Ethics Commentary

Child and adolescent psychiatrists encounter ethical situations that often differ from those of general psychiatrists. Several factors increase the complexity of ethical practice in child and adolescent psychiatry including the variety of persons involved in meeting the mental health needs of children, the care of a vulnerable population whose welfare relies on others, the limited access to mental health services for children, and the advancements in science which provide an increasing number of diagnostic and treatment options.

Notably, general psychiatrists also provide care for patients younger than 18 and for college-age youth for whom developmental considerations are highly relevant. These clinical interactions arise due to clinician interest or out of necessity i.e. the shortage of child and adolescent psychiatrists, or limited access to care in rural settings. All psychiatrists completing general residency from an accredited program have had exposure to the care of children, adolescents and their families, but the frequency and depth of clinical care of youth by generally trained psychiatrists varies widely.

This column provides an overview of the American Academy of Child and Adolescent Psychiatry (AACAP) code of ethics, which in theory applies to the clinical care of all patients, and was designed specifically to provide child and adolescent psychiatrists, as well as other clinicians who care for the mental health needs of children, with an ethical framework of practice (1). Further discussion of all ten principles of the code, and information and an extensive bibliography on ethics in child and psychiatry, can be found online at the Ethics Resource Center of AACAP (2). Given the discrete nature of this column, discussion will focus on three vignettes and the principles of the code that are commonly utilized by child and adolescent psychiatrists: developmental perspective, assent / consent, and confidentiality.

Because pediatric patients develop within a unique ecological system inhabited by many individuals (e.g. siblings, parents, other family, friends, teachers, coaches, clergy, clinicians), and organizations (e.g. schools, clinics, foster care, government and legal agencies), such complexity demands careful attention to the needs of all stakeholders. Above all, child and adolescent psychiatrists must identify the best interests of the developing child, who as a minor has limited decision-making abilities and autonomy amid this varied landscape. In all contexts, the child and adolescent psychiatrist must often balance competing agendas and provide care within an ethical framework, applied in day-to-day practice.

The ethical foundations of child and adolescent psychiatry stem from traditional biomedical ethics with specific applications to psychiatry. These include the four pillars of autonomy, beneficence, nonmaleficence, and justice (3, 4). However, specific considerations in the clinical care of children have necessitated the development of a code of ethics that serves youth in need of mental health care.

In 2008, the American Academy of Child and Adolescent Psychiatry (AACAP) Executive Council revised it's code of ethics and instituted a requirement that member clinicians obtain, and attest to, at least one hour of ethics training every two years. Although modest in nature, this requirement demonstrates the strong belief that knowledge of medical ethics is a sine qua non for competent child psychiatrists—whether clinicians, researchers or administrators. In 2009, AACAP published its code of ethics to outline 10 principles that are intrinsic to the care of patients to guide clinicians in all professional encounters, whether routine or unusual (Table 1).

Developmental perspective: principle I

The medical and psychiatric care of children would be incomplete without consideration of physical, cognitive, psychological, and social development. In addition, families also evolve and their ability to understand factors surrounding medical decision-making may change over time as their understanding and acceptance of illness progresses. Over the past few decades, the importance of a child’s right to self-determination has influenced how children are integrated into decision making (5). Studies in child development have demonstrated that understanding the right to self-nurturance versus the right to self-determination varies based on chronological age, however the progression of concrete to abstract reasoning for these two types of rights differed at all ages (6, 7). Younger children more easily identify the right to be cared for and protected, and older children (around age 14) regard the salience of issues regarding self-determination and nurturance equally. Therefore, children’s understanding of various types of rights does not occur at the same pace; conceptualization of rights develops at different ages. These nuances of development necessitate further attention from practitioners and families on how to include children in decision-making in the most therapeutic way, while upholding their best interest.

Case vignette 1

Ashley is a 6-year-old girl in first grade who has received over a dozen “oops” slips for disruptive behavior in the classroom since the beginning of the academic year four months ago. She is rarely invited to birthday parties; her teacher has called her parents several times for parent-teacher meetings at school, and she consistently earns low marks because she forgets her supplies and assignments. She has struggled with similar challenges and complaints in kindergarten. Her parents report it takes a long time to get her ready for school and for bed because Ashley is always physically active, easily distracted by toys, television, and what others are doing in the house. Based on her clinical history, mental status exam, collateral report and scales from parents, teacher, and after-school caregivers, your primary diagnosis is attention deficit hyperactivity disorder-combined type (ADHD-CT). In providing feedback about the evaluation to Ashley and her parents, Ashley says with downward gaze “No one likes me. They won’t let me play with them at recess.” After supplying further psycho-education about ADHD-CT, you recommend a trial of a medication. Ashley then says “I am always in trouble. I keep doing everything wrong.”

This brief vignette demonstrates the importance of assessing the developmental stage of the patient for 1) proper assessment of the presenting clinical problem, 2) the patient’s pattern of response to that problem, and 3) the patient’s ability to partake in treatment planning and decision making.

Ashley’s early elementary school experience suggests that her ability to sustain attention and follow directions is developmentally different than the majority of her peers. For someone her age, the home routine, the structure of the elementary school classroom environment, the guidance of the teacher as authority figure and role model, and the wish to gain mastery of new skills in learning and play provide children with the psychosocial support to succeed in expressions of industry [versus inferiority] (8). Ashley is having difficulty with some of these Ericksonian milestones, and this has impaired her functioning and impacted her development by isolating her from her peers and limiting her academic success.

Ashley’s response in session conveys her awareness of her repeated difficulties. Peers and teachers view her negatively and she is not meeting the expectations of her parents who have brought her to the doctor. Cognitively, she knows something is “wrong.” The concept that her problems may stem from differences in brain structure and chemistry affecting her executive functioning and behavior is likely far beyond her reasoning abilities. In fact, her age-appropriate tendency for concrete and magical thinking may lead to further confusion about a biologically based explanation for her problems and the role of medication. Thus, it is the child psychiatrist’s role to explain the diagnosis and treatment in a developmentally appropriate manner.

As treatment options are discussed, given her developmental stage, Ashley will likely defer to her parents to make decisions. As noted given her developmental stage, she will expect her parents to protect her from harm and provide her with care; she is less likely to see that she has a choice. Therefore the power differential in the patient–doctor relationship should not be unwittingly exploited to persuade a decision in favor of treatment with medication simply because that may be the doctor’s initial recommendations. Additionally, how Ashley is involved in these decisions may compound her feelings of inadequacy (if she is completely disregarded), or her agency can be used to enhance a sense of control and problem solving (an important developmental milestone at her current age). Finally, the parents’ tone in how treatment planning is presented to their daughter should be carefully considered, as their approach will strongly influence her beliefs about the risks and benefits of treatment. Providing caregivers with time to ask questions and express ambivalence about treatment options without the patient present allows the ultimate decision makers the opportunity to arrive at a unified and consistent message. Clarity from adults is always in the best interest of the child when seeking assent to any intervention.

Assent and consent (autonomy): principle IV

The concept of informed consent focuses on respecting the rights of patients and caregivers to make their own informed decisions without pressure. Youth under the age of 18 years should be involved in the decision making about their care and assent should be obtained. Guardians must always consent to treatment except in emergencies or in certain states when treatment is available to a minor without guardian consent and it is in the best interest of the child to bypass the guardian. Practitioners should provide full communication about all relevant issues for informed decisions to be made. Particular care should be taken when youth and guardian disagree (1).

Complicating this ethical guideline is the fact that the minor is often not the one initiating the evaluation for mental health concerns or treatment. And, when it comes to the use of psychotropic medications, some treatments lack rigorous pediatric data supporting their effectiveness, or information on their potential neurodevelopmental impact is still under study. In situations when parental consent is required for an intervention, assent should be obtained from the child or teen patient in question. There is considerable variation between jurisdictions as to whether youth are legally allowed to refuse treatment despite parental consent, and whether a pediatric patient can consent to treatment against their parents' wishes. Finally, some children and teens may have restrictions on their ability to assent or consent depending on their circumstances. For example, children and adolescents in state custody often cannot decide with whom they live and those incarcerated may not be able to make decisions about treatment (1).

Case vignette 2

Carlos is an 11-year-old boy with moderate motor tics, referred to you from the general pediatrics clinic. Carlos is well liked by teachers and other adults due to his sweet nature and insightful comments that are mature for his age, but he has trouble making and keeping friends his own age. He seems oblivious to this, stating that he has “many friends” his age, both in and out of school. His parents tell you privately that this is not the case, and that he gets teased and ostracized by peers due to his phonic and motor tics. His parents want treatment started before “he starts middle school, to minimize teasing.” The patient is adamant that he doesn't want to take medication, and says “I don't need to be fixed. I like me just the way I am.” The parents want to support his autonomy, but ask you to help convince him to begin a medication trial as soon as possible, “before things get worse.”

This case illustrates several clinical issues. The parents seem well-intentioned, and hope that the doctor can convince their son to choose the path (taking medication) which can help to alleviate potential future suffering because of teasing. As the clinician considers whether the parents are also worried about their own sense of embarrassment over the child's symptoms, it is important to consider the perspective of both parent and child in order to develop a strategy to overcome this impasse. Because Carlos seems wary of being “changed” by any medication treatment (“I like me just the way I am”), yet also seems oblivious to his social isolation for now, the clinician would be wise to first focus on Carlos' sense of autonomy (right to self-determination and need for assent over his own care), and thus try to establish a solid therapeutic alliance in order to create a relational context with Carlos that can serve as fertile ground for future discussions about medication, as as well as other forms of treatment. This involves advocating on his behalf to the family to allow him to defer medication treatment for now, because he currently seems to understand the nature of the problem (his tics), and though he is minimally aware of consequences (social isolation), the symptoms don't bother him at present and are not causing distress to him currently. At the same time, the clinician must strive to maintain a dual alliance (9), so as not to alienate the parents from bringing Carlos back for further treatment. This includes emoting and communicating an understanding of the parents' current concerns and worst fears from their point of view. This can allow for a discussion in the child's best interests, and can make both parent and child feel that the doctor understands their different perspectives.

Previous authors (10, 11) have described the informed consent process in adults, which can be modified for application to this pediatric case. The three aspects of informed consent include information sharing, decision-making capacity, and voluntariness. The latter two are worth highlighting here. Carlos demonstrates decisional capacity regarding its four main components: to communicate a preference, to comprehend the information necessary for the decision, to appreciate the significance of the choice being made in the context of one’s life, and to reason (to weigh information, compare options, and consider consequences). Though the significance of his social isolation may not be apparent to him currently, this may change as he gets older. He may also be open to a nonmedication intervention first (e.g. habit reversal training) as recommended by the doctor as long as he perceives the medical team not to be “pushing medication” as the only treatment option.

The third component of informed consent, voluntarism, is the ability to make a free and uncoerced decision. Four domains of influence affect an individual’s ability to make a voluntary decision, including developmental factors, illness-related factors, psychological, cultural, and religious factors, and external features and pressures (10, 11). In the case of obtaining pediatric assent for treatment, it may be necessary to interview the child/teen separately to ensure freedom from a real or implied coercion from parents. Also, in instances where the physician encounters resistance to pharmacotherapy (or other treatment) by a reluctant patient or family, the clinician must be open to self-reflection about his or her own underlying motives, noble as they may seem during the doctor-patient-family encounter. For a further discussion of how to avoid turning the informed consent process into one of informed coercion, please see Krener and Mancina (12).

Confidentiality (autonomy/fidelity): principle V

As applied to child and adolescent psychiatry, the principle of confidentiality focuses on the patient's right to have information kept private and confidential. Practitioners should explain the nature (and any known limits) of confidentiality to their pediatric patients at the beginning of the treatment relationship. Furthermore, both patients and their families should always be told, preferably in advance, about necessary disclosures of information such as the reporting of abuse or neglect. The AACAP Code of Ethics (1) states, “Certainty that their verbal expressions are protected as confidential allows minor patients to reveal their feelings and thoughts to the clinicians providing care, with the assurance that the contents of their discussions will not be communicated to others without their permission.” Fidelity and autonomy are linked ethical concepts that are relevant to confidentiality when applied in child and adolescent psychiatry, in that “fidelity” refers to upholding one's duty and loyalty to a patient, while “autonomy” refers to the child's (and especially, the adolescent's), right to self-determination within a developmental context.

It is important to obtain both parent/guardian consent as well as patient assent for exchange of information with others involved in the child's care, such as the primary care provider and the child's school. While teens in particular can be reticent to allow disclosure of any mental health issues to school personnel, we and others (13) have found that identifying one key adult in school whom the teen can trust cannot only help empower the community safety net, it can also help de-stigmatize mental health disorders in important ways by following a similar protocol as one would with medical disorders (while still acknowledging the sensitive nature of the former). Selective and planned disclosure (pending approval from the teen) to a trusted adult (doctor, parent, teacher or other) regarding sensitive issues can also help guard against feelings of isolation or alienation, especially when dealing with a mental health condition.

Case vignette 3

A 16-year-old boy with ADHD and anxiety tells his psychiatrist that he is using marijuana and getting high before classes, several times per week. He has also sold marijuana on at least three occasions in school. He is disclosing this in therapy because he is sure that this will stay confidential, and also feels that “the THC is helping me to stay calm and focused for my classes.” He would like the doctor to prescribe medical marijuana for him which is legally available in his home state. He is currently treated with psychostimulants and an SSRI, in addition to collateral family support and individual therapy. His parents are concerned that the treatments are not working well enough, and “that he still is argumentative with us and getting in lots of trouble at school.”

The psychiatrist sees this as an opportunity for engagement (on a topic of importance to the patient), psychoeducation (basic facts on the neuroscience of attention, motivation, and the effects of THC on the brain) and limit setting (about the prescriber's scope of practice), while also being concerned for the potential harm to others (selling drugs) and harm to the patient (expulsion resulting form selling on school campus). A patient-centered, private, matter-of-fact discussion itself can be supportive of the adolescent's autonomy and personal sense of agency. In this case, the psychiatrist may decide to not disclose the patient's marijuana use to the parents to uphold the principle of confidentiality, yet would still raise concerns directly with the patient about the potential functional impairment from repetitive marijuana use, especially during the school week, and about the severe consequences that would result if he were to be caught dealing.

This case illustrates how issues of trust and confidentiality are more complex in child and adolescent psychiatry because we interact with parents as well as the patient. The rights of parents to know certain information about their child or teen needs to be balanced with the patients’ interests (14). In some cases, problematic behaviors may need a more systemic (family or school based) component, and adolescent patients may be more open to these interventions if there is a trusted relationship with the mental health provider beforehand. A motivational interview paradigm (15) may be the best approach, not only to engage the adolescent in the stages of change paradigm, but also to prevent the psychiatrist from being “parentified” by the patient or viewed as judgmental. The patient's responsibility for his educational progress and autonomy for his own care may be highlighted by having a frank and open family session about issues in treatment which may be either enhancing or impeding progress in treatment. Themes to include in the family session would be discussed with the patient ahead of time, and follow up sessions with the patient could address sensitive issues brought up in the family session.

Summary

These cases illustrate how developmental context and the ethical principles of informed consent and autonomy are essential elements in pediatric psychiatry practice, and for general psychiatrists treating minors and transitional age youth. With children and adolescents, attention to the treatment alliance is crucial for therapeutic progress. Furthermore, contextual elements are ever present and a dual alliance is required, wherein parents/guardians must play an important role, while not impeding the therapeutic activity between doctor and patient. The AACAP Code of Ethics represents a best practices approach and offers sound theoretical and practical guidelines for child and adolescent care providers.