Beyond Shared Decision-Making in Youth Psychiatry: a Dynamic Continuum of Decision-Making Practices.

While shared decision-making (SDM) is widely recognized as a reference model in adult psychiatry, its implementation in youth psychiatry remains under-explored, despite the specific challenges inherent to this field. This exploratory qualitative study investigates how child and adolescent psychiatrists describe and adjust their decision-making practices in clinical care, including their attitudes, strategies, and perceived limits of SDM. Sixteen semi-structured interviews were conducted with youth psychiatrists via videoconferencing. Data were analyzed using thematic analysis. Five overarching themes were developed : (1) the perceived benefits of SDM, such as improved adherence and engagement; (2) a dynamic continuum of decision-making practices, from full collaboration to ethically guided protective decisions; (3) the role of parents as co-participants in the decision-making process; (4) the modulation of the clinician-patient relationship along a vertical-horizontal axis; and (5) contextual influences, including institutional constraints and limited resources. Psychiatrists generally support SDM as a desirable framework. However, their accounts point to a broader and more flexible continuum of practices, in which the degree of sharedness varies depending on factors such as the young person's age, developmental stage, illness severity, crisis situations, and parental involvement. Some practices described by clinicians fall outside strict definitions of SDM and belong instead to the domain of substituted or protective decision-making. These findings invite a nuanced and context-sensitive understanding of decision-making in youth psychiatry.