Can Teenagers with AN Give Consent for Treatment?

Parents have long acted as decision-makers for their teenage children who need treatment. This has been based on an assumption that adolescents do not have enough cognitive maturity to make their own decisions about treatment. Sheri L. Turrell, PhD and colleagues at the University of Toronto noticed that to date there had been no empirical comparisons of the ability of teens with and without mental illness to understand, appreciate, reason, and make their own treatment choices (Int J Eat Disord 2011; 44:703).

Dr. Turrell and her co-authors also noted that the issue of capacity is daunting when the patient has anorexia nervosa (AN). Intervention with AN patients can be problematic due to a combination of the tenacity and egosyntonic nature of AN and most patients’ denial that they are ill. Since AN patients are frequently reluctant to participate in recommended treatment, it would be logical to assume that they would be poor candidates for making decisions about their own treatment.

To test their theory, the authors designed a study of 35 adolescents with AN, all of whom were inpatients in a tertiary care, university-affiliated hospital, and 40 healthy adolescents from the community. The goal was to compare the ability of the inpatients and healthy adolescents to make decisions about treatment. To do so, the authors used hypothetical vignettes describing medical and psychiatric illnesses requiring treatment decisions. After obtaining consent from the patients’ parents, the team approached potential participants, and all agreed to participate. All the participants completed the same measures: body mass index, the Eating Attitudes Test (EAT-26), the Youth Self-Report, a self-report questionnaire for 11- to 18-year-old covering a broad range of symptoms, including internalizing and externalizing problems. Participants also took the Wechsler Abbreviated Scale of Intelligence, and the Immediate Verbal Memory subscale of the Children’s Memory Scale. To test their treatment decision-making ability, the participants participated in the MacArthur Competence Assessment Tool Treatment (MacCAT-T), a semi- structured interview that assesses the four components of capacity to consent to treatment in the context of real and/or hypothetical illnesses. All participants were presented with two hypothetical vignettes depicting individuals with illnesses, scoliosis and depression. The participants were presented with two treatment options, the risks and benefits of each, and finally with the participants reasoning about which treatment choice they would prefer. Information about each illness was given.

In addition to responding to the two vignettes, participants with AN completed the MacCAT-T in relation to information relevant to their own admission for AN. Although it was made clear that “no treatment” was not an actual option in their own cases, this was used as a second treatment option.

Patients were less able to make consistent treatment decisions

The authors reported that participants with AN were less able than community participants to engage in consequential reasoning, less apt to generate everyday consequences of their decisions, and less able to make logistically consistent decisions about the vignettes. The authors noted that since many persons with AN perceive the illness as an integral part of their identity, it may be very difficult for them to objectively compare and contrast the pros and cons of treatment.

Most of the teens with AN and those from the community were in high school (71% and 70%, respectively). Participants with AN had significantly lower BMIs and higher EAT-26 scores than did their counterparts from the community. One participant from the community was removed from the study when the screening showed she had symptoms of an eating disorder.

The authors suggest that future studies focus on factors that relate to indications of capacity, as well as attempting to gain a better understanding of the impact of hospitalization on reasoningboth with an eye to protecting AN patients’ rights to informed consent about treatment.