Protecting the Privacy of Foster Kids’ Therapy Notes

file folder labeled "confidential" in filing cabinetThere is a question that has been asked of me multiple times over the past few months that I would like to answer. The question is: “Should a child’s foster parent(s) be granted access to their child’s psychotherapy notes?” The answer is not as straightforward as it may seem.

The short answer is: “No, a child’s foster parent(s) should not be granted access to their child’s psychotherapy notes.”

First, we must understand what the HIPAA privacy rule is, as it will ultimately answer the question. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, is a federal law which resulted in the establishment of the HIPAA Privacy Rule in December 2000. The HIPAA Privacy Rule is designed to protect information about individuals’ health care treatment. To understand privacy protections in the United States, you must start with this federally established framework and then consult state laws to determine whether there are any additional requirements to observe.

Second, we must understand what the HIPAA Privacy Rule has to say about “individual personal representatives.” An individual personal representative is any person with the authority to receive or access another individual’s protected health information (PHI).

In some cases, adults and emancipated minors have individual personal representatives, such as someone holding “power of attorney” or in a court-appointed adult guardianship or conservatorship. Otherwise, adults and emancipated minors do have uniquely boundaried privacy protections, whereas minors (children under 18 years old, with the exception of children—typically 16 or 17 only—who have been formally “emancipated” from dependency status by a court of law) always have at least one individual personal representative.

Children and adolescents in foster care tend to have many individual personal representatives, including representatives from Child Protective Services, attorneys, designated child-placing agency representatives such as case managers, foster parents acting as medical consenters, and, in some cases, juvenile probation officers. In rare cases, even court-appointed special advocates (CASA) may obtain status as medical consenters through a court and would, then, hold the distinction of an individual personal representative.

In addition, foster kids benefit from an extensive continuum of care including doctors, dentists, psychiatrists, clinical psychologists, school psychologists, school counselors, collaborative treatment team participants such as child-placing agency treatment directors (such as myself), and other consultants (at my agency, we have psychiatric fellows and residents as well as a program manager, intake coordinator, and, in some cases, a higher-level program administrator who all may participate in the ongoing treatment staffing related to a child’s case planning), therapists (individual, sibling, family, group), early childhood interventionists (speech, physical, and occupational therapists), and skills trainers. Each of these treatment providers freely accesses PHI of other providers in the course of treatment, which is necessary and beneficial for collaborative treatment.

Ultimately, these supports are beneficial, but often, along this stream of care, the “minimum necessary requirement,” a best-practices principle generally recognized and affirmed through the HIPAA Privacy Rule, is not sufficiently revered, and foster kids’ private and protected health information may not always be protected in practice with the same degree of diligence that it is in so many other sectors of health care. It is in this current that foster parents often believe that they, too, are entitled to the most private of health care information, their child’s therapy providers’ psychotherapy notes. I know this to be true from my own professional experience.

The third thing that you must understand to answer this question is that psychotherapy notes are given unique privacy protections within the HIPAA Privacy Rule, more so than all other protected health information (PHI), including purely diagnostic or evaluative information, case notes, other treatment services such as developmental therapies (speech, physical, occupational), as well as other treatment summaries or reports. Even reports via email from a therapist summarizing general or overall progress of therapy—or any other generalizing or summarizing report—are not given the same protections as psychotherapy notes themselves (U.S. Department of Health & Human Services [HHS], 45 CFR 164.508, 2006).

There is one final piece of this puzzle: The HIPAA Privacy Rule clarifies that, in certain circumstances, parents are not privileged to act as their minor children’s personal representatives—with respect to certain protected health information—and thus neither control the child’s health care decisions nor the protected health information related to that care:

  1. If no existing state statute or binding legal precedent requires a parent’s consent prior to a minor child obtaining psychotherapy treatment, and if the minor child then consents to his or her own psychotherapy treatment without the expressed consent of a parent, then, with respect to the minor child’s participation in that psychotherapy treatment, no parent acts as the child’s personal representative and, thus, the parent(s) will not be provided access to the psychotherapy notes without the child’s written consent.
  2. If a court grants or other law authorizes another adult to act as the personal representative for a minor child as it relates to the child’s health care, then the minor child may obtain consent for such psychotherapy treatment from another personal representative, as provided, without consent from a parent. Similarly, in this case, with respect to the minor child’s participation in that psychotherapy treatment, the parent(s) will not be provided access to the psychotherapy notes without the child’s written consent.
  3. If a parent provides a written and signed waiver expressly relinquishing his or her own right to participation in a confidential relationship between their minor child and a psychotherapist, then the privacy of the psychotherapy notes—as well as, in some cases, other protected health information—will remain boundaried and protected between the provider and the minor child, and parent access will be restricted unless the minor child provides written consent to the access of these protected records.

Further clarification in the Code of Federal Regulations (CFR) should be noted: “Even in these exceptional circumstances, where the parent is not the ‘personal representative’ of the minor, the Privacy Rule defers to state or other laws that require, permit, or prohibit the covered entity to disclose to a parent, or provide the parent access to, a minor child’s protected health information. Further, in these situations, if state or other law is silent or unclear concerning parental access to the minor’s protected health information, a covered entity has discretion to provide or deny a parent with access to the minor’s health information, if doing so is consistent with state or other applicable law, and provided the decision is made by a licensed health care professional in the exercise of professional judgment”(U.S. Department of Health & Human Services [HHS], 45 CFR 164.502, 2003).

Because foster children do not require the consent of foster parents before they can obtain psychotherapy services—and may obtain consent, if required, by way of other representative adults (such as child welfare caseworkers, child-placing agency case managers, etc.), whether the child independently consents or secures a nonparent consent to participate in such therapy, then, under the HIPAA Privacy Rule, the foster parent(s), for the purposes of this particular health care service, will not be provided distinction under the law as the child’s personal representative, and, thus, will not be provided the right to access documentation from the treatment record.

However, again, it is not that the HIPAA Privacy Rule expressly denies that foster parents have access to their children’s therapy notes, and, in fact, a “covered entity,” or provider (meaning, the child’s therapist) does retain prerogative to provide or deny a parent access with discretion if doing so is consistent with state and other applicable laws. Yet, this should be justified therapeutically.

In most cases, it is difficult to make a case that it is in the best interests of the child, therapeutically, to take away what is typically the only confidential outlet a foster child or teen has within the convoluted and institutional system in which they live and, thus, it is best practice in my state (K. Teutsch, personal communication, January 4, 2013) and in every state to preserve the therapeutic relationship by preserving the boundaries of confidentiality within that relationship and of privacy concerning the psychotherapy notes.

References:

  1. K. Teutsch, Division Administrator for Medical Services, Texas Department of Family and Protective Services, personal communication, January 4, 2013.
  2. U.S. Department of Health & Human Services – Office for Civil Rights (2006). HIPAA Administrative Simplification: Regulation Text [45 CFR 160, 162, & 164]. Washington, DC: US Government.
  3. U.S. Department of Health & Human Services – Office for Civil Rights (2003). OCR HIPAA Privacy: Personal Representatives [45 CFR 164.502(g)]. Washington, DC: US Government.

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  • Vicky

    Vicky

    January 10th, 2013 at 2:13 PM

    I am not sure that I understand this. Wouldn’t a birth parent have acces to their child’s therapy notes and shouldn’t a potential foster parent be prepared in the same way?

  • Natalie

    Natalie

    January 12th, 2013 at 10:07 AM

    Vicky,

    No one has access to my actual psychotherapy session notes without a judges orders ( other than my supervisor). I give parents ( biological or foster) updates, but certainly not my actual notes. I will type summaries and recommendations for case workers. Kids in general, but particularly foster kids, need to know there is something in the world that will be kept in confidence. I will tell kids that if there is something I feel their parents need to know, I will talk to the kid first and we will decide how to tell the parents/caseworker. I have never ( I’ve only been a counselor for 3 years) had a parent or case worker ask for my actual notes. Best, NT

  • Logan

    Logan

    January 11th, 2013 at 4:02 AM

    But Vicky, don’t you see that if potential foster families had access to this then they might change their minds and not want to foster the kids at all?
    These children come with a whole lot of baggage. Better to get to know the children first than jump to conclusions before you even get to know them, and I guess this is the reasoning behind this.

  • megan

    megan

    January 11th, 2013 at 9:40 AM

    “The answer is not as straightforward as it may seem.”

    It sure is tough to actually make a decision here. But as the final decision should be in the best interests of the child therapeutically,I think it would be a good thing if the psychotherapist or other professional advises the foster parent(s) about anything they need to observe or practice at home. his can be done rather than giving access to notes. it will protect the privacy and derive benefit for the child.

  • Dr. Tamela Sadler

    Dr. Tamela Sadler

    January 11th, 2013 at 3:59 PM

    PSYCHOTHERAPY is a private and protected relationship between the therapist and the client. If there is No guarantee of privacy the client will not feel safe to discuss or disclose issues. The therapist is not a conduit for parents, Foster parents, case managers or others to receive inside information on the child. Many children in Foster care are forced into therapy. They then often discover that their conversations are not private. Over time, these children learn that they have no privacy and they begin distrusting therapist in general and any potential therapeutic benefit is lost. These kids in particular become very distrustful of therapist and they report no benefit or actual harm resulting from involvement in therapy.

  • Vince

    Vince

    January 11th, 2013 at 11:18 PM

    There is valid points on both sides here. Although privacy is important sometimes it may be better if those living with the child are made aware if the things happening in therapy. But what should be done should be what benefits the child the best possible way maybe they can have a case to case consideration? Is there any consensus on the same from the mental health community?

  • Blake Edwards

    Blake Edwards

    January 17th, 2013 at 9:44 AM

    As you imply, Vince, it is always critical that any parent is involved and supportive in their children’s therapy. In best case scenarios, parents themselves are engaged regularly in family-based therapy sessions in conjunction with any individual sessions. Parents should seek out a collaborative relationship with therapists and request any available progress summaries or other reports. The Law certainly provides for this. It is the psychotherapy notes themselves–typically notes taken in-session or immediately after a session by a therapist in tracking their observations, interventions, clients’ responses, and further treatment planning–that receive special protection above other protected health information (PHI) under the HIPAA Privacy Rule.

  • Vernon Bradley, MFT

    Vernon Bradley, MFT

    March 17th, 2013 at 9:32 PM

    As part of the agreement between the agency and the foster parent in California, Foster parents are expected to act as parents in signing consent forms. Foster kids in general get bounced around from placement to placement, from therapist to therapist. Part of the problem is US, as therapists. We are trained, most of us, to work with the family as the client, so what are we doing working with an individual foster kid when they have a foster family where they live 24/7. We need to work with the foster child in the context of his foster family and then there are no “secret” notes and the child has a chance to experience healing in the context of his foster family and has a better chance then of staying in ONE foster family instead of getting bounced around. FOSTER PARENTS are not the ogres many of us therapist think they are. They are good people and deserve our support and respect and we need to recognize that they are the primary healers, not us. I’ve been working with children in out of home placement since 1967, so I speak from experience. We need to work with foster kids the way we were trained in the context of family. And sometimes the birth family can also be included. We are way behind the times folks and I don’t know why.

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