(This syllabus is not part of the opinion of the Court. It has been prepared by the Office of the Clerk for
the convenience of the reader. It has been neither reviewed nor approved by the Supreme Court. Please
note that, in the interests of brevity, portions of any opinion may not have been summarized).
IN THE MATTER OF THE COMMITMENT OF N.N. (A-70-95)
Argued January 16, 1996 -- Decided August 5, 1996
HANDLER, J., writing for a unanimous Court.
In November of 1994, N.N., a fifteen-year-old, was arrested after an altercation in which she
allegedly assaulted another youth with a box cutter. N.N. claimed that she acted in self-defense. N.N. was
charged with juvenile delinquency and spent approximately one month at a county detention center. On
December 6, 1994, N.N. signed a request for voluntary admission to the Bridgeton Hospital because the
judge in the juvenile proceeding wanted her to have a seven-day evaluation. During her stay, N.N. showed
no behavioral problems, nor did she need any medication to control her behavior. When N.N. was told that
her psychiatrist at the hospital, Dr. Williams, recommended that she stay at least another week, she had a
short behavioral outburst. N.N. did not hit or threaten anyone during this episode.
Because N.N. revoked her voluntary status under the statutory and regulatory standards, a hearing
was conducted by the trial court to determine whether N.N. should be involuntarily committed. Dr. Williams
testified that N.N. suffered from a conduct disorder that he described as a disturbance of mood, but not as a
disturbance of thought, perception or orientation. Dr. Williams believed that he was justified in seeking
involuntary commitment because, in his opinion, N.N. met both the "dangerousness" standard and the
alternative "in need of intensive psychiatric therapy" standard necessary for involuntary commitment. Based
on the testimony, the court declined to find N.N. could be committed under the "dangerousness standard."
Instead, the court found that N.N. should be committed because she needed inpatient intensive attention and
because she suffers from a disturbance of mood.
The Public Defender appealed to the Appellate Division and then petitioned the Supreme Court for
certification of the appeal pending unheard. The Court granted certification.
HELD: A standard that would authorize the involuntary commitment of a minor under fourteen years of age
requires: 1) a showing that the minor is mentally ill, as defined in terms of childhood mental illness;
2) a demonstration that the child is in need of intensive, institutional psychiatric treatment that
cannot be provided in the home, the community or on an out-patient basis; 3) a determination that,
due to mental illness, the minor's condition poses a danger to that minor or to others, which may
include the substantial likelihood of significant developmental harm if that treatment is not provided;
and 4) that the above prerequisites for involuntary commitment be established by clear and
convincing evidence, determined by specific and particularized findings of fact.
1. The standards governing civil commitment are provided by statute, at N.J.S.A. 30:4-27.1 to -27.23, and in
Rule 4:74-7. Rule 4:74-7 is the only codified standard applicable to the commitment of minors. Rule 4:74-7(f) specifies the involuntary commitment standard applicable to adults, which requires a mental illness that
causes a danger to self or others. The involuntary commitment of minors also is governed by an alternative
standard (the "necessary-treatment" standard) that omits any need to demonstrate mental illness that causes
dangerousness to self or others. It requires, instead, the need for intensive psychiatric therapy. (pp. 6-10)
2. The Civil Practice Committee has proposed, based on the recommendations of the Subcommittee on
Mental Commitments, a Rule that addresses only minors under the age of fourteen. All minors fourteen
years or older would be governed by the adult standard for commitment. The proposed rule would provide
an alternative commitment standard for minors up to fourteen years. That standard requires a finding of
mental illness and dangerousness or "a need of intensive [institutional] psychiatric therapy." This appeal
arose before the Civil Practice Committee's proposed Rule could be considered by the Court. The Court did
not act on the proposal, deciding to determine the standards that must govern the involuntary commitment of
minors through the adjudication of this case. Although a decision with regard to N.N. is moot, a decision by
this Court is necessary because the issues posed involve significant matters of public policy, are extremely
important and undoubtedly will recur. (pp. 10-15)
3. The current Rule is construed to required mental illness as a precondition for involuntary commitment.
Because civil commitment implicates significant individual liberty interests of minors, the protections
necessary to adequately safeguard those interests reasonably require a clear and convincing demonstration
that the minor is suffering from or is afflicted with a mental illness, before commitment can be authorized.
The standard for involuntary commitment of minors must include a requirement of "childhood mental illness"
defined in comparative developmental terms. (pp. 15-17)
4. The language of the necessary-treatment standard denotes minimally that involuntary commitment must
be based on a showing of a need for inpatient care, consisting of intensive psychiatric therapy that can be
provided only at a psychiatric hospital. That meaning is sufficient to overcome the claim of constitutional
vagueness. (pp. 17-22)
5. The State has an interest in providing treatment and care for children who suffer from mental illness, and
who may benefit from such care. That interest, however, is not sufficiently compelling to justify the
curtailment of a child's liberty interest by involuntary commitment to a psychiatric hospital. A standard
based only on the "need of intensive [institutional] psychiatric therapy" as a condition for the involuntary
commitment of minor does not vindicate a compelling state interest, and is insufficient to protect the
individual liberty interests of the minor. Involuntary commitment of a minor who is mentally ill and found to
be in need of intensive institutional psychiatric therapy may not be undertaken without a finding based on
clear and convincing evidence that the minor without such care is a danger to others or self. (pp. 22-26)
6. The necessary-treatment standard for minors under the proposed Rule differs from the adult standard of
dangerousness by requiring "dangerousness" only as an alternative to the necessary-treatment basis for
juvenile commitment. That difference in approach responds to the criticisms of the adult dangerousness
standard as applied to minors; acknowledges the uncertainty and difficulty in applying the concept of
dangerousness to children; and reflects the desire not to foreclose needed and appropriate treatment for
those children, not dangerous by adult standards, who seriously require intensive psychiatric therapy. The
criteria for commitment of minors based on dangerousness must reflect their heightened needs and
vulnerability and the State's concomitant greater responsibility to assure their health and well being. A
dangerousness standard that applies to minors must be derived from and related to childhood mental illness.
The standard of "dangerousness to self" applicable to a child suffering from mental illness as a basis for
involuntary commitment must encompass the substantial likelihood that the failure to provide immediate,
intensive, institutional, psychiatric therapy will create in the reasonably foreseeable future a genuine risk of
irreversible or significant harm to the child arising from the interference with or arrest of the child's growth
and development and, ultimately, the child's capacity to adapt and socialize as an adult. (pp. 26-32)
7. In the absence of a fuller record and more extended argument addressing the status of minors as they
approach the age of maturity, the differentiation of minors at age fourteen, as proposed by the Civil Practice
Committee, may be followed. (pp. 32-34)
8. The involuntary commitment of N.N. failed to satisfy the standards now adopted: the evidence was
insufficient to establish that N.N. suffered a childhood mental illness, that she required intensive, institutional
psychiatric therapy or that she suffered a condition of dangerousness that threatened irreversible or
significant interference with her developmental capacity if such treatment were not promptly provided. (pp.
34-35)
9. The standards and procedures governing involuntary juvenile commitment should be addressed by the
Legislature. In the meantime, the Civil Practice Committee is directed to consider and recommend a Rule
of Court to implement the standards set forth in this opinion. (pp. 36)
Judgment of the trial court is REVERSED.
JUSTICES POLLOCK, O'HERN, GARIBALDI, STEIN and COLEMAN join in JUSTICE
HANDLER's opinion.
SUPREME COURT OF NEW JERSEY
A-
70 September Term 1995
IN THE MATTER OF THE
COMMITMENT OF N.N.,
Appellant.
Argued January 16, 1996 -- Decided August 5, 1996
On certification to the Superior court, Law
Division, Cumberland County.
Theodore S. Novak, Managing Attorney, argued
the cause for appellant (Susan L. Reisner,
Public Defender, attorney; Mr. Novak and
Stanley M. Shur, Staff Attorney, on the
brief).
Daisy B. Barreto, Deputy Attorney General,
argued the cause for respondent, Attorney
General of New Jersey (Deborah T. Poritz,
Attorney General, attorney; Joseph L.
Yannotti, Assistant Attorney General, of
counsel).
The opinion of the Court was delivered by
HANDLER, J.
In this case, a fifteen-year-old girl was involuntarily committed to a psychiatric hospital because of conduct problems including an assaultive episode with another youth. She
initially entered a psychiatric hospital for a seven-day
examination. The examining psychiatrist attributed her condition
to a mood imbalance amounting to a type of mental illness, and
recommended a continued commitment. The court reviewing her
commitment found that she did not present a threat of danger to
herself or to others.
The Court's rule, under which the girl was committed,
provides that a minor may be involuntarily committed if a court
finds that the minor is in need of therapy that cannot be
provided anywhere but in a psychiatric hospital. The issue in
this case is whether the standard governing the involuntary
commitment of minors, which does not require that the minor
suffer from a mental illness that poses a danger to self or
others, is unconstitutional.
In November of 1994, N.N., a fifteen-year-old, was arrested after an altercation in which she allegedly assaulted another youth with a box cutter. N.N. claimed that she was being harassed by the other youths, and stated that she acted in self-defense.
N.N. was charged with juvenile delinquency and spent approximately one month at the Atlantic County Detention Center (hereinafter "Harborfields"). On December 6, 1994, N.N. signed a request for voluntary admission to the Bridgeton Hospital because the judge in the juvenile proceeding wanted her to have a seven-day evaluation. The court did not issue a detainer requiring her presence at Bridgeton nor mandating her return to Harborfields after the seven-day examination.
N.N. had previously received psychiatric therapy during a month-long inpatient stay at the Child Guidance Clinic in Philadelphia in June and July of 1993. There are no records of her diagnosis from this clinic, although it is asserted that this treatment was due to N.N.'s "depression and poor impulse control." N.N. also had problems at school. She was expelled from Catholic school for yelling at a nun; she repeated the ninth grade, due to "family problems," and attended an alternative school for a time.
Apparently, N.N. did not exhibit any behavioral incidents or problems while at Bridgeton Hospital. No psychiatric medication was prescribed for her prior to her admission to Bridgeton Hospital, and none was administered during her seven days in the hospital.
N.N. believed that she would be returning home with her mother after the seven-day evaluation, and would subsequently attend a partial care program. The hospital's family therapist had made arrangements for outpatient referrals and follow-up care for N.N. following her discharge. However, when N.N. was told that her psychiatrist at the hospital, Dr. Williams, recommended that she stay at least another week, N.N. became tearful, started to curse, slammed the door and kicked a water fountain. However, N.N. did not hit or threaten anyone during this episode.
At a hearing reviewing the voluntary admission, the
examining psychiatrist, Dr. Williams, noted that N.N. had
requested to go home, thereby revoking her voluntary status under
statutory and regulatory standards. N.J.S.A. 30:4-27.20; R.
4:74-7(k). Dr. Williams testified that he would attempt to
obtain a temporary order for involuntary commitment, and a
hearing for involuntary commitment was scheduled in the Superior
Court, Law Division, Gloucester County. The trial court then
conducted a hearing to determine whether N.N. should be
involuntarily committed. N.N. testified that the episode lasted
less than five minutes, and that she calmed down as soon as she
was told to calm down. The doctor offered her medication to
quiet her, but N.N. refused. The patient progress notes for that
night indicate that N.N. was "placed in the quiet room for her
own protection," but that she "was able to calm down and come out
of the quiet room" and there were "[n]o suicidal tendencies
noted" for that night.
Dr. Williams regarded this outburst not as an episode caused
by the stress of being told to remain in the hospital, but rather
as the product of a mental illness that he diagnosed as a
"conduct disorder" and post-traumatic stress disorder. Dr.
Williams described this as a disturbance of mood, but not as a
disturbance of thought, perception or orientation. The diagnosis
of post-traumatic stress disorder related to an incident that
N.N. recounted in her therapy session with Dr. Williams, in which
N.N. was "gang-raped" by a group of five adolescents when she was
eight years old. The doctor noted that N.N. "faulted herself for
the rape" and kept this to herself until she was admitted to the
Child Guidance Clinic program.
Generally, Dr. Williams felt that N.N. had poor impulse
control and was "volatile" in the sense of having a "labile
affect": she could be "very changeable, rather whimsical, based
on something [internal] irregardless [sic] of what you might
expect from the environment." The doctor conceded that he did
not mean "volatile" in the sense of "out of control." The
doctor believed that N.N. suffered from a "substantial
disturbance of mood perception," which would have qualified her
for commitment under the adult standard of mental illness.
Dr. Williams also felt that N.N.'s symptoms were not more
severe only because she was in a protected environment. He
expressed concern that N.N. would injure herself or another
person if she were not receiving inpatient care. He stated that
if stressed, "she will fall apart and lose her judgment; and, as
long as she is not stressed and her needs are met, she can be
quite cooperative." The doctor reported that if N.N. were
involuntarily committed, she could receive individual and group
therapy in a secure, locked-ward environment, "within
. . . total control and authority."
The doctor felt justified in seeking involuntary commitment,
because in his opinion N.N. met both the "dangerousness" standard
and the alternative "in need of intensive psychiatric therapy"
standard necessary for involuntary commitment. The doctor stated
that he would pursue involuntary commitment even if N.N.'s mother
were to object to her continued institutionalization.
The trial court found that N.N. had a "disturbance of mood"
evidenced by her behavior the night before the hearing. The
court noted that the psychiatrist had characterized this behavior
as being "out-of-control." However, the court declined to find
that N.N. could be committed under the "dangerousness" standard.
Instead, the court found that N.N. should be committed because
she needed "inpatient, intensive attention," and because "she is
subject to, or she did display, or does have a disturbance [of
mood]." The trial court specifically declined to make a finding
regarding whether N.N.'s mother consented to the commitment.
The Public Defender appealed the case to the Appellate
Division, and then petitioned for certification of the appeal
pending unheard. This Court granted certification.
142 N.J. 442
(1995).
The United States Supreme Court has recognized that juveniles subject to involuntary commitment have significant liberty interests and are entitled to due process protections. Parham v. J.R., 442 U.S. 584, 601, 99 S. Ct. 2493, 2504, 61 L. Ed.2d 101, 118 (1979). "Because commitment effects a great restraint on individual liberty," this Court has stated that "this power of the State is constitutionally bounded," and its exercise must "comply with due process." In re S.L., 94 N.J.
128, 137 (1983) (citations omitted). The fundamental issue posed
by this appeal relates to the standard that must be followed by
the State when it exercises its power to commit involuntarily a
minor to an institution for psychiatric treatment. The issue is
of constitutional dimension.
The standards governing civil commitment are provided by
statute at N.J.S.A. 30:4-27.1 to -27.23, and in the current Rules
of Court, Rule 4:74-7. The issue in this case involves the
provisions for involuntary commitment contained in the Rules at
R. 4:74-7(f). That rule specifies the commitment standard
applicable to adults:
The court shall enter an order authorizing
the involuntary commitment of an adult
patient if it finds, by clear and convincing
evidence presented at the hearing that the
patient is in need of continued involuntary
commitment by reason of the fact that (1) the
patient is mentally ill, (2) mental illness
causes the patient to be dangerous to self or
dangerous to others or property as defined in
N.J.S.A. 30:4-27.2h and -.2i, (3) the patient
is unwilling to be admitted to a facility for
voluntary care, and (4) the patient needs
care at a short-term care or psychiatric
facility or special psychiatric hospital
because other services are not appropriate or
available to meet the patient's mental health
care needs.
The involuntary commitment of a minor is governed by an
alternative standard, viz:
Alternatively, if the patient is a minor, the
order may be entered if the court finds that
the patient is in need of intensive
psychiatric therapy that cannot practically
or feasibly be rendered in the home or in the
community or on an outpatient basis.
That alternative standard (hereinafter also referred to as
the "necessary-treatment" standard) omits any need to demonstrate
a mental illness that causes dangerousness to self or others. It
requires, instead, the need of intensive psychiatric therapy. It
is contended that the standard is vague, and by its failure to
require as a condition for involuntary commitment mental illness
that causes dangerousness to self or others, it violates due
process.
The alternative, necessary-treatment standard for the
involuntary commitment of minors has an extensive history that
explains its meaning and purpose. That history, therefore, is
relevant to the constitutional adequacy of the necessary-treatment standard governing involuntary commitments of minors.
The current rules on civil commitment were drafted pursuant
to this Court's request to its Committee on Civil Practice to
formulate standards and procedures for involuntary commitments
that would address the inadequacies of prior laws, and would
incorporate the rulings of then-current decisions.See footnote 1 Report of
the Supreme Court Civil Practice Committee,
98 N.J.L.J. 377, 387-88 (1975). The Court anticipated at the same time that the
Legislature would enact legislation that would provide the basis
for involuntary commitments. The rules were adopted by the Court
in 1975, and were revised in 1976. The 1976 revisions contained
the alternative standard for minors, which provided a "need of
intensive psychiatric therapy" as the criterion for involuntary
commitment of a minor. It omitted any requirement of a
demonstration of dangerousness to self or others as a basis for
involuntary commitment. According to the Comment to the Rule,
that criterion was adopted partly due to "the recognition that
the 'probable-danger' standard is not applicable to children, at
least not in the same way that it is in the case of adults."
Pressler, Current N.J. Court Rules, comment 1, on Rule 4:74-7(b)
(1995).
The Public AdvocateSee footnote 2 had opposed the necessary-treatment
standard for minors contained in the 1976 rule. It contended
that there was no reason that the commitment standard for
children should be different from that applied to adults, and
that there was no documentation indicating that the
"dangerousness" standard could not be used in juvenile
commitments. Despite those criticisms, the alternative standard
for juvenile commitments, based on a finding that the minor is in
"need of intensive psychiatric therapy which cannot practically
or feasibly be rendered in the home or in the community or on an
outpatient basis," was adopted.
In 1987, the Legislature enacted the current involuntary
commitment statute. N.J.S.A. 30:4-27.1 to -27.23. The statute
provides a uniform standard for involuntary commitment, requiring
a showing by clear and convincing evidence that the patient
suffers from a mental illness and poses a danger to self, others
or property. N.J.S.A. 30:4-27.2m; N.J.S.A. 30:4-27.15a. Through
its definition of "patient" as a person over age eighteen, the
statute's application is limited to adults. N.J.S.A. 30:4-27.2s.
The prior statute, which governed commitments of minors as well
as adults, N.J.S.A. 30:4-46, was repealed by the new statute,
effective June 7, 1989. Because the 1987 statute was limited to
adults, the repeal of the prior statute eliminated all statutory
authority for the commitment of minors. Though legislation
pertaining to juvenile commitments was anticipated at the time of
passage of the new statute, no such statute has been enacted.See footnote 3
Thus Rule 4:74-7, as revised in 1976, is the only codified
standard applicable to the commitment of minors.
The juvenile commitment standard of Rule 4:74-7 was again
challenged in 1991, when the Public Advocate requested a revision
of the Rule. The challenge reflected its earlier concerns about
the inadequacies of the Rule's standard in protecting juveniles.
Specifically, the Public Advocate criticized the Rule's failure
to require findings of mental illness and dangerousness as
conditions for involuntary commitment. The Supreme Court
Committee on Civil Practice remanded the matter of juvenile
commitments to a Subcommittee on Mental Commitments, which
produced a recommendation. Report of the Mental Commitments
Subcommittee of the Civil Practice Committee (Dec. 1993)
(hereinafter "Subcommittee Report"). The Subcommittee
recommended that a finding of mental illness constitute an
explicit prerequisite for the involuntary commitment of a minor.
According to the Subcommittee's report, it believed that by
implication the juvenile standard incorporated the mental illness
requirement of the adult standard. That conclusion was based on
its understanding that a finding of mental illness was
constitutionally fundamental for involuntary commitment. The
Subcommittee further noted that the official commitment forms
used by examining psychiatrists required a finding of mental
illness, thereby making a finding of mental illness a functional
requirement for commitment and an accepted practice of the
psychiatric community.
The Subcommittee also recommended a commitment standard for
minors based on "dangerousness to self or others or property."
That proposed dangerousness standard, however, was not mandatory.
The recommendation proposed retaining the necessary-treatment
standard as an alternative criterion. The Subcommittee stated
that the primary requirement of a finding of mental illness and
the alternative requirement based on either dangerousness or
necessary treatment were changes in conformity with the
"Certificate for Involuntary Commitment of a Minor" of the
Department of Human Services, which required the certifying
psychiatrist to make findings of dangerousness or of a need for
treatment.
A minority of the Subcommittee on Mental Commitments issued
a separate report that proposed a standard for involuntary
juvenile commitment reflecting the position of the Public
Advocate. That standard required a finding of dangerousness to
self, others or property as defined by the provisions of N.J.S.A.
30:4-27.2h and -27.2i, the statutory provisions applicable to
adults. The proposal also included changes to the voluntary
commitment standards for minors. Its proposed standard
differentiated between minors under the age of fourteen and those
fourteen years and older: voluntary commitment for a minor age
fourteen or over would require the consent of the minor, but if
the minor was under fourteen, the parent or parents could consent
to the commitment.
Although the Public Advocate's proposal, endorsed by the
Subcommittee minority, approved a requirement of dangerousness
identical to the adult standard, it explicitly required a finding
of "childhood mental illness" as a precondition of commitment.
It defined mental illness in children as
a current substantial disturbance of thought,
mood, perception, or orientation from that
which is typical of children at a similar
developmental stage and which significantly
impairs judgement, functioning, or capacity
to recognize reality as compared to children
at a similar developmental stage. The
presence of a seizure disorder, developmental
disability, organic brain syndrome, physical
or sensory handicap, or of brief periods of
intoxication caused by alcohol or another
substance is not sufficient to satisfy the
criteria for childhood mental illness, but
does not exclude a child otherwise determined
to satisfy those criteria.
[Letter from Alma L. Saravia,
Director, Division of Mental Health
Advocacy, Department of the Public
Advocate, to Deborah T. Poritz,
Chair, Subcommittee on Mental
Health, Supreme Court Committee on
Civil Practice (April 5, 1993)
(reprinted in Subcommittee Report
(emphasis added)).
That definition essentially mirrors the adult definition of mental illness, N.J.S.A. 30:4-27.2r, with an important modification: it requires a comparison of the patient's condition with that of children "at a similar developmental stage." The definition thus modifies the general adult standard of mental illness to allow treatment for children who may not display traits of mental illness on an adult scale, but who may show evidence of mental illness in comparison to children of similar age or developmental level. In support of the separate definition for childhood mental illness, one comment indicated: "Without such a definition [oriented towards children], the proper identification and possible commitment of seriously mentally ill youth may not occur." Letter from Hugh J. Adams, Mental Health Administrator, Mercer County Mental Health Board to
Keith Endo, Counsel to the Director, Administrative Office of the
Courts (June 29, 1994).
The Civil Practice Committee accepted the Subcommittee
majority's proposal with certain modifications. The rule that it
proposed addresses only minors under the age of fourteen. All
minors fourteen years old and older would be governed by the
adult standard for commitment, which requires a finding of mental
illness and dangerousness to self or others. The proposed rule
would provide an alternative commitment standard for minors up to
fourteen years. That standard requires a finding of mental
illness. It further requires, in the alternative,
"dangerousness" or a "need of intensive [institutional]
psychiatric therapy," viz:
If however, the patient is a minor under the
age of 14, the order may also be entered if
the court finds that the patient is mentally
ill and either that the mental illness causes
the patient to be dangerous to self or others
or property, or that the patient is in need
of intensive psychiatric therapy that can be
provided at a psychiatric hospital and that
cannot practically or feasibly be rendered in
the home or in the community or on an
outpatient basis.
The present appeal arose before the proposed rule could be considered by the Court. Accordingly, the Court declined to act on the proposals, deciding instead to determine the standards that must govern the involuntary commitment of minors through the adjudication of this case. We thus proceed to consider on the basis of the record and in the context of this case what
substantive standards are constitutionally required in order to
authorize the involuntary commitment of a minor.
We note further that at the time of her involuntary
commitment, N.N. was over the age of fourteen and was no longer
confined when this appeal was filed. Nevertheless, we conclude
that a decision by this Court is necessary though the case as it
applies to N.N. is moot. The issues posed by this case involve
significant matters of public policy, are extremely important,
and undoubtedly will recur in cases that are likely to be mooted
before adjudication. See, e.g., In re Farrell,
108 N.J. 335, 347
(1987); In re Conroy,
98 N.J. 321, 342 (1985).
There is general agreement that mental illness is a prerequisite for the involuntary commitment of minors. The necessity of a finding of mental illness as a condition for involuntary commitment is consistent with both the federal constitutional standard, Foucha v. Louisiana, 504 U.S. 71, 80, 112 S. Ct. 1780, 1786, 118 L. Ed.2d 437, 448 (1992); Vitek v. Jones, 445 U.S. 480, 492-93, 100 S. Ct. 1254, 1263, 63 L. Ed.2d 552, 564-65 (1980); Parham v. J.R., 442 U.S. 584, 609, 99 S. Ct. 2493, 2507, 61 L. Ed.2d 101, 123 (1979); O'Connor v. Donaldson, 422 U.S. 563, 573-76, 95 S. Ct. 2486, 2492-2494, 45 L. Ed.2d 396, 406-08 (1975), and with State constitutional principles. In re S.L., supra, 94 N.J. at 138; State v. Krol, 68 N.J. 236, 252-53 (1975).
We construe the current Rule to require mental illness as a
precondition for involuntary commitment. As suggested by the
Attorney General, the alternative standard contained in current
Rule 4:74-7(f) must be read in conjunction with Rule 4:74-7(k),
which provides that "a minor shall be institutionalized for the
treatment of mental illness only upon a court order entered in
accordance with the procedures prescribed by paragraphs b through
g . . . ." (Emphasis added). Additionally, the Department of
Human Services "Certificate for Involuntary Commitment of a
Minor" requires that the examining psychiatrist make such a
finding of mental illness.
Although not explicit or precise, the Rule clearly
contemplates that the purpose of the commitment standard is to
authorize involuntary hospitalization of the mentally ill, and,
by implication, such a consideration of mental illness must be
undertaken in proceedings affecting minors under the alternative
standard. Regardless of whether the requirement for such a
finding of mental illness is implied by reference to the adult
statute, or is presupposed by the official clinical forms
completed by the examining psychiatrist, which require such a
finding, we conclude that a requirement of mental illness is
indispensable as a prerequisite to the commitment determination
applicable to minors.
We note that the Public Advocate included in its proposals
for rule revisions a definition of "childhood mental illness"
that was essentially similar to the definition of mental illness
currently provided by Rule 4:74-7(a) for use in adult commitment
proceedings. The proposed definition provides a basic
explanation of the elements of "mental illness." However, it
further requires a comparison of the mental condition of the
minor facing commitment proceedings with the mental condition of
a child "at a similar developmental stage." See discussion supra
at __ (slip op. at 12-13) (quoting proposed definition of
"childhood mental illness").
We believe that a definition of mental illness with the
focus on such a comparison will be beneficial to children with
significant mental disorders and will aid in insuring that such
children will have the realistic opportunity to receive
treatment, while serving to prevent the inappropriate involuntary
placements of children whose mental condition is consistent with
that of other children at their level of development. Because
civil commitment implicates significant individual liberty
interests of minors, we conclude that the protections necessary
to adequately safeguard these interests reasonably require a
clear and convincing demonstration that the minor is suffering
from or afflicted with a mental illness, before commitment can be
authorized. The standard for the involuntary commitment of
minors must include a requirement of "childhood mental illness"
defined in comparative developmental terms.
The Public Defender argues that the present alternative
standard for the commitment of minors, which requires only a
finding that an individual "is in need of intensive psychiatric
therapy that cannot practically or feasibly be rendered in the
home or in the community or on an outpatient basis," is
impermissibly vague and insufficiently protective of the
important liberty interests of minors, and, therefore,
constitutes a violation of due process.
Constitutional analysis for determining the vagueness of statutory provisions is well-settled. Drawing from the authority of the United State Supreme Court in Grayned v. City of Rockford, 408 U.S. 104, 108-09, 92 S. Ct. 2294, 2298-99, 33 L. Ed.2d 222, 227-28 (1972)), this Court observed in State v. Cameron that "the requirement of statutory clarity is essentially a due process concept grounded in notions of fair play." 100 N.J. 586, 591 (1985) (citations omitted). The purpose of the constitutional ban on vague laws is "to invalidate regulatory enactments that fail to provide adequate notice of their scope and sufficient guidance for their application." Ibid. Those who are affected by the law -- those who are responsible for its administration and those who are subject to its imposition -- should not "necessarily guess at its meaning and differ as to its application." Coates v. Cincinnati, 402 U.S. 611, 614, 91 S. Ct. 1686, 1688, 29 L. Ed.2d 214, 217 (1971); In re Petition of Soto,
236 N.J. Super. 303, 327 (App. Div. 1989), certif. denied,
121 N.J. 608, cert. denied,
496 U.S. 937,
110 S. Ct. 3216,
110 L. Ed.2d 664 (1990). Further, "[t]he determination of vagueness must
be made against the contextual background of the particular law
and with a firm understanding of its purpose." Cameron, supra,
100 N.J. at 591.
There is no doubt that the constitutional liberty interests
that are implicated in the context of civil commitment
proceedings are sensitive and substantial. Parham v. J.R.,
supra, 442 U.S. at 601, 99 S. Ct. at 2504, 61 L. Ed.
2d at 118.
Involuntary commitment "effects a great restraint on individual
liberty" and therefore the State must comply with due process
when restraining the liberty of its citizens through involuntary
commitment. In re S.L., supra, 94 N.J. at 137 (citations
omitted). Consequently, in light of the significant
constitutional freedoms at stake in commitment proceedings, the
necessary-treatment standard for juvenile commitment must receive
careful scrutiny to determine whether it is clear and
understandable and provides adequate substantive protections.
The Public Defender contends that the alternative standard
itself is devoid of a common general meaning or understanding and
has no established scientific, professional or technical meaning
in either a legal or medical context. The phrase "in need of
intensive psychiatric therapy" is not defined in the Rule, nor in
any statute or case; it is not a phrase recognized in the
Diagnostic and Statistical Manual of Mental Disorders (4th ed.
1994), the standard source of classification and nomenclature for
the American Psychiatric Association. The Public Defender notes
that "intensive psychiatric therapy" "could mean anything from
the use of medication to occasional counseling or anything else a
particular physician might wish to recommend." She further
claims that the infirmities of the standard are not remedied by
the modifying phrase: "which cannot practically or feasibly be
rendered in the home or in the community or on an outpatient
basis." She argues that if "intensive psychiatric therapy"
cannot easily be defined, then it is impossible to determine
whether such services could be provided in the home or in the
community or on an outpatient basis.
The Attorney General argues that the phrase "in need of
intensive psychiatric therapy" essentially denotes inpatient
therapy, and relies on an analogy to "intensive care" as
informing that interpretation of the standard. See Modern
Dictionary for the Legal Profession 448 (1993). The Attorney
General, therefore, contends that the standard applies to
situations in which "moderate, occasional or intermittent
therapy" are not sufficient, thus indicating inpatient care.
The provisions of the alternative standard take on meaning
from its context. The standard is included within the Rules
dealing with "Civil Commitment," and is part of a section
entitled "Final Order of Commitment." R. 4:74-7; R. 4:74-7(f).
Other provisions of section (f) refer to commitment of adults to
"a short-term care or psychiatric facility or special psychiatric
hospital," indicating that, in general, commitment involves
confinement to such institutions. The inference to be drawn is
that "intensive psychiatric therapy" necessarily would entail
institutional treatment.
Moreover, the exclusionary language of the balance of the
Rule also implies that inpatient treatment would be reflected in
the "need of intensive psychiatric therapy." Under the standard,
commitment would not be justified for minors whose need of
treatment could be adequately provided on an outpatient basis.
Further, the Civil Practice Committee's proposed juvenile
commitment standard also associates the need for intensive
psychiatric therapy with the need for inpatient treatment at a
psychiatric hospital. The proposed alternative standard is
premised on a "need of intensive psychiatric treatment that can
be provided at a psychiatric hospital." The clear implication is
that such treatment would necessarily consist of inpatient care.
Certainly, that proposed revision clarifies the language of the
existing rule, and, as claimed by the Attorney General, supports
an implied congruence between the "need of intensive psychiatric
therapy that cannot practically or feasibly be rendered in the
home or in the community or on an outpatient basis" and a need
for inpatient treatment in a psychiatric institution.
We accordingly determine that the language of the
alternative standard denotes minimally that involuntary
commitment must be based on a showing of a need for inpatient
care, consisting of intensive psychiatric therapy that can be
provided only at a psychiatric hospital. That meaning, we
conclude, is sufficient to overcome the claim of constitutional
vagueness.
The determination that the current standard for juvenile involuntary commitment, based on necessary treatment, has a sufficiently understandable meaning to satisfy constitutional vagueness concerns advances the significant cognate issue: whether that standard satisfies constitutional due process. That issue may be posed in terms of whether the standard vindicates a compelling state interest sufficient to justify the loss of liberties entailed in the involuntary civil commitment of minors.
We note that other jurisdictions have invalidated commitment standards that are premised on a "need for treatment" basis because such a standard is too vague to ensure reasonable and sound applications and therefore insufficiently protective of liberty interests. E.g., Colyar v. Third Judicial District Court, 469 F. Supp. 424, 429 (D. Utah 1979); Stamus v. Leonhardt, 414 F. Supp. 439, 451 (S.D. Iowa 1976); Doremus v. Farrell, 407 F. Supp. 509, 514-15 (D. Neb. 1975). In Johnson v. Solomon, 484 F.Supp. 278 (D. Md. 1979), a juvenile commitment statute provided for commitment under either a dangerousness test or a need-for-treatment standard. The court found that the "'in need of care' standard was impermissibly vague because it lacked the degree of specificity mandated by due process considerations in light of
the serious nature of the child's loss of liberty." Id. at 284
(citations omitted).
"The authority of the State to civilly commit citizens is
said to be an exercise of its police power to protect the
citizenry and its parens patriae authority to act on behalf of
those unable to act in their own best interests." In re S.L.,
supra, 94 N.J. at 136 (citations omitted). However, "[t]he civil
commitment process must be narrowly circumscribed because of the
extraordinary degree of state control it exerts over a citizen's
autonomy." Id. at 139. Thus, the Court has recognized that
under the parens patriae authority, "[t]he State cannot
constitutionally commit individuals to mental hospitals solely on
the basis of mental illness." Id. at 137. The parens patriae
power to authorize involuntary commitment is generally restricted
to instances in which the individual poses a danger to self. See
Addington v. Texas,
441 U.S. 418, 426,
99 S. Ct. 1804, 1809,
60 L. Ed.2d 323, 331 (1983). We recognize that: "In order to
justify commitment in New Jersey the State must show that an
individual is likely to pose a danger to self or others or
property by reason of mental illness." In re S.L., supra, 94
N.J. at 138 (citing State v. Krol, supra, 68 N.J. at 257.
Moreover, the risk of dangerousness that will warrant involuntary
commitment must be relatively immediate: "Commitment requires
that there be a substantial risk of dangerous conduct within the
reasonably foreseeable future." State v. Krol, supra, 68 N.J. at
260; N.J.S.A. 30:4-27.2, see Doremus v. Farrell, supra, 407 F.
Supp. at 514 ("[i]n the mental health field, where diagnosis and
treatment are uncertain, the need for treatment without some
degree of imminent harm to the person or dangerousness to society
is not a compelling justification" for involuntary commitment).
Significantly, the Legislature in the enactment of the 1987
civil commitment statute confirmed the essentiality of a finding
of dangerousness as a necessary precondition to involuntary
commitment:
Because involuntary commitment entails
certain deprivations of liberty, it is
necessary that State law balance the basic
value of liberty with the need for safety and
treatment, a balance that is difficult to
effect because of the limited ability to
predict behavior; and, therefore, it is
necessary that State law provide clear
standards and procedural safeguards that
ensure that only those persons who are
dangerous to themselves, to others or to
property, are involuntarily committed.
Furthermore, it is the policy of this state
that the public mental health system shall be
developed in a manner which protects the
individual liberty and provides advocacy and
due process for persons receiving treatment
and insures that treatment is provided in a
manner consistent with a person's clinical
condition.
The State assuredly has a deep and abiding interest in insuring the mental health and well-being of its children. That interest clearly authorizes the State to provide treatment and care for children who suffer from mental illness, and who may benefit from such care. However, that interest, while
significant, is not sufficiently compelling to justify the
curtailment of a child's liberty interests by involuntary
commitment to a psychiatric hospital. Johnson v. Solomon, supra,
484 F. Supp. at 287 (noting that, "in the specific context of
involuntary commitment to a mental hospital where the deprivation
of liberty is very great, and the possibility of stigmatization
is very real, the mere possibility of benefit is not enough to
justify such official paternalism"); Colyar, supra, 469 F. Supp.
at 429; cf. Lois A. Weithorn, Mental Hospitalization of
Troublesome Youth: An Analysis of Skyrocketing Admission Rates,
40 Stan. L. Rev. 773, 797 (1988) (noting inappropriate
hospitalization can have serious adverse psychological
consequences that must be considered when weighing compelling
interests at stake in authorizing involuntary commitment).
There has been some recognition that in the case of minors a
need-for-treatment standard does not express a State interest
sufficiently compelling to warrant a child's loss of liberty
through involuntary civil commitment. See Johnson v. Solomon,
supra, 484 F. Supp. at 284 (ruling that need-of-care standard did
not satisfy due process "in light of the serious nature of the
child's loss of liberty," citing Colyar, supra, 469 F. Supp. at
429 (ruling in adult commitment case that only compelling State
interest sufficient to offset loss of individual liberties at
stake in commitment process would be State's interest in
protecting citizens who posed danger to themselves)). We,
therefore, determine that a standard based only on the "need of
intensive [institutional] psychiatric therapy" as the condition
for the involuntary commitment of a minor does not vindicate a
compelling state interest, and is insufficient to protect the
individual liberty interests of such a minor. We hold that the
involuntary commitment of a minor who is mentally ill and found
to be in need of intensive institutional psychiatric therapy may
not be undertaken without a finding based on clear and convincing
evidence that the minor without such care is a danger to others
or self.
The statute recognizes and requires dangerousness as a basis
for involuntary commitment. N.J.S.A. 30:4-27.1b; -27.2m.
However, that statute is applicable only to adults. Supra at __
(slip op. at 9-10). The current rule's alternative standard
pertaining to minors omits any requirement of dangerousness. The
proposed rule likewise fails to require dangerousness as a
condition for the involuntary commitment of minors.
We must acknowledge the cogent criticisms of the adult
"dangerousness" standard in the context of minors in need of
commitment. The dangerousness standard, as traditionally
understood and applied to adults, may be regarded as
inappropriate and insufficient when sought to be applied to
minors. That standard is typically formulated in terms of the
potential for suicide or infliction of physical injury to
oneself. Cf. Louisiana Childrens' Code, La. Ch.C., art. 1404
(West, 1991) (defining dangerousness to self to include the risk
that a person "will inflict physical or severe emotional harm
upon his own person"); La. Rev. Stat. Ann. § 28:2(4) (same). The
standard also encompasses the inability to provide for oneself
the basic necessities of life, such as food, clothing or shelter.
N.J.S.A. 30:4-27h. See Colyar, supra, 469 F. Supp. at 430-31;
Stamus v. Leonhardt, supra, 414 F.Supp. at 451; Doremus v.
Farrell, supra, 407 F. Supp. at 514-15; In Re Roger S.,
569 P.2d 1286 (Cal. 1977) (describing dangerousness to self based on
inability to secure basic necessities as the "gravely disabled"
standard).
The traditional concept of dangerousness that extends to one
who is "gravely disabled" is appropriate in the case of adults,
whose rights and presumed capacity to refuse treatment for mental
illness necessarily requires a strict and limited standard before
the refusal of treatment may be overridden by the police or
parens patriae power of the State. "[A] State cannot
constitutionally confine without more a nondangerous individual
who is capable of surviving safely in freedom by himself or with
the help of willing and responsible family members or friends."
O'Connor v. Donaldson, supra, 422 U.S. at 576, 95 S. Ct. at 2494,
45 L. Ed.
2d at 407. Nevertheless, the application of such a
concept of "dangerousness" in the context of juvenile commitments
may be inappropriate. Cf. In re S.C.,
421 A.2d 853, 856-57 (Pa.
Super. Ct. 1980) (applying adult standard of dangerousness to
minor aged 16). Most children are ordinarily dependent on others
for life's necessities. They do not have the opportunity to
demonstrate that they are "capable of surviving safely in
freedom." Thus, the "gravely disabled" sense of dangerousness is
ill-suited to identify minors who have seriously harmful
conditions. Cf. In re Roger S., supra, 569 P.
2d at 1293 n.7
(applying statutory definition that "a person of any age may be
`gravely disabled.'") Because it is to be strictly and narrowly
applied, such a dangerousness standard could exclude mentally ill
children whose condition places them in significant physical or
mental peril and who should be treated even on an involuntary
basis.
The alternative standard for minors under the proposed rule,
as noted, diverges from the adult standard of dangerousness by
requiring "dangerousness" only as an alternative to the
necessary-treatment basis for juvenile commitment. That
difference in approach by the Civil Practice Committee responds
to the criticisms of the adult dangerousness standard as applied
to minors, and acknowledges the uncertainty and difficulty in
applying the concept of dangerousness to children. See Pressler,
Current N.J. Court Rules, comment 1, on R. 4:74-7(b)(1995). The
Committee's position also reflects the desire not to foreclose
needed and appropriate treatment for those children, not
dangerous by adult measures, who seriously require intensive
psychiatric therapy. See id.
The calculus of the commitment decision changes in the case
of minors. Their well-being has always been a concern of the
State. E.g. Hoefers v. Jones,
288 N.J. Super. 590, 607 (Ch. Div.
1994) ("As it relates specifically to children's issues and the
rights of children, parens patriae is the philosophical source of
state law, of public policy governing their general welfare, best
interests, right of protection, right to be free from harm and
abuse."), aff'd
288 N.J. Super. 478 (App. Div. 1996). "The State
as parens patriae may act to protect minor children from serious
physical or emotional harm." In re Dept. of Pub. Welfare,
421 N.E.2d 28, 36 (Mass. 1981).
We have long recognized in a variety of settings that the
State has an interest in providing adequate treatment of
juveniles when that treatment is medically necessary to correct
and remedy demonstrated emotional, psychological or behavioral
problems of a severity that could endanger future personality
development. New Jersey Div. of Youth and Family Services v.
A.W.,
103 N.J. 591, 603-605 (1988) (explaining in context of
termination of parental rights the significance of "serious
impairment of the child's health or development"); Sorentino v.
Family and Children's Society of Elizabeth,
72 N.J. 127, 132
(1976) (stating in context of custody dispute, "[t]he possibility
of serious psychological harm to the child in [such] case[s]
transcends all other considerations"); Katterman v. DiPiazza,
151 N.J. Super. 209, 214 n.1 (App. Div. 1977) ("We recognize that the
responsibility of the court as parens patriae of all minor
children transcends all other considerations when there exits a
potential for serious psychological harm to a child.") The
prospect that "[t]he child's health and development either have
been or will be seriously impaired" will justify the exercise of
the State's parens patriae authority. In re Guardianship of
A.A.M.,
268 N.J. Super 533, 543 (App. Div. 1993) (construing
statute governing termination of parental rights).
The liberty interests of children have traditionally been
more circumscribed and subject to greater state control than
those of adults: "The liberty interest of a minor is
qualitatively different than that of an adult, being subject
. . . to reasonable regulation by the state to an extent not
permissible with adults." In Re Roger S., supra, 569 P.
2d at
1294 (Cal. 1977) (citing Planned Parenthood of Cent. Mo. v.
Danforth,
428 U.S. 52, 72,
96 S. Ct. 2831, 2843,
49 L. Ed.2d 788, 806 (1976)); Ginsberg v. New York,
390 U.S. 629, 638,
88 S.
Ct. 1274, 1280,
20 L. Ed.2d 195, 203 (1968); Prince v.
Massachusetts,
321 U.S. 158, 170,
64 S. Ct. 438, 443,
88 L. Ed. 645 (1944). The criteria for the commitment of minors based on
dangerousness must therefore reflect their heightened needs and
vulnerability and the State's concomitant greater responsibility
to assure their health and well-being.
We have now recognized and determined that, in the context
of involuntary commitments, the concept of "mental illness" that
constitutes a condition for the involuntary commitment of a minor
must be adapted and related to juveniles as a class, and must
take into account the characteristics and needs that are unique
to the young, immature, and developing person. Mental illness in
a child must be correlated and evaluated in terms of a comparison
with similar children, see discussion, supra, at __ (slip op. at
15-17). Likewise, the use of "dangerousness" to describe and
identify an aspect of the child's mental condition must also take
into account the distinctive nature of children. "Because
children are still developing, the physical and emotional aspects
are more closely intertwined than they are for an adult."
American Academy of Child and Adolescent Psychiatry, Child and
Adolescent Psychiatric Illness: Guidelines for Treatment
Resources, Quality Assurance, Peer Review and Reimbursement 74
(1987) (hereinafter "Guidelines for Treatment").
A dangerousness standard that applies to minors must be
derived from and related to childhood mental illness. Childhood
dangerousness must reflect the understanding that there are
children with mental illnesses "whose unfolding development can
be interfered with irreversibly by a lack of corrective
treatment." Elyce H. Zenoff & Alan B. Zients, M.D., "If Civil
Commitment is the Answer For Children, What Are the Questions?,"
51 Geo. Wash. L. Rev. 171, 205 (1983). "When a child's more
severe psychiatric problems go untreated, that child has a
greater potential not only to be chronically psychiatrically ill,
but to develop costly physical problems and to experience
thwarted productivity." Guidelines for Treatment, supra, at 74.
"The child who is unable to learn, to develop affectional
relationships, or to engage in other age-appropriate activities
is not simply missing particular experiences at a point in time:
without prompt assistance, a seriously disturbed child cannot
ripen into an autonomously functioning adult." Zenoff & Zients,
supra, at 205.
Childhood dangerousness may consist of the lasting effects
that can ensue from unattended mental illness.
Psychiatric illness in a child causes
suffering in the form of symptoms such as
school failure, anxiety and suicidal
behavior. There is also another critical
change, namely, a disruption in the child's
emotional development so that he or she
functions emotionally, socially or in school
at a level well below that appropriate for
his or her age. Untreated children who lag
developmentally because of a psychiatric
illness often later need more intensive
treatment, including hospitalization,
prolonged outpatient treatment, and partial
hospitalization. The overall outcome of
treatment may be less favorable, and they may
never complete important developmental tasks
such as graduating from high school,
permanent employment and independence from
parents.
[Guidelines for Treatment, supra,
at 75.]
We determine that the standard of "dangerousness to self"
applicable to a child suffering from mental illness as a basis
for involuntary commitment must encompass the substantial
likelihood that the failure to provide immediate, intensive,
institutional, psychiatric therapy will create in the reasonably
foreseeable future a genuine risk of irreversible or significant
harm to the child arising from the interference with or arrest of
the child's growth and development and, ultimately, the child's
capacity to adapt and socialize as an adult.
We address briefly in conclusion another important component
of the standard governing the involuntary commitment of minors.
We acknowledge that at a certain age, a juvenile will have acquired the rights of autonomy and self interest of an adult, and therefore be entitled to the protections of constitutional due process that apply to adults. It is, of course, difficult to mark that moment. See Zenoff & Zients, supra, at 207. The Civil Practice Committee, as noted, proposed a standard that differentiates between minors under and at the age of fourteen. Supra at __ (slip op. at 13-14). In the absence of a fuller record and more extended arguments directed to the status of minors as they approach the age of majority, the differentiation of minors at age fourteen, as proposed by the Civil Practice Committee, may be followed. The position reflected in the proposed rule is sensitive to the concerns for the rights of adolescents and reflects a reasoned assessment of the difficult considerations of public policy. That age-differentiated standard is based on an understanding that children possess certain constitutionally protected liberties, and that the weight and significance of those liberties increase with the age of the child. Though "there is some degree of arbitrariness" in determining at what age a child should be subject to adult hospitalization procedures, Zenoff & Zients, supra, at 207, a differentiation in the juvenile commitment scheme at age fourteen is consistent with other principles of New Jersey law, which afford fourteen-year-olds the right to consent to psychiatric treatment, R. 4:74-7(k), and allow juvenile offenders to be tried as adults, N.J.S.A. 2A:4A-27. We infer, without deciding, that
in the absence of a contrary showing, such a differentiated
standard meets the constitutional due process requirements
applicable to such minors.
We now hold that a standard that would authorize the involuntary commitment of a minor under fourteen years of age must first require a showing that the minor is mentally ill, as defined in terms of childhood mental illness. Secondly, it must be demonstrated that the child is in need of intensive, institutional psychiatric treatment that cannot be provided in the home, the community or on an outpatient basis. Thirdly, the minor's condition due to her me