Methodological Discussion: Can the Maturity of A Minor Be Measured?
The present study aimed to design a valid, reliable, and easy-to-manage scale for assessing the maturity of adolescents. This scale was designed to be used in a clinical population given that no such scale meets these requirements at present.
Regarding psychometric characteristics, the examined test has a high feasibility rate, as it was completed by over 99 per cent of respondents. The estimated duration of T17 is 23.2 minutes on average (IC95 per cent: 22.5–23.9). For T9, the estimated duration is about 15 minutes. This calculation is based on an approach that considers the response time of each test item for the T9 test as proportional to the duration of the T17 test. However, the duration of completion and correction of the Kohlberg MJI or the Rest DIT is approximately 1.5 hours. The reliability, measuring internal consistency, obtained using the KR-20 remains around 0.5—a rating considered as moderate (Thorndike
1989). This moderation is explained in part by the design of the test: limited extension, dichotomous response structure, and multidimensionality (Ruiz Bolivar
2011). The moderation is also explained by the homogeneity in terms of age and culture of the population for which the test was performed. When compared with other tests measuring adolescents’ competence to decide, the Youth Decision-Making Competence (Y-DMC), a test consisting of seven subscales, two of which have dichotomous data and low number of items, obtains Alpha-CR coefficients of 0.30 and 0.03 (Bruine De Bruin, Fischhoff, and Parker
2007). In contrast, the Values in Action Inventory for Youth (VIA-Youth) obtains an Alpha-CR > 0.7, with a test of 198 items (Park and Peterson
2006). However, in a recent validation of the Rest DIT in a Turkish university population, an Alpha-CR of 0.5 was obtained (Cesur and Topçu
2010). The intraclass correlation coefficient (ICC) is 0.79 (T-17) and 0.77 (T-9), a high value, much better than that of VIA-Youth or others, with an ICC above 0.5.
Regarding structural validity, the variability of the test shows an appropriate discriminative capacity regarding the maturity of the participants (“ceiling and floor effect” < 15 per cent). Regarding convergent validity, the test has a high correlation with the gold standard used (T17: ICC=0.74/T9 ICC=0.65), positioning itself as a good test to measure the maturity of minors. In the study of the validity of extreme groups, it must be noted that regarding age, the data in the assessment of maturity by the tutor show a statistically significant progressive upward trend, something also seen in the test under validation and in the MJI, as expected (Chenneville et al.
2010; Moon
1986; Billick et al.
2001), although in these two cases, the high score of twelve-year-olds must be emphasized. In light of the reviewed literature, this suggests that twelve-year olds still work with a pattern of the values transmitted by their parents: this might explain why they take less time giving a mature response (Thurstone
1972; Marsh
1989).
In this line of thought, regarding informed consent, Grisso (
1972) supported by Melton (
1981) and Pearce (
1994) suggest that it is towards fourteen years when a minor is able to give consent. Leikin (
1983) argues that at age twelve, many children are already competent to make decisions, and Mann (
1989) considers that at around age fifteen to seventeen, they achieve the adequate self-esteem necessary to make decisions. However, all children of school age highly value the fact of being informed of and being able to participate in decisions affecting their own health (Coad and Shaw
2008; Jeremic et al.
2016; Martenson and Fagerskiold
2007).
Therefore, their thoughts should always be taken into account before making any decision concerning them. Regarding gender, the test to validate, in line with the published literature, points to a more rapid development of maturity in adolescent girls (Cesur and Topçu
2010; Alderson
1993; Gibbs et al.
2007). Sensitivity to change is explored by observing whether the same approach of dilemmas can, over time, develop the moral competence of the individual. In this sense, there is an improvement with statistical significance in the test score of 0.3, supporting the idea that education in ethical conflicts, through reflection and discussion about moral dilemmas, is able to improve maturity in reasoning and decision-making (Ruhe et al.
2015).
Conceptual Discussion
This test raises hypothetical ethical conflicts that classify maturity stages according to the preconventional or conventional moral stages of Kohlberg. The test results correlate with the maturity assessed by the gold standard (MJI) and with the appraisal made by the tutors that it is a useful tool to measure maturity.
To classify the degree of maturity of a minor based on the test, results were compared with the MJI stages, and three groups of maturity are proposed: a higher score corresponds to more mature individuals and vice versa (table
6).
Table 6Maturity T9 test ranges proposal, according to Kohlberg’s maturity stages
<= 5 | 76 % | 25 | 0 % |
6-7 | 21 % | 37 | 16 % |
8-9 | 3% | 38 | 84 % |
However, the minor’s maturity is an important part of the competence assessment, but not the only one. Revising the literature, we propose a structured and multidimensional way of assessing children’s decision-making competence, with four complementary areas: evaluation of the maturity of moral reasoning of the minor, assessment of the minor's ability to understand information, assessment of the gravity of the decision, and assessment of the minor's context and of the decision (Pearce
1994; Leikin
1983; Mann, Harmony, and Power
1989).
In the second step, evaluating the ability to understand the provided information, Appelbaum (
2007) suggest the following four criteria of assessment in adults: understanding of the relevant information to make a decision, appreciation of the situation and its consequences, rational manipulation of information, and ability to make a choice. They developed the MacArthur Assessment Tool, with different version for treatment or clinical research.
In minors, a noteworthy study was realized by Weithorn and Campbell (
1982), in which Appelbaum’s criteria were applied in a group of healthy minors and adolescents (aged nine, fourteen, eighteen and twenty-one), exposing them to four hypothetical dilemmas involving healthcare decisions. All four standards of competence (ability of choice, rational choice, rational motivation, understanding of the decision) were assessed. All children under the age of fourteen decided in a similar manner to young people aged from eighteen to twenty-one. Other studies applied the MacArthur Assessment Tool in clinical adolescent population, with mixed results (Miller, Drotar, and Kodish
2004; Koelch et al.
2010; Turrell, Peterson-Badali, and Katzman
2011).
In the third step, it’s also important to consider the gravity of the minor’s decision. Drane’s Sliding Scale of Competency (
1994) refers to the proportionality of the decision (the more serious the decision, the greater the level of competence required from the person taking it). It is the benchmark for this type of assessment.
And in the fourth step, other factors that influence the degree of involvement of adolescents in decisions must also be taken into consideration (McCabe et al.
1996; Marsh
1989; Reder and Fitzpatrick
1998), whether they depend on the minor themselves (pain, anxiety, consumption of medicines or drugs) or on family or cultural issues and situational factors (doctor–patient relationship of trust, emergency context) (McCabe et al.
1996; Chenneville et al.
2010; Pearce
1994; Mann, Harmony, and Power
1989; Reder and Fitzpatrick
1998; Shaw
2001).
Among health professionals in their usual clinical practice, this tool offers a reflection on the minor's participation in a daily consultation and on their ability to make decisions regarding their own health, simply because they have a tool designed to assist them in the assessment of this competence. The physician needs to acquire certain skills to fulfil this task (Martenson and Fagerskiold
2007).
Furthermore, facilitating communication between children, parents, and professionals and involving children in the process of decision-making provides greater satisfaction regarding the provided medical care, both for parents and children, enhanced cooperation from the child during treatment, and an increased sense of control, resulting in the illness being perceived as less stressful and reducing the feeling of discomfort; not to mention it also shows respect for the child’s abilities and encourages their development (McCabe et al.
1996; Alderson
1993).
The limitations of the study include the structure of the test. Its dichotomous nature, multidimensionality, and short length may be limiting factors in the degree of reliability achieved, although the short length was needed to design a quick and easy-to-use tool. Another element that can influence the outcome of this coefficient is that the study population was very homogeneous; the tool also needs to be tested in heterogeneous environments. There is no proper gold standard, despite using an indirect, semiqualitative measurement through the MJI and the evaluation of the tutor. The test still needs validation in the real context of healthcare decisions.