Ethical Issues in Child and Adolescent Psychiatry
Sound, ethical decision making is essential to astute and compassionate clinical care. Wise practitioners readily identify and reflect on the ethical aspects of their work. They engage, often intuitively and without much fuss, in careful habits—in maintaining therapeutic boundaries, in seeking consultation from experts when caring for patients with difficult or especially complex conditions, in safeguarding against danger in high-risk situations, and in endeavoring to understand more about mental illnesses and their expression in the lives of patients of all ages, in all places, and from all walks of life. These habits of thought and behavior are signs of professionalism and help ensure ethical rigor in clinical practice.
Psychiatry is a specialty of medicine that, by its nature, touches on big moral questions. The conditions we treat often threaten the qualities that define human beings as individual, autonomous, responsible, developing, and fulfilled. Furthermore, the conditions we treat often are characterized by great suffering, disability, and stigma, and yet individuals with these conditions demonstrate such tremendous adaptation and strength as well. If all work by physicians is ethically important, then our work is especially so. As a service to Focus readers, this column provides ethics commentary on topics in clinical psychiatry. It also offers clinical ethics questions and expert answers in order to sharpen readers’ decision-making skills and to advance astute and compassionate clinical care in our field.
Laura Weiss Roberts, M.D., M.A.
Psychiatrists who care for children and adolescents find themselves in ethical situations distinct from those of general psychiatrists who provide clinical care for adults. Children, by nature, are a vulnerable population who rely on the higher developed judgment of their caretakers, and often many more individuals are involved in the care of minors than in the care of adult patients. When issues of neglect or mistreatment of young people arise, legal imperatives are introduced to the clinical care situation. The distinct situations encountered in the psychiatric care of children and adolescents require greater awareness of ethical principles and how to apply them to fulfill optimal standards of care.
A developmental perspective, mindful of a child’s ability to understand illness and treatment decisions, influences the role the child will play in his or her care. Ethical engagement of young people requires attention to their evolving capacity for autonomy, balancing self-determination with the need for nurturance. The natural drive for independence among adolescents invites situations in which risky behavior may be explored. These experiences may be shared with the psychiatrist but withheld from the parent, introducing many new dilemmas. A well-designed conversation between the patient, parent or guardian, and child and adolescent psychiatrist at the first clinical contact about the limits of confidentially will minimize or prevent problems, in terms of ethical practices as well as the therapeutic relationship itself, later in treatment. Carefully considering the pros and cons of disclosing personal information of the child or adolescent, along with imagining several possible outcomes, will help the psychiatrist decide when and how to pull other stakeholders into clinical care.
An ecological approach may add to the understanding of a patient’s habitat with all of the related stresses, resources, and stakeholders. Patients do not arrive with all of the people who are significant in their lives, and those who possess fewer interpersonal and familial supports often have greater needs—and sometimes generate more ethical concerns. On institutional and organizational levels, schools and mental health, government, and legal agencies add another layer of complexity that demands careful attention by the psychiatrist to serve the needs of the child while fulfilling obligations to others. APA (1) and the American Academy of Child and Adolescent Psychiatry (2) have developed ethical guidelines and resource documents that may be helpful in addressing issues in clinical practice and training related to the psychiatric care of children and adolescents.
Ethical issues encountered in the care of children and adolescents thus are distinct and challenging. Engaging with young people in a manner that is informed by developmental and ecological approaches will help identify and resolve ethical dilemmas in their care.
Multiple-Choice Questions
Case Illustration 1
Jeffrey is a 10-year-old boy who attends fifth grade at a local public school. He arrives at his appointment with the child and adolescent psychiatrist accompanied by his mother, who reports that Jeffrey’s grades have dropped over the past 2 years. As the material has become more difficult, Jeffrey has struggled with composing longer papers and organizing how to start and finish assignments. Jeffrey shares that he feels badly about his poor performance and would like to do better but is afraid to ask his teacher for help. He denies feeling significantly depressed or anxious but admits he has some frustration. Jeffrey’s 12-year-old brother, Ryan, was identified as having difficulty with attention 3 years ago and happened to have the same teacher as Jeffrey. The teacher, Mrs. Samuels, would make comments to Ryan such as, “Did you have your pill today?” and “Maybe you need more medication.” Jeffrey does not want Mrs. Samuels to know that he has been to the doctor because he thinks she will embarrass him. Jeffrey refuses to have Mrs. Samuels complete rating scales about his school performance and behavior. He asks if the psychiatrist can give him a medicine like his brother’s. The psychiatrist explains to Jeffrey and his mom that information from school is necessary to assess the scope of Jeffrey’s needs. The psychiatrist suggests asking another teacher to complete the scales or gather information from report cards and progress reports. Jeffrey and his mother agree to supply rating scales from other sources and report cards. The rest of the visit is spent gathering a complete history and inventory of current symptoms and functioning.
| 1. | Which set of ethical principles most likely shaped the child and adolescent psychiatrist’s response about gathering collateral information?
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Two weeks after the initial appointment, after reviewing the completed rating scales, the psychiatrist recommends that Jeffrey take a low dose of a psychostimulant medication to help with focus, distractibility, and executive functioning. He expresses concern about not growing, because “my brother Ryan is kinda short.” He asks if he will also be short.
| 2. | Which ethical principle prevails in responding to Jeffrey’s concern about his growth?
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Case Illustration 2
Riley, a 16-year-old girl in 11th grade, presents to the psychiatrist with her mother, who is concerned that Riley has been breaking curfew and sneaking out of the house at night even though her mother took away Riley’s driver’s permit. Her mother is concerned that Riley has been depressed since her parents divorced about a year ago. After speaking with the psychiatrist and her mother together for approximately 15 minutes, Riley agrees to talk one on one with the psychiatrist. Riley shares that she has been feeling “bummed on and off” for about 3 years. She had a feeling that her parents would separate but thought that they would get back together. She is worried about her mom, who has had to go back to work, and her sister, who is 11 years old and has stopped playing sports and hanging out with Riley. Riley says that it is hard to sleep at night with all that is on her mind and that she has trouble concentrating on her homework. She denies any suicidal thoughts. The only thing that helps is hanging out with her friends and smoking marijuana after school and before bed. She started smoking in the summer between 10th and 11th grades, about 8 months ago. She smokes once or twice nearly every day. She purchased a vaporizer pen online that she uses at night so her mother and sister do not smell the smoke. Her mother is not aware of her marijuana use. Riley denies using tobacco or other recreational drugs. She reports that she drank beer and hard liquor on three different occasions in 10th grade but did not like the effect because she felt “too out of control.” She denies smoking marijuana while driving or at school.
| 3. | Which of the following statements accurately reflects the American Academy of Child and Adolescent Psychiatry’s ethical recommendations regarding confidentiality?
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When asked about friends, Riley mentions a guy she has been dating. She describes that they met about a year ago and started dating 6 months ago. Jake is 17 years old and attends the same school. He is her only sexual partner, and she takes birth control pills, so they do not use any other form of contraception. She adamantly denies that he has any other sexual partners. She reports that the relationship is consensual and a source of support for her. When asked what she likes about Jake, she replies, “He makes me laugh, and he listens to me.” She says her mother has met him but thinks they are just friends. Riley will tell her mother that she is at a friend’s home and stay over at Jake’s house on the weekends sometimes. Jake’s mother is aware that Riley is over, but she thinks that Riley’s mom has given her permission.
| 4. | Which of the following next steps, governed by the associated ethical principle, is recommended?
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Matching Questions
| 5–10. | Match the term with the relevant scenario: | ||||
| A. | Autonomy | ||||
| B. | Beneficence | ||||
| C. | Confidentiality | ||||
| D. | Respect for the law | ||||
| E. | Veracity | ||||
| ___ | 5. Reporting suspected physical abuse of a 7-year-old child. | ||||
| ___ | 6. Informing an adolescent about the side effects of a new medication, after obtaining parental consent. | ||||
| ___ | 7. Documenting aspects of the family medical history accurately in the electronic medical record. | ||||
| ___ | 8. Respecting a parent’s decision not to treat an infant with antibiotics due to religious preferences. | ||||
| ___ | 9. Deciding to refer a 5-year-old patient with severe obsessive-compulsive disorder to another clinician who has more expertise in treatment. | ||||
| ___ | 10. Respecting an adolescent’s request that his parents not be informed of his gender identity and sexual activity. | ||||
Answers
| 1. | The answer is B. The psychiatrist hears the patient’s concern that his privacy be protected. By brainstorming with Jeffrey about other methods of obtaining information, the psychiatrist models flexibility in problem solving, supports Jeffrey’s need for self-reliance, and demonstrates awareness that at Jeffrey’s current developmental stage, incorporating his input will support his attainment of confidence and competence. | ||||
| 2. | The answer is D. Jeffrey is asking about the effects of possible decreased appetite and nutritional deficits in the setting of treatment with a psychostimulant. The psychiatrist’s highest priority in the context of this question is veracity. The psychiatrist must acknowledge the patient’s concern and the possibility of loss in the growth curve. Fidelity upholds the ideal that serving one’s patient faithfully despite conflicts is paramount. Additional information about medication holidays, methods of improving growth, and examining Jeffrey’s rationale in comparing himself to his brother will also be helpful. Exploring these ideas will build rapport and also ultimately be in Jeffrey’s best interest, representing the tenet of beneficence. | ||||
| 3. | The answer is D. Many ethical dilemmas can be prevented or minimized by stating at the outset of care that each patient has a right to confidentiality but that the limitations found therein may require disclosure when the safety of the patient or another is in question. The risks and benefits of breaching confidentiality need to be carefully weighed with, but not limited to, consideration of the working alliance, the patient’s symptomatology (e.g., psychosis), potential for serious harm (medical, psychological, legal, financial, etc.), retribution from parents (i.e., possible harm to the patient), and the developmental stage of the patient. | ||||
| 4. | The answer is E. Although the other answers are justifiable, none of those actions would reflect a tempered approach to clinical care in light of the information provided. Although Riley’s choices may be maladaptive to some degree (e.g., daily marijuana use, lying to her mother, and possibly underprotected sexual behavior), Riley is not an imminent danger to herself or others. With an awareness of Riley’s developmental tasks, such as independence, role formation, separation and individuation, and the importance of her “social ecosystem,” disclosing the shared information from the visit would likely undermine the nascent therapeutic relationship and Riley’s autonomy. | ||||
| 5. | The answer is D. By law, the clinician must report suspected neglect or abuse of a child to the proper authorities. | ||||
| 6. | The answer is A. Informing an adolescent about the side effects of a medication, although the parents have provided formal informed consent, demonstrates respect for the patient’s evolving autonomy. Another potential correct answer for this question is E, in which the clinician provides honest information to the patient about the proposed treatment. | ||||
| 7. | The answer is E. Accurately documenting information in the electronic medical record is an expression of truthfulness. | ||||
| 8. | The answer is A. Respecting the religious preferences of a parent regarding the care of an infant demonstrates respect for autonomy. Another potential correct answer for this question is D, because the law protects this right of parents in making decisions for their children in accordance with the parents’ religious beliefs. | ||||
| 9. | The answer is B. When clinicians are aware of their limitations, they are more able to act in the best interest of the child. | ||||
| 10. | The answer is C. The privilege of confidentiality is afforded to young people regarding sexual health issues. | ||||
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