The Dublin Metropolitan District Court reviewed an order under section 25 of the Mental Health Act 2001 for a teenage girl who was suffering from anorexia nervosa, and extended that order. The parents were consenting to the extension of the involuntary admission of their daughter.
The solicitor representing the parents expressed concerns regarding their daughter receiving adequate psychological therapeutic input while under the order. They wanted her to receive psychological input with clear plans, “structure, routine … and the close scrutiny of the court.”
The solicitor representing the guardian ad litem (GAL) stated that the girl wanted the GAL to be discharged which was “a natural response for any teenager that is deprived of her liberty”. The court would hear medical evidence and have to make a direction in her best interests, with the admission being as short a time as possible using this opportunity to “frontload the supports available to her.”
The court heard that the girl was under the care of the Child and Adolescent Mental Health Services (CAMHS). It was anticipated when she was discharged that she would require psychological supports, but the psychological supports were not available at the service. It was requested that the GAL be invited to the multi-disciplinary team meeting to allow the GAL to be “acutely aware of her condition”.
The Health Services Executive (HSE) was seeking a three-month extension, with a court review at four and eight week intervals due to effect of the order and her deprivation of liberty.
The young person’s treating consultant psychiatrist gave evidence to the court that there had been progress since she was admitted four weeks previously, when she had been transferred from a paediatrics department. Her medical condition was serious and her physical well-being was a huge concern. It was extremely important that her physical safety be addressed before moving onto physical wellness.
Since her admission at the treatment facility the staff were monitoring her bloods and carrying out a bone density scan as she had borderline osteoporosis due to the period of significant malnutrition. At present, she was evaluated as being 81 per cent of her ideal body weight which was progress “but she had a way to go”. She was gaining weight each week. However, her tests continued to present as “abnormal” in respect of her vitals and blood tests. There was a meal plan in place, the option of using a feeding tube was omitted from her plan on the basis that it was “not good for her mental disorder.”
The court was told that there had been two meetings with the parents since her admission. There was a time table for her to see a psychologist. In the psychiatrist’s view, it was unwise to commence therapy too early as she was severely malnourished. She had “limited ability to engage about psychological intervention.” There was input from nurses and an occupational therapist. Her parents were very involved. She had been prescribed an anti-psychotic; she would see the benefit from that in terms of managing her stress levels.
The young person had a previous diagnosis of obsessive-compulsive disorder (OCD). In terms of behaviours, it was difficult to tease out the eating disorder from the OCD. Her brain was so malnourished, she was experiencing restrictive focus and struggling with touching surfaces. Furthermore, she had a difficulty with prolonged standing due to swelling in her knees and ankles. After a period of severe malnutrition this was common.
The girl was of the view that she would not like to be in hospital and under an order of the court. However, she had had seven previous hospital admissions due to her disorder. It was described as a “very strong eating disorder, the recovery takes an average of seven years.”
The psychiatrist said: “It is important that the illness is treated aggressively with evidence-based treatment. For some young people their insight into their illness is poor.” There were care plan meetings scheduled with clinicians, and they had no issue with the keyworker attending multi-disciplinary team meetings. The key worker met with her for feedback, and they went through the care plan together.
When asked whether this case might benefit from obtaining a second clinical opinion, the psychiatrist replied: “I am open to anything that would be of benefit to [the young person].” She highlighted the medical input and the “large number of opinions present…[it was] important for the eating disorder that someone was taking control of that.”
It was the psychiatrist’s clinical opinion that “she would not receive the treatment unless detained”.
The solicitor representing the parents asked about communication between the psychiatrist and the parents. They were unable to have face-to-face meetings with anyone other than nurses from the service. The keyworker contacted them weekly via telephone.
The parents were made aware that the young person’s treating doctor had been on sick leave since the detention order was made. The solicitor asked whether she was engaging with the staff at the service. The psychiatrist responded: “To the best of her ability.” The young person needed the supports, for example, she was complying with taking the prescribed medication but initially there was a difficulty with this. In relation to the CAMHS community services input, it was “highly unusual that they would have input when the young person was an in-patient.”
The court heard that the girl was not allowed in her room for the majority of the day. She had discussed that quite a lot with her parents. The psychiatrist explained that this was “depending on her physical state” which was reviewed twice weekly, to consider whether she required supervision with toileting and showering, etc.
It was brought to the psychiatrist’s attention that the young person had told her parents that she was being interrupted by staff during her schooling. The solicitor asked whether the staff could be more mindful of this. She told the court that the girl attended school at the service, which was appropriate to her needs. The teachers in the service said she was “managing very well… she was a bright young girl, however her education was interrupted by her illness.”
The court heard that the GAL supported the application for the detention order. The solicitor for the GAL explained that the community services had flagged the girl’s OCD diagnosis. The young person had been admitted for her eating disorder “at risk of death, thankfully she has moved a good distance from that and she is progressing.”
She had to reach a certain base in respect of her physical well-being, then the grounds for continued detention might fall away. If that was the position, the GAL expressed a concern surrounding her treatment for the OCD following discharge. Should the treatment she was receiving during her admission not extend to looking at both? Or was it primarily for the eating disorder?
The psychiatrist responded that the “stakes were so high”, the physical well-being had to be addressed first, otherwise there was the potential for relapse; “her parents were very concerned about this.” Voluntary admission might be an option further down the line, “[the staff] were not going to ignore the OCD.” She flagged to the judge that the young person gave “different accounts on a different day”.
The GAL told the court that she liaised with the service, the keyworker and young person. “No young person wants to be in a unit. [She is] aware of what’s going on. Unfortunately she won’t engage with nursing staff. [She] just stands in the corridor all day and is a very angry young person at the moment.”
In the opinion of the GAL, the teenager was not ready for therapy just yet. Her “biggest fear was that this would happen again,” that the OCD “would bring her back in the door again.”
The judge commented that it was “heartening to see the parents, through their instructing solicitor, welcoming and consenting to the application. What a child wants, and what is in the best interests of the child, are not always the same.”
The court had “no hesitation in granting the extension” noting that this was not the girl’s first admission. There was no need for the GAL to attend the multidisciplinary team meetings for the young person as her doctor had made it clear this was for clinicians.
The court welcomed the suggestion that there be reviews every four weeks in this matter.
