Tricky Old Teen

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OPEN MINDS: BETTER MENTAL HEALTH CARE
Obtaining consent in medical health cases involving adolescent patients can be tricky.
PUBLISHED MAY 24, 2015
UPDATED MAY 24, 2015
This article was published more than 6 years ago. Some information in it may no longer be current.
This is part of a series about improving research, diagnosis and treatment. Join the conversation on Twitter with the hashtag #OpenMinds
What happens when a child wants help with a mental-health issue, but a parent, fearful of stigma or unwilling to go the medication route, refuses? What happens if the child won't go along with treatment?
The question of consent is complex — and can be particularly contentious in high-conflict situations such as a divorce — but it is considered one of the most important pillars of the Canadian health-care system. Many experts believe that there needs to be a better understanding of consent's guiding principles. Here, a primer on the concept and how it plays out in doctor's offices:
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What is the age of medical consent in Canada?
For the most part, there is no age of medical consent in Canada, with the exceptions being Quebec (age 14) and New Brunswick (16) Unlike with age-of-majority laws for drinking, driving and smoking, consent for medical treatment is more fluid and situational. It depends on the mental and emotional capacity of the patient, not his or her age. When teens under 18 are deemed to have that capacity, they can consent to treatment without parental permission. In effect, they are forming a contract for treatment themselves, and it can't be overwritten by their parents. More complex illnesses and treatments require a higher degree of competency to be able to consent.
In Quebec, at the age of 14, a person can seek medical care — be it birth control or psychiatric counselling — without parental consent, and health professionals are forbidden from sharing health information without the teen's written consent.
Lawmakers found that, especially among adolescents, age can be an arbitrary and sometimes inaccurate measure of maturity. "Some kids are much less mature by the age of 18, 19, 20, and some kids are a lot more mature when they're 14 and 13,"says Rose Geist, chief of mental-health systems at Toronto's Trillium Health Centre, who has written a guide for doctors on assessing young patients' capacity to consent to treatment.
"Every patient is different. Every situation is somewhat different. You cannot have hard and fast rules," says Gordon Wallace, managing director of safe medical care at the Canadian Medical Protective Association, which provides education, legal assistance and malpractice insurance to physicians. "It's all contextual with patients' conditions, what is being proposed and the maturity of the patient."
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To be capable of giving consent, young patients must understand their condition, the information given to them, the prognosis and the risks and benefits of accepting or refusing treatment.
"Do they understand that when they go to see a therapist that they're going to be participating in counselling? That things may get a little bit worse before they get better? That this probably isn't going to be a one-shot deal? That if they choose to participate, there may be some benefits that come their way as well as some consequences?" says Patrick Baillie, a Calgary-based lawyer and psychologist.
Just because a child says "yes" doesn't mean that he or she is capable of consenting, Dr. Geist stresses. Capable young patients "can consistently communicate a choice. They don't change their mind every minute," she says.
Furthermore, capable patients aren't comatose, neither do they have delirium, she explains.
Under most circumstances, capable teens will choose to involve their parents in decision-making; physicians are encouraged to support collaboration between family members.
What's the difference between good, bad and informed choices?
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An important distinction is that capacity isn't about the wisdom of the decision. "It's not about whether the person is making the right decision. It's simply about whether they understand the information and appreciate the consequences," Dr. Baillie says. "Some people make poor choices, but if they understand and appreciate [them], then we let them make those decisions. Whether or not they are making the 'right' decision is irrelevant."
As Dr. Geist puts it: "We don't have to consider the decision reasonable. We only have to prove that it's reasoned."
How does a doctor ascertain that an adolescent is mature enough to determine his or her own care?
Communication is key, experts say, stressing that consent is an ongoing process between patient and doctor.
Dr. Wallace asks patients to explain back to him what they've discussed: "Can you tell me in your own words what we just stated?"
When language barriers pose a problem, he recommends that doctors use an official translator, even if it means waiting until one is available.
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What is the upside of not having a legal age of consent for mental-health treatment?
"This is about patient autonomy," Dr. Wallace says. Experts say that when you remove the issue of parental consent for capable teens, you open up the services to a group of people who feel that they might not be supported by their parents to get help. "Individuals can opt into treatment without needing to initially go through the filter of their parents," Dr. Baillie says.
The process allows kids to become engaged and involved in their own care, Dr. Geist says. "The outcome is better because they're not helpless but active agents in their treatments."
While the set-up gives patients maximum autonomy, it can also prove challenging for doctors who don't specialize in mental health to properly assess capacity in young, diverse patients. "The challenge arises when people don't know or are not trained in the assessment of capacity or in cognitive development," Dr. Geist says.
Physicians who rarely treat teenagers may take the approach that parents need to be involved, Dr. Baillie adds.
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Who decides consent when parents are divorced?
Cases arise where one divorced parent is incensed to learn that the other has taken their child to a psychologist, without his or her knowledge.
The Canadian Medical Protective Association recommends that doctors determine the custodial status of divorced parents before treating their kids – they need to make reasonable inquiry into who has guardianship of the child, never assuming that the parent who brings in the child has sole custody, especially in high-conflict cases. Both parents have to sign off on consent when there is joint custody.
"Bottom line is that everyone involved has to act in the best interest of the child," Dr. Wallace says.
Are there situations in which a parent tries to deny a capable child mental-health treatment?
Some parents insist on "dealing with it at home." They don't place their trust in the mental-health profession, a relatively new medical discipline without the clarity of diagnoses that other doctors enjoy.
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"We don't have straightforward blood tests or other physical tests in mental health," Dr. Baillie explains. "And so there are people who have some skepticism about whether or not mental health is scientific or based on the political or social whims of the time."
For some parents, it's cultural; they find psychologists and psychiatrists "too liberal in their social views," Dr. Baillie says.
Other times, it's simply denial, with parents assuming it's a phase all kids go through. "Generally I think it's well-intentioned rather than malicious," he says.
Still, if the child is mature enough to give consent, reluctant parents can't actually override his or her wishes.
And if a child's health or development is at risk of being harmed by the decision-making of the parent, doctors are required to seek out child protection authorities.
What happens if a teen refuses to consent to treatment, be it medication or talk therapy?
Ethics codes say health-care practitioners require their patients' consent; even if the patient is under 18 and the parents give consent, the doctor still requires the patient's assent. "Logistically it's extremely difficult to do therapy with somebody who doesn't want to do therapy," Dr. Baillie says.
In such cases, it's up to the therapist to try to engage the patient. "For a young person, 'no' can be a natural expression of autonomy," Dr. Geist says. "It can be oppositional behaviour, it can be overwhelming anxiety, or it can be a capable person actually saying 'no' to a treatment. You have to understand what 'no' actually means and you have to be skilled to access that."
A "no" can also be a symptom of depression, with some kids not feeling they truly deserve the help, she says.
Does a young capable patient's refusal of treatment get overruled in an emergency?
"To the general principle that consent must always be obtained before any treatment is administered, there is an important exception. In cases of medical emergency when the patient (or substitute decision-maker) is unable to consent, a physician has the duty to do what is immediately necessary without consent," Dr. Wallace says.
Can kids challenge the system if they're deemed not to be capable mature minors?
"If an individual kid is said to be incapable, they do have the right to challenge that by going before the Consent and Capacity Board. If the kids do request it, it's quite a time-consuming procedure for the physician. They have to take time off their work and they aren't compensated. It can be a very stressful interaction and it can challenge the relationship," Dr. Geist says.
What about confidentiality under 18?
Confidentiality is murkier if a patient is younger than 18 years old. Being deemed capable at 13, 14, 15 and so on doesn't preclude parents from having access to medical records. "On the one hand, we're saying to kids, 'Hey, you're old enough to make your own decisions about treatment, but I may still have to tell your parents what we've been talking about,'" Dr. Baillie says, adding that there isn't enough clarity about confidentiality for young patients.
Editor's Note: The original digital version of this article incorrectly stated that only Quebec has a defined age for medical consent. In fact, New Brunswick also has such a law. This digital version has been corrected.
The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. The organization had no involvement in the creation or production of this, or any other, story in the series.
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FOLLOW ZOSIA BIELSKI ON TWITTER
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Looking for a present idea for the teenager in your life? Teens can be hard to buy for – and with that in mind, we’ve scoured the best online retailers for the best present ideas for teen girls and teen boys of all ages.
Whether you’re shopping for your fashion and beauty-obsessed teen niece or your avid gamer teen son, we've got you covered. These cool gifts will earn you major brownie points on birthdays and special occasions!
Nike Air force 1 Pixel leopard, £94.95 Footlocker
The sneaks that redefined street style have been given a revamp and they couldn’t be more cool. Get these freshly launched Nike Air Force 1 crater trainers before they sell out.
GoPro HERO9 Black action camera, £328.98, GoPro
Does your teen have their eyes on being the next big YouTuber? or are they interested in filmmaking and photography? Then the GoPro HERO9 Black action camera is the ultimate gift. Okay, it might seem like a bit of a splurge, but it's a fantastic investment camera that will last them well into adulthood. You get the camera, a one-year GoPro subscription and a 32GB SD card and a case for £328.98. It's an impressive piece of easy-to-use, high spec kit with endless features, including 5k video shooting, 20mp photo capabilities, a front screen, touch screen rear display and 30% more battery life than previous models, alongside it being rugged and waterproof up to 33ft. This really is the perfect present for fostering their creative and artistic side.
Revlon One Step Dryer & Volumiser, was £79.99 now £59.99, Amazon
A TikTok-approved hairstyler is the perfect gift for teenage girls. It has gone viral with over 90 million hashtag views and it’s easy to see why - combines the power of a dryer and volume of a styler to deliver effortlessly beautiful, full-bodied and frizz-free hair with 22% more shine and in up to half the time. It’s available in both large and small barrel sizes – the large one pictured above is best for longer hair, find the smaller one for short hair here.
Most parents will remember the joy of rearing their own digital pet – and now the 90s toy is back and has been given a snazzy 2021 makeover with new styles and patterns. These Tamagotchis will keep teens on their toes – there’s hours of fun to be had.
Monster Hunter rise collector’s edition, was £89.99 now £79.99, Amazon
If your teen has a Nintendo Switch, this new launch makes the perfect gift idea. It’s an epic open-world game where they must battle fearsome monsters and use rewards to craft a huge variety of weapons and armour. If you don’t want the collector's edition you can also grab the regular game for 20 quid cheaper at the above link.
Salter handbag style toastie maker, £24.99, Amazon
A toastie maker that looks like a Chanel handbag? What could be more perfect, teen girls will love this one!
Daisy Eau so Fresh spring, £70, The Perfume Shop
Marc Jacobs’ freshly launched 2021 spring scent will transport your teen girl to a world of blooming daises and lush greenery with notes of green tea blossom, matcha and a bright burst of pink pepper. And you can buy it gift wrapped, perfect!
GXT 105 Izza illuminated gaming mouse, £12.99, GAME
This seriously cool mouse is a must-have gift for PC gamer teens! It lights up in a rainbow of jazzy colours, has an ambidextrous design to suit both left-handed and right-handed players, has six responsive buttons and a long braided cable which makes it durable and tangle resistant. Definitely one to elevate their gaming experience!
American Originals cinema style popcorn maker, £74.99, Argos
This is perfect for movie night! Cinema-style popcorn in minutes, just add oil. It has everything you need to make up to 16 cups of popcorn and includes 4 popcorn buckets, popcorn serving tray, a kernel spoon and oil spoon.
Trust gaming resto chair, was £199 now £179, Amazon
I know what you’re thinking – nearly 200 quid for a chair? But trust me, if you’re a gamer, this is not a chair, it’s a throne! It’s fitted with a premium class 4 gas lift, which lets you seamlessly adjust it from 47 to 54.5 cm. And the backrest is adjustable over 90 degrees, meaning you could even put the backrest flat for a quick rest after a sweeping victory! It can also be tilted forward to reduce pressure on the legs, or tilt it backwards to properly align your spine to prevent back problems. You have to consider these things if your teen spends hours gaming. Needless to say, the armrests’ height is adjustable as well and it comes with two removable and adjustable cushions to provide optimal comfort.
Exotic paisley flip flops, £14.99, Gandys
How about a gift that helps give back? These cute flip flops are by travel-inspired fashion line Gandys. It has an incredible back story - the brand was started
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