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Psychiatric Ethics (5 edn)
Sidney Bloch (ed.), Stephen A. Green (ed.)
https://doi.org/10.1093/med/9780198839262.001.0001
Published: 2021 Online ISBN: 9780191877131 Print ISBN: 9780198839262
CHAPTER
https://doi.org/10.1093/med/9780198839262.003.0020 Pages 469–498
Published: January 2021
Abstract
Keywords: child and adolescent psychiatry, ethics, assent agency, assessment, treatments, research,
transitional age, youth, social media, marijuana, LGBTQ, minorities, global conflict
Subject: Medical Ethics, Psychiatry
Collection: Oxford Medicine Online
20 Child and adolescent psychiatry
Adrian Sondheimer,Niranjan Karnik,Peter Jensen
Ethical dilemmas unique to child and adolescent psychiatry are consequences of the child
psychiatrist’s duty to serve as advocate for child patients while simultaneously having professional
responsibilities to the parents and guardians of the children, as well as to child-related institutions
inclusive of schools, juvenile justice systems, and childcare agencies. In addition, awareness of
developmental dierences is paramount, as continuous maturation occurs from ages zero through
eighteen years and beyond. With this in mind, the chapter rst reviews ethical principles and
reasoning and the inuence of context on such ever-present matters as assent/consent/dissent,
agency, assessment, treatments, and condentiality, and then hones in on current and future
dilemmas posed by the needs of transitional age youth and the impacts of social media, marijuana
decriminalization, alternative sexual and gender expressions, minority vulnerabilities, and casualties
of global conicts. A separate section focuses on ethical considerations relevant to research performed
with child subjects.
Since children are the embodiment of the future, all societies are concerned with their growth. For centuries
children were considered as objects, wares, or animals, owned by the adult male of the family. However, a
quid pro quo prevailed. In return for the fruits of their labour, the father was obliged to provide food and
shelter. The child’s working life, at times as an apprentice, began at about age six. Childhood as a separate
stage in human development ostensibly did not emerge until the seventeenth century, arguably
accompanied by unremitting hostility towards the youngsters (1, 2, 3). Since the nineteenth century, adult
focus on child upbringing has grown enormously.
Cognitive, physical, and emotional immaturities of children were acknowledged, resulting in societies’
legislations to safeguard their welfare. Laws were passed in Western countries establishing juvenile courts
and national bureaus created to oversee children’s welfare (4). In England, the Guardianship of Infants Act
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was passed in 1925 (5). Given the enormous number of cases of abuse and neglect of children brought to the
attention of administrative authorities in modern times, it is startling to consider that such behaviour was
not legally recognized in the United States until the 1970s. Laws extending protections to children as a
group became universal in 1989, reected in the United Nations Convention on the Rights of the Child (6).
Thus, in the late twentieth century, governments worldwide assumed responsibility for children’s care and
welfare.
These enacted laws and declarations were paralleled by developments in medical practice. The end of the
nineteenth century saw the emergence of paediatrics as a speciality. American psychiatrists organized
themselves as a professional association in 1921 (7) and devised criteria for training a decade later. Thirty
years later psychiatrists whose work centred on children contributed to the formation of national bodies
that assumed responsibility for training and certication of child psychiatrists. Given the developmental
immaturity of children and their need for specialized interventions, it is ethically sound that they receive
their care from professionals with pertinent training. Child and adolescent psychiatrists (we will refer from
now on to ‘child psychiatrists’ for convenience) are exposed in particular to child-related ethical
dilemmas and become well-suited to deal with them (8).
p. 470
Professional responsibility and children
Clinicians who work with youngsters invariably like children. That is all to the good since it promotes an
agreeable atmosphere and a positive patient–clinician relationship; they are similarly likely to empathize
with the concerns of the parents. On the other hand, the child psychiatrist faces certain risks. The
behaviours of both children and parents can be seductive or alienating. The neglected or abused child may
arouse rescue fantasies in the therapist. A mother at her wit’s end, consequent to caring for a child with
profound decits, may direct her anger at the clinician. The seductive adolescent or parent may stimulate
sexual fantasies in the practitioner. By contrast, angry and occasionally vicious youth may engender fear
and retributive fantasies
In all these circumstances, the child psychiatrist’s duty is to behave professionally, regarding the patient’s
best interests as paramount. This responsibility encompasses the competent application of specialized
knowledge and skills, as well as exercising honesty, integrity, accountability, and propriety, acknowledging
a duty extending beyond the self, while providing rationales underlying clinical decisions and treatment
recommendations (9). Patients and their families need to be assured of the delity of their clinician, feel
secure that treatment will not be jeopardized in the event of adverse circumstances or at her whim, they will
not be exploited, and professional boundaries will be maintained (10).
Exploitation can take many forms, both obvious and subtle. Obviously, children are not to be used for sexual
gratication or dealt with punitively. Subtle manifestations include prolonging inpatient stays to ‘keep the
census up’, enticing patients into research, extending treatment of ‘fascinating’ patients, and according
‘special’ status to wealthy families who may be coaxed into donating to research funds (11). Since ethical
dilemmas are grey, self-monitoring is crucial. When in doubt, consultation with peers is the best course of
action.
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Ethical principles and children
Children and ethics
In considering ethics as it applies to children in the psychiatric context, one way is to emphasize their
dierences from adults. Children make signicant developmental leaps in physical, cognitive, language,
and interpersonal domains in a shorter period than at any other life stage. Thus, 2, 5, 10, 13, 17, and, for
that matter, 21 year olds will be noticeably dierent from one another across all of these domains and,
therefore, need dierent approaches to care. However, all children share one element in common—they do
not have the wherewithal, at least legally, to function in society as adults. Therefore, adults, usually their
parents or other designated guardians, are responsible for their basic needs: food, shelter, education, and
nurturance to facilitate growth and socialization.
p. 471
Research in the neurosciences since the 1990s continues apace, showing that brain development continues
to the mid-20s (12). Individuals arriving at the arbitrary cut-o point of 18 years old, at which adolescence
is deemed to end in resource-rich countries, have achieved semiautonomous status. Many adult
developmental tasks remain to be addressed, however, and most youths in this cohort remain beholden to
their parents’ direction and support. Students pursuing higher education are not only developing their
vocational identities but also taking rst steps at dealing with peers of various ethnicities and a range of
political, religious, and sexual attitudes (13). Relatedly, youths cared for by public agencies often have their
care extended to at least age 21years as societies gain awareness that the cohort ‘ageing out’ at 18 years is
not yet developmentally capable of taking on adult responsibilities and self-advocacy (14). Thus, it is
ethically indicated that the child psychiatrist’s purview should encompass ‘transitional-age youth’ (TAY)
(15).
While a range of approaches to moral reasoning compete for our attention (16) (see Chapters 1 and 3),
several ethical principles are judged as fundamental and universally applicable (17). When ethical dilemmas
arise, principles may conict with each other and be used in contradictory ways. Given that children are
continuously maturing but require adult care and oversight, challenging situations involving conicting
principles are inevitable. Some dilemmas can be outlined simply. For example, to what degree should
autonomy be granted to a child in regard to making medical decisions? To whom should the psychiatrist
extend delity, child or parents? Should limited health care resources be justly allocated to the individual
child or to society’s needs?
Considering the relevance of ethical principles to a particular case or situation, the child psychiatrist must
determine the most benecial approach for the patient and avoid causing him harm. However, despite
applying these principles that are theoretically universal, a particular context often inuences the
professional’s thinking. Thus, child psychiatrists practicing in dierent cultures may face dissimilar
expectations regarding patterns of behaviour in children. For example, the child expressing anger towards
his parents will receive plaudits from the psychiatrist for being ‘open’ with his feelings in one culture, in
contrast to another culture whose values favour personal restraint and obedience to one’s elders. For
another, the economic structures of countries’ health care systems unconsciously inuence medical
decision-making. Limited versus open-ended allotment of funded visits will be available in dierent
communities for treatment of impulsive behaviours associated with attention decit hyperactivity disorder
(ADHD). Child psychiatrists in one locale may assume an autistic child will receive education in mainstream
settings while provided accessory aids, occupational therapies and focused behavioural treatments;
colleagues’ choices elsewhere will be limited to permanent institutional placement. Unmistakably,
benecence in clinical practice is limited by context.
p. 472
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Concerns about the care of children
Societal norms, corresponding approaches to treatment, and assumptions on which they are based change
over time. In Westernized countries, for example, psychoanalytic thought dominated child psychiatric
practice during the mid-twentieth century but was supplanted by emphasis on use of psychotropic
medications, an approach that has grown progressively since. Similarly, the use of inpatient treatment
predominated in the 1980s until funding revisions led to a reduction of available beds. During the past three
decades, reduction in health insurance expenditures for child psychiatrists’ provision of psychotherapy is
yet another development. Enduring ethical principles operate in all the above examples, and the subtle but
powerful inuences of context aect their application by the clinician, knowingly or not.
Several tenets apply to the provision of proper medical care. Firstly, it is incumbent to perform a
comprehensive patient evaluation prior to recommending treatment (18). This is particularly important
with children as the child psychiatrist must meet with parents or guardians to obtain clinical information
not retrievable from, or withheld by, the child. This material includes genetic, temperamental,
developmental, intrafamilial, educational, social, and cultural factors related to past and current history.
Secondly, the clinician must attend to the child’s immediate needs and his longer-term interests when
treatment is recommended. Indeed, the nature of the interactions (pleasant or disagreeable), written
reports (which have lives of their own and can aect professional decisions years later), and treatment
recommendations and how they will be implemented will all probably have long-lasting inuence.
Consequently, and notably, treatment requires the child’s guardian’s consent.
p. 473
The child psychiatrist striving to provide quality care is behaving ethically. In most circumstances the
practitioner does not question her clinical inclinations because ‘doing the right thing’ is self-evident. The
third tenet is that each child must be considered on his individual merits. For example—James, a sad,
socially withdrawn seven-year-old boy, suered the traumatic loss of a beloved grandparent several
months earlier. The child psychiatrist advised both individual and family psychotherapies in parallel. James
eagerly attended the weekly sessions. His mood improved substantially. Several ethical principles were
operating in this scenario. James assented to therapy (his autonomy was respected), he welcomed his
parents’ participation, and obtained care that others with identical needs should have also been oered
(justice). Given the positive outcome, his treatment satised criteria of benecence (doing one’s best by the
patient) and nonmalecence (rst of all, do no harm).
By contrast, the child psychiatrist will encounter more complex situations, engendering uncertainty.
Alteration of some above features, highlighting the patient’s age and attitude, illustrate this complexity:
Peter, a 16 year old, suered the loss of his girlfriend when she abruptly broke their relationship.
Traumatized, he became dispirited, angry, and abandoned his studies. Three weeks later he got drunk, drove
while intoxicated, and crashed the family car. Evaluated by a child psychiatrist, individual and family
psychotherapies were recommended. Peter dissented. Threatened by his parents, he reluctantly attended
weekly sessions, remaining silent during the rst six sessions, and he participated slightly more in the next
pair. How and when should Peter’s autonomy be respected? Are the treatments showing benets or causing
harm? The answers seem unclear. Both examples involve male youngsters, depressed mood, disordered
behaviours, and treatment attendance. In Peter’s case, however, his behaviour during treatment raised
ethical quandaries—quite typical of practice with teenagers.
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Ethical reasoning and clinical application
Facing an ethical dilemma prompts the clinician to engage in ethical reasoning (19). This process implies an
objective risk-benet analysis, using supporting or conicting ethical principles. Moreover, the therapist
may well question himself about how his childhood, including conicts with his parents and adolescent
romantic entanglements, and previous experiences with similar teenagers, might inuence his judgment
and therapeutic choices.
p. 474
Children may provoke powerful responses in their psychiatrists (20). Older therapists, for example, may
react to them as they do, or did, with their own ospring and nd themselves allying with the parents.
Younger colleagues more commonly identify with the plights and outlooks of the child. Bringing such
powerful and distorting inuences into consciousness permits an objective assessment of the child’s
interests and leads to sound ethical decisions.
Incontrovertibly, the clinician’s rst duty is to consider the child’s safety. If she is in peril, whether due to
externally or internally derived aggression, the psychiatrist is required to shed concerns about
condentiality and plan protective interventions. Consider the following examples: a distraught adolescent
may attempt suicide by swallowing potentially lethal pills and proclaiming her wish to die, but object to
hospitalization. A scrawny, virtually mute, ve year old, with cigarette burns on his arms, obviously abused
and neglected by his drug-addicted parents, notwithstanding wants to continue to live with them. An
explicit protective response outweighs respect for the child’s autonomous wishes. Informing a child
protection agency and thus breaching condentiality is clearly required.
Determining potential benets and risks, and approaches to duty to intervene are, commonly, most
challenging. Three illustrations: a parent receives psychiatric care but is subject to intermittent brief
psychotic episodes at which times her eight-year-old daughter necessarily becomes the primary caretaker
while also fending for herself; a child who announces his intentions to engage in non-life-threatening but
distinctly risky behaviours, (e.g., hacking into computers, engaging in drug experimentation, or driving
without a licence); or a child in foster care whose adoption by a loving foster parent is stymied by laws
mandating placement with distant but biologically related family. In the rst example, the child might be
better o receiving care elsewhere, but doing so would disrupt a mutually loving mother–daughter
relationship. In the second, a heavy-handed response to a child’s verbal threat is overkill, while a ‘hands-
o’ response could backre should the child follow through with his announced intent. In the last case,
questionable competences of the social services agencies or foster care adequacy raises concerns about
intervention; moreover, how does the practitioner handle his responsibility for proper patient care when
morally objecting to irrational legal requirements?
All potential solutions to ethical dilemmas inherently harbour problems, and the above scenarios require
the child psychiatrist to weigh duties to perform ‘good acts’ while avoiding causation of harm; one duty
does not outweigh the other. Rather, he has to reect deeply, consulting with colleagues where necessary, to
respond in the most benecial way.
p. 475
Assent and consent
Many more children receive treatment as outpatients than as inpatients. Hospitalized youngsters usually
represent dangers to themselves or others or are cognitively severely compromised. Mental health law
permits their involuntary admission to protect the child’s welfare (21). Legal protections ensure necessary
care and resumption of respect for autonomy as clinical improvement permits.
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Most treatment is not carried out in such dire circumstances. More commonly, a parent requests a
nonemergency appointment for her child experiencing an emotional or behavioural diculty. The question
of consent immediately presents. Did the mother tell the child of her intent to seek treatment for him? If
not, why not? If so, how did the child respond? If the child welcomes the initiative, parent and child are in
agreement, and the child is considered to ‘assent’. If the child disagrees or opposes, the child ‘dissents’.
When should the child’s autonomy be respected or overridden? How should the parent and the clinician
proceed in these circumstances (22)? These considerations hold equally for children who request parental
aid in seeking professional help for them and oppositional youngsters who a priori dissent from parental
views.
Two factors stand out as paramount—cognitive capacity (often a function of age) and the desirability of the
youngster’s collaboration with his clinician (23). Commonly, the legal concept of childhood spans the
chronological range from birth until age 18 years. Ordinarily, continuous development occurs in cognitive,
emotional, interpersonal, motor, and language spheres. The average 3, 10, and 17 year olds clearly dier
with respect to understanding and reasoning capacities. While all children warrant optimal regard and care,
their dissent from that care should be respected to varying degrees. Thus, the objections of a three year old,
squalling in the face of a recommended vaccination, are usually overridden, whereas an adolescent’s
objection to psychiatric care, despite his parent’s demand that he agree to it, is often heeded. The three year
old possesses insucient mental capacity and thus lacks competence to understand the eects of her
attitude and proposed treatment context. By contrast, the adolescent’s developing ability to consider risks
and benets leads to respect for her decisions, including those that counter medical and/or parental
advice.
p. 476
A child’s assent to treatment is desirable as he senses that participation is his choice. It produces greater
cooperation with professional recommendations; facilitates improved communication between child
psychiatrist, child, and the family (24); and promotes mutual respect between clinician and child. The
dissenting child, however, can be treated. Consideration of patients’ or other directly aected peoples’
safety overrides autonomous dissent. In less fraught situations, indirect child treatment is provided via
parental counselling. Not infrequently, an initially refusing child later cooperates.
Consent is both an ethical and legal matter. Commonly the age of consent, ‘of majority’, is 18 years. With
exceptions for severely cognitively compromised adolescents, the 18 year old is legally competent and
capable of appreciating the nature and eects of her acts, thus attaining adult comprehension abilities.
Some younger children can similarly reason. Societies, however, draw arbitrary chronological boundaries to
protect their children who, as a group, tend to immature reasoning. These societal decisions prevent the
underaged child from engaging in consent in a legal sense but respect the child’s autonomy by enabling
assent. These issues of children’s assent, dissent and consent are addressed internationally and enjoy
universal agreement (6), though the degree to which these rights are observed is situationally and culturally
dependent.
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Agency
To whom does the child psychiatrist owe ‘good enough care’? Is he an agent (25) for the child patient,
parent/guardian, whole family, referring agency, child’s school, employing institution, private insurance
company, or national health service? He has obligations to them all. Can he disregard any? Are there
conicts of interests? A brief example: Julie, a 16-year-old girl, diagnosed with major depressive disorder, is
hospitalized following self-injury, a nonlethal wrist cut. Having lived sequentially with her long-separated
parents, she was expelled from her mother’s home following an unintended pregnancy and termination.
The wrist cut followed her father’s physical assault on her, designed to prevent his daughter from living
with her 20-year-old ne’er-do-well boyfriend. State child protective services investigated the case during
the hospital admission but found ‘no cause for intervention’. Both parents set ‘impossible’ conditions on
Julie for return to their homes. Meanwhile, her mood improved such that inpatient treatment was no
longer necessary. Hospital administration, therefore, pressed the child psychiatrist to discharge Julie,
despite unresolved domicile issues and needs for follow-up care.
p. 477
Julie’s saga depicts various pressures, individual and institutional, with their conicting agendas. Acceding
to the demands of one automatically ignores or alienates the others. Multiple agency is thus a no-win
situation for both child psychiatrist and patient. Ultimately, the professional’s primary overriding
responsibility is to determine the child’s needs and pursue appropriate interventions. Other considerations,
for example, his wish to respect the opinions of others, avoid alienating his employer, or follow personal
biases, should be set aside to pursue the least harmful care. Thus, the child psychiatrist exhibits delity and
support and advocates for the vulnerable child.
The child psychiatrist may also foster communication among relevant protagonists, busy pursuing their
agendas at the expense of collaborating in the patient’s best interests. An exchange of opinions between
agencies, each culturally dierent from the other, is an aspect of clinician advocacy. Youth detention
facilities emphasize strict adherence to rules; psychiatric wards promote psychological awareness; juvenile
justice and family court systems are overwhelmed by caseloads; social service agencies must determine
parental rights—all are institutions devoted to childcare, but their specic foci, goals, and responsibilities
may dier and clash.
Assessment and diagnosis
In the 1960s and 1970s, some professionals opposed diagnosing mental illness disorders. They argued that
little was known about aetiological factors and that diagnoses, applied to people, raised the burden of
stigma. Much has changed in the interim. Molecular biology developed knowledge of the human genome
and points to gene sites putatively associated with psychiatric disorders. Such knowledge, however, is not,
as yet, denitive. Similarly, correlations between societal and familial variables and psychiatric disorders
have been more rmly established, but one-to-one correlations hardly exist. With the third edition of the
American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-III) in 1980 and renements
since, diagnosis moved from aetiology-driven (psychoanalytic notions) to objectively observable
phenomena. Independent observers could thereby achieve greater inter-rater reliability, though
accompanied by scepticism concerning the validity of the criteria (26). Data pooled from dierent patient
populations, based on diagnoses shared in common, could then lend themselves to the development of
improved treatments.
p. 478
The rst section of DSM-IV (1994) devoted itself to child and adolescent diagnoses manifesting before age
18 years. Thus, learning, communication, pervasive developmental, externalizing, attention decit, eating,
tic, and elimination disorders, as well as mental retardation, appeared here. Similarly, DSM-V (2013)
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maintained the majority of these categories in a rst section entitled ‘Neurodevelopmental Disorders’.
While experts might argue against classifying certain of these disorders as psychiatric (e.g., mental
retardation and tic disorders could be conceptualized as neurologically based), all of these disorders
describe in common psychological distress accompanied by behavioural manifestations with brain-based
origins. Thus, childhood diagnoses since DSM-III have progressively honed criteria, enhancing more
specic treatments.
Regarding labelling—while informed societies become less stigmatizing of mental disturbance, prejudice
against children labelled with psychiatric disorders continues. Diagnoses may remain xed indenitely;
prognoses therefore are assumed to be foretold, with original diagnoses often not subsequently revisited
and, in some jurisdictions, resulting in refusals of private health insurance coverage for ‘pre-existing
illnesses’. These consequences are legitimate concerns, and simultaneously telling examples of shoddy
clinical and administrative practice. Such negative impacts of stigma should not be confused with decient
professional behaviour. The latter is under the professional’s control, while the professional often has little
inuence over others’ promotion of stigma (27).
Accurate diagnosis is an essential component in the provision of sound medical care. Avoidance of this step
is inimical to children’s short- and long-term interests as they would miss out on diagnostic precision and
corresponding evidence-based interventions. Stigma associated with diagnostic labels is best approached
through gentle education of uninformed and fearful people. When diagnoses are communicated to families
and children, geared to their levels of cognitive maturity and using language shorn of jargon, full
explanation is required in order that the information be used in the child’s best interests.
Additional ethical concerns about diagnosis prevail. Diering rates of diagnoses of specic disorders exist in
dierent communities (e.g., a signicant increase in incidence and prevalence rates in the United States and
other countries of autism and bipolar disorder of childhood has been documented). What distinguishes the
concepts of ‘disorder’ and ‘illness’? Do such constructs as ‘oppositional deant’, criticized by some as a
function of the ‘eye of the beholder’, have diagnostic validity (28)? A similar question surrounds the
diagnostic features and vague prevalence gures of the newly created diagnosis of ‘disruptive mood
dysregulation disorder’ (29). And multiple questions have been raised concerning the diagnostic process
leading to treatments of psychotic disorder prodromes (30).
p. 479
The diagnostic process is only as good as its underlying science. Psychiatry has achieved little to date by way
of objective illness markers. As the applications of molecular genetics and brain imaging studies continue to
operate in earlier stages of development, consensually rated observations and valid questionnaires remain
the primary means to facilitate diagnostic agreement. With improvement in scientic rigour and ‘major
disorders’ diagnostic specicity, transnational rates will more likely resemble each other. When a sudden
increase in rates occurs in one geographical area compared to another, that phenomenon is due to broader
denitions in the indexed region (31). Similarly, discrepant diagnostic rates between locales reect dierent
usages of observation and measurement (32, 33). These dierences in illness characterizations and rates
could prove useful and thus ethically and clinically benecial, or, conversely, deleterious.
Is the term disorder a consensus grouping of signs and symptoms, a statistical manifestation of a minority
within a larger population, or dened by disruptive behaviours? When does a disorder become an illness? Do
these terms reect semantic dierences, barely related concepts, or points on a continuum? Are childhood
disruptive behaviours, including ADHD, oppositional deant disorder, disruptive mood dysregulation, and
conduct disorders, entities whose inclusion criteria can be objectively measured and consensually validated
and thus characterized as illnesses? Might these diagnoses reect discomted communities wanting to
extrude bothersome individuals? To enhance solid bases for diagnostic assessments, an ethical stance
requires assiduous reection on these questions.
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Diagnostic criteria have been expanded in the twenty-rst century, including the eort to discern
prodromal manifestations of psychiatric disorders (34, 35), though the latter approach has recently
withered due to lack of supportive evidence. Prevention of debilitating illness is all to the good. But, having
diagnosed a ‘prodromal condition’, ethical questions remain (36). An immense diculty presents in
determining the intervention eects on disease prevention (i.e., how to know if disease expression was
prevented if it may never have naturally manifested?). Further, risks are inherent in specic treatments
(e.g., psychotropics for prodromal schizophreniform symptoms in adolescents, anticonvulsants for
preschool children diagnosed with bipolar disorder). Indeed, the pharmaceutical industry has interests in
fostering medication prescribing to large numbers of individuals and groups who might otherwise not
receive them (37, 38, 39).
p. 480
Medical knowledge constantly expands; diagnoses are continuously revised. Theoretical speculations,
subject to rigorous scientic examination, usually precede additions to the medical knowledge base. The
ethical practitioner must always distinguish solidly grounded knowledge from speculative theory and not
confuse the two—thus, the movement towards evidence-based treatments (40).
Treatment
When a mental illness is diagnosed, whether treatment will be provided and its nature are functions of the
degree of harm that could result from nontreatment, while the prime consideration remains the safety of
the child. The actively suicidal, violent, or acutely psychotic child will require inpatient care. In the past,
hospitalization of adolescents for extended periods, using looser criteria than current ones, compromised
respect for their autonomy. Adolescent autonomy and needs are similarly not respected by pressures in this
century for ‘too-short’ hospital stays. The prevailing consensus is that most children do not require
extended restrictive stays and can be treated eectively as outpatients. Nonetheless, practitioners should
remain wary of nancial or other motivations that could inuence their clinical decisions. The child
psychiatrist should only provide clinically indicated treatment and resist parental or institutional pressures
for uncalled for care (e.g., ‘Focus on my child’s misbehaviour, not on my ‘tantrumming’, which is followed
by his ill-tempered response’).
Treatment in both inpatient and outpatient contexts may involve psychotropics in combination with one or
more psychotherapies (i.e., ‘blended treatments’). All approaches warrant a careful risk/benet analysis as
no single approach is indicated for all conditions or without risk. The clinician is ethically obliged to keep
abreast of the growing evidence base regarding the eectiveness of medications and various forms of
psychotherapy (41).
Because of prevailing economic and administrative structures in dierent countries, mental health
specialities may not oer similar therapies. In the United States and other high-income countries, child
psychiatrists, prior to the 1990s, provided combined medication and psychotherapy. ‘Split treatment’ has
overwhelmingly become the norm since then (i.e., psychiatrists oversee prescribing of medications while
nonmedical mental health professionals conduct psychotherapies). Whether split treatment produces equal,
better, or worse results than one practitioner doing all the work is not known (42). On the other hand,
‘split treatment’ in theory permits more children to be treated by child psychiatrists, in line with
distributive justice (17). Thus, society benets as a greater number receive equal amounts of care, while
reducing attention to the needs of an individual patient. To what extent such practice models will spread
remains to be seen.
p. 481
If child psychiatrists are relegated to limited evaluation and prescriber roles, their knowledge of
psychopharmacology, coupled with external and internal pressures, could encourage greater use of
medication. Such pressures may have contributed to a documented steady increase in (43) and caution
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concerning (44) such practice. ‘O-label’ prescribing, that is, using medications for children that have only
been tested and approved for adults (45), and the creation of diagnoses whose criteria may be elastic, for
example, ‘bipolar disorder of early childhood’ and disruptive mood dysregulation disorder, may represent
benecial or detrimental developments in child psychiatry. New diagnostic tools purporting to guide more
eective treatment approaches (e.g., the use of genetic swabs) could lead to inappropriate costs in advance
of proven and accepted ecacy (46). Also, except for variations on cognitive-behavioural therapy for
specic disorders, supporting evidence is scant for the eectiveness of many forms of psychotherapy (47).
To provide ethically based care, these issues deserve scrutiny.
Notably, preventive treatments have been proposed for large groups of traumatized children, to forestall the
development of posttraumatic disorders, via stress inoculation techniques designed to foster resiliency and
psychological strengthening (48). Well-designed studies have supported the eectiveness of these eorts,
in which the major ethical ‘lapse’ is the withholding of the treatments from control groups. These eorts
are planned to benet the many and thus the pursuit of (social) justice.
Psychotropic medications and other somatic treatments
In the past, dissimilar classes of psychotropics were discussed as if dierent ethical issues pertained to each.
It is preferable to raise concerns about any medications used with children. What is known about their
short- and long-term impacts on maturing brains; the evidence underlying their use in specic disorders in
children and adults; the soundness of speculation concerning ‘o-label’ use for a childhood disorder?
Further, do dierences exist in the frequency of medication provision in private versus public sectors (49)?
If signicant dierences are present, why? What degree of a child’s disorder’s severity warrants
medication; has a benet/risk analysis been carried out concerning the use of a particular drug for a specic
child; is the medication oered as a stand-alone treatment or as a component of a larger care programme?
Crucially, have these considerations been addressed with parents, as part of an informed consent process, as
well as with the child to obtain his informed assent (50)?
p. 482
Little is known about the eects of most psychotropics on the developing brain (51). Longitudinal studies
conrm, for example, correlation of weight gain with ‘atypical’ antipsychotics and some mood stabilizers,
and stimulation or exacerbation of tics by stimulants. Evidence has accrued that particular medications are
useful in treating specic disorders—for example, stimulants for ADHD; selective serotonin reuptake
inhibitors (SSRIs) for depression, bulimia, and obsessive-compulsive disorders; and mood stabilizers for
bipolar disorder in adolescence. However, many drugs prescribed for children are only known to be
ecacious in adults, while much fewer studies have been carried out in youngsters. These medications were
at times proven to have similar eects on the children. Thus, antipsychotics and mood stabilizers are used
for chronically explosive or severely disruptive behaviours, and SSRIs for depression. Of note, two or more
medications might be prescribed concurrently for a range of disorders. Clearly, o-label prescribing raises
ethical concerns since there is a potential for harm while benets are at best uncertain. Caveats should
always be sounded when legitimate suspicions are aroused that a high-spirited child is recommended for
medication due to his irritating qualities rather than for a measurable attention disturbance, or a shy child
who might well respond to social skills training is solely prescribed a SSRI. Ultimately, the child psychiatrist
is ethically responsible to keep fully abreast of developments in psychopharmacology and to apply, to the
extent possible, evidence-based care (41).
Comments about the use of electroconvulsive therapy (ECT) in children focus on the paucity of randomized
clinical trials and concerns about stigma, while noting the benets of the modality for a select group of
young patients with intractable mental disturbance (52). Ethical questions arise. Since benet from ECT has
been conrmed when accurately indicated and risks identied, why is it used so sparingly? To the extent
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that risks such as cognitive decits and adverse responses to anaesthesia are identied, obtaining informed
consent and assent should not dier from the process prevailing with psychotropics or the psychotherapies.
As it is unethical to withhold a potentially helpful treatment, further research is indicated.
Knowledge is minimal about the benets and risks in children of transcranial magnetic stimulation (posited
for use in depression and autism) and vagal nerve stimulation (eective for epilepsy). More is known about
the benets and risks associated with use of complementary and alternative medicines (CAM) (53, 54),
particularly for children with long-term disorders (55). Light therapy yields benets, and its side eects are
transient in children. In sum, it is ethically incumbent on clinicians to be aware of all treatments that might
help youngsters, and to prevent CAM-prescribed drug interactions by inquiring about use of alternative
medicines.
p. 483
The psychotherapies
Psychodynamic, behavioural, cognitive-behavioural (CBT), family, play, and group therapies are all used in
child psychiatry. The ethically minded therapist is aware of risks and benets in their application. Most of
these therapies have not been adequately evaluated (56).
It is incumbent on the child psychiatrist to be knowledgeable about major concepts underlying the tenets of
the various psychotherapies. Most importantly, she must determine when aspects of each are to be used
and, as a provider, be adept at their integration. As is true of the use of psychotropic medications, no one
size ts all (i.e., it would be unethical to administer a single form of psychotherapy to all patients
irrespective of their diagnoses and clinical presentations).
Specic ethical concerns apply to psychotherapy with youths. The therapist must weigh the competing
needs of child and parent as facilitating change in the child might adversely impact long-standing family
dynamics. For example, helping parents to impose structure on an unruly youngster, suggesting to
excessively rigid parents to relax control over their children, and advising parents and their child about
dealing with alternative gender roles or frankly sexual behaviours, could exacerbate family tensions. And a
cautionary note—the inept practice of psychotherapy can exert adverse eects on a child or family as
readily as the inappropriate use of psychotropics.
Confidentiality
Ethical practice requires clinicians to regard information divulged to them as condential, for transmission
to others only with the patient’s permission (17). The sole exception is imminent danger, such that when
a patient communicates his intent to cause self- or outer-directed harm, the clinician is obliged to prevent
this behaviour by breaching condentiality. He does so for two reasons—to promote safety and avoid harm,
and to assess apparent severely impaired, irrational thoughts.
p. 484
While condentiality in the treatment of adults is sacrosanct, it is less so in children. Children under the age
of seven years use prelogical cognitions (57). They have not yet achieved a mature sense of autonomy and
cannot understand the nature of condentiality. Even at age 12 years, their cognitive processes may still be
inconsistent (58, 59). Thus, an assertion that condentiality is inherently valuable in therapy should not
automatically be applied in the case of children. Since parents initiate and are involved in the psychiatric
care of their child, they expect relevant information about progress, and pretreatment discussion about
condentiality is required. In theory the parent has access to the entire exchange between child and
therapist, but in practice, the latter determines what can be disclosed.
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Occasionally, children divulge information in therapy they insist be withheld from others, especially from
parents. Given their relative immaturity, the therapist determines whether to safeguard or breach
condentiality. Similarly, parents convey information to the child psychiatrist. She must decide whether to
communicate its substance to the youngster. Parents may explicitly demand that she observe their right to
privacy, but astute clinical judgment and tact should determine her decision (24). In that regard, universal
agreement exists among professionals, working in dierent countries, regarding the handling of
intrafamilial condentiality concerns (60).
An additional concern surrounds exchanges with referring or requesting agencies. Report and application
information is condential. While guardians must give permission for information transmission, its uses
are out of the child’s hands. Digitally exchanged information could be stored ‘forever’ and unearthed at any
time, including after reaching the age of majority (61). Who owns the information and what may be done
with it remains uncertain, despite attempts to create safeguards (62). Ownership complications can also
arise in divorce cases, with a sole-custodian parent having legal control over her own and the child’s
information. The child psychiatrist should encourage, when indicated, sharing of material with the
noncustodial parent.
Nowhere are the issues of condentiality more complex than when treating adolescents. Depending on the
jurisdiction, they may have the legal right over decisions regarding the disclosure of condential material,
but psychological immaturity can compromise their ability to make the best choices for themselves (63).
Although conceptualizing condentiality evolves gradually, most children understand and value its nature
by early adolescence, when they pass from Piaget’s stage of moral realism to that of moral relativism and
acquire the sense of responsibility essential to the development of mature ethical standards. Conrming the
long-held belief that condentiality is important to adolescents (64, 65), a study (66) found that 58 per
cent had health concerns they wished to keep private from parents; a quarter would not seek health care if
their parents ‘might’ nd out; and only a third were aware of their privacy rights. Notwithstanding,
adolescents will bring forth issues that challenge the therapist. In the face of a refusal to waive a right to
privacy, what should the therapist do if an adolescent divulges a plan to run away; use of stimulants,
cocaine, or other illicit drugs; intent (as a 13 year old) to engage in sex with an 18 year old; active sexting; or
parental parading in the nude?
p. 485
The most useful approach to concerns about condentiality is to adopt a family approach (24). By meeting
initially with the child and parents/guardians, ground rules regarding sharing of clinical information can be
established immediately and understood by everyone (with the exception of preschoolers). The assurance
that condentiality will not be broken without prior discussion, excepting in emergencies, is crucial.
Similarly, concerns about forwarding clinical material to relevant agencies and services, when this matter
arises, should be addressed with all participants. Mutual collaboration and sensitive care commonly result
in trusting the child psychiatrist, including the professional’s intent to respect the patient’s rights while
simultaneously considering her clinical needs.
Child psychiatrists have progressively played an increased role in treating TAY, dened as individuals aged
18 years and older by at and viewed legally as adults. Therefore, their rights to privacy are inviolate except
for situations involving imminent risk of danger to self or others. Challenging circumstances for the
therapist include the college student failing due to lack of interest in her studies, substance abuse, marked
mood disturbance, or the unwitting signing of nancially unaordable contracts. The TAY is viewed not
only as ethically but legally autonomous as well, presenting additional roadblocks surrounding
condentiality (13).
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Culture and religion
With the advent of globalization and large-scale immigration, child psychiatrists have to familiarize
themselves with the sociocultural norms of many ethnic and national groups (67). Not uncommonly, the
newly arrived parental generation nds itself at odds with the youngsters of the succeeding generation
who tend to be more comfortable adopting the mores and attitudes of the host culture or a minority of
whom adopts even more stringently observant or traditional behaviours than those of their parents. The
child psychiatrist might suggest conceptualizing oppositional behaviour as a normative attempt to separate
and individuate and thereby useful to the culture; similarly, psychotic disturbance or profound withdrawal,
culturally viewed as divine retribution or visitation by ancestral spirits, as behavioural manifestations
whose improvement in cognition or behaviour, through the use of psychotropics, might be culturally
welcomed. Families are usually receptive to sensitive counselling in accordance with respect for their
customs and beliefs (68).
p. 486
Current ethical challenges
The world does not remain static; it continually evolves and presents new challenges that require the
application of ethical thought. Some of these changes signicantly impact children.
Conflict and violence
Countries dier in their political systems, health services, resources, technological levels, and cultural
beliefs and practices. Despite internationally agreed-upon standards of medical and psychiatric services for
children (69, 70) and conventions on their rights (6, 71), large numbers of children are victims of wars,
refugees, homeless, orphaned, and, consequently, vulnerable to abuse, exploitation, and violence. Often, in
war-torn and impoverished countries, mental health services for children are negligible or worse.
Nevertheless, an ethically derived obligation to provide as much help as possible prevails (72), often
emphasizing public health approaches (73), which could include employing non–mental health personnel
(e.g., teachers) who receive basic training in the subject (48).
Disadvantaged children and unconscious bias
Child psychiatrists assess and treat patients in various settings, private and public. They may pay closer
attention to patients seen privately given the pressure in public facilities to treat large numbers in a
limited time. An unconscious bias may emerge against children in the latter setting, many of whom are
likely to be disadvantaged, belong to ethnic minorities, and be victimized by abuse, violence, neglect, or
abandonment. For example, children in foster care are often solely prescribed psychotropics shorn of
comprehensive treatment plans or follow-up (49), indicating compromise of indicated care.
p. 487
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Social media
The rapid, widespread expansion of social media enables exchanges, both valuable and risk-laden, between
youngsters and between them and their family, friends, and strangers. Social media encourages self-
expression and self-exposure, which is, within limits, positive. But the risk of harm lurks. Given that
children have not fully acquired self-inhibitory controls of inclinations to violence, substance use, or sexual
behaviours, a risk prevails for poorly self-censored sharing of provocative digital messages or images with
others; normalization or encouragement of aberrant (e.g., eating disordered and self-harm) behaviours;
harassment, cyberbullying, and hate messaging; furthering of depressive and suicidal ideations; self-harm
contagion; sexting; legal violations of sending child pornography; and addiction to social media itself (74,
75). The therapist is therefore ethically obliged to spell out to children, especially the vulnerable and naive,
harms that may result from inappropriate use of social media.
Marijuana decriminalization
Decriminalization and social mainstreaming of marijuana use have progressed rapidly since the early 1990s,
particularly in high-income Westernized countries. In the United States, half the states have legalized
cannabis for recreational or medicinal use. Over a dozen countries permit medical prescribing, while many
others enforce legislation against its sale in limited fashion (76). Psychiatric concerns about childhood use
include easier accessibility, negative impacts on the evolving brain, precipitation of anxiety, mood and
psychotic disorders, cannabis dependence, and a pathway to more potent illicit drugs. The child psychiatrist
is ethically obliged to respond (77) using an evidence base while guarding against succumbing to personal
bias. Her interventions should be governed by the individual needs of her patients.
Sexual orientation and gender identification
p. 488
Considerable growth in the public expression of alternative sexual orientations and gender identications
have occurred since the 1970s. While the proportion of people who identify as ‘alternative’ or ‘nonbinary’
may not have changed in contrast to what are majority heterosexual and binary identications (78), the
degree to which the LGBTQ community has progressively pursued visibility in the public sphere appears to
have exploded, particularly in Westernized countries.
Remonstrations undertaken since the 1970s by the homosexual community to decriminalize their
orientation and enjoy equal rights have accelerated among publicly-identied lesbian, gay, bisexual,
transgender, and questioning people. What began as a civil rights movement of adults rapidly ltered down
to adolescents, who also emerged as a visible entity (79). These changes have met continuously with
opposition, while the scientic community has struggled to keep apace. In 1973 the American Psychiatric
Association (APA) removed homosexuality from its diagnostic compendium of psychiatric disorders (80), in
eect suggesting that prior therapeutic attempts to change alternative sexual orientations were
inappropriate. Only in 1998 did the APA declare that ‘conversion therapies’ were unethical and harmful (81).
Numerous mental health organizations (including the World Psychiatric Association), a growing number of
states in the United States, and other jurisdictions such as the State of Victoria, Australia, and Canada have
followed suit. Such ‘therapy’ interventions continue nevertheless, particularly at the behest of religious
fundamentalists and in a number of countries (e.g., China). Their activities pose a threat to the mental
health and well-being of children and adolescents who identify, either privately or publicly, with alternative
sexual lifestyles. The children’s parents not uncommonly feel distressed if not personally challenged and
may seek out ‘conversion’ therapies despite the harms that can result (82).
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Given the absence of intrinsic psychopathology, consequent psychological diculties often relate to the
anticipation or experience of judgmental responses from family or the community at large. Child
psychiatrists have an ethical duty to help these children nd adaptive pathways to comfortable self-
acceptance and sexual self-expression by acting as their advocates, while paying attention to the family’s
responses and needs (83).
Research
p. 489
When children are asked to participate in research studies, the child psychiatrist researcher is duty-bound
to consider the ethical implications, especially risks and benets. The assessment of safety and ecacy of
psychotropic medications for this age group is an example (84). Diligent attention to the ethical dimensions
of these research eorts reects investigators’ adherence to the protocols of statutory bodies, including the
US Food and Drug Administration, the UK Medical Research Council, and the Australian National Health and
Medical Research Council.
The need to balance a study’s potential benets for yielding new knowledge, versus the possible risks it may
pose to the research subject, is paramount. These issues traverse the traditional domains of
pharmacological and biological research (focusing on safety and ecacy) to include psychotherapeutic and
physiological studies engaged in the search for mechanisms of, and best treatments for, childhood mental
illness.
Research often elicits sensitive information that children may not wish revealed to others or could produce
harm. Routine procedures for maintaining condentiality could prove insucient as when, for example,
self- or other-destructive acts or ideations, substance misuse, child abuse, sexual risk-taking, or illegal
behaviours become known. Once a participant or her guardian has agreed to share personal information,
investigators must ensure it is divulged solely in a manner consistent with prior mutual agreement.
Thus, assent and consent procedures require special consideration. Children lack legal capacity to consent
and, depending on age and the research focus, may lack cognitive capacity to comprehend its purpose,
scope, and nature. Children may be averse to participation but feel uncomfortable refusing an investigator’s
cooperation request. To ensure protection of children’s rights, parental, legal guardian, or acting in loco
parentis consent should be obtained. Children’s rights are further protected by obtaining their assent. This
assumes the cognitive capacity and emotional maturity to understand the research’s nature and its risks
and benets. Extra time for explanation of the research rationale, in terms the child can comprehend, might
be necessary. Parental consent alone permits research to proceed with young children deemed incapable of
assenting. However, the objection of children of any age is binding, unless the study holds the prospect of
direct benet achievable only through the experimental procedure.
Investigators must be sensitive to coercion in consent procedures with children. Families asked to consent
while seeking professional care may believe failure to consent would result in withdrawal of sought help, or
custody loss of their child. Similarly, where health care services are limited, parents may feel urgency to
obtain care for their child and seek a research programme while subject to the misconception that
participation in the study will make treatment readily available. Investigators should help families
understand that participation in research is voluntary and that children will receive equal care whether they
enrol in a protocol or not. Informed consent is also a continuing process, monitored throughout a study
(‘staged consent’). Longitudinal studies’ protocols may be modied over time to match children’s changing
cognitive understanding, autonomy, and condentiality rights.
p. 490
The ethical challenges facing investigators conducting child research are more complex than those
encountered with adults in that studies must benet participants directly and/or generate knowledge about
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Minimal risk research
Research with more than minimal risk but likely to benefit the subject directly
Research with more than minimal risk, no prospect of direct individual benefit,
but likely to yield disorder-relevant knowledge
Research not otherwise subject to approval
their psychiatric disorder. National guidelines (85, 86) recognize children’s vulnerabilities as follows (87).
Research is considered minimal risk when the probability and magnitude of the anticipated harm or
discomfort do not exceed those ordinarily encountered in daily life or routine physical or psychological
examinations or tests—venepuncture and most psychological assessments are examples. A sole
parent/guardian can provide consent with assent solicited from the child.
This category requires justifying risks and discomfort vis-à-vis expected benets to the child or society
while demonstrating the benet-to-risk ratio is as favourable as available interventions or treatment.
Parental/guardian consent with solicitation of the child’s assent is required. Because of the potential benet
to the child, parental consent might override a child’s refusal.
p. 491
This category involves studies expected to result in new knowledge for understanding or ameliorating
psychiatric disorders, while the risks must constitute a minor increment over minimal risks consistent with
those the child would experience due to the condition itself. Parental/guardian consent and child assent are
required.
Studies that may increase understanding, alleviation, or prevention of serious health problems while risks
rise beyond the levels outlined above require statutory body approval of the research. The highest standards
of consent (i.e., from two parents/guardians and the child’s assent) are required.
Frontiers of research design and ethical issues
Trial designs have long held placebo randomized control trials as the ‘gold standard’. There are reasons to
consider alternatives, especially with regard to children. Psychotherapeutic approaches are paired with
medications or provided prior to the initiation of medication. Such combined modality study designs are
rare; more should be encouraged to derive useful knowledge. Second, social media and networks have
profoundly impacted children’s lives. A signicant need exists to study the impacts of these technologies on
children and their behaviours, as minimal guidance about best practices is available and the ensuing harms
are well-known (88).
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Conclusion
Children constitute society’s largest vulnerable group, but they are limited in their abilities to protect their
own interests. Clinicians treating, and researchers studying, them are therefore obliged to appreciate ethical
dilemmas that may arise and thus promote children’s rights. Furthermore, child psychiatrists respecting
these rights to assent or dissent, balancing the children’s interests and those of relevant others, applying
sound evidence-based treatments whenever possible, and contributing to new knowledge can thus play
profound roles in the lives of their patients, families, and society.
p. 492
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