7/2/2013

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Forensic Aspects of Child and Adolescent Psychiatry

Waqar Waheed

University of Calgary

Children’s Rights

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Age of Majority v. Legal Age

• The age of majority in Canada is the age at which a person is considered by law to be an adult. 

• A person younger than the age of majority is considered a "minor child." 

Age of Majority v. Legal Age

Age of Majority is 

• 18 years in AB and 5 other provinces (SK, MB, ON, QC and PEI) 

• 19 years in the remaining provinces/territories

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Age of Majority v. Legal Age

• The term “legal age” generally refers to the age at which a person can legally do something (the “age of licence”)

Legal Age‐To drink alcohol

• Canada‐18 years in AB, MB, QC (19 elsewhere) 

• US – 21 years

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Legal age‐ To consent to sexual activity

Canada‐ 16 years  (Federal law, Tackling Violent Crime Act, 2008) if not in a relationship of trust, authority or dependency or any other exploitation of the young person (if so, the age of consent is 18 years) 

– “close‐in‐age exception” 

» 14 years if partner is no greater than 5 years older

» 12 years if partner is no greater than 2 years older)

Assent

• It involves an interactive process between a minor and healthcare provider involving developmentally appropriate information sharing and solicitation of the minor’s willingness and preferences.

(American Academy of Pediatrics Committee on Bioethics 1995) 

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Dissent

To withhold assent

The patient indicates that they do NOT agree or concur with participating in research or to a medical procedure

Treatment without Parental Consent

• Emergency settings

• Emancipated minor

• Mature minor

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Emancipated Minor

• No formal legislative process, traditional common law approach applies to those 16+ years of age who are 

– Living independently/Financially independent

– In the military

– Employed

– Married

– Pregnant

– With child(ren) 

Capacity of a (mature) minor to consent

• If a minor understands:

– the nature of the treatment being proposed

– the consequences of proceeding with, or refusing, that treatment….

he or she is considered to be a mature minor with the capacity to agree to or refuse the treatment (Picard and Robertson, 1996)

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Determining who is a mature minor

• Factors to weigh on a case‐by‐case basis (Age/Intelligence/Maturity/Seriousness of decision/Informed consent)

• Healthcare provider does not assess capacity to make all decisions…

…only the ability to decide with respect to the specific treatment being proposed

(Bailey and Russell, 2005)

Provincial Variation‐Mature Minor

• Quebec: Fixed age of 14 years and older as having the capacity to consent

• Newfoundland has legislation that creates a presumption of capacity to consent at  age 16

• Other provinces utilize the “mature minor” principle

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COnfidentiality

• “CLINICIAN’S OBLIGATION to avoid sharing information obtained in confidence to third parties.”

• Limitations to information sharing should be discussed with patient and parents at the outset of assessment

• Exceptions to confidentiality include information placing the adolescent (or others  at imminent risk of harm

PRivilege

• “PATIENT’S RIGHT  to bar a clinician from imparting information obtained in confidence to third parties.”

• Ambiguity exists for information shared by a parent/other third party or in the presence of both patient and parent 

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• Exceptions may include

– Automatic waiver in child custody cases

– Parents may be able to waive privilege

• It is recommended that parental authorization be obtained prior to releasing information to third parties even for subpoenas

CHILD CUSTODY

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Basis of Child Custody Decisions

• Well into the 19th century, custody was routinely perceived as a concomitant of the father’s power. 

• Children, like wives, were in effect the father’s chattel/property.

The Tender Years Doctrine

• Late in the 19th century, the predominant view began to be that the determining factor in a child’s custody should be the child’s own best interests.

• With that change in perspective also came a presumption that children of “tender years” are best served by remaining with their mothers.

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The Tender Years Doctrine

• Unless the tender‐years presumption could be rebutted by a showing of unfitness 

• When it was rebutted, it was often de facto punishment for the mother’s fault in the divorce (e.g., adultery) rather than a

real concern with the mother–child

relationship.

Current Views

• Although maternal custody remains the norm, the trend is toward determining the best interests of the child by examining the relationship with both parents.

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The Best Interests of the Child

• Most jurisdictions now determine custody on the basis of the best interests of the child. 

• The court is usually given some guidance as to the factors to be included in determining best interests, but the weight to be accorded them is left to judicial discretion.

What are “The Best Interests”?

• This concept encompasses the physical, emotional, intellectual and moral well‐being of the child.

• The court must look not only at the child's day‐to‐day needs but also to the child's longer term growth and development.

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• The ultimate conclusion as to best interests is at least as value‐laden and unscientific as other legal determinations, it should clearly be preserved for the factfinder. 

• A clinician should never reach a conclusion as to the parent who would better meet a

child’s interests.

Father Custody

• Although the law now is ostensibly gender‐neutral, father custody remains a relatively rare event in law and an even more uncommon arrangement in

practice. 

• Only 10–15% of divorced fathers have physical custody of their children

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Stepparents/grandparents Custody

• The general rule in most jurisdictions remains that biological parents may lose custody to a nonparent only when the parents are unfit.

• Although much is known about the effects of divorce on children there has been remarkably little research meeting minimal standards of methodological rigor about the effects of various custody arrangements on children and families of different characteristics.

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General Suggestions

• Avoid involvement if a family member has been your patient

• Avoid testimonial opinion on any individual you have not assessed  [“the other (bad) parent”]

• Mental health professionals are primarily helpful as investigators in custody disputes

• The most basic ethical issues for clinicians involved in custody disputes may be ones of monitoring the limits of competence and avoid overreaching these limits.

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TESTIMONIAL CAPACITY

• Until the 1970s, in much of North America, children under a certain age (e.g., 10 or 14) were presumed incompetent to testify, meaning that the party tendering the witness had to prove competency.

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• The modern presumption that everyone is competent is rebuttable

Testimonial Competence Criteria

• Focus on five capacities

– (1) The ability to observe the event

– (2) the ability to remember it

– (3) the ability to communicate that memory

– (4) the ability to tell the difference between truth and falsity, and 

– (5) the ability to understand the obligation to tell the truth in court

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The Ability To Remember The Event Free Of Suggestibility

• All but the youngest children (usually <3 years of age) probably have good enough memories to pass the minimal requirements for testimonial capacity.

Why are younger children more suggestible?

• A number of possible contributions

– Weaker memory (developmentally)

– Greater respect for authority—a hypothesis supported by simple learning theory, which suggests that children’s behavior will be shaped by their perceptions of adults’ expectations.

– Lesser level of moral development (based on Kohlberg’s ratings) 

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MEDICAL MALPRACTICE (NEGLIGENCE)

The 4 D’s of Medical Malpractice (Negligence) 

• Dereliction of

• Duty causing 

• Damages

• Directly

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Malpractice: Off‐label use of meds in pediatric populations

• Be aware of the following

– How well is the treatment accepted by one’s peers?

– How appropriate is the treatment for the condition?

– Has the pt/guardian been given info that med is being recommended as an off‐label use?

– Has the pt/guardian provided informed consent?

Suicide

• 2nd most common cause of death among adolescents in Canada (1st is Accidents)

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Suicide

• The assessment of pediatric patients for self‐injurious behavior is based on the review of three basic questions:

1. Is the patient likely to commit suicide in the future? 

2. Is the patient likely to make a suicide attempt in the future? 

3. Will the patient follow through on a psychiatric referral based on this evaluation?

FirearmsHanging

Toxic Ingestion

Common means of completedsuicide by adolescents

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Risk Factors for Suicide

• Historical

• Nature of the Attempt

• Family Factors

• Mental Status Examination

Historical

• Previous suicide attempt(s)

• A friend or family member who has committed suicide 

• Exposure to recent news stories or movies about suicide 

• Poor social supports 

• Victim of physical or sexual abuse

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Historical

• Verbalization or threats regarding suicide 

• Substance abuse 

• Poor impulse control 

• A recent loss or other severe stressor

Nature of the attempt

• Accidental discovery (vs. attempt in view of others or telling others immediately)

• Careful plans to avoid discovery

• Hanging or gunshot

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Family Factors

• Wishes to be rid of child or adolescent

• Does not take child's problems seriously

• Is overly angry and punitive

• Depression or suicidality is present in a family member 

• Is unwilling or unable to provide support and supervision

MSE

• Depression/Hopelessness • Regret at being rescued • Belief that things would be better for self or others if dead 

• Wish to rejoin a dead loved one • Belief that death is temporary and pleasant • Unwillingness to implement safety plan before attempting suicide 

• Psychosis • Intoxication

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Some questions to ask

• Why was this method chosen? 

• What were the expectations from the attempt (did the patient think that the attempt was going to kill her)? 

• How reversible was the attempt? If possible, could the patient change her mind and quickly recover from the attempt? 

• Does the patient demonstrate any ambivalence about living? 

• How strong was the patient's intent to die? 

• Was there evidence of premeditation, including preparations and precautions against discovery ?

• In an ingestion, for example, does the patient take a large number of pills or perhaps all of the pills that are available? 

• Does the patient tell anyone about the ingestion, particularly responsible caregivers? 

• What does the patient do immediately after taking the pills? 

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• Does she seek help or does she simply disregard the danger of the ingestion and go to bed? 

• When the patient experiences the physical consequences of an overdose and is discovered, does she acknowledge her suicidal behavior or continue to hide the reasons for her discomfort?

To hospitalize or not to hospitalize?

• 15 % of suicidal pts assessed in ED never attend outpt. follow‐up

• 1/3 rd attend 1‐2 outpt appts.

• 1/4 th attend 3‐4 outpt. appts.

Hospitalization is associated with    higher rates of outpt. follow‐up

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• Recommendation for psychiatric hospitalization should usually be made when the patient actively voices suicidal ideation with intent

• Additional considerations:

– Intoxication

– Aspects of recent attempt (impulsivity/lethality)

– Unsuccessful outpt treatment

Contract for Safety

• Empirically based evidence to support the use in any population is very limited, particularly in adolescent populations.

• Legal review ‐ contracting for safety is never enough to protect against legal liability and may lead to adverse consequences for the clinician and the patient

Garvey et al J Am Acad Psychiatry Law 2009

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Contract for Safety

• A suicide prevention contract from the patient tends to be an event whereas suicide risk assessment is a process.  (Simon, J Am Acad Psychiatry Law 1999)

Criminal Law

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YOUTH CRIMINAL JUSTICE ACT

Youth Criminal Justice Act

• No person shall be found guilty of an offence in respect of an act or omission on the person’s part while the person was a child (under 12 years old).

• The Act applies to 12 to 17 year old individuals

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“Violent Offence”

• An offence – causing bodily harm

– attempting or threatening bodily harm or

– an offence associated with substantial likelihood of causing bodily harm

“Serious Offence”

• “An indictable offence under an Act of Parliament for which the maximum punishment is imprisonment for five years or more”

• Such as child pornography, murder, impaired driving, assault, sexual assault, theft over $5,000, breaking and entering, etc.

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"Serious Violent Offence"

• Murder

• Attempted murder

• Manslaughter or

• Aggravated sexual assault

Presumptive Offences

• The YCJA identified the following four– First and second-degree murder

– Manslaughter

– Attempted murder

– Aggravated sexual assault

Or an offence for which an adult would be liable to imprisonment for a term of more than two years

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Presumptive Offences

• A presumptive offence meant that the young person, over the age of 14, could receive an adult sentence if found guilty.

(Repealed, 2012, Violation of Sec 7

Canadian Charter of Rights and

Freedoms)

No longer presumptive

To have an adult sentence imposed, the prosecutor will have to convince the youth court that:

1.The presumption of diminished moral blameworthiness/culpability of the young person is rebutted; and

2.A youth sentence would not be of sufficient length to hold the young person accountable for his or her offending behaviour

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Presentencing Evaluations

• Section 34 of YCJA allows courts to seek mental health assessment after adjudication to guide sentencing.

• These assessments may include – psychiatric assessments

– risk of violence or sexual reoffending or

– psycho educational assessments

Pre-sentencing Detention

• Prohibited, except where– the young person is charged with a “serious

offence” or

– where “they have a history that indicates a pattern of either outstanding charges or findings of guilt.”

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Possible Outcomes for Adolescents

• Extrajudicial Measures/Sanctions

• Youth Diversion

• Judicial Sentences– Reprimand

– Fine

– Compensation/Restitution

– Community Service/Program Involvement

– Probation

– intensive Support and Supervision Program

– Incarceration

• NCR

• Unfit to stand trial

Extra-judicial Measures/Sanctions“Punishment, but not by a judge”

• For minor offenses, often for first offenses

• No active MH concerns related to the offense

• (Re. Sanctions) The offender– Freely agrees to participate

– Has been given a chance to consult with a lawyer

– Is willing to accept responsibility

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Extra-judicial Measures/Sanctions

• There are no court proceedings and thus no youth “criminal” record A record of participation in the program is kept for 2 years.

Extra-judicial Measures/Sanctions

– Extrajudicial Measures• Take no action (police)

• Caution (police)

• Formal warning (police and crown)

• Referral to community program (police)

– Extrajudicial Sanctions• Referral to other appropriate program (police and

crown)

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Youth Diversion

• Individuals routed to these diversion programs (treatment programs) are those with – Minor/first-time offenses and

– MH disorder closely related to the offence, e.g., ADHD-related impulsive theft

Grounds for Incarceration

• Violent offence

• Failed to comply with two or more non-custodial sentences

• Exceptional case, where the aggravating circumstances warrant a custodial sentence

• Indictable offence for which an adult would be liable to imprisonment for a term of more than two years and the adolescent has several findings of guilt (or extrajudicial sanctions)

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Criminal Responsibility

NCR is an Affirmative Defense

• The burden of proof that an accused was suffering from a mental disorder so as to be exempt from criminal responsibility is on the party that raises the issue

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Criminal Responsibilityv.

Competence/Fitness

State of mind at the time of the crime

(Criminal Responsibility)

State of mind at the time of trial

(Fitness to Stand Trial)

Elements of a Crime

I. An illegal act (actus reus)

I. The necessary intent to commit the act (mens rea)

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The effects of mental disorder may justify the conclusion that mens rea was absent

Not Criminally Responsible

SEC 16. (1) No person is criminally responsible for an act committed or an omission made while suffering from a mental disorder that rendered the person incapable of appreciating the nature and quality of the act or omission or of knowing that it was wrong

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(2) Every person is presumed not to suffer from a mental disorder . . . until the contrary is proved on the balance of probabilities.

(3) The burden of proof…is on the party that raises the issue

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Common Bases for NCR

– MR

– Psychosis

– Automatisms

– Temporal Lobe seizures

– Disruptive Behavior/impulse Control disorders (ADHD/Kleptomania) usually do not meet the NCR test

• often viewed as impulses not resisted rather than irresistible impulses.

Outcome of Being Found NCR

• Absolute Discharge (if no longer considered a risk)

• Discharge with Conditions

• Detention in a Treatment Center

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The Provincial Review Board subsequently decides when to “absolutely discharge “ a NCR offender.

Until absolute discharge, the Review Board must recommend the “least restrictive“ disposition for the NCR offender.

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• There is no presumption of dangerousness.

• The NCR offender does not bear the burden of proving a lack of dangerousness.

Fitness (Competence) To Stand Trial

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A legal concept which allows postponement of criminal proceedings for defendants unable to participate in their defense as a result of mental disease

Section 2 : CC

“Unable on account of mental disorder to conduct a defence at any stage of the proceedings before a verdict is rendered or to instruct counsel to do so, and, in particular, unable on account of mental disorder to…

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• (a) understand the nature or object of the proceedings

• (b) understand the possible consequences of the proceedings, or

• (c) communicate with counsel.”

There is a presumption of fitness, so the issue only needs to be considered if someone raises it.

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• Only physicians may provide an opinion regarding fitness to stand trial

• Only judges make the final decision

Presence of a mental disorder is necessary but not sufficient

It is important to note that a seriously mentally ill adolescent may still be deemed fit for trial.

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If Unfit…

The individual is typically remanded to a hospital setting for a period of time during which an attempt is made to restore competency.

If the person later becomes mentally capable of being tried, he or she can be tried at that time. There will be an inquiry every year for adolescents to see if such a change has occurred

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If Still Unfit…

After multiple attempts at restoration of competency/fitness are unsuccessful, the individual may be released from custody orcommitted to a mental health treatment setting

ADOLESCENT VIOLENCE

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RISK FACTORS

• Biological Factors

• Psychological Factors

• Social Factors

BIOLOGICAL FACTORS

–Male sex

–Substance use

–Prefrontal lobe damage

–Low resting heart rate

–High testosterone levels

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PSYCHOLOGICAL FACTORS

–History of violence

–History of non-violent offending

–Positive attitude about violence

–Lack of empathy/remorse

–Cognitive distortions (ambiguous situations perceived to be hostile, negative)

–Multimedia exposure to violence

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–Mental Disorders• ADHD

• Conduct Disorder

• Mood disorders

• Suicidal Behavior

• Antisocial personality traits (lack of planning, novelty seeking, low harm avoidance)

–Below average intellectual functioning

–Impaired executive functions•Task initiation

•Inhibitory control

•Concept formation

•Problem solving skills

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SOCIAL FACTORS

–Exposure to domestic violence

–Exposure to abuse or neglect

–Poor relationship with parental figures

–Inconsistent parenting

–Lack of supervision

–Peer delinquency/gang involvement

–Negative/hostile school environment

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–Parent/caregiver criminality

–Loss of one or both parents

–Low educational achievement

–Community disorganization (poverty, crime)

PREVENTION APPROACHES

Most are applicable as primary, secondary and tertiary approaches

• Preventive Counselling

• Individual/Group cognitive-behavioral therapeutic approaches

• Family focused programs

• Multi-Systemic Therapy

• Parent Management Training

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Preventive Counselling (Pediatricians/Fam Physicians)

–Gun safety

–Media violence

–Domestic violence

–Abuse or neglect

INDIVIDUAL/GROUP COGNITIVE-BEHAVIORAL THERAPEUTIC APPROACHES

–Problem solving skills

–Coping skills

–Social skills

–Academic success skills

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–Anger control training

–Massage therapy

–Teaching adolescents about healthy relationships through school-based programs.

–Programs focusing on reduction of dating violence (school and community activities)

FAMILY FOCUSED PROGRAMS

–Parent Management Training

–Functional Family Therapy

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PMT

• Parent Management Training (PMT) is based on the principles of operant conditioning and social-learning theory.

• In PMT parents are encouraged to use positive reinforcement, to adopt more effective discipline strategies, and to learn how to negotiate with their children

Multi-Systemic Therapy

– Usually a tertiary level of prevention

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MST

• Originally developed as an alternative to incarceration for serious juvenile offenders, MST is an intensive home & community-based intervention grounded in social ecological theories of behavior

• MST therapists typically treat families for 4–5 months, averaging approximately 60 hours of face-to-face contact during treatment.

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• Initially, therapists engage with family members and others in the youth's ecology (teachers, peers, neighbors) to determine the drivers of the youth's behaviors across school, neighborhood, peer, and family systems.

• Therapists draw from a number of intervention techniques including behavioral, cognitive-behavioral, parent management, behavioral family systems, and pharmacological treatments.

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MALINGERING

Threshold Criteria For Malingering

The following criteria should alert the forensic examiner to a high likelihood of malingering by the claimant:

1. Inconsistency in symptom presentation2. Evasiveness3. Overidealized functioning before the trauma4. Antisocial personality traits5. Unvarying repetitive dreams6. Discrepant capacity for school/work and recreation7. Prior “incapacitating” injuries8. Poor school/work record

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Detecting Cognitive Malingering

• The use of probability-based tests of cognitive effort (TOMM- 16+ years)

• The use of multiple sources of information

• Lack of a temporal gradient in retrograde amnesia (Ribot’s Law)

Detecting Psychological Malingering

• Use of the MMPI-A (14-18 years)– Look for rare/defensive/inconsistent

responding

• Use of the Personality Assessment Inventory-Adolescent (12-18 years)

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References

• Rosner, R.: Principles and Practice of Forensic Psychiatry , 2nd Ed., London, UK, Arnold, 2003

• Simon, R.I.: Clinical Psychiatry and the Law, 2nd

Edition, Washington, D.C. American Psychiatric Press, 1992

• Melton, G. et al Psychological Evaluations for the Courts, 3rd Ed., NY/London, Guilford Press, 2007