Involuntary Treatment of Minors with Severe and Enduring Anorexia Nervosa

Ethics of Involuntary Treatment

This case describes the continued role of involuntary inpatient psychiatric hospitalization in the treatment of severe and enduring anorexia nervosa in adolescents. For patients experiencing severe illness resulting in significant morbidity and mortality risk, having involuntary treatment available as a last resort can be beneficial.

Involuntary treatment of anorexia nervosa is a controversial topic. Some clinicians advocate for expanding the use of involuntary hospitalizations for severely ill patients, given the high risk of adverse consequences including mortality.^1,32,–,35 Compulsory treatment is typically reserved for severe cases when an individual is at imminent risk of death at the time of admission, and it may be of critical importance in preventing death in patients with severe and enduring anorexia nervosa and psychiatric comorbidity.^1,32,–,35 Delayed treatment of children and adolescents can result in a variety of irreversible medical problems and psychosocial dysfunction, affecting family and peer relationships, self-esteem, and education.^2,32 Pro-ponents of involuntary admission assert that patients with anorexia nervosa are unable to appreciate the severity of their illness in part due to cognitive changes resulting from malnutrition and cite a lack of insight as a hallmark of this illness.^32,33,40 While a lack of insight may be more apparent in patients with other forms of severe mental illness, patients with severe anorexia nervosa have a similarly impaired quality of life compared with patients with severe depression or schizophrenia.³⁴ With children and adolescents, this lack of insight is compounded by developmental limitations; in general, providers utilize broader commitment criteria for minors and may struggle to accept a palliative care model for a treatable illness in a minor when detainment is an option.^1,42,43 Relying solely on parental consent of treatment to override an adolescent's treatment refusal may have a deleterious effect upon the parent-child relationship. Parents of adolescents with chronic, severe, and treatment-refractory anorexia nervosa are often physically and emotionally exhausted and may suffer significant psychosocial dysfunction as a result of their child's illness.¹⁷ Parents are forced either to endure constant pressure from their child to avoid treatment by discharging from the hospital prematurely or to accept continued eating disorder behaviors at home, which helps perpetuate the illness.³⁵

Complicating factors to consider in involuntary treatment of anorexia nervosa include the ambiguity surrounding the criteria for legal coercion and the considerable variation between regions, treatment facilities, and individual practitioners.^{1,24,32,–,35,38,42,43} There are also clinical concerns regarding the humanity of coercive refeeding, the efficacy of involuntary psychotherapy, environmental differences between inpatient units and home resulting in limited generalizability between settings, and the role of the structured inpatient setting in allowing pathological behaviors such as rigid attention to detail and inflexibility to thrive.^{1,18,32,–,35,38}

There are recognized similarities between substance use disorders and anorexia nervosa; the limited efficacy of involuntary substance use treatment is used as an example when suggesting a motivational interviewing framework for treating eating disorders, as motivation to change is essential for successful treatment.^32,35 While involuntary treatment for patients in the precontemplative stage can be beneficial, it could undermine the patient's engagement in treatment when they have progressed to ambivalence or active change along with the therapeutic alliance.³² Providers who pursue involuntary treatment are likely to be opposed by the patient and family who are upset that the patient is being subjected to the indignity and lost autonomy of involuntary hospitalization, which can also be stigmatizing.^1,35,46,47 Outcome data comparing voluntary and involuntary treatment suggest minimal clinical differences between these populations, with the involuntary treatment group's longer average length of stay explained by higher acuity.^1,18,33,34

Despite these complicating factors, multiple studies assert that involuntary treatment of patients with eating disorders is ethically and legally justifiable when the patient is at imminent risk of death from the medical complications of the disorder.^{1,24,32,–,35,38,48} The literature has generally demonstrated that clinicians are more willing to employ involuntary treatment for children and adolescents when compared with adults, especially for younger patients at higher risk.^{24,32,33,35,42,43} While the threshold for adults is typically an immediate risk of death from medical complications, the threshold for minors expands to include prevention of irreparable medical or developmental damage.^33,38,42 While many patients with anorexia nervosa express opposition to coercive treatments in the moment, this can be mitigated by positive relationships with caregivers and clinicians, and patients may reverse their opposition during recovery.^35,48 Outcome data also show that a significant portion of patients who do not recover immediately may still recover several years later, which argues against a palliative approach.²⁹

Court Cases Involving Anorexia Nervosa

Legal challenges have established that the definition of “gravely disabled” does not require the respondent to be near death, but that the respondent be in danger of serious physical harm because of an inability or failure to provide one's self with the essential human needs of food and medical care.¹ In In re LaBelle, 728 P.2d 138 (Wash. 1986), the Supreme Court of Washington rejected the patient-appellants' claim that imminent or present danger must be required for detention, or that a patient be decompensated to the point of “danger of serious harm” at the time of the commitment hearing.⁴⁹ The court reasoned that the effect of being placed in the hospital often eliminates the imminence of one's dangerousness and that maintaining imminent danger as a prerequisite for continued hospitalization may result in the premature release of patients still unable to provide for their health and safety.⁴⁹ Furthermore, the court rejected the requirement of a recent overt act to establish danger, reasoning that danger may arise from passive behavior such as an inability to provide for one's essential needs.⁴⁹

While In re LaBelle established legal precedent in Washington, how states define “grave disability” as it relates to eating disorders varies. An example in Colorado is In re P.A. (unpublished appellate decisions in 2012 and 2013), described by Westmoreland and colleagues.¹ P.A. appealed two trial court decisions determining that she was gravely disabled and required involuntary commitment, which also granted the facility the authority to administer medication involuntarily and place a feeding tube. P.A. alleged that, because her weight had been partially restored in the facility, she was no longer a danger to self or gravely disabled, as she was no longer near death. The Court of Appeals of Colorado upheld both trial court decisions and found that “gravely disabled” does not require a person to be near death, only that the person be in danger of serious physical harm due to their inability or failure to provide themselves with essential human needs of food and medical care.¹

While In re P.A. was similar to In re LaBelle, other states have contrasting examples. The Court of Appeals of Iowa in In re S.A.M. reversed the Iowa District Court's involuntarily commitment of S.A.M. four months prior.⁵⁰ The reviewing court stated that S.A.M.'s weight, risk of metabolic abnormalities, and risk of osteoporosis at the time of commitment could not be considered recent overt acts that demonstrated she was a danger to herself at the time of the appeal.^1,50

It is important to consider that the significant physical risk to patients with anorexia nervosa may be distinct from the general conditions for involuntary treatment, such as the risk to health and safety of self and others, including the impact upon psychosocial functioning. Compulsory treatment of anorexia nervosa may be counterproductive to patient autonomy in the long term, although there may not be a theoretical reason to assume that patient autonomy is more important in eating disorders than other mental illnesses such as depression and schizophrenia.³⁵ Given the high risk of mortality in anorexia nervosa compared with other psychiatric illnesses, including a significantly elevated risk of suicide, this difference in approach is not justified by less risk to the anorexia patient.^{1,3,4,8,32,35,38,51} Autonomy may not be developmentally appropriate for children and adolescents, especially when considering the compounding impact of malnutrition in anorexia nervosa on development.^{2,32,–,35,42,43} In some cases involuntary treatment may mean that the hospital and treatment providers temporarily assume the parental role when a minor is developmentally and psychiatrically unable to make safe decisions and their guardians are unable to do so alone.

Role of Family in Involuntary Treatment

Even when parents are in favor of treatment, an adolescent's opposition to treatment can be difficult to overcome. Parents deciding not to pursue involuntary commitment can potentially be held responsible for a permissive approach. The case of United States v. Robertson involves the tragic death of a 15-year-old adolescent male with anorexia nervosa and bulimia nervosa who resisted his father's continued attempts to get him into treatment, often violently.⁵² His father did not pursue involuntary treatment, and the youth died suddenly of cardiac failure due to starvation.⁵² The father was initially convicted of negligent homicide, which was then upheld by the Court of Military Review.⁵² The U.S. Court of Military Appeals ultimately reversed this conviction, citing insufficient proof that the father's approach of attempting to persuade his son into treatment rather than pursue involuntary commitment was negligent in proximately causing his son to die from anorexia and bulimia.⁵²

There are few studies on the involuntary treatment of anorexia nervosa involving children and adolescents, however, and there is limited research on what to do when both the patient and family are opposed to treatment that is emergently necessary.^{18,24,33,–,35,38,44} Literature has demonstrated increased risk of adverse outcomes for adults and adolescents with anorexia nervosa who are discharged prematurely against medical advice.^35,53

Clinicians may seek to involve the court system when suspecting medical neglect related to an adolescent's anorexia nervosa. In In the Interest of R.H., the Children's Hospital of Philadelphia sought emergency custody of a 15-year-old female with anorexia nervosa because of concerns that she was at serious physical risk if she left the hospital with her mother.⁵⁴ The child had struggled with anorexia nervosa since age nine despite receiving treatment at multiple facilities.⁵⁴ The child's mother had requested discharge earlier than advised by treating clinicians on multiple occasions, and each time the child's health had deteriorated rapidly upon discharging to her mother's care, requiring readmission within days due to the child's critical state.⁵⁴ The trial court placed the child in custody of the Cumberland County Children and Youth Services, and the mother's later appeal was denied by the Court of Common Pleas of Cumberland County.⁵⁴

Although child welfare laws vary by state, clinicians in the United States are mandated to report medical neglect to a child-protection agency.^55,–,58 The agency then determines whether to investigate; if an investigation results in a positive finding, it can lead to a temporary or permanent loss of custody and decision-making authority for the legal guardians through court proceedings.^58,59 When a child is in imminent danger, most states require that investigations be initiated within 24 hours.⁵⁸ Only 28 states (plus Washington D.C., Guam, and the Northern Mariana Islands) specify a timeframe for completing the investigation or assessment; thus, this can be a time-consuming process that may delay nonemergent treatment and may not be feasible when treating a disorder with high morbidity and mortality risk such as anorexia nervosa if treatment is delayed.⁵⁸ Neglect is the most common form of child maltreatment, accounting for 75 percent of calls to child protection agencies and a similar percentage of substantiated claims.⁶⁰ Among child abuse fatalities, 75 percent were identified by the U.S. Department of Health and Human Services 2016 survey as the outcome of caretaker neglect.⁶⁰ Despite the frequency and grave consequences of neglect, there is no cohesive definition, and it can be difficult to diagnose or prove.^60,61

Family-based interventions have the most evidence for treating anorexia nervosa in adolescents and target the family dynamics involved in disordered eating through family therapy.^2,8,17,18,62 Inpatient care alone does not treat anorexia nervosa sufficiently in children and adolescents; there is a high risk of rapid weight loss and rehospitalization without an effective outpatient approach to maintain the weight and behavioral changes gained during hospitalization.^18,53 If a minor is removed from parent custody and placed into the child welfare system, the family may be unable to participate in family-based step-down care. As the long-term outcomes of this approach are likely to be poor and add the trauma of removing a minor from the family, involving the child welfare system for medical neglect in anorexia nervosa must be reserved for extreme cases.

Washington's Involuntary Treatment Act, when employed for adolescents, removes mental health decision-making capacity from both patients and their legal guardians for up to 180 days at a time without terminating the guardians' custody. The adolescent is court-mandated to remain in treatment either in the hospital or in a less restrictive setting, if identified. The family is allowed to continue to participate in treatment without the ability to make treatment and disposition decisions. Including the conditional release clause within the Involuntary Treatment Act streamlines the process of transferring from the inpatient psychiatric unit to a specialized treatment facility for eating disorders, thus granting the patient access to a less restrictive treatment setting while still mandating treatment under the authority of the committing court itself.⁴⁵

A similar process exists in Minnesota following two landmark cases involving patients with anorexia nervosa. In 1987, in In re Kolodrubetz, the Court of Appeals of Minnesota held that the committing court may not become involved in treatment decisions when the treatment offered is within accepted professional standards.⁶³ In In re Kellor seven years later, however, the Court of Appeals of Minnesota upheld the district court's decision to grant the patient's request for transfer to an out-of-state facility offering a less restrictive treatment option in the absence of an appropriate in-state option, holding that the trial court has wide discretion in determining the least restrictive setting.⁶⁴

With the responsibility of decision-making capacity removed from both patient and family under the Involuntary Treatment Act (without removing the minor from the custody of the legal guardian), the patient and family can shift their efforts to treatment and adopt a common goal of regaining decision-making capacity by sustaining recovery. While the literature on this subject is limited, there is some evidence of positive treatment outcomes associated with the involuntary treatment of adolescents with anorexia nervosa.^24,33,35 It may reduce a patient's guilt and internal blame about accepting nutrition and treatment. It can indicate to the patient the serious nature of the condition, and it can mitigate the denial that helps maintain the illness. This approach can reduce the pressure placed on parents because they cannot be blamed for treatment by the patient, and it can enable the patient to view parents as supportive. Involuntary treatment reduces the risk of premature discharge, increases the potential for establishing appropriate aftercare, and may reduce readmission rates.³⁵ A patient's treatment nonadherence and prioritizing of anorexia over life can change with appropriate treatment, even when this treatment is involuntary.^35,52,65

The case illustration demonstrates the potential benefits of this approach. The patient and guardian demonstrated an inability to make decisions that would lead to recovery from the illness, significantly increasing the patient's morbidity and mortality risk. Although the patient and guardian opposed involuntary treatment, there were nonetheless several positive outcomes of this process. The patient demonstrated markedly improved treatment adherence and insight into her illness following compelled medication treatment. The patient also admitted that it was easier to focus on recovery when not consumed by escaping treatment. The relationship between the patient and her legal guardian evolved from contentious and enmeshed into a supportive one, allowing them to work together in choosing an appropriate long-term treatment option. By the time of transfer to the outside treatment facility, the patient achieved weight restoration for the first time since the onset of illness. The legal guardian's decision-making authority was restored upon the patient's arrival to the outside facility.⁴⁵