Are disturbed and normal adolescents equally competent to make decisions about mental health treatments?

Abstract

This study uses a structured vignette procedure to assess competency to make treatment decisions in two groups of adolescents, one at risk for institutional placement and the other a matched community sample. Scores on Factual Understanding (the ability to recall facts), Inferential Understanding (the ability to make inferences about those facts), and Reasoning (the ability to weigh risks and benefits of various treatment options and to make choices based on that reasoning) were compared. Results showed that while at-risk adolescents and their community counterparts did not differ in their factual and inferential understanding abilities, the at-risk adolescents did significantly less well than the community adolescents in reasoning. This difference couM not be fully explained by differences in verbal 1Q. Girls, no matter what their risk status, scored higher than boys on the Reasoning scale. Implications for legal policies concerning adolescents are discussed.How much adolescents should be involved in decision making about mental health treatment is a controversial policy question, Historically, parents or the state have been entrusted to see that adolescents received care when it was in their best interest (Parham v. J.R., 1979;Melton, 1984). Recently, however, many have questioned this general framework (e.g., Melton, 1989). A call to expand adolescents' autonomy under the law has arisen, especially regarding their rights to make decisions about their own medical care (Interdivisional Committee on Adolescent Abortion, 1987; Gittler, Quigley-Rick, & Saks, 1990).The empirical support for this position rests primarily on a set of studies that compared how adolescents and adults make decisions about hypothetical treatment situations. These studies have generally demonstrated no difference in the outcomes chosen and the logic used by adults and adolescents above the age of 14 (e.g.,

Children's Competence for Assent and Consent: A Review of Empirical Findings

“…But "poor" readers fell between the 2 groups No age differences on decision dilemmas (reasoning). 30% of 10-to 13-year-olds and 21% of 14-to 19-year-olds considered competent based on a predetermined cutoff score On decision dilemma, Caucasian children, children without prior experience in therapy, better readers, and children whose problems were moderate rather than severe scored higher Scores on risk/benefit task were positively correlated with scores on decision dilemma Reference Mulvey & Peeples (1996) Participants 45 14-to 17-year-olds in "at risk group" and 41 in matched community sample …”

“…Almost all (n = 26) studies measured one dimension of competence, and only three examined more than one aspect of competence in the same study (Kaser-Boyd et al, 1986;Mulvey & Peeples, 1996;Weithorn & Campbell, 1982). These studies typically examined both understanding and reasoning.…”

“…In three of these studies (Ambuel & Rappaport, 1992;Lewis, 1980;Urberg & Rosen, 1987), participants were asked questions about decision-making related to potential or actual pregnancy. In five of these studies, participants listened to hypothetical dilemmas related to various treatment or research decisions (e.g., cosmetic surgery, experimental acne medication, psychotherapy, treatment for diabetes) and were then asked open-ended questions to assess decision-making skill (Halpern-Felsher & Cauffman, 2001;Kaser-Boyd et al, 1986;Lewis, 1981;Mulvey & Peeples, 1996;Weithorn & Campbell, 1982).…”

Black Boxing Restraints: The Need for Full Disclosure and Consent

“…These conditions may lead to distrust and impaired decision-making (Mulvey and Peoples 1996). Coercion, either real or perceived, is a danger where these dynamics are present.…”

“…Information presentation effects, such as the order of information presented, presenting the data as relative or absolute, the format of information presented (numerical or verbal), combined with framing effects of information can greatly influence the weight or importance given to information presented. Consenting to any procedure is affected by socio-cultural and affective factors and psychiatric illness may impair information processing (Mulvey and Peoples 1996) impeding capacity to make an informed choice. The same applies to bewildered families who are overwhelmed and devastated.…”