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Forensic Issues in Child Psychiatry


Large numbers of children have no home, no school and no family. ... Haemorrhage. Inappropriate explanation of child's injury. Wariness of adult contacts ... – PowerPoint PPT presentation

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Title: Forensic Issues in Child Psychiatry

Forensic Issues in Child Psychiatry
Lt. Col. Neatu Narang Associate Professor
Psychiatry Classified Specialist Psychiatry Base
Hospital Delhi Cantt.
  • Child population is not homogeneous. Large
    numbers of children have no home, no school and
    no family.
  • They can be in orphanages, destitute homes,
    beggars homes, juvenile homes, rescue homes,
    remand homes and on streets.

Tenth Five Year Plan (2002-07)
  • "The development of children is the first
    priority on the countrys development agenda,
  • not because they are the most vulnerable,
  • but because they are our supreme assets
  • and also the future human resources of the
  • these words underlines the fact that the future
    of India lies in the future of Indian children
  • across income groups, geographical locations,
    gender and communities.

As per 2001 census
  • India has around 157.86 million children,
    constituting 15.42 of India's population,
  • - who are below the age of 6 years.
  • 75.95 million children are girls
  • Remaining 81.91 million children are boys.
  • Sex ratio among children (0-6 years) - 927
  • - i.e. 927 females per 1000 males.
  • A significant proportion of these children lives
    in economic and social environment which impedes
    the child's physical and mental development.

Magnitude of Child Psychiatric Morbidity
  • ? 10-12 of lt 18 yrs suffer from disorders in
    behavior, learning and development.
  • ? ICMR (2001) - Mental Behavioural Disorders
  • in children adolescence 12.8
  • ? WHO (2001) Serious Emotional Disturbances in
  • children adolescents 15

Constitution of India
  • Article 15(3) ensure that there is no
    discrimination and access to all public
  • Article 39 (e) protects child labor
  • (f) opportunities to develop in healthy manner
    and protect against moral and material
  • Article 45 State will provide early childhood
    care and education till 6 years age
  • Article 47 - State to raise level of nutrition
    and prohibit harmful intoxicating substance and

Criminal procedure code 1973
  • Section 125
  • Any person having sufficient means neglects or
    refuses to maintain . . .
  • (b) his legitimate or illegitimate minor child
    whether married or not unable to maintain itself.
  • (c) . . .(not being married) attained
    majority, where such a child is, by reason of any
    physical or mental abnormality or injury is
    unable to maintain itself . . .

Admissions under MHA 1987
  • Section16
  • voluntary admissions - on request by guardian for
    admission of ward patient
  • Involuntary admissions

Discharges under MHA 1987
  • Section 18
  • On request by guardian
  • On attaining majority while inpatient intimate
    at the earliest and unless continuance is
    requested within a month

  • Common psychiatric evaluations include
  • Determination of child custody,
  • Evaluation of parenting capacity, and
  • Termination of parental rights. 
  • Child custody evaluations focus on
  • the "best interests of the child." 
  • Interviews with the parents, children, and
    collateral contacts play an integral role in
    forming recommendations for the court.

Scope of Forensic Child Psychiatry
  • In the juvenile justice arena,
  • the child forensic psychiatrist assists the court
    in determining
  • juvenile's - psychiatric diagnosis,
    - amenability to treatment,
    - eligibility for being tried in court,
    - risk for future

Scope of Forensic Child Psychiatry
  • Important assessments of many juveniles
    involved in the justice system
  • Competency to participate in delinquency
  • Competency to stand trial as an adult
  • Evaluate Adolescents tried in adult court who
    raise an "insanity" defense.

WHO Definition-Child Abuse
  • ''Child abuse or maltreatment constitutes all
    forms of physical and/or emotional ill-treatment,
    sexual abuse, neglect or negligent treatment or
    commercial or other exploitation, resulting in
    actual or potential harm to the child's health,
    survival, development or dignity in the context
    of a relationship of responsibility, trust or

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  • Physical Abuse
  • Sexual Abuse
  • Emotional Abuse
  • Negligence

  • US - 1 in 50 infants-non fatal abuse
  • 12.1/1000 children suffer abuse.
  • India - 2/3rd children physically abused
  • ? 50 are sexually and emotionally abused.

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Physical Abuse
  • Bruises or welts Burns, scalds, sprains
    dislocation, bites, Fractures, especially in
    infants Shaking injuries e.g. retinal
    Haemorrhage Inappropriate explanation of
    childs injury Wariness of adult contacts

Child Sexual Abuse
  • Out of the most fundamental violations of
    childrens rights and an underlying obstacle to
    their overall development.
  • The offenders are usually
  • Family members
  • Neighbours
  • Friends
  • Teachers, etc
  • Prevention mainly includes the conception of
    personal safety education to children.

Sexual Abuse
  • Discloses sexual abuse Sophisticated
    sexual behaviour
  • Constant headache or abdominal pains
    Difficulties at school Persistent habit
  • Sleep disorders Inhibition to play
    Serious difficulties relating to peers
  • Self-destructive behaviour.

Role of Psychiatrist in Child Abuse
  • Acquire specialized knowledge
  • Be alert to the fact abuse is highly prevalent
  • To protect the child from continuing harm
  • Take measures to diminish long-term effects
  • Collaborate with multi-disciplinary team that
    deal with child abuse

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  • Child Abuse

  • New Delhi, the 26th day of October , 2007
  • Rules under the Juvenile Justice
  • (Care and Protection of Children) Act 2000
    (56 of 2000)
  • as amended by the Amendment Act 33 of 2006,
  • to be administered by the States

NOTIFICATIONNew Delhi, the 22nd June, 200IRules
under the Juvenile Justice (Care and Protection
of Children) Act, 2000 (56 of 2000)
  • Considered expedient to re-enact the Juvenile
    Justice Act, 1986
  • Bearing in mind the standards prescribed in the
    Convention on the Rights of the Child,
  • The United Nations Standard Minimum Rules for the
    Administration of Juvenile Justice, 1985 (the
    Beijing Rules),
  • The United Nations Rules for the Protection of
    Juveniles Deprived of their Liberty (1990),
  • and all other relevant international instruments

Juvenile Justice (care and protection of
children) Act, 2000
  • (herein under referred to as the said Act) was
    enacted to consolidate and amend the law relating
    to juveniles in conflict with law and children in
    need of care and protection,
  • by providing for proper care, protection and
    treatment by
  • catering to their development needs,
  • and by adopting a child friendly approach in the
    adjudication and disposition of matters in the
    best interest of children and
  • for their ultimate rehabilitation through various
    institutions established under that Act.

Few Important Definitions of JJ Act.
  • abandoned means an unaccompanied and deserted
    child who is declared abandoned by the Committee
    after due inquiry
  • best interest of the child means a decision
    taken to ensure the physical, emotional,
    intellectual, social and moral development of
    juvenile or child

  • child friendly means any process and
    interpretation, attitude, environment and
    treatment, that is humane, considerate and in the
    best interest of the child
  • community service implies service rendered to
    the society by juveniles in conflict with law in
    lieu of other judicial remedies and penalties,
    which is not degrading and dehumanizing.
  • - cleaning a park
  • - getting involved with Habitat for Humanity
  • - serving the elderly in nursing homes
  • - helping out a local fire or police
  • - helping out at a local hospital or nursing
  • - serving disabled children.

individual care plan
  • comprehensive development plan for a juvenile or
    child based on age specific and gender specific
    needs and the case history of the juvenile or
    child, prepared in consultation with the juvenile
    or child, in order to restore
  • juveniles or childs self-esteem,
  • dignity and self-worth and nurture him
    into a responsible citizen

individual care plan
  • Accordingly the plan address following needs of
    a juvenile or a child
  • - Health needs
  • - Emotional and psychological needs
  • - Educational and training needs
  • - Leisure, creativity and play
  • - Attachments and relationships
  • - Protection from all kinds of abuse, neglect
    and maltreatment
  • - Social mainstreaming and
  • - Follow-up post release and restoration.

Fundamental Principles Of Juvenile Justice
Protection Of Children
  • Principle of presumption of innocence
  • A juvenile or child or juvenile in conflict with
    law is presumed to be innocent of any malafide or
    criminal intent up to the age of eighteen years.
  • The juveniles in conflict with law or child's
    right to presumption of innocence shall be
    respected throughout the process of justice and
    protection, from the initial contact to
    alternative care, including aftercare.
  • Any unlawful conduct of a juvenile or a child or
    a juvenile in conflict with law which is done for
    survival, or is due to environmental or
    situational factors or is done under control of
    adults, or peer groups, is ought to be covered by
    the principles of innocence

  • Age of innocence
  • - is the age below which a juvenile or child or
    a juvenile in conflict with law cannot be
    subjected to the criminal justice system.
  • - The Beijing Rule 4(1) clearly lays down that
  • - the beginning of the age of criminal
    responsibility shall not be fixed at too low an
    age level bearing in mind the facts of mental and
    intellectual maturity.
  • - the mental and intellectual maturity of
    juvenile or child or a juvenile in conflict with
    law below18 years is considered insufficient
    through out the world.

The idea is to allow certain benefits to a
juvenile in conflict with law vis a vis his
mental development assessed by the experts in the
field through out the world as of 18 years being
the time of demarcation and with this end in view
the yardstick can only be the' date of occurrence
because the whole spirit is to impart benefit to
such juvenile on grounds of lesser development of
his mental faculty.
  • A juvenile or child is presumed to be innocent of
    any malafide or criminal intent up to the age of
    seven years in all cases and upto twelve years in
    the cases wherein he is unable to understand the
    consequences of his action on account of
    immaturity of understanding

Indian Penal Code
  • Section 82 nothing is an offence which is done
    by a child under 7 years of age
  • Section 83 nothing is an offence which is done
    b a child between 7 to 12 years of age who has
    not sufficient maturity to understand the nature
    of conduct and the consequences

Provisions of Legal aid and Guardian Ad Litem
  • Juveniles in conflict with law have a right to be
    informed about the accusations against them and a
    right to be legally represented.
  • Provisions must be made for guardian ad litem,
    legal aid and other such assistance through legal
    services at State expense.
  • This shall also include such juveniles right to
    present his case before the competent authority
    on his own.

Principle of dignity and worth
  • Treatment that is consistent with the childs
    sense of dignity and worth is a fundamental
    principle of juvenile justice.
  • Reflects the fundamental human right enshrined in
    Article 1 of the Universal Declaration of Human
    Rights that all human beings are born free and
    equal in dignity and rights.
  • Respect of dignity includes not being humiliated,
    personal identity, boundaries and space being
    respected, not being labeled and stigmatized,
    being offered information and choices and not
    being blamed for their acts.
  • The juveniles or childs right to dignity and
    worth has to be respected and protected
    throughout the entire process of dealing with the
    child from the first contact with law enforcement
    agencies to the implementation of all measures
    for dealing with the child.

Principle of Right to be heard
  • Every childs right to express his views freely
    in all matters affecting his interest shall be
    fully respected through every stage in the
    process of juvenile justice.
  • include -creation of developmentally appropriate
    tools and processes of interacting with the
  • -promoting childrens active
    involvement in decisions regarding
    their own lives -providing opportunities
    for discussion and debate.

Principle of family responsibility
  • The primary responsibility of bringing up
    children, providing care, support and protection
    with the biological parents.
  • However, in exceptional situations, this
    responsibility may be bestowed on willing
    adoptive or foster parents.
  • All decision making for child should involve the
    family of origin unless it is not in best
    interest of the child to do so.
  • Family - biological, adoptive or foster (in that
    order), must be held responsible and provide
    necessary care, support and protection to the
    juvenile or child under their care and custody
    under the Act, unless the best interest measures
    or mandates dictate otherwise.

Principle of Safety (no harm, no abuse, no
neglect, no exploitation and no maltreatment)
  • At all stages, from the initial contact till such
    time he remains in contact with the care and
    protection system, and thereafter, the juvenile
    or child or juvenile in conflict with law -
  • - shall not be subjected to any harm, abuse,
    neglect, maltreatment, corporal punishment or
    solitary or otherwise any confinement in jails
    and extreme care shall be taken to avoid any harm
    to the sensitivity of the juvenile or the child.
  • The state has a greater responsibility for
    ensuring safety of every child in its care and
    protection, without resorting to restrictive
    measures and processes in the name of care and

Principle of non-stigmatizing semantics,
decisions and actions
  • The non-stigmatizing semantics of the Act must be
    strictly adhered to,
  • Use of adversarial or accusatory words, such as,
    arrest, remand, accused, charge sheet, trial,
    prosecution, warrant, summons, conviction,
    inmate, delinquent, neglected, custody or jail is
    prohibited in the processes pertaining to the
    child or juvenile in conflict with law under the

Principle of non-waiver of rights
  • No waiver of rights of the child or juvenile in
    conflict with law, whether by himself or the
    competent authority or anyone acting or claiming
    to act on behalf of the juvenile or child, is
    either permissible or valid.
  • Non-exercise of a fundamental right does not
    amount to waiver.

Principle of equality and nondiscrimination
  • There shall be no discrimination against a child
    or juvenile in conflict with law - on basis of
  • - age, sex, place of birth, disability, health,
    status, race, ethnicity, religion, caste,
    cultural practices, work, activity
  • - or behaviour of the juvenile or child or that
    of his parents or guardians,
  • - or civil and political status of juvenile or

Principle of right to privacy and confidentiality
  • Juvenile's or child's right to privacy and
    confidentiality shall be protected by all means
    and through all the stages of the proceedings and
    care and protection processes.

Principle of last resort Institutionalization
of a child or juvenile in conflict with law
shall be a step of the last resort after
reasonable inquiry and that too for the minimum
possible duration.
Principle of repatriation and restoration
Every juvenile or child or juvenile in
conflict with law has the right to be re-united
with his family and restored back to the same
socio-economic and cultural status that such
juvenile or child enjoyed before coming within
the purview of the Act or becoming vulnerable
to any form of neglect, abuse or
exploitation. who has lost contact with his
family, eligible for protection under the Act
and to be repatriated and restored, at the
earliest, to his family, unless such
repatriation and restoration is likely to be
against the best interest of child.
Principle of Fresh Start
The principle of fresh start promotes new
beginning for the child or juvenile in conflict
with law by ensuring erasure of his past
records The State shall seek to promote
measures for dealing with children alleged or
recognized as having impinged the penal law,
without resorting to judicial proceedings.
Rehabilitation and Social Reintegration.?
  • The primary aim
  • - is to help children in restoring their dignity
    and self-worth and mainstream them through
    rehabilitation within the family where possible,
  • or otherwise through alternate care programmes
    and long-term institutional care shall be of last

Adoption.? The primary aim of adoption is to
provide a child who cannot be cared for by his
biological parents with a permanent substitute
  • Surrendered child
  • - is one who had been declared as such after due
    process of inquiry by Committee and in order to
    be declared legally free for adoption, can be any
    of the following
  • born as a consequence of non-consensual
  • born of an unwed mother or out of wedlock
  • child in whose case one of the biological parents
    is dead and the living parent is incapacitated to
    take care
  • child where the parents or guardians are
    compelled to relinquish him due to physical,
    emotional and social factors beyond their control

Foster Care.?
  • For children who cannot be placed in adoption,
    order shall be issued for carrying out foster
    care, under the supervision of a probation
    officer or case worker or social worker, as the
    case may be,
  • and the period of foster care shall depend on the
    need of the child.
  • Every State Government shall design its own
    foster care programme so as to reduce
    institutionalization of children and enable a
    nurturing family environment for every child.

Criteria for selection of families for foster
  • Foster parents should have stable emotional
    adjustment within the family
  • Foster parents should have an income in which
    they are able to meet the needs of child and are
    not dependent on the foster care maintenance
  • Monthly family income shall be adequate to take
    care of foster children
  • Medical reports of all the members of the family
    residing in the premises should be obtained
    including checks on HIV, TB and Hepatitis B to
    determine that they are medically fit

Criteria for selection of families for foster care
  • Foster parents should have experience in child
    caring and the capacity to provide good child
  • Foster parents should be physically, mentally and
    emotionally stable
  • Home should have adequate space and basic
  • Foster care family should be willing to follow
    rules laid down including regular visits to
    pediatrician, maintenance of child health and
    their records
  • Family should be willing to sign an agreement and
    to return the child to specialized adoption
    agency whenever called to do so
  • Foster parents should be willing to attend
    training or orientation programmes

Juvenile or Child suffering from dangerous
diseases or mental health problems.?
  • When a juvenile or a child placed under the care
    of a fit person or a fit institution under the
    provisions of the Act,
  • is found to be suffering from a disease or
    physical or mental health problems requiring
    prolonged medical treatment,
  • or is found addicted to a narcotic drug or
    psychotropic substance,
  • the juvenile or the child be sent to an
    appropriate place for such period as may be
    certified to be necessary for proper treatment
    of the juvenile or the child
  • or for the remainder of the term for which he has
    to stay.

  • When the juvenile or the child is cured of the
    disease or physical or mental health problems,
  • if the juvenile or child is still liable to stay,
    order the juvenile or the child to be placed back
    in the care of fit person or institution from
    where the juvenile or child was removed for
  • and if the juvenile or the child is no longer
    liable to be kept under the care of fit person or
    institution, the competent authority may order
    him to be discharged.
  • The order of restoration of a juvenile or a child
    suffering from an infectious or contagious
    disease to his parents or guardian shall be based
    on the principle of best interest of the juvenile
    or child,
  • keeping in mind the risk of stigmatization and
    discrimination and discontinuation of treatment.

Commissions For Protection Of Child Rights 2005
  • No. 4 of 2006 (20th January, ,2006,
  • An Act to provide for the constitution of a
    National Commission and State Commissions for
    Protection of Child Rights and Children's Courts
    for Providing speedy trial of offences against
    children or of violation of child Rights and for
    matters connected therewith or incidental
  • United Nations (UN) General Assembly Summit
    in1990, which adopted a Declaration on Survival,
    Protection and Development of Children
  • India has also acceded to the Convention on the
    Rights of the Child
  • (CRC) on the ll th December, 1992
  • in order to ensure protection of rights of
  • one of the recent initiatives that the Govt have
    taken for Children is the adoption of National

Functions and powers of commission
  • Examine and review the safeguards provided by law
    being in force for the protection of child
    rights and recommend measures for their Effective
  • Present to the Central Government, annually and
    at such other intervals, as the Commission may
    deem fit, reports upon the working of those
  • Inquire into violation of child rights and
    recommend initiation of proceedings in such
  • Examine all factors that inhibit the enjoyment of
    rights of children affected by terrorism,
    communal violence, riots, natural disaster,
    domestic violence, HIV /AIDS, trafficking
    maltreatment, torture and exploitation,
    pornography and prostitution
  • - Recommend appropriate remedial measures .

Functions And Powers Of Commission
  • look into the matters relating to children in
    need of special care and protection
  • - including children in distress, marginalized
    and disadvantaged children,
  • - children in conflict with law, juveniles,
  • - children without family and children of
    prisoners and recommend appropriate remedial
  • study treaties and other international
    instruments and - - undertake periodical review
    of existing policies, - programmes and other
    activities on child rights and - make
    recommendations for their effective
  • implementation in the best interest of children

Functions And Powers Of Commission
  • undertake and promote research in the field of
    child rights
  • spread child rights literacy among various
    sections of the society and promote awareness of
    the safeguards available for protection of these
    rights through publications, the media, seminars
    and other available means
  • inspect or cause to be inspected any juvenile
    custodial home, or any other place of residence
    or institution meant for children, under the
    control of the Central Government or any State
    Government or any other authority,
  • - including any institution run by a social
  • - where children are detained or lodged for the
    purpose of treatment, reformation or protection
  • - and take up with these authorities for
    remedial action, if found necessary

Functions And Powers Of Commission
  • inquire into complaints and take suo moto notice
    of matters relating to -
  • - deprivation and violation of child rights
  • - non-implementation of laws providing for
    protection and development of children
  • - non-compliance of policy decisions, guidelines
    or instructions aimed at, mitigating hardships to
    and ensuring welfare of the children and to
    provide relief to such children
  • or take up the issues arising out of such matters
    with appropriate authorities and
  • such other functions as it may consider necessary
    for the promotion of child rights and any other
    matter incidental to the above functions.

Consent of a Minor
  • In general minors, so far, have been considered
    as incapable of giving consent
  • Exceptions to this can be when minors seek birth
    control, treatment of STD, substance abuse and
  • Informed consent for adolescents seems like the
    right thing in the therapeutic setting
  • Patient, parent and therapist conflicts in
  • The debate continues as minors are becoming high
    income earners and self sufficient

Refusal of Treatment
  • Legal right to refuse med or psych treatment
  • Complex Evolving area
  • Who may exercise that right ?
  • - The Parent
  • - The Minor
  • - or Both
  • Fact that pt is hospitalized does not
    automatically mean that pt lacks legal capacity
    to consent or withhold consent

Refusal of Care by Parents
  • Law recognizes greater auth on the part of
    parents to refuse Elective Care
  • Significant Factors include -
  • - Whether Refusal based on religious grounds
  • - Whether parents child are in conflict or
  • in agreement
  • When parents refuse care that courts believe to
    be essential, jurisdiction invoked under child
    neglect laws to remove child, at least
    temporarily, from parents legal custody to
    authorize Rx

Confidentiality Disclosure Mandatory
  • What must not be disclosed?
  • What may be disclosed?
  • What must be disclosed?
  • Who controls Disclosure ?

Circumstances in which parents are the ones to
consent for care, they may well be the ones who
have right to authorize or to Withhold
permission to release information Ethically
Appropriate it not legally required to seek
Concurrence of minor / adolescent to release
Confidentiality Disclosure Mandatory
  • At least 3 key situations for mandatory
  • Determination of suicidal risk or serious risk of
    harm to himself or others
  • Necessary to take preventive measures
  • Legal duty to warn intended victim of a pt who
    has expressed direct threat against identifiable
    indls life or to alert law enforcement auth. to
    that threat
  • Duty to report Sexual or Physical Abuse abrogates
    Physician-pt psychotherapist-pt privileges

  • The legal situation in India
  • Laws governing adoption In India Are
  • The Hindu Adoption and Maintenance Act 1956
  • The Guardians and Wards Act 1890
  • Juvenile Justice Act 2000

  • A couple desirous of giving a child, a family can
  • They should have a reasonable and regular source
    of income
  • Neither the parents should have a major illness
    that would come in the way of parenting
  • There should be no criminal record
  • Preferable age between 25 -45 years
  • Single parenting up to 45 years can Adopt

Malpractice Issues
  • Failure to get informed consent
  • Diagnostic and medication errors
  • Failure to warn a third party of endangerment
  • Disclosure of information
  • Inappropriate behavior towards a child

Ethical conflicts
  • Conflict of interest with the referral agency and
    that of the patient
  • Consent for collecting collateral sources of
  • Privileged communication and confidentiality
  • Privacy and confidentiality of information given
    to the therapist and demands of the parents

Guidelines for Assessment
  • Why this child?
  • Who requests assessment?
  • When is the report needed?
  • Who will pay for the cost?
  • Will the report have secondary aims?
  • Where will the report be filed and who will
    access it?

Future research
  • Outcome of legal decisions
  • Maintenance of links with non-residential parents
    by children who are adopted
  • Assessment of non-family based care in relation
    to the welfare of children
  • Effects of social and economic policy on mental
    health of children
  • Effectiveness of legislation and legal structure
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