1.9 Assessing competency

Obviously children at different stages of development will have differing capacities to take responsibility for their own health care, although these capacities are not necessarily defined just by age. Children’s capacities are highly dependent on the experiences they have had. For example, young children who have experienced major surgery or frequent medical interventions may have a profound understanding of life or death and how decisions will affect them. There are two distinct issues to consider here.

1. All children can be involved in decisions about their health care, even though the actual decisions will be taken by adults. For example, while five-year-old children may lack the competence to decide that they need to go to hospital for an operation, they can indicate if and why they feel comfortable at the hospital, and provide suggestions to improve their stay.
2. Some children will have the capacity to give formal consent to their treatment or to refuse treatment, although the legal rights to do so will be determined by the legislation in any given country. You need to know what the law says in your country. Considerations to take into account in assessing children’s capacities to give or refuse consent can include:
   • Is the child able to understand and communicate relevant information? The child needs to be able to understand the alternatives available, express a preference, express concerns and ask relevant questions.
   • Is the child able to think and choose with some degree of independence? The child needs to be able to exercise a choice without coercion or manipulation and to think through the issues for themselves.
   • Is the child able to assess the potential for benefit, risk and harm? The child must be able to understand the consequences of different courses of action, the risks involved and the immediate and long-term implications.

In general, health professionals need to listen to children, provide appropriate information and give them time to articulate their concerns, so that children can develop the confidence and ability to contribute effectively to their own health care.