Ethical Considerations in Child and Adolescent Psychiatry Ethics Commentary

Michelle Goldsmith, M.D., M.A.
Shashank V. Joshi, M.D.
Ethics Commentary
CHILD
AND
ADOLESCENT PSYCHIATRY:
LIFE CYCLE AND FAMILY
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
focus.psychiatryonline.org
CLINICAL
SYNTHESIS
Ethical Considerations in
Child and Adolescent
Psychiatry
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
Author Information and CME Disclosure
Michelle Goldsmith, M.D., M.A., Division of Child & Adolescent Psychiatry, Stanford University School
of Medicine, Stanford CA
Shashank V. Joshi, MD, Division of Child & Adolescent Psychiatry, Stanford University School of
Medicine, Stanford CA
Dr. Goldsmith and Dr. Joshi report no conflicting interests.
Laura Weiss Roberts, M.D., Column Editor for Focus Ethics Commentary, Department of Psychiatry
and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA.
Owner, Investigator; Terra Nova Learning Systems.
Address correspondence to Michelle Goldsmith, M.D., M.A., Stanford University, 401 Quarry Road,
Palo Alto, CA 94304; michelle.goldsmith@stanford.edu (e-mail).
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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
PRINCIPLE I
PERSPECTIVE:
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 decisionmaking 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 decisionmaking in the most therapeutic way, while upholding their best interest.
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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
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ETHICS COMMENTARY
Table 1.
Summary of the 10 Guiding Principles From the AACAP Code of Ethics
Principles
Developmental Perspective
Focus
c Children and families evolve through stages of development
c Physical, cognitive, social, and emotional aspects of development influence a child’s ability
to understand and make decisions
c Chronological age and developmental status are not always the same
Promoting the Welfare of Children and
Adolescents (Beneficence)
c The wellbeing, functioning, and development of youth as individuals, and as a group, should
be optimized whenever appropriate
c Societal, familial and other group pressures should not override the best interest of the
child
Minimizing Harmful Effects
(Nonmaleficence)
c Clinicians should avoid any practice that is harmful to, or may hinder, the optimal de-
velopment of the patient
c Efforts should be made to minimize harm to children as a group due to the action of
others
c Relationships with patients beyond professional interactions should be carefully considered
CLINICAL
SYNTHESIS
c Whenever possible, evidence-based methods of treatment should be used in care
and avoided when indicated or harmful
c Any conflicts of interest or obligations to those other than patient should be readily disclosed
Assent and Consent (Autonomy)
c Respecting the rights of youth in medical decision making is key to establishing trust
c For those under 18 years old, consent for treatment should be obtained from the guardian
with assent from the minor however in some states certain treatments are available to
minors without guardian consent
c Additional attention should be paid when guardian and youth disagree about treatment
decisions
c When youth are involved in research protocols, the decision making will be more complex
and informed assent and consent require additional measures
Confidentiality (Autonomy/ Fidelity)
c Limits of confidentiality and circumstances necessitating disclosures should be discussed
in a developmentally appropriate manner with the patient and the guardian
c Documented release of information to outside entities must occur with guardian consent
and patient assent except in emergencies
Third Party Influence (Fidelity)
c A patient’s best interests supersede competing interests
c Practitioners should contemplate how his/her role may be influenced by outside parties and
monitor their professional interactions to support patient welfare
Research Activities
c While research to advance knowledge of child and adolescent psychiatry is important, the
welfare of youth should never be compromised for research efforts
c Risks of research must always be fully disclosed
c When youth are involved in research protocols, they must always assent to participation and
can rescind at anytime; the decision making will be more complex and will require additional measures
c Researcher and organizational conflicts of interest must always be fully disclosed
Advocacy and Equity (Justice)
c Practitioners should strive to make access to mental health care available to all children and
families in need
c Risks of care or research should not be unjustly borne by excessively vulnerable youth
Professional Rewards
c Rewards may influence practitioner decision making and can impact youth and family
welfare
c Care should be taken to avoid negative influence of merits and rewards on practitioner
judgment and action
Legal Considerations
c Local, state and federal laws impact the practice of child and adolescent psychiatry
c Legal and ethical practice may be coincident or in conflict with each other, and practitioners
should be aware of this complex and changing relationship
c Laws outline minimally acceptable actions; ethics strive optimal planning and behavior
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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.
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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 selfdetermination 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
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CONFIDENTIALITY (AUTONOMY/
FIDELITY): PRINCIPLE V
As applied to child and adolescent psychiatry, the
principle of confidentiality focuses on the patient’s
focus.psychiatryonline.org
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 selfdetermination 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
CLINICAL
SYNTHESIS
(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).
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
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ETHICS COMMENTARY
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
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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.
REFERENCES
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Washington, DC, AACAP 2009; Available from: http://www.aacap.org/
galleries/AboutUs/AACAP_Code_of_Ethics.pdf.pdf.
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http://www.aacap.org/cs/media/view_news_release?pressrelease.
id51476.
3. Beauchamp TL, Childress JF: Principles of biomedical ethics. USA, Oxford
University Press, 2001
4. Roberts LW, Dyer AR. Concise guide to ethics in mental health care: American Psychiatric Pub; 2004.
5. Hart SN: From Property to Person Status: Historical Perspective on Children’s Rights. Am Psychol 1991; 46:53–59
6. Ruck MD, Abramovitch R, Keating DP: Children’s and adolescents’ understanding of rights: balancing nurturance and self-determination. Child Dev
1998; 69:404–417
7. Melton GB, Limber SP. 14. What Children’s Rights Mean to Children:
Children’s Own Views. The ideologies of children’s rights. 1992;
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8. Davies D: Child development: A practitioner’s guide The Guilford Press,
2010
9. Joshi SV. Teamwork: the therapeutic alliance in pediatric pharmacotherapy.
Child and adolescent psychiatric clinics of North America. 2006;15(1):23962. Epub 2005/12/03.
10. Hoop JG, Smyth AC, Roberts LW. Ethical issues in psychiatric research on
children and adolescents. Child and adolescent psychiatric clinics of North
America. 2008;17(1):127-48, x. Epub 2007/11/27.
11. Roberts LW. Informed consent and the capacity for voluntarism. The American journal of psychiatry. 2002;159(5):705-12. Epub 2002/05/03.
12. Krener PK, Mancina RA: Informed consent or informed coercion? Decisionmaking in pediatric psychopharmacology. J Child Adolesc Psychopharmacol 1994; 4:183–200
13. Feinstein NR, Fielding K, Udvari-Solner A, Joshi SV. The supporting alliance
in child and adolescent treatment: enhancing collaboration among therapists, parents, and teachers. Am J Psychother. 2009;63(4):319-44. Epub
2010/02/06.
14. Schetky DH: Ethics, in Lewis’s Child and adolescent psychiatry: a comprehensive textbook, 4th ed. Edited by Lewis M, Martin A, Volkmar FR.
Philadelphia, Wolters Kluwer Health/Lippincott Williams & Wilkins, 2007,
pp 17–22
15. Dilallo JJ, Weiss G. Motivational interviewing and adolescent psychopharmacology. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48(2):108-13. Epub 2009/12/31.
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decisionmaking.
Campbell AT. Consent, competence, and confidentiality related to psychiatric
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Koocher GP: Ethics in child psychotherapy. Child Adolesc Psychiatr Clin N Am
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Ratner RA. Ethics in child and adolescent forensic psychiatry. Child and adolescent
psychiatric clinics of North America. 2002;11(4):887-904, ix. Epub 2002/10/26.
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02/05.
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Case Studies in Ethics:
Childhood and Adolescence
These case studies in ethics are adapted with permission from LW Roberts, JG Hoop: Professionalism
and Ethics: Q&A Self-Study Guide for Mental Health Professionals. Arlington, VA: American Psychiatric Press, Inc., 2008, pp 120–122
A. Accept the father’s cultural explanation and
ask him to further educate the therapist about
the ethnic minority group’s traditions and
cultural practices
B. Accept the father’s cultural explanation and
set it aside as no longer a clinical issue
C. Consult with a colleague who is knowledgeable about the specific ethnic minority group’s
traditions to increase the therapist’s sensitivity
and competence and inform the parents about
their state’s definition of child abuse and the
therapist’s role as a mandatory reporter
D. Consult with a colleague who is knowledgeable about the specific ethnic minority group’s
traditions to increase the therapist’s sensitivity
and competence and use this as a guide for
treatment
E. File a report to the local children’s protective
services agency, because spanking and other
forms of corporal punishment always constitute child abuse
Clinicians have a responsibility to be sensitive to
and knowledgeable about the cultural and ethnic
differences that exist among their client populations.
More specifically, clinicians are expected to recognize
and appreciate the perspective of culturally different
clients and how this perspective informs their values,
psychological processes, and behavior. Providers must
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recognize the limitations of their cultural competence
and utilize consultations and educational experiences
to expand their competence.
Concurrently, clinicians in the United States are
legally mandated to report child abuse to the appropriate state agency. This obligation transcends
the cultural differences that may exist between the
patient and therapist. However, the provider is
expected to educate the patient and family about
their state’s definition of child abuse and the provider’s duty to report child abuse. Providers are encouraged to not allow their personal prejudices to
dictate their perceptions and clinical judgment. There
is a dual responsibility to be sensitive to cultural differences and to protect children from harm (1–3).
Answer: C
Case B: A first-year psychiatry resident rotating
through a busy outpatient pediatrics clinic is assigned
to see a 16-year-old girl for a new patient evaluation.
The patient was registered at the front desk by her
mother, who then left. The patient reports that she is
“relieved” to come to the doctor’s office because she
gets “stressed out sometimes.” Relevant state law
indicates that adolescents must have parental consent
for medical evaluation and treatment, except in relation to sexual health and mental health.
The resident’s best option is to:
CLINICAL
SYNTHESIS
Case A: A 9-year-old boy who derives from a
distinct ethnic minority group is brought to treatment by his parents because of his oppositional behavior. The father reports using corporal punishment
as a means of disciplining his son. The therapist, who
is not familiar with the culture and values of the
family’s ethnic group, tells the father that corporal
punishment has not proven to be an effective form of
discipline. The father informs the therapist that
corporal punishment is part of the ethnic group’s
tradition of disciplining children.
What best describes the therapist’s ethical obligation(s)?
A. Contact a legal representative regarding the
appointment of a guardian for the patient
B. Contact the state child protective services to
report that the patient was left at the clinic
without parental supervision
C. Tell the patient that the visit must be rescheduled for a time when her mother can be present
D. Assign a staff member to act as the patient’s
guardian during the evaluation
E. If the patient agrees, start the evaluation even
though the mother is not present
Laws regarding adolescent medical and mental
health care and parental consent vary from state to
state. In many localities, advising adolescents about
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ETHICS COMMENTARY
specific topics such as contraception and sexually
transmitted diseases does not require parental
consent for evaluation and treatment. When parental consent for treatment is needed, it may be
demonstrated in a number of ways: if the parent
participates in the medical visit, sends the teen with
written permission for treatment, or gives consent
by telephone. In this case, by registering the patient
and leaving her in the waiting room, the mother’s
action may be viewed as giving implied consent
for the visit to proceed without her presence. The
patient can also give assent to the visit: a 16-yearold can be expected to say whether he or she prefers
to wait for the parent to return and to be able to
give a relevant and adequate medical history (4, 5).
Answer: E
Case C: A 6-year-old child is brought to a psychiatrist for individual psychotherapy. The child
states that he does not want to see the psychiatrist,
that he does not want to be in therapy, and that he is
coming only so that he will not “get into trouble”
with his parents. The psychiatrist continues the
psychotherapy.
What is the best ethical justification for the psychiatrist’s continuation of treatment despite the
patient’s lack of agreement?
A. The child is not being physically forced to
come
B. The child is unlikely to be developmentally
capable of free and autonomous informed
consent
C. The child’s oppositional behavior demonstrates the need for therapy
D. The psychiatrist has specialized knowledge
about what is best for the child
E. There is no ethical justification for the treatment of this child
It is always important to respect children who are
patients and to attempt to obtain their assent for
treatment. However, the capacity to make treatment
decisions in a truly free and autonomous manner is
tied to the developmental stage of the child. At 6 years
of age, a child does not have the cognitive capability
for his consent to be informed. Through the developmental trajectory, the cognitive capacities
grow, and obtaining a child’s assent and eventually
consent becomes more and more important. The
same statements about therapy made by a 16-yearold should be given much greater weight (6, 7).
Answer: B
The parents of a 14-year-old girl want her included
in a research study that is investigating a new
medication that may or may not offer modest benefit
for diabetes and that involves numerous blood draws.
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The parents sign the informed consent form. The
girl, however, does not wish to participate in the
study.
What should the researchers do?
A. Enroll the girl because she is a minor and legally unable to provide informed consent
B. Enroll the girl because the legal guardians
consented to her participation
C. Enroll the girl without informing her of her
participation
D. Not enroll the girl because she did not provide her assent to participate
E. Not enroll the girl because she is decisionally
impaired
Guidelines from the U.S. Department of Health and
Human Services stipulate that in addition to receiving
parental permission for a minor child to participate in
research, investigators must obtain the assent of the
child before he or she can be included in the research
protocol. Information about the research needs to be
presented to children in a manner that is congruent to
theirageandlevelofcognitivedevelopment.Assentmust
be communicated in the form of an affirmative agreement;children canthereforeveto their own participation
(8–10).
Answer: D
REFERENCES
1. American Psychological Association: Guidelines for Providers of
Psychological Services to Ethnic, Linguistic, and Culturally Diverse
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1990
2. American Psychological Association: Guidelines on multicultural education,
training, research, practice, and organizational change for psychologists.
Am Psychol 2003; 58:377–402
3. Gibbs JT, Huang LN: Children of Color: Psychological Interventions with
Culturally Diverse Youth. San Francisco, Jossey-Bass, 1998
4. American Psychiatric Association: Ethics Primer of the American Psychiatric
Association. Washington, DC, American Psychiatric Association, 2001a
5. Beauchamp TL, Childress JF: Principles of Biomedical Ethics, 5th ed. New
York, Oxford University Press, 2001
6. Hurley JC, Underwood MK: Children’s understanding of their research rights
before and after debriefing: informed assent, confidentiality, and stopping
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7. Nurcombe B: Malpractice, in Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd ed. Edited by Lewis M. Philadelphia, PA, Lippincott
Williams & Wilkins, 2002
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Graham P, Zametkin A, Castellanos FX, et al: Ethical issues in biological
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