Nuances of Forensic Child psychiatry − A special focus on child custody, corporal punishment, and the relevance of the Mental Health-Care Act for children and adolescents

GENERAL INTRODUCTION

The management of children and adolescents presenting with mental health disorders in the clinic are only a part of the overall scope of the discipline of child and adolescent psychiatry. In reality, most disorders that children eventually develop would have originated from a complex interplay between biological vulnerability and specific environmental risk factors. Of all the environmental risk factors, those that are most consistent with adverse developmental outcomes are adverse childhood experiences encountered in the home and school. It is critical for mental health professionals to understand these contexts in which children’s psychological difficulties are deeply rooted and institute corrective measures where possible. In view of this, we have decided to focus on the important issues of corporal punishment in schools and child custody following parental divorce. We attempt to highlight the importance of these topics, their bearing on child mental health and well-being and the role of mental health professionals. In the third article in the series, we have analyzed the Mental Health-care Act (MHCA) through the lens of child mental health and attempted to throw light on the key changes and lacunae in this legislation.

INTERFACE OF LAW AND PSYCHIATRIC PROBLEMS IN CHILDREN – SPECIAL FOCUS ON CUSTODY

Introduction

Divorce and separation inevitably leave a trail of bitterness in which the child is trapped and often pays a heavy price. One of the thorny issues following divorce is regarding the custody of the child. With increasing cases of divorce in the country, the need for understanding the legal and psychological implications of child custody is the need of the hour. This is primarily a legal matter; however, a mental health professional is often asked for an expert opinion and occasionally is required to treat the concerned parties.

Definition of terms

Custody in the English language is defined by Collins dictionary (https://www.collinsdictionary.com/dictionary/english/custody) is “the legal right to keep and look after a child, especially the right given to a child’s mother or father when they get divorced” This term is not defined in the Indian family law. Guardians and Wards Act, 1890 describes a guardian as a “person having the care of the person of a minor or of his property or of both his person and property.” The law also describes a “natural guardian” as the person legally recognized as a guardian of a minor who is accepted to make all decisions for the minor. The legal difference between custody and guardianship is that in some religious personal laws, the mother is chosen to be the custodian of very young children, yet the father always is the natural guardian.

Laws

Statutory laws governing custody and guardianship are described in Table 1.

Table 1.

Laws governing custody and guardianship

Law	Salient feature
GWA, 1890	Secular law overseeing the guardianship and custody for children of all religious beliefs and within the territory of India
	It empowers the District court for appointment of a guardian of the person or property of a minor. If the natural guardian as per the minor’s personal law or the testamentary guardian neglects his/her responsibilities. Section 25 of the GWA discusses the right of the guardian over the custody of the ward. This is decided based on the welfare of the child
	Amendment discusses joint custody, expands discussion on visitation rights, child support and mediation
HMGA, 1956	“(1) In case of a minor boy or unmarried minor girl, the natural guardian is the father, and “after” him, the mother; and
	(2) the custody of a minor who has not completed the age of five years shall “ordinarily” be with the mother”
	The principle of welfare of child has to be followed
	Recent amendment include adoptive parents and suggests to remove the dominant position of one parent versus another
Hindu Marriage Act, 1955	Section 26 of this act allows courts to pass, revoke or cancel interim orders with respect to custody of minor children, keeping the child wishes in mind
Islamic Law	Here the custody is with the mother till the girl attains puberty and the son is 7 years of age. This is applicable even after dissolution of marriage unless the mother’s condition or behavior does not make this in the best interest of child
Parsi and Christian Law	Under these acts the court can pass interim order for custody of child

GWA – Guardians and Wards Act; HMGA – Hindu Minority and Guardianship Act

Considerations for deciding custody

The welfare principle is meant to guide the court in making decisions regarding custody. A guideline of factors to be considered has been described.

1. Best interest of child: The factors to consider are enlisted in Table 2

2. Ascertaining the preference of the child: This may be assessed by the judge by questioning the child in his chambers without the presence of the parents or by the report of the appointed guardian who represents the best interest of the child. Alternatively, the judge may ask a mental health professional for their opinion. The child’s answer carries significance if the child is considered to be intelligent and mature enough to make a choice and is not swayed by extraneous factors such as availability of more toys in one of the parent’s place

3. Time with other family members: Consideration should be given to the child’s relationship with grandparents, siblings, peers and other family members, and their ability to visit the child

4. Parenting plan: There should be concurrence between parents regarding important issues such as education, practice of religion, medical plans, choice of extracurricular activities, and traveling with one parent. Besides these domains, the parent’s plans to care for the child and their plan of parenting are determined. The maturity of a parent to communicate with the other parent, plan for visits, sharing information about the child are also a part of the plan. Although not a legal document, it can have a legal effect if it is approved by court. The objective of this plan is to promote the parents to jointly agree on the distribution of duties and responsibilities in the rearing of the child. This would decrease parental conflict and reduce need for court involvement.

Table 2.

Factors to be considered when deciding the best interest of the child

The parent child relationship

The role of other people such as siblings, grandparents and other family members

The parental contribution in the care of the child

The parental potential to care for and support the child

The relationship with the other parent and the parent’s ability to resolve differences regarding the offspring

Preference displayed by the child

History of abuse

Types of custody

In the Indian legal scenario, the court usually decides on ascertaining the sole parental custodian (SPC) and draws a plan for visitation rights of the other parent. With changing times, just as the reasons for divorce are changing from fault finding to mutual consent there is a role in offering joint parental custody (JPC) in certain cases. JPC is known to be beneficial to the child as compared to SPC. The amendment of the GWA, states

1. “Joint custody” is where both the parents:--

   1. Share physical custody of the child, which may be equally shared, or in such proportion as the court may determine for the welfare of the child; and
   2. Equally share the joint responsibility for the care and control of the child and joint authority to take decisions concerning the child; and.

2. (b) “Sole custody” is where one parent retains physical custody and responsibility for the care and control of the child, subject to the power of the court to grant visitation rights to the other parent.” (p70)

To ensure co-operation and settle differences between the parents, various methods including mediation are attempted. This is a process of conflict resolution with the assistance of a neutral third party who aids the parents to agree to a mutually acceptable settlement. Rather than finding faults, it focusses on problem-solving to satisfy the needs of the family and look after the best interest of the child. This method is advantageous as both parents contribute toward it and are accountable for the decision, and therefore, more likely to abide by it. They know the child’s needs best and therefore can plan better. The child too is more comfortable knowing it is a joint parental decision. The process paves way for restoration of some trust between parents and gives an opportunity to negotiate in the future. It also is more economical and saves the time of the court.

Mental health issues in custody/role of a psychiatrist

The decision of custody is a legal process and an evaluation by a mental health professional is indicated in a few circumstances. Referral from the judiciary may be when the following situations arise in a case of custody

1. Parenting is affected by significant mental illness,

2. Presence of domestic violence,

3. There is a possibility of a psychiatric illness in child

4. One of the parents instigates the child or tries to alienate child from the other parent.

The process of formulating a report includes a sequence of interviewing parents and child and gathering relevant information [Figure 1].

Figure 1.

The process of creating an evaluation report

Parental interview: The focus is on gathering relevant information while at the same time avoiding long narratives on allegations about partner

Information collected is:

1. Sociodemographic information

2. Details of marriage, the relationship between them, and relationship with other family members

3. Personal, social, family, criminal, medical and psychiatric history of each parent, and their current relationships

4. The details of divorce/separation and reasons for the same

5. Details of the legal process, the stage of the case, the current or interim order, and dates of next hearing

6. Current arrangement for the child

7. The child’s history, development, schooling, adjustments, illness, and relationships

8. The parent’s relationship with child and their understanding of the needs of the child

9. The parents desire for custody, reasons, and his/her plan for parenting if child is given in their custody.

Interviewing the child

The type of interview depends on age and maturity of the child. It may include observation of child parent interaction and an interview with the child alone. The latter should be attempted in all instances. In the beginning, it is necessary to inform the child of the process and the reason for interview. The child should be aware that the final decision rests with the court. The use of age appropriate methods such as play, art, sentence completion, and storytelling may be required in the process of gathering information. The details required are as follows:

1. Child’s awareness and understanding of current situation

2. Child’s attachment to parent and other family members

3. Impact of the divorce/separation

4. Assessment if either parent is alienating the child against the other parent

5. Child’s wishes about custody

6. Assessment for psychiatric disorders such as separation anxiety, depression, adjustment disorder, and posttraumatic stress disorder

7. Observe parent child interaction (play interaction in young children).

Other sources of information

Information from school, counselor, grandparents, and peers is often required to get a complete picture.

Role of psychological testing

To assess parental psychopathology, MMPI, Rorschach, and TAT may be used. For children, Child Apperception Test, Ravens Controlled Projective Test, IQ assessment may be indicated.

Creating a report

Once history is gathered, observations are made and test results obtained a report is generated. This needs to be short and free of jargon. It should include the following:

1. Initial information: The background details in form of sociodemographic details of child and parents

2. Details of referral: The details for referral, the mandate for evaluation, and the specific reason for referral are to be noted. This also includes the current position of the case, the custody and visitation schedule being followed, a synopsis of the marriage and divorce details

3. Details of evaluation procedure: This should include the dates of interviews/meeting that have occurred, the information collected, and the reports of the psychological tests applied

4. Report of observations: The report is to be formulated for each parent and child. For parents, their parenting skills, presence of any physical or psychological illnesses, personality or any other factor the professional believes would influence their ability to look after the child is mentioned. The child’s report should include the child’s preference regarding custody, the attachment of the child with each parent, the possibility of the child being deliberately alienated against a parent, the child’s reaction to the current situation and methods used to deal/cope with the same, and the presence of any mental illness

5. Conclusion: Based on the above information, the professional can opine on the child’s attachment to a specific parent, the parenting skills of each parent and if there are any factors that may either improve or impair the child’s welfare

6. Recommendations: This logically follows the above-mentioned steps. Opinion regarding custody, visitation schedule, need for supervision is to be clearly stated. If treatment, counseling or parental skill training is indicated either for parents, child or other family members it is to be suggested.

Conclusion

The role of a psychiatrist in divorce cases is usually to help the court take a decision with regard to custody issues. It is therefore important to plan a careful evaluation with the whole family together and separate interviews with the child and each parent to arrive at a neutral, unbiased conclusion about what form of custody would be in the best interest of the child. Evaluating the child for psychiatric disorders and offering help for the same is also imperative. Even those children and families without psychiatric disorders may benefit from brief supportive counseling to help them tide over the significant transition that they are undergoing

CORPORAL PUNISHMENT IN SCHOOLS

Corporal punishment in schools is still prevalent in our country despite laws to prohibit it. A study “Child Abuse in India – 2007,” by the Ministry of Women and Child Development, found that every two out of three school children reported facing corporal punishment. The Right to Education Act 2009, Section 17 reads, “Prohibition of physical punishment and mental harassment to child-(1) No child shall be subjected to physical punishment or mental harassment. (2) Whoever contravenes the provisions of sub-section (I) shall be liable to disciplinary action under the service rules applicable to such person.” Similarly, Section 23 of the JJ Act, 2000 states as follows: “Whoever, having the actual charge of, or control over, a juvenile or the child, assaults, abandons, exposes or wilfully neglects the juvenile or causes or procures him to be assaulted, abandoned, exposed or neglected in a manner likely to cause such juvenile or the child unnecessary mental or physical suffering shall be punishable with imprisonment for a term which may extend to 6 months, or fine, or with both.” Guidelines have also been given in the law about how to handle difficult situations at school for the teachers. Various methods of effective disciplining have been explained. However, implementation of these laws and guidelines are often lacking at the school level and should be looked into on a priority basis.

Definition of corporal punishment

There is no statutory definition of corporal punishment of children in the Indian law. As per the National Commission for Protection of Child Rights guidelines, corporal punishment could be classified as (a) physical punishment, (b) mental harassment, and (c) discrimination. Physical punishment could be in form of causing physical harm to children by hitting, kicking, asking children to assume an uncomfortable position, forced ingestion of anything or detention at any specific place. Mental harassment could be in the form of passing sarcastic remarks, humiliating, intimidating, shaming, or name calling the child. Discrimination could be on the basis of caste, gender, or socioeconomic status.

Impact of corporal punishment on the child and society

Despite the evidence of harm caused by corporal punishment and lack of evidence that it causes any benefit, corporal punishment is persisting. It may cause pain and discomfort and may even lead to serious physical injuries such as fractures or rupture of tympanic membrane. Similarly, it could create problems with learning. Children experiencing corporal punishment may develop fear and hatred for school and may then dropout from school. With regard to psychiatric conditions, it could precipitate disruptive behavior problems in some and emotional problems such as anxiety and depression in others. The self-esteem of the affected child may also be negatively affected. When adults use corporal punishment, it teaches children that hitting is an acceptable way of dealing with conflict. As a result, children subjected to punishment often prefer aggressive conflict resolution strategies with peers and siblings. The cost to society of school dropout as a result of corporal punishment has been calculated to be around 0.13%–0.64% of the Gross Domestic Product of India.

Role of mental health professionals

It is important for mental health professionals to actively engage with schools, as only the existence of laws is not enough to mitigate this problem. Teachers and parents need to be educated about the lack of efficacy of corporal punishment to improve behavior and its detrimental impact on children. Multidisciplinary collaboration between school administrators, nongovernmental organizations, and mental health professionals is necessary to develop and promote school environments that provide a safe and nurturing learning experience. The central aim should be to facilitate holistic development of the child which should include cognitive, social, emotional, and moral development. Teachers should be trained in positive disciplinary methods (ignoring minor tantrums, setting limits, star charting, and removing privileges), in identifying and addressing burnout in themselves and their colleagues and in newer methods of teaching. One such suitable school model is available (raisingvoices.org/good-school) which has been successfully implemented in Uganda.

Psychiatrists may be directly involved with the school. He/she can assess the infrastructure of the school and incorporate the views of management, staff, and students to take decisions about school environment, sensible student-teacher ratio, effective teaching/disciplining methods, and ways to minimize corporal punishment. The psychiatrist will be able to assist teachers to provide life skills education and enhance the self-esteem of children. Another responsibility of mental health professionals is to conduct workshops and sensitization programs for teachers to identify learning or behavioral problems and make appropriate referrals for intervention. Psychiatrists could also be part of child rights advocacy groups that sensitize teachers, parents as well as children regarding the rights of children.

Conclusions

Corporal punishment of children in schools is a prevailing problem in our society despite existing legislations that attempt to address this issue. It is the need of the hour for psychiatrists to step in and liase with schools, teachers, parents, and children. Creating a positive, conducive school environment with open communication across all levels, educating teachers about the negative effects of corporal punishment and alternate effective disciplining methods, addressing burnout in teachers and assisting teachers to quickly identify children with psychiatric problems will go a long way toward mitigating this harmful practice.

Effects of corporal punishment on children

• Difficulties with concentration, academic decline, school refusal and school dropout

• Emotional problems such as depression, anxiety, and low self-esteem

• Behavioral problems such as disobedience, aggression, oppositional behavior, and delinquency

• Physical injuries

Role of psychiatrists in reducing the extent of corporal punishment in schools

• Training teachers to identify problems such as learning difficulties and Attention Deficit Hyperactivity Disorder in students so that they can receive help. Hence, the likelihood of teachers opting for corporal punishment to discipline these children is reduced

• Training teachers in the appropriate use of behavioral strategies to address problematic classroom behaviors

• Sensitizing students regarding their rights and addressing any behavioral or psychological consequences of corporal punishment.

CHILD AND ADOLESCENT MENTAL HEALTH PERSPECTIVE OF MENTAL HEALTHCARE ACT, 2017

Introduction

Children and adolescents constitute about two-fifth of the Indian population. Half of all individuals with psychiatric disorders report an onset by the age of 14 years (Kessler et al., 2007). High psychiatric morbidity in youth has been reported in the recently concluded National Mental Health Survey of India (Gururaj et al., 2016) and a systematic review and meta-analysis conducted by Malhotra and Patra in 2014 corroborates the same.

Given the high burden of child and adolescent mental health (CAMH) disorders in the country, there is a vital need of appropriate policies, programs and laws to integrate CAMH services across India (Sagar, 2020). The MHCA, 2017 has direct implications on the provision of mental health services to the youth of the country. In view of this, we are critically appraising the MHCA, 2017 with specific focus on CAMH services and initiatives.

The mental healthcare act 2017-overview

In accordance with the United Nations Convention on Rights of Persons with Disabilities that India ratified in 2007, the MHCA, 2017 came into existence on April 7, 2017 and came in to force on May 29, 2018. MHCA provides greater clarity on a range of issues pertaining to CAMH compared to its predecessor, the Mental Health of 1987. MHCA has several provisions relevant for CAMH like role of nominated representatives (NR) in advance directives for minors, mandatory stay of NR during inpatient treatment of minors, reporting to mental health review board (MHRB) within 72 h of admission of a minor patient, mandatory requirement of prior permission of MHRB for using electroconvulsive treatment (ECT) in minors, and provision for stay of ≤3-year-old child with the mother receiving treatment for mental health issues (Sharma andKommu, 2017) Specific provisions for Children and Adolescents in MHCA are detailed in Table 3 and Key highlights of the Mental Healthcare Act pertinent to children and adolescents are mentioned in Table 4.

Table 3.

Specific provisions for children and adolescents in Mental Healthcare Act, 2017 (reproduced)

Chapter	Provision
Chapter I: Preliminary	Section 1 (2) t: Definition of “minors”: A person who has not completed 18 years of age
Chapter III: ADs	Section 11: (4) The legal guardian shall have right to make an AD in writing in respect of a minor and all the provisions relating to AD, “mutatis mutandis,” shall apply to such minor till such time he attains majority
Chapter IV: NR	Section 15. (1) Notwithstanding anything contained in section 14, in case of minors, the legal guardian shall be their NR, unless the concerned Board orders otherwise under subsection (2)
	(2) Where on an application made to the concerned Board, by a MHP or any other person acting in the best interest of the minor, and on the evidence presented before it, the concerned Board is of the opinion that
	(a) The legal guardian is not acting in the best interests of the minor, or
	(b) The legal guardian is otherwise not fit to act as the NR of the minor, it may appoint, any suitable individual who is willing to act as such, the NR of the minor with mental illness: Provided that in case no individual is available for appointment as a NR, the Board shall appoint the Director in the Department of Social Welfare of the State in which such Board is located, or his nominee, as the NR of the minor with mental illness
Chapter V: Rights of persons with mental illness	Section 21 (2) A child under the age of 3 years of a woman receiving care, treatment or rehabilitation at a MHE shall ordinarily not be separated from her during her stay in such establishment: Provided that where the treating Psychiatrist, based on his examination of the woman, and if appropriate, on information provided by others, is of the opinion that there is a risk of harm to the child from the woman due to her mental illness or it is in the interest and safety of the child, the child shall be temporarily separated from the woman during her stay at the MHE: Provided further that the woman shall continue to have access to the child under such supervision of the staff of the establishment or her family, as may be appropriate, during the period of separation
	(3) The decision to separate the woman from her child shall be reviewed every 15 days during the woman’s stay in the MHE and separation shall be terminated as soon as conditions which required the separation no longer exist: Provided that any separation permitted as per the assessment of a MHP, if it exceeds 30 days at a stretch, shall be required to be approved by the respective Authority
Chapter XII: Admission, discharge, and treatment	Section 87: (1) A minor may be admitted to a MHE only after following the procedure laid down in this section
	(2) The NR of the minor shall apply to the medical officer in charge of a MHE for admission of the minor to the establishment
	(3) Upon receipt of such an application, the medical officer or MHP in charge of the MHE may admit such a minor to the establishment, if two psychiatrists, or one psychiatrist and one MHP or one psychiatrist and one medical practitioner, have independently examined the minor on the day of admission or in the preceding 7 days and both independently conclude based on the examination and, if appropriate, on information provided
	by others, that, (a) the minor has a mental illness of a severity requiring admission to a MHE; (b) admission shall be in the best interests of the minor, with regard to his health, well-being or safety, taking into account the wishes of the minor if ascertainable and the reasons for reaching this decision; (c) the mental healthcare needs of the minor cannot be fulfilled unless he is admitted; and (d) all community based alternatives to admission have been shown to have failed or are demonstrably unsuitable for the needs of the minor
	(4) A minor so admitted shall be accommodated separately from adults, in an environment that takes into account his age and developmental needs and is at least of the same quality as is provided to other minors admitted to hospitals for other medical treatments
	(5) The NR or an attendant appointed by the NR shall under all circumstances stay with the minor in the MHE for the entire duration of the admission of the minor to the MHE
	(6) In the case of minor girls, where the NR is male, a female attendant shall be appointed by the NR and under all circumstances shall stay with the minor girl in the MHE for the entire duration of her admission
	(7) A minor shall be given treatment with the informed consent of his NR
	(8) If the NR no longer supports admission of the minor under this section or requests discharge of the minor from the MHE, the minor shall be discharged by the MHE
	(9) Any admission of a minor to a MHE shall be informed by the medical officer or MHP in charge of the MHE to the concerned Board within 72 h
	(10) The concerned Board shall have the right to visit and interview the minor or review the medical records if the Board desires to do so
	(11) Any admission of a minor which continues for 30 days shall be immediately informed to the concerned Board
	(12) The concerned Board shall carry out a mandatory review within 7 days of being informed, of all admissions of minors continuing beyond 30 days and every subsequent 30 days
	(13) The concerned Board shall at the minimum, review the clinical records of the minor and may interview the minor if necessary
	Section 88. Discharge of independent patients: (2) Where a minor has been admitted to a MHE under section 87 and attains the age of 18 years during his stay in the MHE, the medical officer in charge of the MHE shall classify him as an independent patient under section 86 and all provisions of this Act as applicable to independent patient who is not minor, shall apply to such person
	Section 89: Admission and treatment of persons with mental illness, with high support needs, in MHE, up to 30 days (supported admission)
	(9) The medical officer or MHP in charge of the MHE shall report the concerned Board, (a) within 3 days the admissions of a woman or a minor; (b) within 7 days the admission of any person not being a woman or minor
	Section 95. (1) Notwithstanding anything contained in this Act, the following treatments shall not be performed on any person with mental illness (a) ECT without the use of muscle relaxants and anesthesia; (b) ECT for minors; (c) sterilization of men or women, when such sterilization is intended as a treatment for mental illness; (d) chained in any manner or form whatsoever
	(2) Notwithstanding anything contained in subsection (1), if, in the opinion of the psychiatrist in charge of a minor’s treatment, ECT is required, then, such treatment shall be done with the informed consent of the guardian and prior permission of the concerned board

ADs – Advance directives; NR – Nominated representative; MHP – Mental Health Professional; MHE – Mental Health Establishment; ECT – Electroconvulsive therapy

Table 4.

Key highlights of the Mental Healthcare Act pertinent to children and adolescents

Mandates prior permission from a MHRB for using ECT in minors

Requirement of separate inpatient accommodation for minors that is consistent with their developmental needs

Two professionals, including at least one psychiatrist are required to admit a minor

All treatment decisions are to be taken solely by the NR, including drafting of the advance directive. The adolescent’s preferences are not factored in

No clear guidelines for children with neurodevelopmental disorders seeking mental health services

MHRB – Mental health review board; NR – Nominated representative; ECT – Electroconvulsive therapy

Critique

Does not include adolescents in treatment decisions

MHCA section 1 (2) has defined a minor as any person below 18 years of age. Several countries have approved participation of minors (age 16–17 years) in health-care decisions. However, in the MHCA, all health-care decisions for minors are taken by the NR. MHCA has neither factored the preferences of adolescents in clinical decision-making nor provided any guidelines to address the issue of their disagreement with the therapeutic plan should the situation arise. It is well-known that coercing adolescents to comply with treatment protocols results in difficulties in establishing and maintaining an effective therapeutic alliance. Therefore, along with parents’, children and adolescents should be part of discussions with mental health professionals so that all their concerns may be systematically addressed (Siddeswara et al., 2018).

Lack of clarity regarding neurodevelopmental disorders

MHCA excludes mental retardation from the definition of mental illness (section 2 [1] [s]), but it does not specify for inclusion or exclusion of other neurodevelopmental disorders, so things appear ambiguous for this sizable proportion of group availing CAMH services. Relationship between ‘guardian’ as per Rights of Persons with Disability act and ‘NR’ in MHCA is also not clear. The Act has also missed commenting on vulnerable groups like orphans/destitute children with mental illness, children in custodial settings or those with mentally ill parents (Sharma and Kommu, 2017).

Lack of clarity regarding inpatient wards

MHCA states the need for separate inpatient facility for minor patients (section 87 [4]), but it does not specify whether provision of a separate facility in the same compound as adult patients is acceptable or whether an altogether different building is required. Although the Act states that a minimum standard of lodging and care similar to that received by any other medically ill child must be provided, it does not specify those standards and requirements. It is known that children with mental illness including developmental disorders need a cognitively stimulating yet safe environment to address their unique needs (Kelly McGuire et al., 2015; Siddeswara et al., 2018). Therefore, specific guidelines and standards of care regarding infrastructure, personnel, and other logistic facilities would be useful after taking into consideration the inputs of parents and mental health professionals.

Procedural issues regarding admission of minors

For admission of minors, MHCA mandates a separate examination by two professionals, of whom at least one must be a psychiatrist (2 psychiatrists, or 1 psychiatrist and 1 mental health professional or 1 psychiatrist and 1 medical practitioner). In the previous act (MHA), only one medical officer in-charge was required for facilitating admission of minors. This provision in MHCA is likely to create logistic issues in resource-poor settings where the number of MHP’s are few and may lead to delays in admission and initiation of appropriate treatment.

Electroconvulsive treatment for minors

MHCA mandates prior permission from a MHRB for using ECT in minors. Although this step has been ostensibly taken to ensure judicious use of ECT in minors, it may however delay the timely management of serious conditions such as catatonia, suicidality, and acute agitation. Ideally, mental health professionals should have been given discretionary powers for the appropriate use of ECT for minors in specific scenarios (Sharma and Kommu, 2017).

Infants of mentally ill mothers

MHCA has created a provision for infants and toddlers to stay with their mother, if she is receiving psychiatric treatment in an inpatient setting (section 21[2]). Although this is important for meeting the child’s needs, it creates a potential risk to the baby from other disturbed patients. Creating separate mother-baby units (MBUs) would address these concerns and with appropriate resource management would immensely support the family (Pavitra et al., 2019). However, the MHCA does not provide clear recommendations or a mandatory provision for creating MBUs in psychiatry wards. Along the same lines, MHCA should add specific provisions for the proper care of older children and adolescents whose parents have mental illness and who are receiving outpatient or inpatient treatment (Sharma and Kommu, 2017).

Decriminalization of suicide

Decriminalization of suicide in MHCA is a pertinent step to reduce barriers in help seeking and is relevant to the child and adolescent population as adolescents have high rates of self-harm behaviors, suicidal attempts, and deaths by suicide.

No mention of preventive and promotive mental health interventions

Arango et al. (2018) comprehensively reported that preventive mental health strategies reduce the incidence of mental illnesses. Therefore, mental health professionals should have effective liaison with other health professionals in the community such as pediatricians and psychologists and focus on preventive and promotive mental health strategies, early intervention, and improving access to comprehensive CAMH services. However, the MHCA does not comment on this aspect at all.

Conclusions

WHO checklist on Mental Health Legislation provides a framework for designing country specific mental health laws as well as to compare existing laws. Using this framework, MHCA’s provisions on minors’ admission process, separate inpatient area with age appropriate environment for minors, and active involvement of adult in the treatment process align with WHO standards. However, lack of clarity about the inclusion of neurodevelopmental disorders, lack of provision of minimal standards and requirements in inpatient health facilities, and lack of a provision for considering the minor’s opinion in treatment decisions are a few areas where the MHCA falls short of the WHO standards (WHO, 2005; Sharma and Kommu, 2017).

To conclude, MHCA, 2017 has given some importance to the special needs of children and adolescents, however considerable revision is required to ensure the timely, developmentally appropriate and holistic care of children, and adolescents with mental health and neurodevelopmental problems.

CONCLUSION

This paper has attempted to focus on child custody, corporal punishment and the relevance of The MHCA for children and adolescents as these are neglected issues in child psychiatry. Indeed, courtrooms and schools influence the practice of child and adolescent psychiatry. Thus there are multiple roles of a child and adolescent psychiatrist in these spaces as the interplay between education, legal and mental health systems impact children. This paper urges psychiatrists to work beyond the clinic with other systems to promote CAMH. Adoption, Protection of Children From Sexual Offences (POCSO) Act 2012 and Juvenile Justice (JJ) Act have not been covered in this paper however some salient points have been mentioned in Tables 5-7 respectively.

Table 5.

Adoption - salient points

Mental health professionals can assist adoptive parents to emotionally prepare children for the transitions that adoption entails, build attachment security, understand, and resolve any emotional or behavioral issues that the child may experience

Disclosure of adoption status to a child should begin early. As early as 3-3.5 years, discussions regarding families and bonds can be initiated, and by the time the child is around 5-6 years of age the narrative can progress to include different types of families (families with biological vs. adopted children) and then of course, the disclosure regarding adoption status. Adolescents may need the issue to be revisited and discussed once again, in light of their advanced cognitive development. Mental health professionals can be instrumental in facilitating these discussions between parents and children

Resources: https://www.nimhanschildproject.in/wp-content/uploads/2018/08/Psychosocial-Perspectives-on-Adoption-Guide-CCAMH-NIMHANS_v2019.pdf https://www.nimhanschildproject.in/wp-content/uploads/2019/01/CARA-Regulation.pdf

Table 7.

Children in Conflict with the Law, JJ act, and Preliminary assessment under section 15 - salient points

According to the Juvenile Justice (Care and Protection of Children) Act, 2015 Children between the ages of 16-18 years who are accused of having committed a heinous offence, will require a preliminary assessment to be conducted to determine whether legal proceedings will be continued in the adult court or limited to an inquiry by the juvenile justice board

A mental health professional may be consulted for inputs regarding the preliminary assessment which is usually drafted under three headings: Circumstances of the alleged offence, Mental and Physical Capacity to commit the alleged offence and Child’s Knowledge of Consequences of Committing the Alleged Offence

Resources: https://www.nimhanschildproject.in/wp-content/uploads/2020/03/Critical-Issues-in-Psychosocial-Care-and-Mental-Health-of-Children-in-CCL.pdf https://www.nimhanschildproject.in/wp-content/uploads/2020/03/Psychosocial-and-Mental-Helath-Considerations-in-Juvenile-Justice-A- framework-for-Judicial-response-to-Children-in-Conflict-with-the-Law01.pdf

Table 6.

POCSO Act 2012 - salient points

The procedure for establishing and/or confirming CSA has three components, namely, (i) Psychosocial and Mental Health Assessment; (ii) Developmental Assessment; and (iii) Abuse Inquiry or Forensic Interviewing for CSA

The purpose of mandatory reporting, under POCSO, is to ensure that sexual offense comes to light and gets punished, to ensure that the child (especially when abusetakes place within the family) is safe and does not continue to suffer abuse, to provide justice to the child concerned and prevent abuse of other children. As justified as it is in its intent, the stipulation of mandatory reporting is ridden with dilemmas and is often difficult to implement

According to POCSO, every state is required to set up Special Courts to ensure speedy trial of CSA cases. The Special Court judge may call upon mental health professionals to assist in the court proceedings to be an expert witness

Resources: https://www.nimhanschildproject.in/wp-content/uploads/2020/03/The-Child-as-a-Witness-Developmental-Mental-Health-Implications-for-Eliciting-Evidence-under-Protection-of-Children-from-Sexual-Offences-Act-2012.pdf http://www.indianjpsychiatry.org/article.asp?issn=0019-5545;year=2019;volume=61;issue=8;spage=317;epage=332;aulast=Seshadri. POCSO – Protection of Children From Sexual Offences; CSA – Child Sexual Abuse

Please find below comprehensive sources for some core areas in Child Mental Health that significantly intersects with the law.

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