ADHD diagnosis in children: Consent, parental disputes and medicolegal risks explained

Case study 

Dr Y is a consultant psychiatrist in private practice. He sees an 11-year-old patient, Amy, whose mother has brought her for an ADHD assessment. Amy struggles to focus at school, and there has been some challenging behaviour at home. Amy’s parents are divorced. She lives with her mother but regularly spends time with her father during the holidays. 

Dr Y conducts an assessment, which includes an interview with Amy’s mother and review of reports from school. He concludes that the diagnostic criteria for ADHD are met and suggests that Amy may benefit from stimulant medication. He discusses the risks and benefits of his proposed management plan and explains the need for ongoing monitoring. He provides a prescription for a low dose methylphenidate and arranges a follow-up appointment.

A week later Dr Y receives a message from Amy’s father stating that he does not agree with the ADHD diagnosis. He says that Amy is well-behaved when with him. He asks Dr Y to revoke the diagnosis and amend the medical records accordingly. He demands that no further medication should be prescribed and threatens to report Dr Y to the Medical Council (MCNZ) if he does not comply with his wishes.

Dr Y contacts Medical Protection for advice. Despite being confident in his assessment, he is concerned about the implications of being reported to the MCNZ. He notes that medication has been beneficial for Amy but asks whether it is reasonable to continue to prescribe, given that Amy’s father does not consent to treatment. 

Medical Protection’s advice 

Dr Y is advised that it may be helpful to meet with the father to discuss his concerns and the diagnosis in more detail. ADHD is a neurodevelopmental disorder that can present differently between genders and through life. Affected individuals may be able to mask their symptoms in certain settings, and a parent who has not witnessed the challenges may question the validity of a diagnosis.

Further, it is not unusual for parents to be reluctant to medicate their child. A holistic assessment is key, and in such a situation it is important to take the father’s account into consideration too. Dr Y is advised to bear in mind his duties in relation to confidentiality, and to check with each parent before sharing any updated report.

Consent  

The MCNZ statement Good Medical Practice outlines clinicians’ professional obligations in relation to consent when treating children. When working with patients under 16 years old, one should determine their competence to understand their condition and make decisions about their treatment1. This position confirms the common law view that minors may provide legally effective consent for medical treatment if they are mature enough to understand what is proposed and are capable of expressing their own wishes2. However, even if the child does meet criteria to be able to provide their own informed consent, parental involvement in the decision-making should be encouraged for important or controversial procedures.

If the child is not competent to consent to their own treatment, then the Care of Children Act states consent for treatment may be given by “a guardian of the child”3. Even though it does not require both parents to consent to the treatment, the ideal situation would involve both parents agreeing with and understanding their daughter’s management plan. So, although only one parent’s consent is required, if the clinician is aware that the other parent does not consent, then agreement between both parents as to how to proceed should be obtained. The Care of Children Act (COCA) encourages parents and guardians to reach agreement for the child’s care,4 When agreement cannot be reached, guardians can approach the courts to assist. Dr Y is advised that now he is aware that the father does not consent, and there is no urgency in providing treatment, he should not continue prescribing until consensus is reached or a court order obtained.

Medical records 

Medical records must be true, clear, and contemporaneous, and, according to MCNZ, ‘If you need to correct or add notes to your patient’s records sometime after an event, these must be clearly identified as corrections or additions”5 . The Health Information Privacy Code (HIPC) involves rules to how health information is collected, used, held and disclosed by health agencies based upon the privacy principles of the Privacy Act. Rule 7 HIPC requires that when a health agency holds health information the individual concerned (or their representative) is entitled to request a correction of that information. There are, however, reasons a health provider may refuse a correction including that the information is the opinion of the clinician held at the time. Dr Y’s clinical opinion also should not be amended purely because a patient or parent disagrees with it. Dr Y was advised that he did not need to change his clinical notes but was required to explain to the father the reasons for refusal and that the father was entitled to have an attachment of a statement to the notes of the correction sought, and his right to complain to the Privacy Commissioner.

Dr Y can listen to Amy’s father and document the information he receives in the medical records. It would be appropriate to note the different viewpoint of each parent and state how each of the accounts received has played into the diagnostic process and any disagreement. The new information may, or may not, influence the overall assessment and recommendations for management, however it is at least likely to assist in understanding the circumstances for Amy overall. In addition, ensuring that the father feels heard may help to prevent any escalation of the matter from a medicolegal perspective.

Learning points 

Medical Protection often advises doctors who find themselves embroiled in a dispute between parents regarding the care of their child. It is important to maintain professional boundaries and to stress to the parents that any decision-making should be in the best interests of the child. The Care of Children Act requires parents to work together in the care of their child. It is not appropriate for medical professionals to act as mediators or conveyers of information but ensuring that both parties are heard can be key in ensuring the right outcome for the patient and resolution of a potentially difficult situation.

References 

1. MCNZ statement onGood Medical Practice, p14 
2. Coles Medical Practice in NZ
3. COCA s36 3 (a) 
4. COCA s39
5. MCNZ statement on Managing patient records para [6]