Ethical Issues in Clinical Practice

This section provides educational resources on ethical issues related to child and adolescent psychiatric clinical practice.

Abuse and Neglect Reporting

At times, the ethical principle of confidentiality will conflict with other critical ethical principles. These conflicts might arise when a child and adolescent psychiatrist (CAP) obtains information concerning suspected child maltreatment (i.e., child abuse or neglect). This information that might be needed to end child maltreatment and protect children. Each state has a system in place to receive and respond to reports of suspected child maltreatment. CAPs are expected to know what standards apply in their state of practice and must report any form of suspected child maltreatment that falls within those standards.

  1. Drake B, Jolley JM, Lanier P, Fluke J, Barth RP, Jonson-Reid M. Racial bias in child protection? A comparison of competing explanations using national data. Pediatrics. 2011; 27(3): 471-8. doi: 10.1542/peds.2010-1710. Epub 2011 Feb 7. PubMed PMID: 21300678.
  2. Lareau CR. Attorney work product privilege trumps mandated child abuse reporting law: the case of Elijah W. v. Superior Court. 2015. Int J Law Psychiatry. 2015,2015;42-43:43-8. doi: 10.1016/j.ijlp.2015.08.006. Epub 2015 Sep 26. PubMed PMID: 26404507.
  3. Newton AW, Vandeven AM. The role of the medical provider in the evaluation of sexually abused children and adolescents. J Child Sex Abus. 2010 Nov;19(6):669-86. doi: 10.1080/10538712.2010.523448. Review. PubMed PMID: 21113834.
  4. Pietranoio AM, Write, Gibson KN, Alldred T, Jacobson D, Niec A. Mandatory reporting of child abuse and neglect crafting a positive process for health professionals and caregivers. Child Abuse Negl. 2013; 37(2-3):102-9. doi: 10.1016/j.chiabu.2012.12.007. Epub 2013 Jan 19. PubMed PMID: 23337443.
  5. Schilling S, Christian CW. Child physical abuse and neglect. Child Adoles Psychiatric Clin N AM 2014; 23:309-19, ix. doi: 10.1016/j.chc.2014.01.001. Epub 2014 Feb 18. Review. PubMed PMID: 24656582.

Assent and Consent to Treatment

Decision-making in child and adolescent psychiatry brings with it a variety of challenges for children, parents/guardians, and child and adolescent psychiatrists. It relies on the concepts of assent and consent by proxy, which is the focus of Principle IV of the AACAP Code of Ethics (2014). Assent recognizes that minors might not, due to their developmental level, be capable of giving completely reasoned consent; however, minors might be capable of having preferences and communicating their preference. Assent recognizes the importance of the involvement of minors in the decision-making process, while also recognizing that a minor's level of participation is less than completely competent. Minors ought to participate in decision-making proportionate to their developmental level. Minors ought to provide assent to care whenever reasonable. Parents/guardians and child and adolescent psychiatrists should not exclude minors from decision-making without clear and convincing reasons.

  1. American Academy of Child and Adolescent Psychiatry. Practice parameter on the use of psychotropic medication in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2009 Sep;48(9):961-73. doi: 10.1097/CHI.0b013e3181ae0a08. PubMed PMID: 19692857.
  2. Belitz J, Bailey RA. Clinical ethics for the treatment of children and adolescents: a guide for general psychiatrists. Psychiatr Clin North Am. 2009 Jun;32(2):243-57. doi: 10.1016/j.psc.2009.02.001. Review. PubMed PMID: 19486811.
  3. Dell ML, Vaughan BS, Kratochvil CJ. Ethics and the prescription pad. Child Adolesc Psychiatr Clin N Am. 2008 Jan;17(1):93-111, ix. doi: 10.1016/j.chc.2007.08.003 Review. PubMed PMID: 18036481.
  4. Hein IM, Troost PW, Broersma A, de Vries MC, Daams JG, Lindauer RJ. Why is it hard to make progress in assessing children's decision-making competence? BMC Med Ethics. 2015 Jan 10;16:1. doi: 10.1186/1472-6939-16-1. PubMed PMID: 25576996; PubMed Central PMCID: PMC4298077.
  5. Koelch M, Singer H, Prestel A, Burkert J, Schulze U, Fegert JM. "...because I am something special" or "I think I will be something like a guinea pig": information and assent of legal minors in clinical trials--assessment of understanding, appreciation and reasoning. Child Adolesc Psychiatry Ment Health. 2009 Jan 28;3(1):2. doi: 10.1186/1753-2000-3-2. PubMed PMID: 19175905; PubMed Central PMCID: PMC2640362.

Boundary Issues

While many child and adolescent psychiatrists (CAPs) assume that physician-patient boundaries are well defined by ethical and legal standards, boundary issues (e.g., boundary crossings or boundary violations) are a multifaceted and controversial aspect of clinical practice. CAPs establish boundaries with each patient for the purpose of promoting a trusting, therapeutic-fiduciary alliance. Boundary crossings are about deviating from traditional therapeutic activity and are not about exploitation. Boundary violations are harmful to patients and are about exploitation.

  1. Gabbard GO, Roberts LW, Crisp-Han H et al. Professionalism in Psychiatry. Arlington: American Psychiatric Publishing, 2012.
  2. Pope KS, Keith-Spiegel P. A practical approach to boundaries in psychotherapy: making decisions, bypassing blunders, and mending fences. J Clin Psychol. 2008:64(5):638-52. doi: 10.1002/jclp.20477. PubMed PMID: 18386835.
  3. Thomas CR, Pastusek A. Boundary crossings and violations: time for child psychiatry to catch up. JAACAP 2012: 51(9):858-60. doi: 10.1016/j.jaac.2012.06.011. Review. PubMed PMID: 22917197.
  4. Werth JL, Hastings SL, Riding-Malon. Ethical challenges of practicing in rural areas. J Clin Psychol. 2010: 66:537-48. doi: 10.1002/jclp.20681. PubMed PMID: 20222121.
  5. Mullin D, Stenger J. Ethical matters in rural integrated primary care settings. Fam Syst Health. 2013:31(1):69-74. doi: 10.1037/a0031860. PubMed PMID: 23566130.

Confidentiality

Principle V of the AACAP Code of Ethics (2014), the ethical principle of confidentiality, focuses on a patient's and a patient's guardian's/parent's right to have their information kept private and confidential. Child and adolescent psychiatrists (CAPs) should inform patients and their parents/guardians about confidentiality and any known limitations to confidentiality at the start of each therapeutic relationship. They need to be informed that threats of harm to self or others will not be kept confidential.

Confidentiality is a frequent concern in child and adolescent psychiatry, because parents/guardians commonly initiate care for their youth. The parents/guardians legitimately expect feedback from the CAPs to attempt improved care for their children.

  1. Ascherman LI, Rubin S. Current ethical issues in child and adolescent psychotherapy. Child Adolesc Psychiatr Clin N Am. 2008 Jan;17(1):21-35, ii-viii. doi: 10.1016/j.chc.2007.07.008. PubMed PMID: 18036477.
  2. Houston M. The psychiatric medical record, HIPAA, and the use of electronic medical records. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):107-14. doi: 10.1016/j.chc.2009.08.011. Review. PubMed PMID: 19951810.
  3. Recupero PR. Ethics of medical records and professional communications. Child Adolesc Psychiatr Clin N Am. 2008 Jan;17(1):37-51, viii. doi: 10.1016/j.chc.2007.07.004. Review. PubMed PMID: 18036478.
  4. Silva RR, Bath E, Beer D, Minami H, Engel L. Administrative issues in child psychiatry. Psychiatr Q. 2007 Sep;78(3):199-210. doi: 10.1007/s11126-007-9041-3. PubMed PMID: 17401689.
  5. Sondheimer A. Ethics and risk management in administrative child and adolescent psychiatry. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):115-29. doi: 10.1016/j.chc.2009.08.002. Review. PubMed PMID: 19951811.

Consultation Liaison Psychiatry/Psychosomatic Medicine

Pediatric psychosomatic medicine often addresses ethical issues related to capacity, consent, confidentiality, autonomy, emancipation and dual agency. There is also an increasing necessity for ethical awareness in pediatric psychosomatic medicine to factors such as:

  1. The advancements in medicine have led to more complex medical treatment options requiring the patient and the patient's parent(s)/guardian(s) to have a higher level of decision-making capacity;
  2. The advancements in life-saving medical technology have led to a decline in childhood mortality rates (in conditions such as HIV and cancers), which has resulted in an increasing number of children are surviving into adulthood with chronic medical conditions;
  3. A growing number of patients and their families are pursuing social media and other online sources to obtain their medical information (which is not necessarily accurate), connect with others affected by similar medical conditions, and play a more active role in their healthcare decisions;
  4. Charting in electronic health records makes child and adolescent psychiatrist's charting more accessible to a variety of medical providers; and,
  5. Diverse religious, spiritual and ethnic characteristics of the patient population, which brings with it a focus on providing culturally competent care.
  1. Baer W, Schwartz AC. Teaching professionalism in the digital age on the psychiatric consultation-liaison service. Psychosomatics. 2011Jul-Aug;52(4):303-9. doi: 10.1016/j.psym.2011.02.002. Review. PubMed PMID: 21777712.
  2. Geppert CM, Cohen MA. Consultation-liaison psychiatrists on bioethics committees: opportunities for academic leadership. Acad Psychiatry. 2006 Sep-Oct;30(5):416-21. doi: 10.1176/appi.ap.30.5.416. PubMed PMID: 17021151.
  3. Mermelstein HT, Wallack JJ. Confidentiality in the age of HIPAA: a challenge for psychosomatic medicine. Psychosomatics. 2008 Mar-Apr;49(2):97-103. doi: 10.1176/appi.psy.49.2.97. Review. PubMed PMID: 18354061.
  4. Mohan I, Wendelborn K, Politis B. Ethical dilemma in consultation-liaison psychiatry. Aust N Z J Psychiatry. 2014 Mar;48(3):291-2. doi: 10.1177/0004867413506499. Epub 2013 Sep 24. PubMed PMID: 24065695.
  5. Wright MT, Roberts LW. A basic decision-making approach to common ethical issues in consultation-liaison psychiatry. Psychiatr Clin North Am. 2009 Jun;32(2):315-28. doi: 10.1016/j.psc.2009.03.001. PubMed PMID: 19486816.

Electroconvulsive Therapy (ECT)

Electroconvulsive Therapy (ECT) is recognized therapy for adults with treatment resistant psychiatric disorders, most commonly depressive and psychotic disorders as well as life threatening conditions such as catatonia. Research and clinical practice has demonstrated that ECT is effective and safe. There is little data on its use in youth, particularly children due to historical concern about this treatment approach. Clinically, ECT mostly has been utilized in the treatment of psychiatrically ill adolescents, for the same conditions that adults are treated with ECT for. There is a significant need for additional research to document the effectiveness and safety of ECT for the care of children and adolescents. Major ethical issues include assent/ consent, concern about best interests and doing no harm, and advocacy.

  1. Sachs M, Madaan V, American Academy of Child and Adolescent Psychiatry Ethics Committee. Electroconvulsive Therapy in Children and Adolescents: Brief Overview and Ethical Issues. View PDF. Accessed August 17, 2017.
  2. Ghaziuddin N & Walter G (eds). Electroconvulsive Therapy in Children and Adolescents. Oxford University Press, London, 2013.
  3. Krishnan C, Santos L, Peterson MD, Ehinger M. Safety of noninvasive brain stimulation in children and adolescents. Brain Stimul. 2015 Jan-Feb;8(1):76-87. doi: 10.1016/j.brs.2014.10.012. Epub 2014 Oct 28. Review. PubMed PMID: 25499471; PubMed Central PMCID: PMC4459719.
  4. Loiseau A, Harrisson MC, Beaudry V, Patry S. Electroconvulsive Therapy Use in Youth in the Province of Quebec. J Can Acad Child Adolesc Psychiatry. 2017 Winter;26(1):4-11. Epub 2017 Mar 1. PubMed PMID: 28331498; PubMed Central PMCID: PMC5349277.
  5. Puffer CC, Wall CA, Huxsahl JE, Frye MA. A 20 Year Practice Review of Electroconvulsive Therapy for Adolescents. J Child Adolesc Psychopharmacol. 2016 Sep;26(7):632-6. doi: 10.1089/cap.2015.0139. Epub 2016 Jan 19. PubMed PMID: 26784386.

Foster Children

Foster care is sponsored and managed by state child protective services for youth who are unable to be cared for by their families. The system is designed to provide support and safety for children and adolescents who have been neglected and abused. In addition to ensuring safety, the priority is to support and help the family so that the involved children and adolescents can be returned to their families. Youth are usually placed with designated families, with some use of group home; it is designed to be a temporary placement. There are multiple ethical issues related to the care of these children which include: developmentally inadequate/ problematic placements and environments; challenges in determining the parameters of best interests and doing no harm; difficulties obtaining truly informed assent/consent for interventions; complicated situations related to confidentiality; significant third party influences; challenges doing scholarship with vulnerable populations; need for significant advocacy and justice activities; difficulties in finding child psychiatrists to provide care for many reasons, including often inadequate professional rewards; and major, pervasive legal considerations.

  1. Alavi Z, Calleja NG. Understanding the use of psychotropic medications in the child welfare system: causes, consequences, and proposed solutions. Child Welfare. 2012;91(2):77-94. Review. PubMed PMID: 23362615.
  2. COUNCIL ON FOSTER CARE; ADOPTION, AND KINSHIP CARE; COMMITTEE ON ADOLESCENCE, and COUNCIL ON EARLY CHILDHOOD. Health Care Issues for Children and Adolescents in Foster Care and Kinship Care. Pediatrics. 2015 Oct;136(4):e1131-40. doi: 10.1542/peds.2015-2655. PubMed PMID: 26416941.
  3. Deutsch SA, Lynch A, Zlotnik S, Matone M, Kreider A, Noonan K. Mental Health, Behavioral and Developmental Issues for Youth in Foster Care. Curr Probl Pediatr Adolesc Health Care. 2015 Oct;45(10):292-7. doi: 10.1016/j.cppeds.2015.08.003.Epub 2015 Sep 26. Review. PubMed PMID: 26409926.
  4. Leve LD, Harold GT, Chamberlain P, Landsverk JA, Fisher PA, Vostanis P. Practitioner review: Children in foster care-vulnerabilities and evidence-based interventions that promote resilience processes. J Child Psychol Psychiatry. 2012 Dec;53(12):1197-211. doi: 10.1111/j.1469-7610.2012.02594.x. Epub 2012 Aug 6.Review. PubMed PMID: 22882015; PubMed Central PMCID: PMC3505234.
  5. McDavid LM. Foster Care and Child Health. Pediatr Clin North Am. 2015 Oct;62(5):1329-48. doi: 10.1016/j.pcl.2015.06.005. Epub 2015 Jul 28. Review. PubMed PMID: 26318955.

Gender Dysphoria

There is increasing recognition that much needs to be discovered and explored in terms of how individuals acquire and maintain their sense of gender identity with the recognition that this aspect of sexuality and identify is more fluid and diverse than the categories of male and female. Along with increasing evidence that gender identity is biologically determined, it is becoming more evident that discrepancies between biological sex and identified gender are more common than previously thought. With the advances in medicine and ever broadening options for intervention, significant ethical issues relevant to development, best interests, no harm and assent/consent exist when determining how to best care and support these youth who have gender issues.

  1. Abel BS. Hormone treatment of children and adolescents with gender dysphoria: an ethical analysis. Hastings Cent Rep. 2014 Sep;44 Suppl 4:S23-7. doi: 10.1002/hast.366. PubMed PMID: 25231782.
  2. Adelson SL; American Academy of Child and Adolescent Psychiatry (AACAP)Committee on Quality Issues (CQI). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2012 Sep;51(9):957-74. doi: 10.1016/j.jaac.2012.07.004. Review. PubMed PMID: 22917211.
  3. Drescher J & Byne W (eds). Treating Transgender Children and Adolescents An Interdisciplinary Discussion. Rutledge Publishing, New York, 2014.
  4. Kon AA. Ethical issues in decision-making for infants with disorders of sex development. Horm Metab Res. 2015;47(5):340-3. doi: 10.1055/s-0035-1547269. Epub 2015 May 13. Review. PubMed PMID: 25970711.
  5. Lee PA, Houk CP. Changing and Unchanging Perspectives regarding Intersex in the Last Half Century: Topics Presented in the Lawson Wilkins Lecture* at the 2015 Pediatric Endocrine Society Meeting. Pediatr Endocrinol Rev. 2016 Mar;13(3):574-84. Review. PubMed PMID: 27116845.
  6. Smith MK, Mathews B. Treatment for gender dysphoria in children: the new legal, ethical and clinical landscape. Med J Aust. 2015 Feb 2;202(2):102-4. PubMed PMID: 25627744.
  7. Vrouenraets LJ, Fredriks AM, Hannema SE, Cohen-Kettenis PT, de Vries MC. Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study. J Adolesc Health. 2015 Oct;57(4):367-73. doi:10.1016/j.jadohealth.2015.04.004. Epub 2015 Jun 25. PubMed PMID: 26119518.

Involuntary Commitment - Inpatient Psychiatry

When treating children and adolescents, involuntary commitment for psychiatric care is complicated by having to consider the opinions of the parents and the youth. While youth can be hospitalized voluntarily if their parents agree, having the child or adolescent disagree with the plan does complicate the situation. Assent/consent are major issues as well as best interests/no harm and development. Given that some populations are more likely to be involuntarily committed, advocacy and justice should always be considerations.

  1. Georgieva I, Vesselinov R, Mulder CL. Early detection of risk factors for seclusion and restraint: a prospective study. Early Interv Psychiatry. 2012 Nov;6(4):415-22. doi: 10.1111/j.1751-7893.2011.00330.x. Epub 2012 Jan 25. PubMed PMID: 22277018.
  2. Golubchik P, Server J, Finzi-Dottan R, Kosov I, Weizman A. The factors influencing decision making on children's psychiatric hospitalization: a retrospective chart review. Community Ment Health J. 2013 Feb;49(1):73-8. doi: 10.1007/s10597-012-9487-0. PubMed PMID: 22294510.
  3. Pelto-Piri V, Kjellin L, Lindvall C, Engström I. Justifications for coercive care in child and adolescent psychiatry, a content analysis of medical documentation in Sweden. BMC Health Serv Res. 2016 Feb 19;16:66. doi: 10.1186/s12913-016-1310-0. PubMed PMID: 26893126; PubMed Central PMCID: PMC4759758.
  4. Turunen S, Välimäki M, Kaltiala-Heino R. Psychiatrists' views of compulsory psychiatric care of minors. Int J Law Psychiatry. 2010 Jan-Feb;33(1):35-42. doi: 10.1016/j.ijlp.2009.10.007. Epub 2009 Nov 10. PubMed PMID: 19906428.

Managed Care

Managed care organizations (MCOs) are expected to ensure appropriate uses of clinical resources, provide coverage for a range of services covered by the particular plan, maintain level of care guidelines derived from medical necessity guidelines, have processes in place for appeals, grievances, complaints, and independent external reviews, and provide quality management oversight. MCOs may seek accreditation from NCQA (National Council of Quality Assurance) or from URAC (Utilization Review Accreditation Commission) although accreditation is not required of MCOs. MCOs may include behavioral health services or in carve out states. There are separate managed care companies for behavioral health called MBHOs or BHMCOs. Ethical issues are inevitable. Ethical considerations may involve multiple stakeholders with competing agendas relative to psychiatric evaluation and treatment, confidentiality concerns, HIPPA, the not so bright line between what is classified as treatment and what may reflect the psychosocial adversity safety net, and consequences when other systems do not step up. AACAP Code of Ethics Principle VI, third party Influence, specifically addresses that CAPs are expected not to allow third parties (includes insurance companies), potential or actual compensation to influence professional judgment and action. However there are additional ethical issues for the CAP: advocacy and equity (justice) so that a full range of quality services are available for children, youth and families, professionalism, i.e., being prepared for peer reviews, clear about the diagnoses, treatment plans, risks and benefits of treatment, understanding the level of care guidelines, knowledgeable about how CAPs and parents/guardians can advocate for denied services using the grievance and appeal process.
  1. Essock SM. What to Do When the Managed Care Firm Says No. JAMA Psychiatry. 2016 Nov 1;73(11):1109-1110. doi: 10.1001/jamapsychiatry.2016.2409. PubMed PMID: 27680607.
  2. Lustig SL, Blank AR, Cirelli RJ, Friedman SR, Green FC, Lopez WM, Massey AG, Nemecek DA, Papatola KJ, Patel NH, Qayyam M, Shah VN, Sipahimalini A, Shampaine VC. Optimizing managed care peer reviews: turning a "Doc to Doc" talk into better advocacy for psychiatric inpatients. Psychiatr Serv. 2013 Aug 1;64(8):800-3. doi: 10.1176/appi.ps.004202012. PubMed PMID: 23903605.
  3. Glasser M. The history of managed care and the role of the child and adolescent psychiatrist. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):63-74; table of contents. doi: 10.1016/j.chc.2009.08.009. PubMed PMID: 19951807.
  4. Schreter RK. Overview of practice management in child and adolescent psychiatry. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):75-87; table of contents. doi: 10.1016/j.chc.2009.09.001. Review. PubMed PMID: 19951808.
  5. Ptakowski KK. Advocating for children and adolescents with mental illnesses. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):131-8; table of contents. doi: 10.1016/j.chc.2009.08.003. Review. PubMed PMID: 19951812.

Polypharmacy

Psychopharmacology has become an essential aspect of psychiatric care for children and adolescents. Medications can be a crucial, beneficial adjunct to a comprehensive, multidimensional treatment plan. For some youth and conditions, use of several medications simultaneously is required. Unfortunately, in many systems, there is a lack of accessible psychotherapeutic and psychosocial interventions so medications can be overly relied upon and youth end up on multiple medications unnecessarily. Best interests and doing no harm are major considerations when prescribing; so is informed assent/consent.
  1. Grudnikoff E, Bellonci C. Deprescribing in Child and Adolescent Psychiatry-A Sorely Needed Intervention. Am J Ther. 2017 Jan/Feb;24(1):e1-e2. doi: 10.1097/MJT.0000000000000552. PubMed PMID: 28059976.
  2. Huefner JC, Griffith AK. Psychotropic medication use with troubled children and youth. J Child Fam Stud. 2014;23(4) 613-6. doi: 10.1007/s10826-014-9941-4.
  3. Mackie TI, Hyde J, Palinkas LA, Niemi E, Leslie LK. Fostering Psychotropic Medication Oversight for Children in Foster Care: A National Examination of States' Monitoring Mechanisms. Adm Policy Ment Health. 2017 Mar;44(2):243-257. doi: 10.1007/s10488-016-0721-x. PubMed PMID: 26860953.
  4. Morden NE, Goodman D. Pediatric polypharmacy: time to lock the medicine cabinet? Arch Pediatr Adolesc Med. 2012 Jan;166(1):91-2. doi: 10.1001/archpediatrics.2011.162. Epub 2011 Sep 5. PubMed PMID: 21893639; PubMed Central PMCID: PMC3248612.
  5. Di Pietro Nina, Illes Judy (eds) The Science and Ethics of Antipsychotic Use in Children. San Diego: Academic Press, 2015.

Psychotherapy

Many ethical issues can present when treating children and adolescents with psychotherapy. These issues include but are not limited to consent, assent, release of information, disclosure of information to parents, guardians and other stakeholders, multiple relationships, boundary crossings and violations, therapy in the context of custody issues, gifts, social media in the context of psychotherapy. One of the key differences between adult and child and adolescent therapy are the ethical dilemmas that arise when treating dependent minors. These concerns are elaborated in the AACAP Code of Ethics (2014) within the preamble and Principle I (the developmental perspective).

  1. Ascherman LI, Rubin S. Current ethical issues in child and adolescent psychotherapy. Child Adolesc Psychiatr Clin N Am. 2008 Jan;17(1):21-35, vii-viii. PubMed PMID: 18036477.
  2. Belitz J, Bailey RA. Clinical ethics for the treatment of children and adolescents: a guide for general psychiatrists. Psychiatr Clin North Am. 2009 Jun;32(2):243-57. doi: 10.1016/j.psc.2009.02.001. Review. PubMed PMID: 19486811.
  3. de Sousa A. Ethical issues in child and adolescent psychotherapy: a clinical review. Indian J Med Ethics. 2010 Jul-Sep;7(3):157-61. Review. PubMed PMID: 20806522.
  4. Edelsohn GA, McGee ME, Leung D, Romero R, Sondheimer. Book Forum Ethics. J Am Acad Child Adoles Psychiatry 2013 Aug; 52 (8): 878-882.
  5. Koocher GP. Ethical issues in psychotherapy with adolescents. J Clin Psychol. 2003 Nov;59(11):1247-56. doi: 10.1002/jclp.10215. PubMed PMID: 14566959.

Restraints and Seclusion

a. Chemical Restraint

Chemical restraint is defined within 42CFR 483.352 as "drug used as restraint means any drug that: is administered to manage a resident's behavior in way that reduces the safety risk to the resident or others; has the temporary effect of restricting the resident's freedom of movement; and is not a standard treatment for the resident's medical or psychiatric condition." The term pharmacologic restraint has been used as well as chemical restraint. The use of chemical restraint is related to the use of PRN medications and STAT medications. Some states prohibit the use of standing orders for PRNs for psychotropic medications in certain levels of care. For example, in Pennsylvania it is permissible to use PRNs for acute behavioral control in psychiatric inpatient settings for children and adolescents, but such use of PRNs is prohibited in psychiatric residential treatment centers, though STAT medication is permitted. STAT medication requires a physician's order, clinical rationale and a face-to-face assessment prior to the psychotropic being administered. These distinctions between chemical restraint, standing PRN orders and STAT medication and the regulations may vary from state to state but do provide a stimulus for ethical issues of balancing safety, risk to self and/or others with a child's autonomy, the use of the least restrictive means to ensure safety and the potential for abuse of psychotropic medications for sedation and convenience. Psychoeducation and relationship building with the youth and family needs to cover scenarios in advance as to when a medication may be used to address escalating aggression or self harm. When CAP has responsibilities for the oversight of the treatment milieu, there are ethical duties to ensure both quality of care and safety in the treatment settings.

  1. Norton AA. The captive mind: antipsychotics as chemical restraint in juvenile detention. J Contemp Health Law Policy. 2012 Fall;29(1):152-82. PubMed PMID: 23424905.
  2. Sonnier L, Barzman D. Pharmacologic management of acutely agitated pediatric patients. Paediatr Drugs. 2011 Feb 1;13(1):1-10. doi: 10.2165/11538550-000000000-00000. Review. PubMed PMID: 21162596.
  3. Stewart SL, Baiden P, Theall-Honey L. Factors associated with the use of intrusive measures at a tertiary care facility for children and youth with mental health and developmental disabilities. Int J Ment Health Nurs. 2013 Feb;22(1):56-68. doi: 10.1111/j.1447-0349.2012.00831.x. Epub 2012 Jun 27. PubMed PMID: 22738390.

b. Physical Restraint and Seclusion

Physical restraint and seclusion are considered as last resort interventions when less restrictive means have not been effective at reducing serious safety threats directed at either the child or adolescent themselves or directed at others. The Centers for Medicaid & Medicare Services (CMS) defines seclusion as the involuntary confinement of a patient in a room or area from which the patient is physically prevented from leaving. Restraint is defined as any manual method or physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move. The use of medication to restrain the patient's movements is included within the types of restraint. There are federal regulations by CMS specifying the type of professional can order restraint and seclusion, the timeframe for such orders to be written, for in-person evaluation must occur, renewals for orders, and for re-evaluation. There are different requirements for children under 9 years of age and for those 9 to 17 years of age. States may impose stricter criteria and some states forbid the use of prone restraints. Since the early 2000's there has been concerted efforts to reduce the use of restraint and seclusion, provide alternative interventions and to recognize the role of trauma relative to restrictive procedures. The ethical issues surrounding the use of restrictive procedures include the use of restraint/seclusion as punishment, or for convenience, as a consequence of power differential , and neglect of the duty to ensure beneficence, non-malfeasance. The article by Masters et al. (2013) discusses the ethical issues when a CAP participants in restraint.

  1. Duke SG, Scott J, Dean AJ. Use of restrictive interventions in a child and adolescent inpatient unit - predictors of use and effect on patient outcomes. Australas Psychiatry. 2014 Aug;22(4):360-365. Epub 2014 May 1. Doi: 10.1177/1039856214532298. PubMed PMID: 24789849.
  2. Green-Hennessy S, Hennessy KD. Predictors of Seclusion or Restraint Use Within Residential Treatment Centers for Children and Adolescents. Psychiatr Q. 2015 Dec;86(4):545-54. doi: 10.1007/s11126-015-9352-8. PubMed PMID: 25733324.
  3. James Masters K, Nunno M, Mooney AJ. Should psychiatrists assist in the restraint of children and adolescents in psychiatric facilities? Psychiatr Serv. 2013 Feb 1;64(2):173-6. doi: 10.1176/appi.ps.001652012. PubMed PMID: 23370623.
  4. van der Schaaf PS, Dusseldorp E, Keuning FM, Janssen WA, Noorthoorn EO. Impact of the physical environment of psychiatric wards on the use of seclusion. Br J Psychiatry. 2013 Feb;202:142-9. doi: 10.1192/bjp.bp.112.118422. Epub 2013 Jan 10. PubMed PMID: 23307922.
  5. Whitley K, Rozel JS. Mental Health Care of Detained Youth and Solitary Confinement and Restraint Within Juvenile Detention Facilities. Child Adolesc Psychiatr Clin N Am. 2016 Jan;25(1):71-80. doi: 10.1016/j.chc.2015.08.003. Epub 2015 Oct 17. Review. PubMed PMID: 26593120.

Social Media

The intersection of social media and ethics covers a wide range of topics and continues to evolve as there are more opportunities for interactions among psychiatrists, patients and their families in both professional and non-professional domains. While the internet, texting, email communications offer certain advantages, the use of social media comes with the need to review basic ethical principles and how they are applied to digital communication. These principles include confidentiality and privacy, boundaries, conflict of interest disclosure. In addition, legal issues such as liability, intellectual property, mandated reporting are impacted.

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