An extension of six weeks was granted in the Dublin District Court under Section 25 (9) of the 2001 Mental Health Act for a teenage girl receiving involuntary inpatient care in a Child and Adolescent Mental Health (CAMHS) unit for anorexia nervosa.
The solicitor for the Health Service Executive (the HSE) told the court that the teenager [A] had been transferred to the CAMHS facility in early Spring under a 21-day order which had incorporated all necessary measures, including if necessary a nasal gastric (NG) feeding tube, restraint and seclusion.
Prior to her admission the teenager had been exercising compulsively and had had a very rapid weight loss of six kilos in six days.
The solicitor for the HSE submitted that although the child’s family lived outside of Dublin, the child was for the time being in the Dublin Metropolitan District (the DMD) and her period of detention was due to expire that day. The original order had been made outside the DMD and the child had been transferred to the unit within the DMD on the basis that any further order sought would be in the DMD.
The solicitor submitted that the judge’s jurisdiction lay under Section 28 of the Child Care Act as the child was a minor found to be in the DMD at the current time. The parents had instructed a solicitor who had sent a letter of their consent to the order.
The solicitor for the HSE was seeking an extension to the order of six weeks with the same provisions for NG feeding and restraint as found in the previous order. The judge found the jurisdiction of the court to be resolved and heard evidence concerning the teenager from her treating CAMHS psychiatrist.
The psychiatrist told the court that the teenager was suffering from a mental health disorder under the meaning of Section 3.1a of the Mental Health Act 2001 and that this was her third admission into a CAMHS unit. She had a diagnosis of anorexia nervosa.
The court heard that progress had been made since A’s arrival. However, on the day of admission A had taken no food or fluids orally all day and her blood sugars were decreasing. Due to her compromised state she required an intervention in order to obtain the nutrition she would have otherwise received through a meal plan and an NG tube had to be inserted which required restraint. Since then the teenager had been 100 per cent compliant with her meal plan.
Part of her treatment required that the teenager complied with her meal plan. The teenager had been admitted to hospital at the end of 2018 having being very unwell and was transferred to the CAMHS psychiatric unit to receive the nutrition she required.
Receiving nutrition was the basic requirement of the unit in order for her to be able to take part in individual psychotherapy support and intensive family therapy work. The psychiatrist told the court that a person had to be sufficiently nourished in order to partake in this type of work: “As you lose weight your brain shrinks and the ability to be able to engage cognitively diminishes. She hadn’t been eating, without her knowing there is the option of nasal gastric food I don’t believe she would eat orally,” said the psychiatrist.
The teenager was at a sub-optimal weight and her bone structure had been affected by her prolonged starvation, causing osteopenia, a precursor of osteoporosis. This occurred when a reduced number of the cells needed for making bone existed. A DEXA scan had been carried out which showed signs of osteopenia in two vertebrae in her spine. “This is usually an illness of the elderly, it’s extremely concerning,” the psychiatrist told the court.
A had made progress since her admission and had been gaining weight for three weeks along with the recommended guidelines of 1kg per week. However, the nurses had carried out an unannounced weigh-in and found that the teenager had lost half a kilo. The psychiatrist explained that the patients would sometimes take on “gallons of water or put weights in their pockets” before being weighed in order to appear heavier.
Nasal gastric feeding and restraint had only occurred on A’s admission into the unit, knowing that option was there had helped the teenager to comply, said the psychiatrist. It had been a struggle engaging with A therapeutically but they hoped to make progress over the coming weeks.
The guardian ad litem (GAL) told the court that she had met with the teenager three times since this admission and had noticed a little bit of a change since her last admission. Whilst previously A would have just shaken her head or shrugged her shoulders she was now speaking in full sentences and smiled. A had told her that she did not believe that she had anorexia and was not open to engaging in therapy as she did not feel it was helpful. “She’s reporting she’s very focussed on her weight,” said the GAL, “she is really struggling with reduced exercise and is very focussed on calories, her meal plan and her weight for height, she feels she doesn’t have anorexia.”
A had spent a huge amount of her adolescence unwell in hospital and missed out on a huge amount of normal adolescent experiences. She was not in contact with her school friends at the moment and was finding it difficult to talk about the future. She was a very sporty teenager so she struggled with the fact that she could not exercise. According to her parents, the anorexia had begun around the start of adolescence and the start of secondary school.
The GAL read out A’s wishes:
“The extension should not be for three months, they are telling me to put on a lot of weight, it’s too much, they say it’s healthy, they won’t let me do any activity, it’s not helpful to talk to the psychologists, they want me to talk to them.”
It was the GAL’s opinion that this was A’s third in-patient admission due to a serious chronic illness and could have a long-term impact on her physical and emotional well-being. She said that the teenager continued to be very caught up in her anorexic thinking and this was still the early stages of admission. A meeting was scheduled for the following week to discuss on-going treatment, supports post-discharge and the commencement of family therapy, which was central to the treatment of anorexia.
The HSE solicitor told the court that while the Mental Health Act 2001 allowed for a three-month extension to the order she was seeking six weeks.
Nasal gastric tube feeding would form part of the treatment only to be used as an absolute last resort and every conceivable effort would be tried first to make sure she had the nutrition she needed.
The judge remarked how important it was that A started to do this for herself as opposed to the fact it was a court order. The court had taken into account her views and was very interested in listening to them but her general health and her weight needed to be healthy in order for her to make progress.
The court was satisfied that the threshold had been met and that it was necessary to extend the order for six weeks.