IACAPAP Textbook of Child and Adolescent Mental Health

Section A
INTRODUCTION TO CHILD &ADOLESCENT MENTAL HEALTH

William H. Johnson: Folk Family. Smithsonian American Art Museum, Washington, DC

IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

A.1

INTRODUCTIONETHICSAND
INTERNATIONAL CHILD AND
ADOLESCENT PSYCHIATRY
Adrian Sondheimer & Joseph M Rey

Hippocrates Refusing the Gifts of Artaxerxes I
Anne Louis Girodet de Roucy-Trioson (1792)

Adrian Sondheimer MD,
FAACAP
Division of Child andAdolescent Psychiatry, SUNY
at Buffalo School of Medicine,
Buffalo, NY, USA.
Conflict of interest: none
declared

Joseph M Rey MD, PhD,FRANZCP

Professor of Psychiatry, Notre
Dame University Medical
School Sydney; Honorary
Professor, University of Sydney
Medical School, Sydney,
Australia
Conflict of interest: none
declaredThis publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Sondheimer A, Rey JM. Ethics and international child and adolescent psychiatry. In Rey JM (ed), IACAPAP
e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied
Professions 2012.

Ethics A.1

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IACAPAP Textbook of Child and Adolescent Mental HealthIn a thoughtful and deliberate move, the opening chapter of the first IACAPAP
textbook of child and adolescent mental health focuses on the relationshipbetween ethics and the field. While this chapter focuses on medical practitioners,
most of the ethical issues discussed apply to all mental health professionals (e.g.,
psychologists, social workers, nursing personnel, therapists) treating children andadolescents. Unless otherwise specified, “child” is used to mean all people younger
than 18 years, “parent” represents parents and guardians, “child psychiatrist” means
child and adolescent psychiatrists, and “child psychiatry” means the discipline ofchild and adolescent psychiatry.
Child psychiatry is a subspecialty of psychiatry, and psychiatry is a medical
specialty. The profession of medicine is intrinsically designed to do battle withwhatever ails the human body and mind, and it attracts practitioners who are so
inclined. If one were to define ethics as that intellectual line of inquiry focusing
on the rightness and wrongness of human behaviors (American Heritage New
Dictionary of Cultural Literacy, 2005) then medicine is an exemplar among theprofessions in that, as a vocation devoted to benefitting both the individual andcollective human condition, it is founded and based on trying to do “the rightthing”. Thus, the medical profession and its practice seem clearly based on an
ethical perspective. If only, however, matters could be viewed so simply. In fact,
the study of ethics most commonly focuses on the complexities of the humancondition which, by definition and experience, is usually composed of gray,complicated and murky areas. Only rarely does an ethical inquiry seem to offer
stark black and white contrasts. That makes the examination of ethical questions
interesting.
Psychiatry, more than any of the other medical specialties, attempts to focus
equally on mind and body (Slavney, 1993). Ideally the specialty strives to integrate
the two, as their functions are both mediated by the brain. Thus, psychiatry’s
perspective embraces the individual patient’s cognitive, affective, interpersonaland behavioral processes, while simultaneously functioning in familial, social,
cultural, economic, religious, educational and political contexts. Child psychiatry,a subspecialty of general psychiatry, focuses on individuals spanning the ages of
infancy through adolescence, with many practitioners extending that range throughyoung adulthood. The development of the child implies growth and maturationin various spheres, including the physical body, cognitions, affects, behaviors, andabilities to judge situations. Insofar as children have not as yet attained adultcapacities in these areas, they require the protection and nurturance of guardians.
In the main parents fill that role, but at other times familial relatives, government
agencies, or other designated individuals provide the settings for youngsters tomature. Unlike their counterparts who limit their work to the treatment of adultpatients, child psychiatrists usually devote their efforts not only to the youngsters
but to the caregiving adults as well, who often provide information that the childis unable or unwilling to do. Working with two generations and their interactions,however, often provides witness to mutual conflicts which, in turn, can trigger
ethical dilemmas.

“Of moral purpose
I see no trace in
Nature. That is anarticle of exclusively
human manufacture –and very much to ourcredit”
Thomas HuxleyThomas Henry Huxley(1825-1895) by Carlo
Pellegrini ("Ape") 1759-1840.
Dibner Library, Smithsonian
Institution.

ETHICS AND THE LARGER CONTEXT
Theoretically, solutions to ethical quandaries would be distinguished fromother responses to these dilemmas by two distinct features. First, the solutions

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IACAPAP Textbook of Child and Adolescent Mental Healthwould be universalizable, i.e., arrived at independent of the circumstances inwhich they emerge and thus applicable in all contexts. Secondly, these objective“universalist” resolutions would trump personal and group motivations.
But, in fact, are these assertions axiomatic? In order to arrive at a wellreasoned and just resolution, in contrast to the judicious or prudent one, can
one legitimately ignore context, be it political, economic, cultural or religious?
On the face of it, that would seem unlikely. When contrasting, for example, theenvironments in which citizens of technologically-advanced democracies live withthose of poverty-ridden, war-dominated, totalitarian autocracies, it is difficult toimagine applying identical ethical reasoning approaches in both settings and arriving
at identical resolutions. Adding to the confusion are countries that have mixes ofthese elements, e.g., those whose current economic development may outstrip thatof the established industrialized democracies but whose political architectures arelargely dominated by “top down” perspectives. Stark examples of contrasts facing
child psychiatrists serve to illustrate this: the luxury of the ethical dilemma ofwhether to prescribe a proprietary medication rather than a generic one, when forprofit insurance companies or government-approved formularies bring pressure on
the child psychiatrist to prescribe the latter, contrasting with a child psychiatrist’s
desire to prescribe an antidepressant – any antidepressant – in a country thatlacks many basic necessities, not to mention an adequate supply of psychotropic
medications; the ethics of resisting the subtle pressure of a prosecutor’s office to“waive” a juvenile offender’s family court case to adult criminal court versus thethreat from a government’s military arm of a child psychiatrist’s loss of livelihood,or worse, should a child psychiatrist refuse to admit a psychiatrically healthy
individual, who has run afoul of political or police officialdom, for treatment toa psychiatric hospital (LaFraniere & Levin, 2010); the ethics of providing care toa recently bereaved child, surrounded by loving relatives with adequate or better
financial resources, versus the provision of care to orphans, whose parents and adultrelatives were murdered by a warring faction, now sheltered and living together ina youth dormitory (Stover et al, 2007; Williamson et al, 1987).
Writing about the ethics of child psychiatry with an international
perspective means considering an enormous range of administrative, political,
religious, cultural and economic contexts (Leckman & Leventhal, 2008). Do
these stark differences in turn imply that ethical reasoning should be approacheddifferently depending on context? In theory, the answer is no. It would appear
that identical reasoning methods ought to be used in all contexts. The settings,
however, most definitely need to be considered in the attempt to arrive at the mostuseful resolutions, and those considerations might well result in contrasting final
choices in seemingly similar cases.

HISTORY OF CHILDHOOD
Optimal development of children is crucial to all societies, as the offspring
will become the societies’ adults who, they hope, will carry on the groups’ traditionsand values. According to predominating views of Western history, after infancy,
children were viewed for millennia as little adults (Aries,1962; DeMause, 1974).
They were considered the property of their parents who, in return for providing
the youngsters with food and shelter, were entitled to the proceeds of their labor.
Inklings of the need for education, beyond that of vocational apprenticeships,

Ethics A.1“I think we ought always
to entertain our opinionswith some measure of
doubt. I shouldn’t wish
people dogmatically tobelieve any philosophy,
not even mine”
Bertrand Russell

Bertrand Russell (18721970)
andsuchandsuch

It would appear that
identical reasoning
methods ought to be
used in all contexts. The
settings, however, mostdefinitely need to beconsidered in the attempt
to arrive at the most usefulresolutions, and thoseconsiderations might wellresult in contrasting final
choices in seemingly similarcases.

3

IACAPAP Textbook of Child and Adolescent Mental Healthbegan to be felt during the 17th century. Accompanying that development,
conceptualization of childhood as a stage of human development separate fromthat of adulthood began to emerge. During the past 100+ years, concentration on
childhood as a unique developmental stage has proceeded apace. During this timelaws have been established mandating school attendance, protecting against childlabor, facilitating and supporting the functioning and health of families, creating
juvenile justice systems with unique approaches to legal procedures, and mandating
reports of the abuse and/or neglect of children to governmental authorities (Enzer,
1985; Graham, 1999). As governments progressively took on responsibilities
for children’s welfare, the medical profession similarly evolved. Pediatrics first
appeared as a specialty in the late 1800s; child psychiatry, as a subspecialty ofpsychiatry, began to emerge in the 1930s/40s (Musto, 2007). In the USA, theAmerican Academy of Child Psychiatry was founded in 1953. During the past
half-century, childhood itself has been subdivided more narrowly, while expanding
its purview to now include the stages of infancy, toddlerhood, preschool, schoolage, and adolescence (this last time frame further subdivided into early, middle andlate stages). Thus, the conception of childhood has evolved over time from that ofa relatively undifferentiated mass to the current one of substantial differentiation,
distinguished by narrow age spans and differing needs and abilities. While all
the stages share in common the requirement for adult-supplied nurturance, thesefine-tuned differences, as will be seen later, often play a significant role in ethicalconsiderations.

“Ethics is knowing thedifference between
what you have a rightto do and what is rightto do”
Potter Stewart

Potter Stewart (1915-1985)
was an Associate Justice of
the US Supreme Court

PROFESSIONALISM AND CHILDREN
Medical ethics comprises a large subset of medical professionalism. The
concept of professionalism extends beyond matters directly affecting patient care,and speaks to the general comportment of the physician (Gabbard et al, 2011;
Wynia et al, 1999). As much of a physician’s behavior affects patient care, indirectly
if not directly, the boundaries between ethics and professionalism can become
hazy. Taking a broad view of the child psychiatry practitioner, child psychiatrists
possibly are attracted to their work with children because they sense a vulnerability
in youngsters that draws on their latent desires to nurture, protect, and educate.
While those factors undoubtedly work in the youngsters’ favor by facilitating goodpatient-doctor relationships, the potential pitfalls in those relationships also are
many. For example, practitioners may find themselves physically or emotionallyattracted to patients’ guardians or to the patients themselves; indulging in rescue
fantasies; feeling the urge to provide special favors for specific patients or theirfamilies; or desirous of soliciting patients’ families for funding of designatedprojects. While such thoughts and fantasies should be understood as not unusual
accompaniments of practice, acting on them in ways that prove deleterious to thepatient would be unprofessional. By contrast, as the cardinal principle of ethicalmedical practice, the child’s safety, welfare and interests must be the practitioner’s
paramount concern. Such a principle mandates that, under no circumstances,
should a child psychiatrist exploit a child patient or the child’s relatives by violating
professional boundaries. These boundaries are both literal and figurative limits,created precisely to forestall such behaviors (Gabbard & Nadelson, 1995; Schetky,1995). Instead, the child and its guardians should be able to expect, with certainty,
that the child psychiatrist will conduct all mutual exchanges honestly, transparently,
with integrity and fidelity.

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IACAPAP Textbook of Child and Adolescent Mental Health

CODES OF ETHICS
Throughout the millennia of existence, all human societies have designatedcertain citizens as its healers. More recently, these individuals were titled its
physicians, or doctors. Throughout these many centuries, the medical practitioners,
inhabitants of disparate societies situated in countries encompassing the entire
globe, have created innumerable codes of ethics to guide their professional
behaviors. The vast majority of these codes, despite emanating from societies
differing starkly from each other along ethnic, religious and geographic lines, sharecommon foci and concerns. Thus, the following principles are addressed in mostof the codes:••••

Primacy of respect for human life
Physician responsibility for the well-being of the patient
Admonition to help or, at least, do no harm; andAn emphasis on virtue and duty.

Attention is often directed as well toward these specific issues:
•
•
•
•
•
•
•

Equality of care independent of the patient’s financial standing
Expectation of setting appropriate fees
Employment of legitimate methods to establish diagnoses, including
clinical observation and sound reasoning
Consideration of whether, and when, to provide treatment; if treatment,
the employment of legitimate therapies
The confidential nature of the patient-physician relationship
Prohibition against sexual relationship between physician and patient;andImposition of punishment or sanctions in the event of inept technicalperformance or code violation.

International codes, adopted by medical organizations, initially appeared informal mode during the 20th century. The World Medical Association’s International
Code of Medical Ethics, first produced in 1949 and revised most recently in 2006,
outlines the general duties of physicians as well as their responsibilities to patientsand colleagues (World Medical Association, 2006). Emphasis is placed on theneed for competence, honesty, dedication, avoidance of bias and/or exploitation,
respect for confidentiality, collaboration, and, interestingly, the obligation ofphysicians to obtain care for themselves in the event of personal mental or physicalillness. Similar global thinking led to the establishment of several psychiatric codesand declarations on a pan-national scale. The World Psychiatric Association’s
Declaration of Madrid (1996), building on the prior Declarations of Hawaii(1977) and Vienna (1983), created international ethical standards and guidelines
for psychiatric practice (World Psychiatric Association, 1996). In addition to thediscussion of such basic elements as the practitioner’s responsibility to the patient,
the need to maintain knowledge of current scientific developments, protectionof participants in research, confidentiality, and maintenance of professionalboundaries, specific attention is also paid to prohibition of participation in
torture, death penalty, sex selection, and ethnic and/or cultural discrimination
procedures; avoidance of industry- and politically-induced conflicts of interests;

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IACAPAP Textbook of Child and Adolescent Mental Health

The Hippocratic Oath is an oath historically taken byphysicians and other healthcare professionals swearing topractice medicine ethically. It is widely believed to have been
written by Hippocrates or by one of his students.
A 12th-century Byzantine manuscript of the Oath (Wikimedia
Commons)

and the expectation that sound treatments must be based on valid diagnoses,
following the patient’s receipt of complete pertinent information and subsequent
provision of uncoerced consent. In 1989, the United Nations Convention on the
Rights of the Child, with the collective weight of the member countries behind
them, established the rights of children to survival, development, protection
and participation, including the rights to voice their views freely, be given
commensurate deference, and live with their families (United Nations, Centre for
Human Rights, 1990) (see Chapter J.7). The United Nations Convention on the
Rights of Persons with Disabilities (2006) emphasizes that respect and dignity are
to be accorded to disabled individuals of all ages, including children, and embraces
the psychiatrically ill, among many others (United Nations, 2007; Stein et al,2009). The document highlights nondiscrimination and equal access to healthcare, and emphasizes the right of all disabled individuals to equal inclusion in all
aspects of life and its fundamental freedoms. Despite the impressive provenanceof these declarations, it is obvious that their implementation varies enormously
among the signatory countries. That is to be expected, given grossly differingsystems of government. Reassurance, however, comes from the continuing global
ethically-based thrust in the direction of greater protections for children andthe disabled, and an increased awareness of forces that promote or impede theirimplementation. In 2006, the International Association for Child and Adolescent
Psychiatry and Allied Professions (IACAPAP) created guidelines and principles
for practitioners in its document entitled Ethics in Child and Adolescent Mental
Health, which in turn derived from IACAPAP’s resolution “Assuring Mental
Health for Children”, promulgated in 1992 and further revised in 1996 and2004 (IACAPAP, 2006). IACAPAP’s document itemizes basic ethical principles;

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IACAPAP Textbook of Child and Adolescent Mental Healthaddresses rights of both children and their parents/legal caregivers; reviews consent
and assent; and addresses topics including confidentiality, potential exploitation,
sexual encounters, honesty, involuntary treatment, gifts from patients or industry,
presentation of patient material in publications and professional meetings, research
ethics, multidisciplinary collaboration, and the association’s guidelines for its
acceptance of financial support.
The initial efforts and subsequent revisions noted in these various
declarations and guidelines are a function of circumstances and influences thatchange over time. The American Academy of Child and Adolescent Psychiatry’s(AACAP) Code of Ethics serves as an example. Promulgated initially in 1980,
revised slightly in 2007 and greatly in 2009, the Code reflects changes in medical
knowledge, modes of clinical practice, payments for services, understandings ofpsychological dynamics, and practices of the pharmacologic and manufacturingindustries that evolved over three decades (American Academy of Child andAdolescent Psychiatry, 2009). The most recent revision addresses, directly andcomprehensively, issues of third-party influence, expectations of publication of all
research study results – positive and negative, conflicts of interest, romantic and/or sexual entanglements with patients and their families, risks of research withchildren, practitioner self-aggrandizement, and expectations that practitioners
will have knowledge of the laws prevailing in the professional’s jurisdiction as
well as tensions that might exist between the law and ethical considerations. As
Beauchamp (2009) notes, “the law is not the repository of our moral standards andvalues”. By contrast, codes of ethics are guidelines for professional behavior andthey differ from laws by providing greater flexibility and choices of action. The
codes embody standards of professional conduct and the current AACAP code is an
example of one that clearly, rather than vaguely, indicates preferred behaviors. For
the practitioner who has questions about his or her own or a fellow professional’s
motivations, inclinations or behaviors, consultation with colleagues and referral
to a code’s guidelines are arguably the most useful and potentially helpful options.

CHILDREN, ETHICS, AND ETHICAL PRINCIPLESChildren and adults differ from each other in discernible ways. Children
are usually smaller, have narrower understandings of historical and external events,
are engaged in a continuous process of rapid development and maturation, andrequire protection by and nurturance from others. Children, however, are nota monolithic group – e.g., the toddler and the late adolescent differ greatly fromeach other in many of the above-cited spheres, even as they also share these traits
in common. Consequent to their ongoing dependence on adults, however, usually
they are legally regarded as minors. Thus, significant decisions, e.g., where andwith whom they will live, their ability to roam or travel, locales of secular andnature of religious educations, and access to medical care, all reside by law inthe hands of their parents/guardians. In countries endowed with effective legal
systems, the state has the legal right to intervene in such decisions only in the eventthat guardians are derelict in providing their children with the basic necessities,i.e., food, shelter and education, or are abusive of the youngsters under their care.
These seemingly “self-evident” and generally accepted legal rules are in fact basedon the employment of basic ethical understandings which in turn are combinedwith extensive knowledge of childhood development. While several approaches tomoral thought vie for supremacy (Bloch, 2007), fundamental principles undergird
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IACAPAP Textbook of Child and Adolescent Mental Healththe ethics of endeavors with children. Thus, the individual clinician is expected
to work toward outcomes that would prove best for the child (beneficence), avoid
practices that are likely to cause the child harm (nonmaleficence), grant respect forthe choices and wishes of the individual patient (autonomy) and treat all patients
under care fairly, equally, and with fidelity (justice). This same ethical structureholds for the creation of administrative approaches designed to provide care andprotection for large groups of children (Sondheimer, 2010). For example, whenplanning measures to foster improved mental health efforts in schools (Bostic &Bagnell, 2001; Brener et al, 2007), provide care for children traumatized by war(Betancourt, 2011; Panter-Brick et al, 2011), or innovate programs for juvenile
offenders (Holden et al, 2003), it is reasonable to expect that authorities would
design their efforts in such ways that the children experience benefit, are not hurt,
feel respected, and receive help and protection equally.
These sentiments and approaches envision the ideal, and some clinical andadministrative conditions might readily lend themselves to stark and clear rightor wrong choices. But reality generally presents conflicts that exist in shades ofgray. Viewing children along maturational continua is an obvious illustration.
Thus, what may be beneficial for a 16 year old (e.g., respecting the autonomousright to refuse treatment) may not be helpful for the recalcitrant seven year old.
Other gray area dilemmas commonly assert themselves as well. For example,
given differing perspectives between child and guardian, to whom does the childpsychiatrist defer, without ignoring the concerns of the other? When a group(e.g., a family) wants to pursue an agenda favored by the majority of its members,
is the minority’s dissenting view (not infrequently that of the child patient) to beaccorded respect, and how? When does the child psychiatrist pay attention to theneeds of an individual patient in the context of limited resources if, from a publichealth perspective, attention to the community’s needs could ultimately benefit
a greater number of patients? Often, the ethical principles employed to pursue
answers to such clinical or administrative questions conflict with each other, and areasoning approach must be employed to achieve a desirable resolution. Notably,
this process should never imply a pre-ordained outcome.

Often, the ethical principles
employed to pursue
answers to clinical oradministrative questions
conflict with each other, anda reasoning approach must
be employed to achieve adesirable resolution.

ETHICAL REASONING
Clinicians usually perform their work with patients without stopping toquestion the ethical bases of their actions. This makes perfect sense. The averagechild psychiatrist is conscientious, has received adequate training and, over time,acquired clinical experience, all of which foster the child psychiatrist’s provisionof good care in relatively routine fashion. On occasion, however, the childpsychiatrist is confronted with confusing or unsettling situations that leave thepractitioner feeling uneasy and uncertain as to how to proceed (Sondheimer,
2011). The child psychiatrist’s hesitation or discomfort could be due to, e.g., aparent’s request to order a urine toxicology screen for her adolescent child while
stipulating that the child not be informed of the test’s purpose; a child’s ambiguous
self-harm verbalization that leaves the child psychiatrist uncertain regarding thepatient’s potential safety; or, an agency’s innocent and appropriate request for
information about a child which, if divulged, might prove injurious to the patient.
When the child psychiatrist consciously focuses on, and does not ignore, his or her
own discomfort, the psychiatrist can use the sense of unease as a salient signal to

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IACAPAP Textbook of Child and Adolescent Mental Healthrecognize the presence of an ethical dilemma and the need for clear and discerning
thought.
The ethical reasoning process follows a consistent pattern. As ethics “is theenterprise of disciplined reflection on moral intuitions and moral choices” (Veatch,
1989), perhaps the most important step in the process is the initial recognition of
the presence of ethical conflict and an acknowledgment of the need for a response.
Commonly, this recognition follows the child psychiatrist’s almost instantaneous
affective response of unease or dread, itself followed by a fleeting desire to flee theproblem or to hand responsibility for its solution to a colleague. This responsecomes on the heels of the realization that none of the possible options forintervention stands out as strikingly superior to others, and all potential choices
inherently harbor problems. As soon as the “immature” responses pass, it becomesincumbent on the child psychiatrist to rationally examine the matter. Several
approaches are useful. In other than extreme situations calling for immediate
action, the child psychiatrist should temporize, ask questions, obtain information,and delay choosing an ultimate clinical or administrative option. The psychiatrist
is encouraged to reflect on the personal values he or she employs in the reasoning
process. Self-inquiry can lead to cognizance of the roles played by the childpsychiatrist’s upbringing, education, and nonprofessional personal experiences, forbetter or worse, in his or her considerations of the dilemma. Third, consultation
with colleagues is often helpful. While the problematic matter may be new to thechild psychiatrist, it is likely to have been encountered by colleagues or addressedin the professional literature. Further, it may help to include the patient andother pertinent principals in the discussion of the ethical conflict, in order thatthey contribute responsibility for the outcome. Finally, after employing the above
stratagems, the child psychiatrist should consider relevant choices and possible
consequences, while performing risk/benefit analyses on all. The four core aforementioned ethical principles, and the guidelines provided by the child psychiatrist’s
national and international codes of ethics, can aid in arriving at an ultimate choiceof action. This resolution often proves to be the least harmful, but not necessarily
the seemingly optimal.

The ethical reasoning
process follows aconsistent pattern... The
resolution often proves tobe the least harmful, but notnecessarily the seemingly
optimalSAFETY
Primum non nocere – above all do no harm – is a cardinal tenet of proper
medical practice (Smith, 2005). Translating its application to psychiatric care, thisfundamental rule emphasizes that the child psychiatrist’s paramount concern is thesafety of the child (patient). For example, the depressed child recently engaged insuicidal behaviors, whose self-harm ideation continues unabated, is best cared forin a psychiatric institution that provides close and constant supervision, despite
the actual and implied infringements on the youngster’s autonomy and freedomof movement. Another child, who is depressed but not suicidal, would likely
benefit from outpatient care while living at home with his or her family. In bothscenarios safety must be addressed as the primary concern, but the respective
potential threats to well-being are differentiated, resulting in treatment provision indissimilar settings. Parenthetically, ethical child psychiatric practice would requirethat the practitioner be fully aware of the legal protections available to the childthat are operative in the practitioner’s jurisdiction, in order that infringements on
the child’s rights are kept to a minimum.

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CONTEXT – CULTURE, HISTORY AND ECONOMICS
Context can play a significant role in ethical considerations as differing
cultures may regard similar behaviors differently. In the US, for example, the adult
who develops garbled and incoherent speech at her suburban, middle-class home,
whose previous similar episodes resulted in psychiatric hospitalizations, is likely toagain be hospitalized at her family’s urging; her similar-aged counterpart, engaged
in the same behavior while “speaking in tongues” in a rural, fundamentalist church,
is likely to receive solicitous and supportive responses from fellow worshipers.
Analogously, the child who verbally disputes a teacher’s provocative assertion in a“progressive” school, located in an industrialized society, is likely to receive plaudits
for her behavior; by contrast, the student living in a traditional tribal setting,challenging her elders by requesting education ordinarily not permitted to girls,
may well be seen as obstreperous, a discipline problem, or spiritually disordered(Robertson et al, 2004). These examples indicate that it is ethically incumbent
on child psychiatrists to bring awareness of context, or “cultural competence”(Bass et al, 2007; DeJong & Van Ommeren, 2005; Kirmayer & Minas, 2000), totheir clinical considerations. Similarly, available resources often play a significant
role. For example, where they are limited, largesse might be considered theinstitutionalization of a brain-damaged youngster, despite that support being
limited to custodial care. A more well-to do environment, by contrast, might
be able to provide a variety of educational, recreational and interpersonallystimulating resources, while simultaneously enabling the child to live at homewith his family. In each case, the ethically optimal intervention is utilized, but theavailable resources dictate different choices.
Knowledge of the history of psychiatry is yet another important factor in
ethical deliberations. Over the course of the past 100+ years, different large-scale
psychiatric movements have held sway. At distinct times psychoanalytic theory,
somatic therapies (e.g., electroconvulsive treatment, insulin shock, psychosurgery),pharmacotherapy, community psychiatry, systems theory, institutionalization,
deinstitutionalization, and both prevalent and fleetingly present psychotherapies(e.g., group, family, cognitive-behavioral, primal scream, milieu) have vied forvisibility with or primacy over the others. Frequently, the integration of several
modalities proffered simultaneously has proved most efficacious (The MTA
Cooperative Group, 1999; March et al, 2004), the opinions of single therapy
adherents notwithstanding. Recent changes in the scientific development of childand adolescent psychiatry have produced an intense current focus on molecular
influences and the nature of their interplay with the environment (Rutter, 2010).
National economic systems have also changed. Public and private funding of care,including health insurance and payments for clinics and programs provided byboth sectors, have varied over time, within and across national borders. Thesechanges constantly affect resources available for the psychiatric needs of children,
thus affecting ethical considerations. The gradual or sudden economic changes do
not alter the fundamental ethical reasoning approaches, but they do impact thebreadth and scope of the child psychiatrist’s available clinical considerations andchoices.

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ETHICS – THE GLOBAL AND THE PARTICULAR
Discussions of ethical dilemmas commonly focus on situations encounteredby clinicians during the care of an individual child and/or family. For thepractitioner, it is easiest to concentrate on and conceptualize one case at a time.
The application of ethical thought, however, embodies the universal, and initialconsideration of children from a global perspective is therefore in order. Studies
performed in disparate countries indicate a prevalence of mental disorders in 5%
to 20% of child populations (Giel et al, 1981; Malhotra, 1995; Patel et al, 2007).
Large numbers of children live as displaced refugees (Forbes, 1992), are homeless(Raffaelli & Larson, 1999), have become orphans due to the deaths of parents
from AIDS (UNICEF, 2000), and are victims of physical or sexual abuse. On
the occasions that well-structured epidemiologic studies are performed, significant
numbers of these children are found to suffer with stress-related, depressive, andanxiety-based symptomatology. The majority of these children live in resourcepoor countries, harboring few available trained mental health personnel. Beyond
addressing the needs of these youngsters for food, mental health and life skills
training of educators and primary care providers by child psychiatry consultative
personnel is arguably, from an ethical perspective, the most beneficial approachfor the children and their often clinically depressed mothers (Fombonne, 2005;
Graham & Orley, 1999; Lewis et al, 2001; Omigbodun, 2008).
Clearly, in resource-poor countries, the needs of the many are great. Child
psychiatry practitioners world-wide, however, tend to be found predominantly
in resource-rich environments. The ethical dilemmas they encounter mostcommonly arise in the context of care provision for a single child, while thedilemmas themselves are universal and transcend national boundaries. Issues ofassessment, diagnosis and treatment; assent/consent/dissent; parent-child conflicts;
confidentiality; agency; physician responsibility; boundaries; and advocacy, areamong many that deserve examination.

ASSESSMENT AND DIAGNOSISPrior to the advent of the third edition of the American Psychiatric
Association’s Diagnostic and Statistical Manual (DSM-3) in 1980, psychiatricdiagnosis in the US was often based on psychoanalytic musings ascribing etiologies
to disorders that were purported to stem from disturbed unconscious intrapsychic
processes. As these diagnoses were based on theoretical constructs and not on
consensually observed phenomena, diagnoses of individuals by the practitionersof those eras commonly conflicted. Furthermore, the “disorder” concept itself,
in the absence of biologic tests that might confirm diagnoses (contrasted with,for example, elevated glucose levels associated with diabetes mellitus; elevatedtroponins, elevated cardiac enzymes, and specific EKG tracings associated withmyocardial infarcts), raised the concern of “the eye of the beholder”. For example,
the disruptive behavior of a child might be viewed by different examiners as anormal variant, symptomatic of an oppositional or conduct disorder, or a reaction
to a stressor. Even with well-outlined diagnostic criteria, it is conceivable that
diagnostic disagreement could exist among conscientious clinicians, raisingquestions about the fundamentals of the diagnostic process and accurate definitionsof “illness” (Pies, 2007). The lack of confidence in psychiatric diagnoses and poor
diagnostic concurrence prior to the 1980s, coupled with fears of “labeling” andEthics A.1

11

IACAPAP Textbook of Child and Adolescent Mental Healthprevailing stigma associated with mental illness, led to a sizable number of vocal
proponents of diagnostic nihilism. In addition, the opprobrium earned by themisuse of psychiatric diagnoses for political purposes (e.g., the former Soviet
Union’s creation and employment of the novel diagnosis of “sluggish schizophrenia”
in order to forcibly hospitalize and treat political opponents of the regime against
their will) highlighted on an international scale the need for a considerably more
rigorous diagnostic consensus (Wilkinson, 1986).
The last 30 years, however, have witnessed consensual agreement bypsychiatric researchers on progressively more rigorous approaches to groupings ofobserved phenomena. These have led in turn to more carefully defined diagnostic
categories. Close collaboration between the consultants producing editions of theInternational Classification of Diseases (ICD) and subsequent DSM volumes has
been the rule, leading to considerable compatibility between these two “official”
versions of psychiatric diagnoses (Sartorius et al, 1993). Thus, the diagnostic
process has undergone a transformation permitting collaborators on transnational
studies to more comfortably assume that study subjects from countries other thantheir own satisfy the same inclusion and exclusion criteria. Cautions remain,
however, regarding inadequate sensitivity to culture-bound variables (Belfer &Eisenbruch, 2007; Van Ommeren, 2003).
Rigorous diagnostic criteria permit the development of treatments thatare tailored to specific diagnoses. When used in this fashion – for the good of
the patient – the diagnostic process clearly satisfies a cardinal ethical principle.
However, the potential problems of “labeling” and stigma remain as possibly
harmful to the child (Pescosolido et al, 2007). The practitioner has little control
or influence over how people, other than immediate family, might misuse thisinformation. Particularly in the current era of electronic transmission a diagnosis
theoretically could attach to an individual “forever”, and relatively unsophisticatedsocieties could become fearful of and devalue a child carrying a psychiatricdiagnosis. Ultimately, it is the child psychiatrist’s responsibility to provide an
accurate assessment and diagnosis in order to better the patient’s condition; follow
procedures guarding the confidentiality of written materials; and contribute to
the education of local societies concerning the prevalence of mental disturbance,
prognostic accuracy, treatment efficacy, and the need for familial and community
support (Rosen et al, 2000; Thara et al, 2001).
In recent years, the US has witnessed a striking increase in the incidenceof childhood autistic and bipolar disorders. While it appears that, in both cases,
these increases are due to a combination of closer scrutiny and greatly expanded
diagnostic definitions of these disorders, these developments remind that scientificprogress does not occur without struggle, controversy, conflict and mistakes(Angell, 2011; Carey, 2007; Kim et al, 2011; Moreno et al, 2007). In the course of
proposed and revised definitions, some children might receive a diagnosis in error
while others may benefit from expanded criteria. In addition, increased awarenessof the diagnoses of childhood ADHD and bipolar disorder in the international
domain may be related to heightened professional education and sensitization ofpractitioners to these disorders, promoted in part by pharmaceutical companies.
Their efforts might well be motivated by the desire to provide benefit to a previously
undetected but substantial number of affected children; that the companies
stand to gain financially from the marketing of relevant medications in new andEthics A.1

Child psychiatrists should
be mindful of various
influences that could playroles in the diagnostic
process, while maintaining
awareness that their efforts
will significantly impact thenear- and possibly longerterm futures of their childpatients.

12

IACAPAP Textbook of Child and Adolescent Mental Health

When Rebecca Riley died in December 2006,
pediatricians and psychiatrists in the US and across theworld were already debating whether preschoolers likethe 4-year-old Hull girl could be diagnosed with bipolar
disorder and attention deficit hyperactivity disorder(Lambert, 2010). In a lawsuit settlement, the Medical
Center defendant agreed to pay $2.5 million to the estateof 4-year-old Rebecca, who died of an overdose of
medications, prescribed by a psychiatrist, and over-thecounter remedies (Baker, 2011).
“Riley… was exceptionally young when she wasdiagnosed [with bipolar disorder], just 2½.” “Rebecca
was prescribed an antipsychotic medication, a drug
used to treat bipolar disorder in adults, and a blood pressure medication that is sometimes
used to help hyperactive children sleep.” “The psychiatric controversy is over diagnosing
children before their teen years. There is virtually no scientific research on children
younger than 6” (Goldberg, 2007).

emerging markets is also a pertinent factor. In the end, it is incumbent on childpsychiatrists to perform their diagnostic work accurately and with care. They
should be mindful of various influences that could play roles in the diagnostic
process, while maintaining awareness that their efforts will significantly impact thenear- and possibly longer-term futures of their child patients.

TREATMENTS – SOMATIC AND VERBAL
Treatments of the individual child, when indicated, should follow anadequate diagnostic process. Leaving preventive efforts aside momentarily,
the current psychiatric knowledge base is limited to the provision of somaticor psycho- therapies or, often ideally, both. Treatment provision, however, isfrequently limited by the locale, surrounding culture, resource availability, andpractitioner knowledge. It is incumbent on practitioners to be aware of available
resources, the degree of psychological flexibility or rigidity of the individuals to
who they provide care, the harm that might befall a child if care is not provided,
and the limitations of their own knowledge. The last factor is best dealt with by
consultation and possible collaboration with professional colleagues.
Evidence-based medicine should function as the primary foundation forprescribed treatments, but due to a lack of extensive studies focused on children
it has limited reach. Studies indicate that certain chemical classes of medications
are useful for specific disorders – e.g., stimulants for ADHD; mood stabilizers
for bipolar disorder; selective serotonin reuptake inhibitors for major depression
and obsessive-compulsive disorders. Such pairings hold similarly true for certain
psychotherapeutic approaches, e.g., cognitive-behavioral therapy for phobic
disorder; inpatient psychiatric milieu treatment for severe suicidal behavior/
ideation. But variability and blended treatments are the norm in the provisionof verbal therapies. As well, treatments frequently prove culturally and locale
dependent. A recent study of the diagnosis and treatment of ADHD in three
resource-rich countries serves as a good example, as it found great differences
between the nations with regard to incidence, views of illness severity, andtreatment approaches (Hinshaw et al, 2011). Other studies produced findings
strongly suggestive of benefits that accrue when psychotropic medications andEthics A.1

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IACAPAP Textbook of Child and Adolescent Mental Healthpsychotherapy are both provided in tandem, in contrast to just one or the other,though the ability to provide the two is conditional on the presence of available
resources and personnel (The MTA Cooperative Group, 1999; March et al, 2004).
Not infrequently, ethical concerns about somatic and verbally-mediatedtreatments are approached as if they present dissimilar dilemmas when, in fact,
similar concerns apply to both. They each have the potential to produce benefit
or harm; risk/benefit analyses should precede the choice of either or both; thepotential for uncalled-for clinician aggrandizement is inherent to the provisionof either; and the inept provision of the one or the other could easily cause harm.
Psychotropic medications, electroconvulsive therapy, and complementary or“natural” medicines all may directly impact developing brain structure, cerebral
neurotransmitter receptor complexes, and other body organ systems. The more
immediate potential side effects are well-recognized, but the possibility of unleashinglong-term ill effects is unclear. Similarly, beneficial or poor psychotherapeutic careis likely to have obvious positive or negative near-term psychological impact, while
the long-term effects on psychological functioning, via cognitive incorporation of
the experience, is difficult to determine.
Off-label prescribing of medications is common in child psychiatry practicedue to the paucity of relevant child-based studies (Baldwin & Kosky, 2007;
Bucheler et al, 2002 ; Efron et al, 2003; Hugtenburg et al, 2005). Its consequentpotential for benefit or harm is uncertain and variable. Examples include alphaagonists used as second-line treatments for ADHD; neuroleptics used to treat severe
disruptive behavioral presentations; and the use of lithium, anticonvulsants, andneuroleptic medications in the treatment of vastly increased numbers of patientsdiagnosed, in the recent past, with bipolar disorder of childhood. Similarly,
the application of a single psychotherapeutic modality for a range of disorders;difficulties in psychotherapy provision due to a diminished emphasis in training(Tucker et al, 2009); focus on the individual patient at the expense of the family or
vice versa; and incorporation of corporal rather than structured restraint methods(even in the context of cultural approval of the former) are all examples of verballyand environmentally-mediated therapeutic impediments or approaches that could
have deleterious impact on some children while nevertheless benefitting others.
The innovations and the liabilities contribute to the development of the fieldby adding to its knowledge base, as they underscore the need for ever-improved
training and expansion of the treatment armamentarium. Simultaneously, theyhighlight the limits of the profession’s expertise and the need to rein in diagnostic
and treatment hubris.
In addition to remedies for diagnosed psychiatric illness, preventive treatment
approaches warrant comment (Layne et al, 2008; Sanders, 2002; Silverman et al,2008). While numerous studies describe treatments of post-traumatic disorders
in children, stress inoculation training was designed to block post-traumatic stressresponses by its introduction in advance of anticipated stress-inducing situations.
Studies describe teacher-mediated group interventions, guided by the instructionof child psychiatrists and other mental health professionals, that employ the stressinoculation training goals of fostering resiliency and psychological strength ingroups of children who formerly experienced trauma en masse (Wolmer et al,2003). While these studies raise an ethical concern, i.e., the withholding of aputatively therapeutic intervention for students comprising the control groups, it

Ethics A.1

Off-label
Off-label prescribingmeans prescribing a
medication for a conditionor age group or using aform of administration(e.g., oral, parenteral) notformally approved by theappropriate regulatory
agencies (e.g., FDA,
EMEA). This may vary fromcountry to country.
Off-label prescribing of
medications is common inchild psychiatry practicedue to the paucity of
relevant child-based
studies. Its consequentpotential for benefit or harm
is uncertain and variable.

14

IACAPAP Textbook of Child and Adolescent Mental Healthappears that child psychiatry involvement in the training of the educators clearlycreated benefits for the treated youngsters. When preventive and potentiallytherapeutic undertakings are performed in this manner, larger numbers of children
are likely to obtain benefit than would otherwise be impacted in after-the-fact
one-to-one care. This approach adheres to the ethical principle of social justice,i.e., by providing benefit to the many in essentially equal fashion. It also provides
a clear contrast, in the child setting, for the ethical thought underlying publichealth models of care with the more traditional perspective of care provision for
the individual.

ASSENT, CONSENT, DISSENT AND AGENCY
Assessment, diagnosis and treatment should, with the exception of
emergencies, be performed solely with the assent of the child and the consent of
the parent/guardian. Legal systems in many countries distinguish between themental capacities of children and adults, though the chronological age defined as
dividing the one stage from the other may vary between different jurisdictions andwithin nations. Adults are defined as individuals competent to make decisions forthemselves and those for whom they are designated as having primary custodial
responsibility. Consequently, only they can give consent for treatment of thechildren under their care (Macbeth, 2002). Children, by legal definition, areperceived as lacking the necessary competence to give consent, but they have thepsychological capacities to voice assent or dissent (United Nations Centre for Human
Rights, 1990), though how meaningful assent can be assessed is open to question(Koelsch & Fegert, 2010). When parents desire treatment for their child, and thelatter assents, psychiatric care ordinarily proceeds without a hitch. However, it is
not unusual for parent/guardian-child conflicts to exist about the need for care,with the parent commonly asserting that need while the child resists or refuses
outright. It is universally understood that the safety of the child dwarfs all otherconsiderations, thus supporting professional decisions that may abrogate a child’s
autonomy rights. Typical scenarios include the suicidal youngster or the physicallyand mentally debilitated anorectic adolescent, psychiatrically hospitalized against
their wishes.
It is always incumbent on the child psychiatrist to consider the degree of
emotional development and cognitive maturation of the child in question. For
example, an oppositional eight year old, who frequently engages in physicallyassaultive behavior in the school setting, might be brought by parents for a psychiatricevaluation against his will. By contrast, the 17 year old who upsets her parents, byrefusing to attend a religious rite, would not seem to require professional services
and, rather, her dissent from participation in a proposed psychiatric evaluation
would appear to warrant respect and deference. In sum, a child’s chronologic age,degree of cognitive and emotional maturity, and concerns about his or her safety
require evaluation when weighing the degree of respect to be paid to the youngster’sautonomous decision-making capacity. These considerations contribute in turn tothe child psychiatrist’s goal of choosing the most beneficial approach to a clinicalsituation. (Parenthetically, it should be noted that similar deliberations prevailwith regard to children who might be involved as subjects in psychiatric research,
an issue discussed in the research section below).

Ethics A.1

Age of consent
In most countries, the ageof majority is 18 (although
it fluctuates between 14
and 21). Age of majority iswhen the law recognisesthat minors cease to beconsidered children (andthe responsibility of theirparents) and assume
control over their own
persons and actions.
However, in some countries(e.g., Australia, UK), minors(people younger than 18)
are able to consent totreatment and to participate
in research from the age of
16 or even earlier (“matureminors”). See also Chapter
J.3.

15

IACAPAP Textbook of Child and Adolescent Mental HealthChild psychiatrists often field requests or demands from a variety of playerswith stakes in clinical outcomes. For example, child psychiatrists providing careto juvenile offenders, who were living in foster care prior to placement by the
judicial system in a psychiatric facility, will likely field inquiries and demands
from involved courts, social service agencies, hospitals and residential treatment
facilities, the offending children and their biological and foster families. Often,
each entity will have differing and possibly opposing goals and objectives. It is
likely that the child psychiatrist would feel a degree of obligation to all – in ethicalterms, the psychiatrist could experience a crisis of agency, i.e., to which of these
entities does one owe allegiance? Ultimately, the principle and concept of fidelity
dictates that the child psychiatrist’s primary responsibility and charge is to engage
in advocacy for the patient, by pursuing the best or least detrimental outcome
for the youngster. Often, that result requires the child psychiatrist to facilitatecommunication among the various interested parties and possibly to mediate
between them. The child psychiatrist’s major ethical obligation, however, is to
advocate for the patient’s interests.
Parents, and countries, periodically engage in highly authoritarian stances.
An illustration on the family level is parents who blame their child for familial
dysfunction, refuse to engage in family therapy, and subsequently “solve theproblem” and defuse the situation by sending the child to a boarding school(Salinger, 1951). An example on the macro level is the city administration that
expels a large number of its residents, including the “unstable” mentally ill, topoints unknown, describing the citizens as threats to public safety (Spegele, 2011).
In both cases, the autonomy rights of relatively defenseless individuals are ignored.
Of course, forces exist that are beyond a child psychiatrist’s ability to control, but
the child psychiatrist as advocate can give professional voice to those interventions
more likely to be respectful of individual choice and to produce clinically better
outcomes for both small and large groups of patients.

CONFIDENTIALITY
Ordinarily, individuals are accorded privacy rights, implying that they control
ownership of their personal information. When such material is communicatedto physicians in the course of evaluation or treatment, the physician is ethically(Winslade, 1978) and legally (Simon, 1987) obligated to regard the informationas confidential, not to be revealed to anyone without the patient’s, i.e., the owner’s,
permission. Such professional behavior is respectful of a patient’s autonomy, andavoids the harm (nonmaleficence) that would easily ensue, directly to the patientand indirectly to the therapeutic relationship, should a deliberate breach occur.
Maintenance of confidentiality under all circumstances, however, is not an
inherent good – such rigid devotion to the concept could conceivably cause harm.
Several matters warrant consideration. First, differences between adult and childcognitive abilities suggest that adults have achieved a cognitive maturity that children
only attain following continuous maturation through adolescence. Thus, children
are perceived as lacking the breadth of understanding presumably available to adults– in the current instance, a solid understanding of confidentiality rights and their
possible limits. Consequently, just as children, using identical reasoning, cannot
legally consent to treatment, only their adult guardians can consent to the release ofchildren’s confidential information to third parties. Second, children’s psychiatric

Ethics A.1

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IACAPAP Textbook of Child and Adolescent Mental Healthtreatments are most commonly initiated by parents or guardians, presumably with
beneficent intent. The parents naturally desire feedback from the physicians about
their children, may themselves be directly involved in the treatment, and often
express their rights to access information about their children, including possibly
confidential material. Third, an understanding of confidentiality, its desirability
and its benefits, develops gradually, concomitant with the child’s developing senseof autonomy. The preschool and early school-age child would likely be shocked
and upset if a practitioner did not provide pertinent information to her parent on
the grounds of guarding the child’s confidences. For a practitioner to do so could
well upset the emotional stability of the patient. It is only as the child maturesthat it becomes more likely for the child and adolescent psychiatrist to hear patient
requests that specific material not be divulged to the parent.
Most commonly, such parent-child struggles over information control
come to the fore during adolescence. Adolescents often raise issues that conflictwith prevailing parental or societal attitudes and mores or provoke safety concerns.
Rhetorically, how is the child and adolescent psychiatrist to address a patient’s
expressed intent to break into a school’s computer system; engage in forbidden
sexual activity; experiment with illicit drugs; break curfews; venture with friends
into unsafe communities; or engage in covert, potentially dangerous, politicalactivity? Such instances sorely test the clinical muscles of the practitioner, and theinternal conflict of respecting or violating the patient’s autonomous confidentiality
rights is placed front and center.
Several principles hold sway. Safety considerations are foremost. Shoulda psychiatrist perceive an adolescent’s imminent threat of danger to self or others,
adherence to confidentiality must be violated and guardians or other protective
entities informed in order to ensure maintenance of the patient’s life and safety ofthe environment. Short of such frank expressions of suicidal and homicidal intents
or behaviors, gray area situations, involving the potential for varying degrees ofrisk (Ponton, 1997), call for a sensitive evaluation of circumstances with, at best,
uncertainty concerning the maintenance or violation of confidentiality rights.
In addition, practitioners can best aid their patients by avoiding entrapment
by rigid rules regarding the observation of confidentiality rights. Rather, adoption
at the outset of a family- versus an individual-based treatment approach, with“mutual trust” rather than the administration of paternalistic advice serving as
the underpinning for the therapeutic relationship, encourages the use of reason,
persuasion, tact, and clinical judgment to dictate the degree to which confidential
information might be transmitted, if at all, and by whom. Similar collaboration
is called for with children and their parents concerning the nature and content of
written material to be transmitted to agencies and other care providers. Caution
is indicated in light of concerns regarding the potential longevity of such material(Alessi, 2001), as well as its occasional inappropriate release to unintended
recipients (e.g., Conn, 2001), both of which should be discussed with the patientand guardian.
Traditional families, living in resource-poorer settings or having immigrated
to resource-richer locales, often contrast with families in developed settings by
paying less attention to the autonomy of the individual child as they, by contrast,
put greater emphasis on the need for the youngster’s will to blend into the goals

Ethics A.1

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IACAPAP Textbook of Child and Adolescent Mental Healthand desires of the family’s or clan’s adults. In these families, the notion of a child’s
confidentiality rights may therefore experience great challenge. For example:“Anything my child wants to say can be said, and must be said, with me present –we have nothing to hide from each other.” Directly confronting such a stance by
trumpeting confidentiality rights is likely to end in a failure to persuade. Rather,acknowledgement of the parent’s desire for pertinent information while promoting
the potential benefits stemming from respect of individual autonomy, in a modelthat emphasizes the inclusion of all family members, is more likely to result inthe most efficacious and beneficent care for the child. In contrast to differingfamilies, a related study, determining the responses of psychiatrists in three
countries to confidentiality scenarios, revealed no significant differences between
the practitioners (Lindenthal et al, 1985).

RESEARCH
Because children cannot give consent by themselves, research involving
young people poses particular ethics challenges. Notably, there has been a growing
appreciation that it is in children’s best interests that good-quality research isundertaken – the lack of evidence about the effectiveness of many treatments inthe young has already been highlighted and extrapolating to children results foundin trials conducted in adult populations is not necessarily valid. To obviate thisproblem some governments (e.g., the US) provide financial incentives (e.g., byextending the patent period of a drug) if research in children is undertaken. This
notwithstanding, research in young people needs to carefully adhere to ethicalprinciples and requirements because of the risks of exploitation. These principles
are spelled out in a variety of documents anchored on the Nuremberg Code (whichcontains research ethics principles for human experimentation set as a result of the
Nuremberg Trials following the Second World War) and the 1974 Declaration of
Helsinki (Chapter J.7 in this book describes in some detail the implications forresearch of the United Nations Convention on the Rights of the Child, particularly
in low income countries and in communities enduring war or civil strife).

Click on the picture to access
IACAPAP’s declarations on
ethical practice

The IACAPAP’s Declaration of Berlin (2004) – Principles of Ethics inChild and Adolescent Mental Health (revised in Melbourne, 2006) – states that
“Informed consent to being a research subject should be based on the following
Principles:•

It is essential that clinical research involving human subjects is dedicatedto promoting health•

The well-being of the research subject has priority over the interests ofscience and society•

The performance of a research project involving human subjects
should be based on a clearly written proposal that is approved byan independent ethical committee which includes representatives ofparents and the law•

Participation is voluntary. Any subject can refuse or discontinue
participation without pressure, penalty or loss of benefit•

Children and adolescents may not have the capacity to give informed
consent to being research subjects. However, their assent must be
obtained. Assent should take into account the age, maturity andEthics A.1

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IACAPAP Textbook of Child and Adolescent Mental Healthpsychological state of the child involved. If the child is unable to giveassent, the “proxy consent” of a parent or legal guardian is required•

Informed consent requires a statement that a study involves research,and information about the purposes, duration and procedures of thestudy. It should include a description of the foreseeable risks anddiscomforts involved, and of the benefits to the subject expected as aresult of the research. Alternative treatments should be discussed•

Today much of the prescription of psychotropic medication in children
is “off-label”. There is an urgent need for pharmacological research inchildren. It is an ethical mandate that drugs be properly studied inchildren and their efficacy empirically established before they are widelyused. The results of clinical trials should be available to the public evenwhen the trial fails to establish effectiveness empirically. ‘No clinical
trial is finished until the data are made available’.”Research involving children as participants should always be reviewed
and approved by appropriately constituted ethics review committees; this isa requirement for publication in most scientific journals. In the US, Federal
Regulations specify the circumstances in which research with children may beapproved; i.e., if research:•

Does not involve greater than minimal risk•

Involves greater than minimal risk but presents the prospect of direct
benefit to the individual subjects. In this case the risk is justified by the
anticipated benefit and the relation of the anticipated benefit to therisk is at least as favorable to the subjects as that presented by available
alternatives•

Involves greater than minimal risk and no prospect of direct benefit toindividual subjects, but is likely to yield generalizable knowledge about the
subject's disorder if :−−•The risk represents a minor increase over minimal risk
The intervention presents experiences to subjects that arereasonably commensurate with those inherent in their actualor expected medical, psychological, social, or educationalsituations, and− The intervention is likely to yield generalizable knowledge
about the subjects' disorder which is of vital importance for theunderstanding or amelioration of the subjects' condition.
Research which presents an opportunity to understand, prevent, or alleviate
a serious problem affecting the health or welfare of children if:−−

The research presents a reasonable opportunity to further theunderstanding, prevention, or alleviation of a serious problem
affecting the health or welfare of children, andThe research will be conducted in accordance with sound ethicalprinciples.

The use of placebo has been more controversial in children than in adults.
While the need for placebo controlled trials is acknowledged, placebos should not
be used if there is risk of harm to participants or when an equally safe treatment
is available.

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IACAPAP Textbook of Child and Adolescent Mental Health

AssentAssent means (Committee on Bioethics of the American Academy of Pediatrics, 1995):•
Helping children gain a developmentally appropriate understanding of the nature of
their illness•
Explaining what they can expect (good and bad) with the treatment•
Evaluating children’s understanding of the situation, including whether they are being
inappropriately pressured, and•Seeking an expression of the child’s willingness to accept the treatment
In the case of participation in research, if children do not have a choice and their refusal
or dissent does not count, it should not be pretended that a requirement for assent is toprovide a choice. Children need to know if they do or do not have a choice. A requirement
for assent protects children from psychological or other harm. Children benefit from knowing
what will happen, having a say and being listened to even though they do not have the final
authority to make decisions. Seeking assent also respects the child as a person. Part of thatis to provide opportunities for children to develop autonomy. However, assent by itself is not
sufficient to authorise participation in research.

Click on the picture to access“Understanding Consent in
Research Involving Children:
The ethical Issues”

Dissent
Means that children’s objections and distress are taken into account even when the child isincapable of taking part in discussions or deciding. In the case of participation in research
trials, dissent does not function only at the point of enrollment. Dissent can be about a childwanting to withdraw from research.

Parents are the main decision-makers for their children, including
participation in research. Parental decision-making is a critical factor in the
study of pediatric research ethics, even though it is recognized that parents, aswell as researchers, may have interests that conflict with the best interests of thechild. The legitimate role of the child in decisions about research participationis also recognized. The ethical concept of assent provides a framework to assist
investigators and parents with efforts to incorporate the views of children who arerecruited as research subjects. Assent is analogous to consent where participants
have a reduced capacity to understand the matter to which they are assenting.
While the general principles about consent to research are widely accepted,
there are variations between countries and the issues become more complex inspecial situations. For example, in Australia and the UK minors can in somecircumstances consent to research without additional parent consent when thechild is “mature enough to understand”. When the young person is of developing
maturity and the risk of research participation is no more than discomfort and theaim is to benefit young people and there are additional good reasons not to involve
parents (e.g., some internet research), then minors can also consent. Moreover,parent’s consent is not always required, for example in situations where seeking
parental consent is inappropriate (e.g., if parents are neglectful or abusive) or offers
no protection (however, consent from another adult might be required if that adult
has responsibility for the child’s safety and wellbeing).
Another potentially troubling issue is whether it is acceptable to offer
money or benefits to children for participating in research and, if so, in which
circumstances (this only arises when cash or valuables are above reimbursementof expenses). Policies about rewards also vary between countries but it would beconsidered unethical if rewards could lead participants – or those deciding forthem – to ignore or significantly undervalue serious risks.

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IACAPAP Textbook of Child and Adolescent Mental Health

POTPOURRI
As ethical thinking undergirds the structure and practice of child andadolescent psychiatry in its entirety, the range of subjects potentially available fordiscussion is vast. The most salient have been addressed, and the topics that follow,
discussed in brief, are open to investigation in much greater detail.
Conflicts of interest
Third party influence has received considerable media attention in the
recent past, stemming primarily from the efforts of the pharmaceutical industry to
promote sales of its products, via overt and subtle subsidies and other inducements
to physicians (Schowalter, 2008). Such external attempts at influence are exerted
as well by health insurance providers, school system personnel, governmental
agencies, guardians, colleagues, and financial investors. Internal competingloyalties can stem from interpersonal rivalries, relationships, and intellectual
passions, resulting in biased rather than dispassionate judgments (Walter et al,2010). Commonly, these conflicts emerge in research and publication contexts aswell as interpersonal. In all instances, the child psychiatrist is obligated to prioritize
the welfare of the patient above the other interests competing for attention. The
child psychiatrist’s internal conflicting impulses are best handled via transparency,
honesty, notification, disclosure, self-examination and self-scrutiny. The acidtest is putting oneself in the patient’s place and examining the matter from thatperspective (Brewin, 1993).
Teaching, training and enforcement
The teaching of ethics is mandated by residency training accrediting
bodies (Dingle & Stuber, 2008). Topics commonly reviewed include advocacy,
consent/assent, agency, autonomy, research concerns, boundaries, confidentiality,
practitioner relationships with health care providers and industry, and therelationship and distinctions between ethics and the law (Sondheimer, 1998).

Authorship
The International
Committee of Medical
Journal Editors (2006)
explains that authorshipshould be based on all
the following criteria:• Substantial
contributions to thestudy’s conception
and design or
acquisition of dataor their analysis andinterpretation• Drafting the article orrevising it critically;and• Approval of the final
draft.
‘Guest’, ‘honorary’ or‘gift’ authorship are allconsidered unethical.
A guest author is one
who is knowingly
listed as an author to
influence reviewers or
to seek some benefit orprofessional favor.

Conflicts of interest
Conflicts of interest may be inevitable for clinicians because of the multiple
responsibilities and relationships that are part and parcel of medical practice. Being subject
to competing interests, however, is not necessarily unethical. Maintaining ethical practice isdetermined by how one handles them. Knowledge of professional standards, recognition ofpotential conflicts and appropriate disclosure are key steps in this process.
Research funded by the pharmaceutical industry reported in psychiatric journals has
been steadily increasing. Moreover, positive outcomes are reported much more often intrials so funded (78%) than in those without industry sponsorship (48%) or those financed
by a competitor (28%) (Kelly et al, 2006). The obvious issue arises as to the extent to which
industry-funded research influences findings and to what degree one can trust such work.
Conflicts of interest are not restricted to drug trials. For example, The Lancet publishedin 1998 a study which suggested a link between autism and the measles-mumps-rubella(MMR) vaccine. The report sent shockwaves around the globe as well as frightening
parents and medical practitioners. As a consequence, MMR vaccination rates in Englanddeclined by 10% in the following 5 years while cases of measles almost quadrupled.
A journalist later established that the principal author had not disclosed that the Legal
Aid Board had commissioned him to determine, for a sizable fee, if evidence sufficed tosupport a legal action by parents of children allegedly harmed by the vaccine. The Lancet
subsequently retracted the article and the UK’s General Medical Council found the leadauthor unfit to practice. Subsequent research has conclusively refuted any link between thevaccine and autism (Demicheli et al, 2005).

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IACAPAP Textbook of Child and Adolescent Mental HealthStudy of one’s child and adolescent psychiatry’s national code of ethics isrecommended. Resources for child psychiatrists faced with ethical dilemmas
include ethics committees, institutional review boards, state or country medical
accrediting bodies, and individuals with known expertise in ethics. Periodically,
complaints of an ethical nature are raised against practicing physicians by a patient’s
family member or, rarely, colleagues. Such complaints should be channeled in the
direction of individuals and committees with ethics expertise, who can then advise
concerning the best manner to pursue subsequent steps.
Administration
Child and adolescent psychiatrists treat individual patients. They also direct
inpatient and outpatient units, hospitals, and residential treatment facilities; areresponsible for small and large research enterprises; and plan care for defined
demographic populations of hugely varying sizes. In these roles they are accountable,
albeit indirectly, for the welfare and working conditions of patients and staff. To
varying degrees, these child psychiatrist administrators will have responsibility
for budgeting; determining the needs for various services; credentialing andprivileging employees; creating smooth supervisory processes with clear lines ofauthority; ensuring documentation in medical and other administrative records;
and supervising the entire gamut of investigational research, including subject
recruitment, obtaining consent, safeguarding confidentiality, data collection andanalysis, and dissemination of findings (Sondheimer, 2010). Ethical problems
often arise in these spheres of activity. How to fund a new clinical service thatis liable to impact negatively on another in the face of limited institutional or
governmental financial resources; how to respond to individual staff members who
observe organizational protocols to grossly differing degrees; how to approach an
institutional review board, some of whose members may be friendlier to a research
proposal than others? An ethical reasoning process helps to sort out the conflicts;
frequently, concentration on the principle of (distributive) justice helps resolve theconflicts between difficult choices (Sabin & Daniels, 1994).

RECENT AND EMERGING CONCERNS
Genomics
The past two decades have witnessed explosions in knowledge of genetic
information, having the potential for decoding children’s entire DNA sequences.
Much effort has been expended to determine relationships between specificgene sequences and psychiatric disorders. While results to date have not yielded
consistent findings, continued investigations will likely produce usable resultsin the future, possibly leading to changes in diagnostic nomenclature and theintroduction of gene therapies. Confidentiality, assent/consent, rights to know
and not know of disease presence, authorized versus unauthorized screenings for
disorders, and predictions of disease onset are among the ethical concerns raisedby the new technologies that will demand ever-closer examination ( Appelbaum,2004).
Psychiatric prodromes
Analogous to the potential of molecular-based genomics to predict theeventual development of psychiatric illness, examination of family trees andEthics A.1

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IACAPAP Textbook of Child and Adolescent Mental Healthclinical observation have led to studies of treatment interventions with adolescentpopulations at risk for the expression of schizophrenia (McGorry et al, 2009).
Similarly, expanded definitions of bipolar disorder have led to the exposure of very
young children to mood stabilizing medications, as already highlighted. While suchpreventive efforts are superficially admirable as they, in theory, have the potential tostave off the development of and suffering from serious mental illness, these efforts
are open to much question given the profession’s current stage of relative ignorance(Cornblatt et al, 2001). Reliable predictive tools of illness development are notavailable, determination of preventive treatment effectiveness is not possible,
treatment interventions with (neuroleptic) medications could conceivably cause
more harm than benefit (especially when prescribed for individuals who, in thefirst place, would not have need for them), and non-psychotic individuals might
be stigmatized (Frances, 2011).
Neuroenhancement
Pharmacologic augmentation of normal function raises related but
different issues. Child psychiatrists are comfortable treating illness or distress(e.g., antidepressants for depression; neuroleptics for severe thought disorder)
thus improving mood, cognitions and relatedness. While diagnoses are usuallybased on meeting designated criteria, at times they are employed because signs
suggest the possible presence of a disorder. For example, parents seeking to create
academic advantages for their child may seek treatment – based on a loose aggregate
of attentional impairments – with stimulant medications in order to help their
youngster focus all the more intently on tasks. Are these parents seeking unfair
advantage? Do such maneuvers diminish the esteem derived from hard work andself-improvement? Will the child psychiatrist consider the potentials for harm, e.g.,side effects or fostering of an initial reliance on drugs as aids? Or, might enhancing
the child’s performance be of overall benefit to the youngster and the larger society(Farah et al, 2004)? Do enhancements of mood and cognitions via prescribed
medications differ from the improvements in physical and emotional functioning
stemming from joint replacement surgery, Botox injections, and morning cups ofcaffeinated coffee? Does society distinguish between body and mind, feeling more
comfortable with enhancing the former and queasy regarding the latter (whileconversely bearing in mind the majority’s antagonism toward the use of steroids
and “cell-doping” in competitive sports)? Neuroenhancement brings questionsof identity, self, free will, and responsibility to the fore, and these questions will
surface with ever-greater frequency for parents concerned about their children(Cheung, 2010).
Electronics, social media, and bullying
Psychiatry, following some initial trepidation, has become immersed in theworld of electronics (Huang & Alessi, 1996). Practitioners and institutions employ
computers for record-keeping, prescribing, billing, scheduling appointments,
and communicating; the profession reacts electronically to media coverage; andpractitioners design personal web pages, blog, and deal with the use and misuse ofa variety of electronic instruments by patients. These new worlds of technology, as
was true of all prior eras ushering in wide-spread technological innovations, havethe potential for positive and negative impacts for its users. They are best judged
by old, traditional ethical criteria; the dilemmas the new technologies raise remain

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IACAPAP Textbook of Child and Adolescent Mental Healththe same, they simply are garbed in novel fashions. In addition to the technologies’
heuristic use to child psychiatrists in daily administration, education, researchand clinical practice, they offer specific benefits for patients, e.g., the opportunity
for pervasive developmentally disordered spectrum children, socially awkward
and fearful, to engage socially with others electronically rather than face to face
(Panyan, 1984). For many such youngsters, these communications provide a senseof comfortable engagement and, for some, lead to later meetings in person with
their contacts. Similarly, many computer programs provide assistance to children
with learning and communication disorders.
As with all new technologies, however, they are also open to misuse.
Bullying of children by peers is a millennia-old problem, but the perpetrator of
the past could always be readily identified. With the advent of current technology,
by contrast, cyberbullying permits anonymous harassment of unsuspecting andvulnerable peers, commonly leading to considerable distress and the occasional
front-page news article following the suicide of a bullied or “outed” youngster (Boyd& Marwick, 2011). Preventive and post-incident interventions have been createdin response but, given children’s immature understanding of consequences andthe anonymity afforded by electronic communications, these malicious behaviors
are likely to continue in a world that currently contains 800 million Facebook
members. Psychiatric ethics requires child psychiatry practitioners to be aware ofthese developments, the potential of electronics to be used for both good and ill,
the need to advocate and care for those who have suffered, to educate communities
concerning potential benefits and dangers, and to aid in the implementation of
relevant school-based intervention programs.

CONCLUSION
Child and adolescent mental health professionals, whether located inwell-to-do, poverty-stricken, or middle-class areas or countries, share the same
responsibilities – to advocate and provide care for youngsters, commonly theleast protected and most vulnerable age group, independent of locale. Ethicalconsiderations, principles, and the ways of thinking about dilemmas, whether
arising in clinical, administrative or research contexts, remain the same, independentof locale as well. Available resources in these locales differ markedly, however,resulting in different resolutions to these dilemmas in different geographic settings.
The fundamental ethical goals of providing protection and beneficial interventions
to children remains the overarching societal and professional expectation of thechild psychiatrist. This chapter, focusing on such basic matters as assent, dissent,
diagnosis, treatment, confidentiality, and research, coupled with a look at recent
developments in the field, has hopefully provided useful food for thought about
ethical matters which impact on child and adolescent mental health practitioners,
independent of their country of citizenship.

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IACAPAP Textbook of Child and Adolescent Mental Health

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