct a life around the devastation and often need to forgo expectations of limit setting, curfews and any remnant of a normal life.  These are good parents.  These are parents that like the rest of us do not have $75,000 to $100,000 a year to place their teen in a safe quality private therapeutic residential treatment program.   These are the parents that have tried to find help for their mentally ill child and tween using their health insurance coverage only to find very short term and ineffective programs available. These are parents that unknowingly are on the brink of a situation that will shake them to the core.  The situation they hoped and prayed maturity of age would resolve…. The loss of parental control and the age of majority.

The age of majority is the threshold of adulthood as it is conceptualized  in law.  The age of majority or the age a child is considered an adult varies by state and country.  In the US the age is usually 18. It is the chronological moment when minors cease to legally be considered children and assume control over their persons, actions, and decisions, thereby terminating the legal control and legal responsibilities of their parents or guardian over and for them. The word majority here refers to having greater years and being of full age; it is opposed to minority, the state of being a minor. The law in a given jurisdiction may never actually use the term "age of majority" and the term thereby refers to a collection of laws bestowing the status of adulthood. The age of majority is a legally fixed age, concept, or statutory principle, which may differ depending on the jurisdiction, and may not necessarily correspond to actual mental or physical maturity of an individual. It is the age a person is allowed to enter into a legal contract and control who has access to their medical and legal information.

In the event of an emergency hospitalization this can be very difficult for parents trying to get information on the reason and plan of treatment for their older teen.

The time to make decisions for your child is now gone without legal action and a court decision of continued guardianship must be obtained if the now adult is unwilling to have a parent participate.  Often the treating psychiatrist can persuade the adult child to accept help from parents but due to instability or destroyed relationships due to the disorders they cannot.

Parents are often put in a very difficult position when seeking information about a loved one with mental illness who is being treated by a mental health provider. Legally adult children with mental illness have the right to decide with whom their clinical information can be shared, and many times this is difficult for parents to understand when they genuinely want to help their child in his or her recovery and yet are told they cannot receive any information about him or her. However, in most circumstances (not all) providers are legally obligated to honor the wishes of a patient who withholds permission to make disclosures to family members.

There are limited cases of how a parent can receive information without consent.  The Director of a State operated psychiatric center is required by law to inform the parents of an involuntary-status patient of the fact that their relative has been involuntarily hospitalized, and must further advise the family where the relative has been hospitalized.This disclosure remains permissible under HIPAA because it is required by New York State Mental Hygiene Law.  Without express objection by the patient (who must be informed ahead of time) or compelling evidence that it would be counter-therapeutic, the family of a voluntary-status patient may be informed of the fact that their child has been hospitalized and where he/she is. In this case, information can also be obtained from the parent in order to obtain facts about the patient that are necessary for his/her treatment.

Even when parents are unable to obtain permission to receive information about their relative, this does not always mean they are barred by confidentiality laws from participating in treatment planning for the patient. In fact, unless it is plainly contraindicated, the New York State Mental Hygiene Law not only allows but requires the involvement of an authorized representative of the patient (which can include parents) in treatment planning, because it is presumed that such involvement has important therapeutic benefits. When done in such a way as to not compromise or reveal information that should be kept confidential, parens involvement can be accomplished without obtaining the express permission of the child and without violating confidentiality. For example, staff could discuss the programs that are available, privileges, family visits, legal status, and plans for discharge. Also, if not clinically contraindicated and appropriate, staff could share information provided by the parents with the patient, such as relaying messages of support.   Being in a psychiatric hospital is not pleasant, it can be very traumatizing and often teens soon seek the support of parents and allow them participate.  As hard as it is for parents for the teen it is absolutely devastating.

Having your 18 year old or legally adult child sign a HIPPA consent release or legal documentation such as a health care proxy giving parents access to information and decision making power for them is essential and can in some cases ward off a lot of problems.  In the event the now adult child will not allow information to be shared or will not agree to hospitalization to stabilize parents are often forced to take legal action to regain control in the capacity of a guardian or conservator.

What is the difference between a Guardian and Conservator?

A Guardian acts in behalf of the disabled person in personal matters. If appointed under the Mental Health Code, a guardian may also manage all of the disabled person's finances and property. In those cases of disability where the Mental Health Code does not apply, a conservator will be appointed to be responsible for such person's financial affairs. If both a guardian and a conservator are necessary, they need not be the same person. The judge must decide whether or not the person in question has a mental, physical or legal limitation which requires the judge to appoint a guardian to make decisions concerning the person's health and personal life or appoint a conservator to make responsible decisions concerning management of property and money.

A good resource for understanding the guardianship law and procedure is here http://www.zalkinlaw.com/pdf/guide_to_guardianships.pdf

Hoping, wishing and praying are wonderful, it keeps the faith and gives us some peace but realistically, if you have a severely mentally ill child.  If your depressed or mentally ill teen child is a risk to themselves or others, plan ahead.  Speak with the treating physician about their upcoming age of majority and or your lawyer about estate planning to ensure care for your adult child should you not be here and also discuss your options in the event of a period of severe mental instability.   Being informed is the best way to deal with the situation should it arise.

Any parent with a child with a mental illness knows being proactive is everything.  There is no more important proactive step you can take with your teen than to ensure their safety in the event they are not capable of making life saving decisions.