Parental disagreements are a frequent cause of clinicians seeking medicolegal input in relation to a clinical case. Dr. Sara Sreih and Dr. Lucy Hanington discuss a scenario following an ADHD diagnosis of a child.
Case Study
Dr. Jolly is a Child and Adolescent Psychiatrist working in private practice. She sees Isla, a ten-year-old girl, at the request of her mother Mary, who wonders whether Isla might have ADHD.
Isla’s only past medical history is asthma. She attends a mainstream school and is generally happy. However, Mary has been called into school to speak with teachers on several occasions recently. Isla is finding it difficult to focus in class, and her grades are falling. Since starting Year Five, she has also had some friendship issues. Mary explains that Isla’s behaviour at home can be tricky with tantrums and frequent meltdowns after school. Isla’s parents are separated and she lives at home with her mother, seeing her father (Ian) some weekends and for a week in the school holidays.
After assessing Isla, interviewing Mary, and reviewing the report provided by school, Dr. Jolly diagnoses Isla with ADHD (predominantly inattentive type). She suggests a management plan which involves a trial of Medikinet XL.
Shortly afterwards, Dr. Jolly receives an email from Ian, disputing the diagnosis. He says that as he has parental responsibility, his consent to assessment and treatment should have been sought. He feels that Dr. Jolly’s conclusions are flawed and based on inaccurate information. He does not recognise the behaviour described by Isla’s mother. He asks for information about the tantrums and meltdowns to be deleted from his daughter’s medical record. He says that if the diagnosis of ADHD is not reconsidered he will take legal action.
Dr. Jolly is worried by the threat of legal action, and unsure how to proceed.
Medicolegal advice
ADHD is a neurodevelopmental disorder which can have lifelong medical, educational and social implications. Given this, and the media storm of recent years, it is hardly surprising that some parents may feel reluctant to seek assessment for their child. They may fear that the ‘label’ may result in stigma, and be concerned about the impact of long-term medication, particularly as stimulants are potential drugs of abuse.
Others may be in denial, unwilling to accept that there is anything wrong, or perhaps do not fully understand the condition. Occasionally, the ‘safe’ parent may be the one bearing witness to the behaviours associated with the condition, with the child effectively masking when with others.
When situations like this arise, it can be helpful to draw the issues out into the open at an early stage so that they may be resolved, whilst taking care to avoid being drawn into any challenging family dynamics. The child should always be the doctor’s main focus, and should be kept at the centre of any discussions or decisions.
It would be difficult to criticise a doctor who can show that they have taken this approach and have acted in the best interests of the child.
In the above scenario, Dr. Jolly is content that her diagnosis is correct, and highlights the fact that the diagnostic criteria for ADHD require evidence of impairment in more than one setting. She says that in her experience, parents can find it hard to accept that their child is different in any way, and that had there not been the threat of legal action she would have simply taken the time to speak with Ian and explore his concerns.
The medico-legal consultant (MLC) suggests that this would remain a sensible approach, especially since Ian had not been involved in the referral or assessment process to date, and advises that Dr. Jolly may find it helpful to invite a colleague to join the discussion, both for support and to take minutes. Dr. Jolly agrees with this plan, but is very concerned that proceeding with an assessment without Ian’s consent is a serious omission. She is also unsure what to do with respect to the request to delete information from the medical record. The MLC talks Dr. Jolly through the relevant medicolegal landscape and guidance.
Consent and Confidentiality
Where a child lacks the capacity to make decisions about their medical care (due to age or other reasons), the consent of one individual with parental responsibility is usually sufficient. There are only a few exceptions to this rule, such as male circumcision, where the consent of both parents is necessary. Nonetheless, parental disagreement can lead to a clinician feeling uncertain as to how best to proceed, and it can be difficult to avoid becoming entangled in an unhelpful family dispute. In the most extreme cases, there is ultimately recourse to the courts, who will make a decision in the best interests of the child. In emergency situations, if parental consent cannot be obtained, the best interests rule also applies.
In this particular case, even with parental responsibility, Ian cannot refuse treatment for his daughter’s ADHD, and it would be reasonable for Dr. Jolly to continue to prescribe it.
It is important to be mindful of issues relating to confidentiality. Ian has parental responsibility, and can therefore request access to Isla’s medical record. However, any such disclosure must be in Isla’s best interests, and certain information, such as third-party information or information that has the potential to cause serious harm (the threshold for this being high), should be withheld. In general, it will be in a child’s best interests for a parent who cares for them to know about their medical history. Steps to achieve a shared understanding will be important as Isla spends time with her father, and his assistance with medication will be needed. It will also be useful for him to have an understanding of her strengths and challenges as she grows. It is likely that in the not too distant future, Isla will have capacity to make her own decisions about disclosure and treatment, and it will be important to keep this in mind for future consultations.
Amendments to medical records
GDPR legislation provides patients with the right to request that inaccurate information in the medical record is rectified or deleted. However, this does not mean that patients can demand that information setting out a clinician’s opinion is removed in the event that they disagree with what has been documented. Nor would it be appropriate for a clinician to amend a factually accurate account of events, for example what was discussed in a consultation. It is important, especially in assessments such as for ADHD, when multiple sources of information are relied upon, that these sources are clearly referenced. It should be clear whether a symptom or sign is something that was observed in the clinic room, reported by a parent, or from a school report, for example.
The preferred approach here is to take steps to accommodate both parents, listening to their views and experiences, without compromising one’s professional clinical views. In this case, it would be reasonable to take Ian’s account, which may also provide Dr. Jolly with a more well-rounded picture of Isla and any difficulties she has, and to document this in the medical records. Dr. Jolly could offer to include a note to indicate those aspects of the information provided which Ian disagrees with and why. The report could also be amended to include Ian’s contribution or Dr. Jolly could write an addendum to the report.
Dr. Jolly could also explain why, despite one parent’s disagreement, she still reached her conclusions. Meeting with Ian would provide an opportunity to explore and attempt to resolve any concerns or queries he might have. This may also have the added benefit of de-escalating the situation from a medicolegal perspective, and hopefully Dr. Jolly can continue caring for Isla without having to be concerned about possible legal action.
Summary
- Parental disputes can complicate the provision of clinical care
- It is important that clinicians do not get drawn into disputes
- In most situations, consent of one individual with parental responsibility is sufficient
- Clinicians should always be mindful of confidentiality
- Inaccurate information can be deleted from the medical record, but patients cannot demand removal of a clinical opinion (or, as here, the opinion of a third party) they disagree with
- It can be helpful to add a note to the medical records to set out the disagreement of the patient/parent
- If in doubt, always contact your medical defence organisation to request advice and support.
Dr. Sara Sreih and Dr. Lucy Hanington are Medicolegal Consultants at Medical Protection.
