Three paths, one destination

Severe mental illness is less common in children and teenagers than
in adults, but young people can still suffer from depression,
schizophrenia and mania. These mental disorders often have the same
core symptoms and signs in young people, and treatment is based on
the same principles that guide the treatment of adults.

Young people with severe mental illness may not be willing or able
to consent to treatment. This may be because they do not recognise
they are ill, or it may be because symptoms – such as suspicion or
despair – lead them not to seek help.

Children who have serious mental health problems and who refuse
treatment may be treated against their will legally. The three
legal options for compulsorily assessing and treating young people
with mental illness are to use the Mental Health Act 1983, the
Children Act 1989 or the powers of parental consent.

The Mental Health Act
The Mental Health Act applies to people of all ages. It gives
unusual powers to specially trained psychiatrists and social
workers to admit to hospital and compulsorily treat anybody who is
suffering from “mental disorder” in the interests of the patient’s
own health or safety or with a view to the protection of other
people.

Social workers make their own assessment of a young person’s
situation and, if necessary, make an application for that young
person to be compulsorily admitted to hospital for assessment and
time-limited treatment. The views of parents or carers should be
considered in this process, but parents cannot prevent an
application being made.

Once admitted to a hospital in this way, a young person must be
helped to understand their rights and how they can appeal against
their detention and treatment. Mental health review tribunals
provide opportunities for a detained person to have their case
reviewed by an independent panel. Patients who do not themselves
apply to have their case reviewed are automatically put forward for
tribunal hearings.

There is some reluctance among professionals to detain and treat
minors using the Mental Health Act. However, I would argue that
this legislation may be the best choice to protect the rights of
children and young people who require a sustained period of
treatment for established mental disorder.

Children Act
Practitioners sometimes turn to the Children Act hoping that it
will provide an alternative means to treat young people with mental
disorder against their wishes. It does not. If the nature of a
child or young person’s difficulties is unclear but they may be
suffering significant harm and an assessment is needed, the
Children Act allows a child to be admitted to a residential
facility for an assessment of their needs using a child assessment
order, a specific issue order or a secure accommodation order. But
if the child is then deemed to require psychiatric treatment for a
mental health problem and the child refuses this, the Children Act
does not give doctors authority to treat children. In fact children
with enough understanding to make an informed decision are given
more rights under the Children Act to refuse medical or psychiatric
treatment than under other legislation.

Parental consent
With the exception of those suffering from mental disorder as
defined by the Mental Health Act, British law allows over-18s to
refuse medical treatment even if this decision seems ill-judged or
unwise. No one else can override this refusal. The law takes a more
paternalistic view of under-18s, deeming that certain other people
can give consent for a young person or child to receive medical
treatment even if the young person refuses.

Parents, local authorities which hold parental responsibility
through care orders, and the court when a child has been made a
ward may give consent for an under-18 to be treated against their
wishes.

It should be noted that the law treats refusal of medical treatment
and consent to treatment as separate issues. (Children and young
people’s rights to consent to medical treatment at any age provided
that they have sufficient maturity and understanding were
established in the Gillick ruling in 1986.) The law holds that
refusal of treatment requires more maturity than the giving of
consent and so only grants the autonomy enjoyed by adults to refuse
medical treatment at the age of 18.

It is evident that when a young person refuses to accept treatment,
practitioners must decide whether to use the powers of the Mental
Health Act or the power of consent by adults with parental
responsibility. There may be a reluctance to apply the powers of
the Mental Health Act to children for fear that this law is
heavy-handed and stigmatising.

A person who has been detained under the act may certainly be
disadvantaged in the future by being unable to follow certain
careers, obtain life insurance or travel abroad. But major mental
illness itself carries stigma and disadvantage, and inadequately
treated mental illness is needlessly debilitating and potentially
fatal. So the decision to detain a young person under the act must
weigh liberty against the need for effective treatment.

Heavy-handedness should be avoided by following the directive
within the Mental Health Act code of practice to use the least
restrictive option, that is, to use detention under the act as a
last resort.

The use of parental consent may seem appealing as a means of
avoiding the use of the Mental Health Act. I feel this has some
important disadvantages.

First, family relationships may be damaged by a parent having
compelled their son or daughter to receive treatment, and
rehabilitation of the young person back home may be difficult in a
climate of mistrust and anger.

Second, it is important to remember that treatment of major mental
illness may take weeks or months during which there is a strain on
family relationships. This is very different from other medical
treatments for which parents sometimes give consent, such as blood
transfusions or operations.

More importantly, a child whose refusal to be treated has been
overridden by their parents’ consent has no power to appeal.
Although young people in psychiatric hospitals should have their
needs assessed by social services departments after three months,
they are not subject to the formal review processes in place for
children accommodated in local authority residential or secure
units.

So, theoretically, a child admitted to hospital by their parents
could be detained there for many months with little recourse to
independent review.

One of the guiding principles in the Mental Health Act code of
practice is the need to consider whether the needs of the child
could be met in a social services or educational establishment as
opposed to a hospital. Only those children or young people clearly
in need of intensive psychiatric treatment should be admitted to
psychiatric hospitals.

Those who are refusing such treatment deserve recourse to
independent arbiters who will oversee their care. Of the available
legislation, the Mental Health Act surely offers the most
safeguards.

Dr Anne Thompson is consultant child and adolescent
psychiatrist at Lincolnshire Partnership NHS Trust. Contact her
at
anne.thompson@lht.nhs.uk