Dr. Grisso spoke first, pointing out that he and Dr. Appelbaum had gone separate ways in their research interests since writing the book. Dr. Appelbaum has focused on the capacity to consent to research, while Dr. Grisso has focused on developmental psychology and adolescent decision-making capacity.
Dr. Grisso's interest in the ability of children and adolescents to make decisions began in the 1980's. Research at that time said that adolescents did about as well as adults in hypothetical decision-making situations, yet his own research on Miranda waivers showed significant differences. While adolescents may reason well cognitively, they also seem to make choices that adults would view as bad choices. So the question arises, do youths arrive at their decisions differently? This led to a developmental literature review on wisdom - a concept related to how one uses personal values in making choices.
In his later work with the MacArthur competency study group, the researchers developed a conceptual framework for thinking about competency and research measures to study competency. When the wave of youth violence that began in the 1980's crested in the mid-90's, Dr. Grisso went back to his research on adolescent decision-making. These questions were made all the more important by the increasing trend to try more juveniles as adults, and at younger ages. For the last 3 years, he has been working with a new MacArthur network of researchers on the subject of juvenile justice and adolescent judgement.
The hypothetical theory now being studied is that by about the age of 13-14, there are no dramatic differences in capacity to understand information and reason between adolescents and adults. However, psychosocial factors are more likely to be different. For example, compared to adults, youths do not give as much weight to long-range consequences, they are more accepting of risk and are more influenced by peers.
A multi-site research study is now underway in California, Virginia, Florida and Pennsylvania looking at youths and adults who are pre-trial versus those admitted to general hospitals. The study examines competency to stand trial measures, perception of risk, peer influence, temporal factors and other measures. Research results are expected to be available in 2001. A volume of perceptual and review papers on juvenile CST and culpability edited by Dr. Grisso and Robert G. Schwartz is currently available from the University of Chicago Press: Youth on Trial: A Developmental Perspective on Juvenile Justice.
Dr. Appelbaum became interested in the issue of competency to consent to research in the wake of reports of abuses of human research subjects. These included studies in which medications were stopped to study predictors of good response off medications, which had the unfortunate consequence of patient decompensation and suicide. Other criticized studies tested placebo treatments of acutely ill individuals. One of the questions raised was whether we can know if these subjects were able to give informed consent.
Dr. Appelbaum studied this subject by comparing community controls to groups of individuals suffering from angina, schizophrenia, or depression on tests of understanding, appreciation and reasoning related to research protocols. On the measure of understanding, controls and angina patients did well, depressed patients did less well, and schizophrenic patients showed the poorest performance. Similar patterns appeared for measures of appreciation and reasoning. If the three standards were combined, significant impairment was found among group members at the following rates: schizophrenia - 1 out of 2 people; depression - 1 out of 4 people; angina - 1 out of 8 people; community controls - 1 out of 25 people.
One instrument developed by the MacArthur research group was the MacCAT-CR (clinical research). This instrument has been found to have high inter-rater reliability. In one study of depressed female outpatients using this instrument, the subjects were found to have good reasoning, understanding and appreciation of the proposed research. Compared to the studies cited above, the difference may be accounted for by the inpatient-outpatient distinction, with more inpatients obviously suffering from active psychosis.
In another study of schizophrenic patients, mostly male, in their early 40's with 20+ years of illness, subjects performed much worse than community controls. Yet, capable researchers such as Will Carpenter, enroll such individuals in studies all the time, and feel that the participants do give informed consent.
To study this question, Dr. Appelbaum has conducted research in which individuals who performed most poorly on the test instrument are placed in a one-week educational program and then re-tested. Significant pre-test/post-test differences have been found, showing improvement after education. Conclusions drawn from this study are that individuals who are decisionally-impaired can be brought to the point of being able to make decisions, but may need more education in order to do so. Several other research projects are now underway to tease out the factors that lead to poor performance.
In closing, Dr. Appelbaum shared 3 lessons he has derived from his research experience. 1) One never knows where one's research will lead. 2) The development of measurement tools can enable studies to be done. 3) One needs a teacher and companion - such as he found in the person of Dr. Grisso - to make this work successful and enjoyable.
An audience member drew a suggestion from this research to clinical practice - the proper response to an impaired person would be to work with him/her to enhance decision-making capacity, rather than jumping immediately to an alternate decision-making apparatus.