Medical treatment of minors, persons under 18 years of age, requires consent of a parent or guardian. While this sounds clear cut, with or without consent, health services often finds itself in the position of making judgment calls regarding treatment and services.

In this article, Marilyn Dickson provides an overview of regulations and procedures related to treating minors. Additionally, she shares a few examples of situations that often fall into a grey area. Health Centers routinely deal with issues related to the health and safety of students and the college. Being aware of and planning for some of the unique challenges outlined in this article is sound prevention.

Legal Purview:

There are numerous laws and regulations that must be considered in the development of policies and procedures for a college health center. The primary issues related to the treatment and care of minors are as follows:

• Medical treatment of minors: in the state of California requires parental consent.
• Emancipated Minors: a person under age 18 who has achieved legal adult status by demonstrating freedom from parental control. To be emancipated, the minor must marry, join the armed services, or obtain a court emancipation order. When emancipated, these minors are entitled to medical treatment without parental consent.
• Confidentiality: minors receiving treatment in the health center are not guaranteed confidentiality. While medical reports are not given to parents, should they inquire, they would receive information regarding the treatment and services of their child for which the consent was given. The state does allow for confidentiality when minors seek counseling for family planning and chemical dependence. Even in this case, however, the health center may decide not to treat without consent but would refer the student to an appropriate public health agency.

Other considerations:

• Standards of Practice: as outlined by The American College Health Association, ACHA, provides guidelines for college health programs. Included in these guidelines is information regarding confidentiality, health records, and sample consent forms. This information is updated and available through ACHA. For more information check out their web site at www.acha.org/index.cfm
• Special governing board policies and procedures: which may be unique to each district. These often address issues related to access, fees, and service.

Consent:

The primary way to insure compliance with all regulations is to require a consent form prior to providing any service to the minor student. The forms are most useful if they differentiate between a blanket consent (in which all services may be provided to the student) and a conditional consent (which designate services to be excluded). Parents and guardians need access to the list of services in order to make an informed choice regarding the consent. The information on services provided may be published in a program brochure or a through the web site of the center.

Programs such as the Middle College High School often have required orientations for students and parents. It is advisable to have the consent forms distributed, discussed, and turned in at this time. If time permits, a tour of the Health Center is advisable. As a minimum, a brochure outlining services should be available to the parents.

The first time all students enter the center each year, they are asked to complete a new or updated medical history information sheet. Ideally, a medical history for minors should be provided by the parent, especially if the minor has chronic problems and/or is on medication. If minors do not have a consent form on file, they are given one at this time, along with a brochure listing the services for the parents to review, and asked to return for service with the completed form the next day.

Emergency Procedures

Students have accidents throughout the campus and it is important for the health center to be notified in all instances. Some emergencies may be treated within the center. If the student is a minor, and no consent form is on file, then every attempt must be made to contact a parent or guardian by phone. If the paramedics are called, the liability for the individual – whether they are a minor or adult – is transferred to emergency medical services.

For Middle College High School students, emergency contact information should be on file in the administrative office of the MCHS and with the Student Health Center. Until the student is 18 years of age, this information needs to be updated annually.

As an additional safeguard, in some cases the college, or individual student, may want to have the medical history information also available to the campus safety and security department. This information is often critical to appropriate treatment by paramedics and other emergency physicians. A regrettable example (not from Orange Coast College) is one in which a minor was treated for a throat infection in an ambulatory care clinic and failed to inform the physician that he had diabetes. The minor died that night. The death may have been prevented had the physician been aware of this minor’s health history.

Grey Areas: As is often the case, there are many grey areas in providing appropriate service to minors. Here are a few examples.

A student under 18 years of age has an emergency on campus, too minor for the paramedics. This is a common situation during the summer when many children are on campus for enrichment programs. There is no consent form on file and the parents cannot be reached by phone. What do you do? An assessment is done of the situation and if minor, such as an abrasion, first aid is dispensed. However, no further follow-up would be provided without written consent from the parent.

A student is experiencing severe depression – perhaps contemplating suicide – and does not want his parents contacted. Prior to seeing a mental health professional, all students must review and sign the program’s Mental Health Contract. In this contract it is stated that confidentiality is never guaranteed and no promise is made regarding contact with parents. During the normal intake procedures, an assessment is done to determine if the student intends to do harm to himself or others. The county Psychiatric Evaluation Team, PET, comes to the campus to do a more thorough assessment and, if the student is a minor, the parents would be called. This team decides whether the student will be released to a parent or will be involuntarily admitted to a hospital.

A minor student is caught smoking pot on campus. This constitutes grounds for suspension for all students. As a minor, parents will be notified of disciplinary action. An option for suspension is participation in a substance abuse group. The Health Center will do an assessment and referral to an appropriate community resource for drug abuse counseling. If there is no consent form on file, the parents must sign the form in order for this alternative to disciplinary action to take place. However, the parents will then not be given information regarding the discussions that occur within the group.

A minor student wants birth control. If there is a consent form on file, and it is considered appropriate by the physician, a prescription may be given. If there is no consent form, the student is referred to a local family planning agency such as Planned Parenthood.

Infectious Diseases:

There is a need for a strong relationship with the local high school districts in order to resolve potential problems regarding infectious diseases. It is not uncommon for there to be different standards in place in which the high school districts are more restrictive and the community colleges more permissive. For example, a student with a positive tuberculin skin test may be excluded by the high school district but not by the college. To that end, the student would not be able to attend their high school classes but could attend their college classes. This is particularly interesting if the student attends a Middle College High School located on the college campus. Secondly, if the County Health Department contacts the high school regarding a student with an infectious disease, and the student fails to tell the county of concurrent enrollment, the college may not find out the information unless notified by the high school.

There is an additional, and unique, challenge around the issue of infectious diseases. The Community Colleges do not require immunization for admissions to the college - unlike the UC & CSU (and, please note, this is not a recommendation that immunizations be required) and not all home schooled children are immunized and may be more susceptive to communicable diseases. At the same time, it is not uncommon to have students in classes who are immuno-compromised due to kidney transplants or cancer and HIV treatment. When an immuno-compromised student comes in contact with a student with an infectious disease – such as Varicella (Chicken Pox) – it could be life threatening. There is no sure solution for this – but there is a need for vigilance.

Safeguards:

While there are no guarantees that will solve all problems related to serving minors in the Health Center, there are some safeguards that may minimize risk. Here are a few:

• Establish agreements with local high school and districts
• If there is a Middle College High School on your campus, get someone from your staff to serve on the Advisory/planning Committee
• Insure that all front counter staff are well trained. These are the individuals that often make the first judgment call on service.
• Review and update procedures regularly with staff
• Monitor consent forms like a hawk.
• When all else fails, remember to ask “Which is the greater risk - treating or turning away?”

Example of the medical information form and consent form will be on the Student Health Center web site by the end of June. At that time they may be viewed at www.occ.cccd.edu/departments/studentsvcs/sthealth/default.html

Director, Student Health Services
Orange Coast College