Children And Young People Tool Kit. - BMA
Children and youngpeople tool kit
Children and young people tool kitContentsContentsCARD 1 . 5Basic principlesCARD 2 . 7Assessing competenceCARD 3. 10Parental responsibilityCARD 4. 15Consent and refusalCARD 5. 19Best interestsCARD 6. 22DisputesCARD 7. 25Use of restraint to provide treatmentCARD 8. 28Children and young people’s health informationCARD 9. 33Unaccompanied minorsCARD 10. 36Sexual activityCARD 11. 42Child protectionBritish Medical Association 1
Children and young people tool kitContentsCARD 12. 4716-17 year olds who lack mental capacityCARD 13. 49Compulsory treatment for a mental disorderCARD 14. 52Research and innovative treatmentCARD 15. 55Useful names and addresses2British Medical Association
Children and young people tool kitAbout this tool kitAbout this tool kitQuestions about children and young people are asignificant area of ethical enquiry for the BritishMedical Association (BMA) with doctors facing evermore complex dilemmas. High profile cases aroundchild protection, access to sexual health services, andthe vaccination of children highlight the sensitivityand difficulties doctors face in this area. Doctorsneed to know when a young person is competentand what this means in terms of their ability toconsent and refuse health care, and what limits areplaced on those with parental responsibility.The purpose of this tool kit is not to providedefinitive answers for every situation but to identifythe key factors that need to be taken into accountwhen such decisions are made and signpost otherkey documents. The tool kit consists of a series ofCards about specific areas relating to theexamination and treatment of people in England,Wales, and Northern Ireland who are aged under18 years, and in Scotland under 16 years. SeparateCards have been produced identifying factors to beconsidered when assessing competence anddetermining ‘best interests’, and sensitive areasincluding child protection and access to sexualhealth services. All Cards refer to useful guidancefrom bodies such as the General Medical Council(GMC), BMA and health departments, which shouldbe used in conjunction with the Cards. In addition,the medical defence bodies and many of the royalcolleges produce specific advice for their members:Card 15 lists contact details for organisations fromwhom further advice can be obtained.British Medical Association3
Children and young people tool kitAbout this tool kitThe tool kit is available on the BMA’s website andindividual Trusts, medical schools and individualhealth professionals may download and adapt it tosuit their own requirements. There are no copyrightrestrictions on this tool kit – please feel free to makemultiple copies.The BMA would welcome feedback on theusefulness of the tool kit. If you have any commentsplease address them to:Medical Ethics DepartmentBritish Medical AssociationBMA HouseTavistock SquareLondon WC1H 9JPTel: 020 7383 6286Fax: 020 7383 6233Email: ethics@bma.org.ukWebsite: www.bma.org.ukThis is the first edition of the BMA’s Children andyoung people tool kit. Information aboutdevelopments since its publication may be obtainedfrom the BMA’s website or by contacting the BMAMedical Ethics Department.4British Medical Association
CARD 1Basic principlesBasic principles have been established regarding themanner in which the treatment of children andyoung people should be approached. These reflectstandards of good practice, which are underpinnedby domestic and international law.The welfare of children and young people is theparamount consideration in decisions about theircare. Children and young people can expect: to be kept as fully informed as they wish, and asis possible, about their care and treatment health professionals to act as their advocates to have their views and wishes sought and takeninto account as part of promoting their welfare inthe widest sense to be the individual who consents to treatmentwhen they are competent to do so to be encouraged to take decisions incollaboration with other family members,especially parents, if this is feasible to be able to expect that information providedwill remain confidential unless there areexceptional reasons that require confidentialityto be breached.Doctors caring for children and young people havea number of ethical and legal obligations withwhich they should be familiar and are outlined inbest practice guidance, statute and case law. ForBritish Medical Association5
Children and young people tool kitBasic principlesexample, the Gillick case, Children Acts 1989 and2004, the Children (Scotland) Act 1995, Children(Northern Ireland) Order 1995, Age of LegalCapacity (Scotland) Act 1991, Mental Capacity Act2005 (England & Wales), Family Law Reform Act1969, Human Rights Act 1998 and the UnitedNations Convention on the Rights of the Child.Key advice General Medical Council. 0-18 years: guidancefor all doctors. Available at www.gmc-uk.org BMA. Consent, rights and choices in healthcare for children and young people. Moreinformation available at www.bma.org.uk/ethics6British Medical Association
CARD 2Assessing competenceCan competence ever be presumed?Yes. All people aged 16 and over are presumed inlaw to be competent to give their consent tomedical treatment and to the release of informationin England, Scotland, Wales and Northern Ireland(see Card 12 for more information on 16-17 yearolds who lack mental capacity).Can a young person be competent under theage of 16?Yes, but this needs to be assessed in each case on acontinual basis. Doctors should aim to involve allchildren and young people in decisions relating totheir medical treatment. It is important to recognisewhen a young person is able to make a valid choiceabout a proposed medical intervention or disclosureof personal medical data and is thereforecompetent to make a personal decision. Doctorsshould not judge the ability of a particular child oryoung person solely on the basis of his or her age.For a young person under the age of 16 to becompetent, s/he should have: the ability to understand that there is a choiceand that choices have consequences the ability to weigh the information and arrive ata decision a willingness to make a choice (including thechoice that someone else should make thedecision)British Medical Association7
Children and young people tool kitAssessing competence an understanding of the nature and purpose ofthe proposed intervention an understanding of the proposed intervention’srisks and side effects an understanding of the alternatives to theproposed intervention, and the risks attachedto them freedom from undue pressure.Competent under 16 year olds are sometimesreferred to as being Gillick competent. In England,Wales and Northern Ireland children who are aged12 or over are generally expected to havecompetence to give or withhold their consent to therelease of information. In Scotland, anyone aged 12or over is legally presumed to have suchcompetence (see Card 8 on children and youngpeople’s health information).Who should assess competence?GPs who have known the young patient for a longtime are well placed to assess their development andmaturity but because these change, it is unwise torely on any assessment that is not contemporaneous.Health professionals who assess competence need tobe skilled and experienced in interviewing youngpatients and eliciting their views without distortion.The treating doctor may be the most appropriateperson, but other members of the health care teamwho have a close rapport with the patient may alsohave a valuable contribution to make.8British Medical Association
Children and young people tool kitAssessing competenceHow can competence be promoted?When assessing a child’s competence it is importantto explain the issues in a way that is suitable fortheir age. A young patient may be competent tomake some, but not all decisions, and clinical staffshould promote an environment in which youngpatients are enabled to engage in decisions as muchas they are able. The child or young person’s abilityto play a full part in decision-making can beenhanced by allowing time for discussion.Key advice General Medical Council. 0-18 years: guidancefor all doctors. Available at www.gmc-uk.org BMA. Consent, rights and choices in health carefor children and young people. Moreinformation available at www.bma.org.uk/ethicsBritish Medical Association9
CARD 3Parental responsibilityWho can consent on behalf of a baby or childwho lacks capacity?Someone with parental responsibility, provided thedecision is in the best interests of the child.Do all parents have parental responsibility?No. Not all parents have parental responsibility.Throughout the United Kingdom, a motherautomatically acquires parental responsibility atbirth. However, the acquisition of parentalresponsibility by a father varies according to whereand when the child’s birth was registered.When does a father acquire parentalresponsibility? For births registered in England, Wales orNorthern Ireland. A father acquires parentalresponsibility if he is married to the mother at thetime of the child’s birth or subsequently. Anunmarried father will acquire parentalresponsibility if he is recorded on the child’s birthcertificate (at registration or upon re-registration)from 1 December 2003 in England or Wales andfrom 15 April 2002 in Northern Ireland. For births registered in Scotland. A father acquiresparental responsibility if he is married to themother at the time of the child’s conception orsubsequently. An unmarried father will acquireparental responsibility if he is recorded on thechild’s birth certificate (at registration or upon reregistration) from 4 May 2006.10British Medical Association
Children and young people tool kitParental responsibility For births registered outside the United Kingdom.The above rules for the UK country where thechild resides apply.Can other people have parental responsibility?An unmarried father, whose child’s birth wasregistered before the dates mentioned above, orafterwards if he is not recorded on the child’s birthcertificate, does not have parental responsibilityeven if he has lived with the mother for a long time.However, the father can acquire parentalresponsibility by way of a court registered parentalresponsibility agreement with the mother or byobtaining a parental responsibility order or aresidence order from the courts. Married stepparents and registered civil partners can acquireparental responsibility in the same ways. Parentalresponsibility awarded by a court can only beremoved by a court.Other people can also acquire parental responsibilityfor a child: a guardian named in a will if no one withparental responsibility survives the person whowrote the will a guardian appointed by a court when a child is adopted, the adoptive parents a local authority (shared with anyone else withparental responsibility) while the child is subject toa care or supervision order. Foster parents rarelyhave parental responsibility for a child born under a surrogacy arrangement,parental responsibility will lie with the surrogatemother (and her husband if she married) until theintended parents either (a) obtain a parentalBritish Medical Association11
Children and young people tool kitParental responsibilityorder from a court under the Human Fertilisationand Embryology Act 1990, or (b) adopt the child.Parents are also entitled to authorise anotherperson to take over particular responsibilities. Forexample, a parent may sign consent for anotherperson to take the child for immunisation or tocollect medication.What if the parents are divorced?Parents do not lose parental responsibility if theydivorce – nor can a separated or divorced parentrelinquish parental responsibility. This is true evenif the parent without custody does not havecontact with the child and does not make anyfinancial contribution.Until what age can parental responsibilitybe exercised?In England, Wales and Northern Ireland, parentalresponsibilities may be exercised until a youngperson reaches 18 years. In Scotland, only theaspect of parental responsibilities concerned withthe giving of ‘guidance’ endures until 18 years –guidance meaning the provision of advice. Therest is lost when the young person reaches 16years, although some may be lost before this ifthe child attains legal capacity to act on his or herown behalf.What is the role of parents who do not haveparental responsibility?It should be noted that parents who do not haveparental responsibility may also play an essential rolein determining best interests and may have a right,12British Medical Association
Children and young people tool kitParental responsibilityunder the Human Rights Act, to participate intreatment decisions.What happens if there is a disagreementbetween people with parental responsibility?Generally, the law requires doctors to have consentfrom only one person in order lawfully to providetreatment. In practice, however, parents sometimesdisagree and doctors are reluctant to override aparent’s strongly held views, particularly when it isnot clear what is best for the child. Discussionaimed at reaching consensus should be attempted.If this fails, a decision must be made by the clinicianin charge whether to go ahead despite thedisagreement. The onus is then on the parent whorefuses treatment to take steps to stop it. If thedispute is over an irreversible, controversial, electiveprocedure, for example male infant circumcision forreligious purposes or immunisation when it isknown one of the parents objects, doctors must notproceed without the authority of a court (see Card6 on disputes – when to seek legal advice). InScotland, however, the Children Act imposes anobligation on any person exercising a parentalresponsibility or parental right to have regard tothe views of any other person with the same rightsand responsibilities.What if the parents aren’t communicating witheach other?There are occasions when parents do notcommunicate with each other but both want tobe involved in their child’s health care. Forexample, GPs are frequently asked to tell theparent with whom the child is not resident whenBritish Medical Association13
Children and young people tool kitParental responsibilitythe other parent brings the child to the surgery.There is no requirement on GPs to agree to suchrequests, which could entail a lot of time andresources if the child presents frequently. It isclearly better if parents are able to communicatewith each other about their child’s health,although doctors may agree to contact the absentparent under certain circumstances, for example ifthere is a serious concern.Where a procedure is controversial, however, forexample non-therapeutic circumcision, if a childpresents with only one parent, the doctor mustmake every effort to contact the other parent inorder to seek consent.Key advice BMA. Parental responsibility. Available atwww.bma.org.uk/ethics14British Medical Association
CARD 4Consent and refusalWho can consent to a child’s or young person’streatment?The following are legally entitled to give consent tomedical treatment of a child or young person: a competent child or young person (see Card 2on assessing competence) a parent or other person or agency with parentalresponsibility where the decision is in the bestinterests of the child (see Cards 3 and 5 onparental responsibility and best interests) a court an appointed proxy (in Scotland where thepatient is over 16 and unable to make decisionsfor him or herself) (see Card 12 on mentalcapacity); or a person caring for a child, for example agrandparent or child minder, may do what isreasonable in the circumstances to safeguard orpromote the child’s welfare (see Card 3 onparental responsibility). In Scotland, the primacyof any known wishes of the parents in thesesituations has statutory force. If a carer brings achild for treatment, steps should be taken toascertain the parents’ views, and if there is doubtabout authority to proceed, doctors should seeklegal advice.British Medical Association15
Children and young people tool kitConsent and refusalAre there any procedures a young person over16 years old is not presumed to be competentto consent to?In England, Wales and Northern Ireland there aresome rare procedures – for example, live organdonation, some non-therapeutic procedures andresearch – where the presumption of competencefor 16-17 year olds does not apply. A 16-17 yearold is only deemed competent if Gillick competent(see Card 2 on assessing competence). Theseexceptions do not apply to Scotland where a youngperson over the age of 16 is treated as an adult.If a competent young person can consent totreatment, does it also follow that s/he canrefuse treatment?No, not always. In England, Wales and NorthernIreland, a competent refusal can be overruled by acourt or by a person with parental responsibility.Health professionals faced with an informed refusalof a treatment they believe to be beneficial shouldtake legal advice – for example a refusal of lifesaving treatment or treatment that would preventpermanent injury. The reasons why the child oryoung person has refused should be discussedbeforehand to ensure that the refusal is not basedon inaccurate perceptions. In Scotland it seemslikely, from current case law and statute, that acompetent refusal cannot be overridden by anyother person, carer or court, even if that treatmentis necessary to save or prolong life. This matter isnot beyond doubt and legal advice should besought where such situations arise.The same principles apply to advance decisions torefuse treatment. In UK jurisdictions where a youngperson’s contemporaneous refusal of treatment may16British Medical Association
Children and young people tool kitConsent and refusalnot be determinative, it follows that advancedecisions to refuse treatment made by young peoplecannot be legally binding on health professionals.Can doctors provide treatment against a child’sor young person’s wishes?If a child or young person refuses treatment, justbecause consent from a parent, or from a court,makes providing treatment lawful does not meanthat it inevitably has to be given. Doctors must lookat whether the harms associated with imposingtreatment on a patient who refuses, whethercompetently or not, should play a part in the decisionabout proceeding. How critical the treatment is,whether alternative less invasive treatments areavailable, and whether it is possible to allow time forfurther discussion with the patient, are all factors tobe weighed. As much time as is practicabl
children and young people in decisions relating to their medical treatment. It is important to recognise when a young person is able to make a valid choice about a proposed medical intervention or disclosure of personal medical data and is therefore competent to make a personal decision. Doctors should not judge the ability of a particular child or young person solely on the basis of his or .
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Level 3 Diploma for the Children & Young People's Workforce (4227 -03/04/05) (England) 3 Contents 1 Introduction to the qualification 7 1.1 Qualification structure 8 2 Optional units (mandatory and pathway units in separate handbook) 18 Unit 032 Support the creativity of children and young people 22 Unit 033 Understand the needs of children and young people who are vulnerable
The Young-Girl as Phenomenon 23 2. The Young-Girl as Technique of the Self 48 3. The Young-Girl as Social Relation 62 4. The Young-Girl as Commodity 74 5. The Young-Girl as Living Currency 88 6. The Young-Girl as Compact Political Apparatus 97 7. The Young-Girl as War Machine 105 8. The Young-Girl Against Communism 114 9.
1 Children’s Commissioner (2018) Children’s mental health briefing 11 per cent of young people aged 10 to 17 report low subjective wellbeing which equates to approximately 550,000 children in England.2 In 2016, the NHS estimated that it supported 25 per cent of children and young people with a mental health condition. The aspiration is to reach 35 per cent by 2020/21.3 The .
The impact of domestic abuse on babies and young children o t Domestic violence has a devastating impact on children and young people that can last into adulthood One in seven (14.2%) children and young people under the age of 18 will have lived with domestic abuse at some point in their childhood 1 A study of 139 overview reports from
young people aged 14-18 were also compared with those of adults. Our key findings are: Young people's participation in social action significantly outweighs adult perception: 68 percent of young people have participated in volunteering or other forms of social action, but just five percent of adults think that young people today are very
