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Establishing informed consent with a young child with autism

Case study: Establishing informed consent with a young child with autism

Hilary, an RMT, works in a multi-disciplinary pediatric clinic. One of the patients is a young child with autism named Alan who is tactilely defensive and uncomfortable with touch. Alan’s mother, Joan, wants Hilary to provide massage therapy for Alan so that he can become more comfortable with touch and with being around people. Although Hilary is used to working with children, she has little experience working with children who have autism. She is concerned and uncomfortable with Joan’s request because she can see that Alan doesn’t want strangers near him. She sees that he reacts quite negatively to any casual touch by anyone other than his mother.

The receptionist in the clinic is unaware of Hilary’s reservations about providing treatment for Alan and she books Joan and Alan into Hilary’s schedule. When Joan and Alan arrive at Hilary’s treatment room, Alan begins to cry and wave his hands anxiously. Joan tells Alan soothingly that Hilary is going to give him a massage treatment. Alan becomes increasingly upset.

With some trepidation, Hilary asks Alan if she can sit beside him. Alan turns his back to Hilary. Joan encourages Hilary to sit beside Alan anyway, suggesting that Alan will get used to her presence in a few minutes. Hilary follows Joan’s instruction and sits beside Alan, even though he clearly indicates that he doesn’t want her to do so by continuing to turn away. Joan suggests that Hilary put her hand gently on Alan’s back to introduce her touch. Alan squirms away from Hilary. They wait a few minutes so that Alan can get used to Hilary’s presence and her hand on his back but his anxiety, hand waving, and body language are amplified. He begins to kick the table and yell “no”.

Did Hilary’s actions meet the consent standard of practice?

No. Despite Alan indicating his discomfort, Hilary follows his mother’s instruction, instead. Even when he clearly demonstrates that he feels anxious and uncomfortable with Hilary’s presence by squirming away, she continues to sit beside him and even puts her hand on his back, making things worse for Alan. Moreover, Hilary follows Joan’s lead in how to relate to Alan, rather than respecting Hilary’s own reactions to the situation.

Though Joan, as a parent, can consent on behalf of Alan (under the Infants Act) as Alan is not capable of doing so, consent is only valid if the treatment is in the minor patient’s best interests. It is up to Hilary to determine if massage therapy is an appropriate form of treatment for Alan. Given his forceful objections, it is clear that no treatment should be provided until Alan becomes more comfortable with the environment, with Hilary, and with receiving touch from a stranger.

In an emergency, it may be necessary to touch someone without the individual’s consent, but massage therapy is an elective form of treatment. It does not constitute emergent or urgent care. Touching any person without their express consent, particularly someone who is anxious or vulnerable, could be construed as a form of assault.

While children may not be able to comprehend the full nature or purpose of a treatment, they will indicate quickly whether or not they are comfortable with the therapist or the approach to care. Although a parent may have a vision of how massage therapy might fit into a child’s reality, both the parent and the therapist must respect the child’s wishes and needs.

Consent standard of practice case studies

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