Children's informed signified and voluntary consent to heart surgery: Professionals' practical perspectives.

BACKGROUND: The law and literature about children's consent generally assume that patients aged under-18 cannot consent until around 12 years, and cannot refuse recommended surgery. Children deemed pre-competent do not have automatic rights to information or to protection from unwanted interventions. However, the observed practitioners tend to inform young children s, respect their consent or refusal, and help them to "want" to have the surgery. Refusal of heart transplantation by 6-year-olds is accepted. RESEARCH QUESTION: What are possible reasons to explain the differences between theories and practices about the ages when children begin to be informed about elective heart surgery, and when their consent or refusal begins to be respected? RESEARCH DESIGN, PARTICIPANTS AND CONTEXT: Research methods included reviews of related healthcare, law and ethics literature; observations and conversations with staff and families in two London hospitals; audio-recorded semi-structured interviews with a purposive sample of 45 healthcare professionals and related experts; interviews and a survey with parents and children aged 6- to 15-years having elective surgery (not reported in this paper); meetings with an interdisciplinary advisory group; thematic analysis of qualitative data and co-authorship of papers with participants. ETHICAL CONSIDERATIONS: Approval was granted by four research ethics committees/authorities. All interviewees gave their informed written consent. FINDINGS: Interviewees explained their views and experiences about children's ages of competence to understand and consent or refuse, analysed by their differing emphases on informed, signified or voluntary consent. DISCUSSION: Differing views about children's competence to understand and consent are associated with emphases on consent as an intellectual, practical and/or emotional process. Conclusion: Greater respect for children's practical signified, emotional voluntary and intellectual informed consent can increase respectful understanding of children's consent. Nurses play a vital part in children's practitioner-patient relationships and physical care and therefore in all three elements of consent.

Cost-Effectiveness of Individual versus Group Psychotherapy for Sexually Abused Girls.

BACKGROUND: Children who have been sexually abused may suffer from emotional and behavioural difficulties. Recent research found that individual and group psychotherapy have similar outcomes. In this study we compare the costs and cost-effectiveness of the two therapies and support for carers. METHODS: Subjects were recruited to two clinics in London and randomly allocated to the two treatments. The different components of each intervention were identified and costed. RESULTS: Total mean costs of individual therapy were found to be £1246 greater than for group therapy. Costs as they would apply in routine practice were relatively unchanged. Group therapy was thus more cost-effective than individual therapy. DISCUSSION: Carefully considering the impact of different therapies could allow more treatment to be offered from available staff resources and budgets. However, this is a single small study and further work is required to strengthen the evidence-base before change in practice is readily undertaken.

Childhood depression: a place for psychotherapy. An outcome study comparing individual psychodynamic psychotherapy and family therapy.

BACKGROUND: Although considered clinically effective, there is little systematic research confirming the use of Individual Psychodynamic Psychotherapy or Family Therapy as treatments for depression in children and young adolescents. AIMS: A clinical trial assessed the effectiveness of these two forms of psychotherapy in treating moderate and severe depression in this age group. METHODS: A randomised control trial was conducted with 72 patients aged 9-15 years allocated to one of two treatment groups. RESULTS: Significant reductions in disorder rates were seen for both Individual Therapy and Family Therapy. A total of 74.3% of cases were no longer clinically depressed following Individual Therapy and 75.7% of cases were no longer clinically depressed following Family Therapy. This included cases of Dysthymia and "Double Depression" (co-existing Major Depressive Disorder and Dysthymia). There was also an overall reduction in co-morbid conditions across the study. The changes in both treatment groups were persistent and there was ongoing improvement. At follow up six months after treatment had ended, 100% of cases in the Individual Therapy group, and 81% of cases in the Family Therapy group were no longer clinically depressed. CONCLUSIONS: This study provides evidence supporting the use of focused forms of both Individual Psychodynamic Therapy and Family Therapy for moderate to severe depression in children and young adolescents.

Reflections on 'an attachment-based treatment of maltreated children and young people'.

This paper considers the work of a skilled clinician (see this volume) who uses attachment theory but also his own vast body of experience. Many of the ideas will be of considerable help particularly to those working with children in substitute families. Caution is needed, however, as this work often involves the uncovering of unexpected abuse experiences which can provoke intense reactions. Training and supervision would seem essential.

Diagnosis and classification in child and adolescent psychiatry: the case of unipolar affective disorder.

Child and adolescent psychiatric classification is a broad domain in which the consideration of a developmental and longitudinal approach is essential. Some of the key issues involved are reviewed in this paper by focusing attention on childhood affective disorders, which are important both clinically and epidemiologically. It has been argued and demonstrated by Kovacs that in contrast to adults, children may not be capable of experiencing or reporting the symptoms thought to be representative of major depressive disorder. Nor may they be able to give an account of their duration. Hence, the pattern of manifested depressive symptoms is likely to vary according to age and stage of development of the child and young adolescent, and this is probably related to concept and language development. Further, distress and negative affect may be expressed by externalising symptomatology, especially in the pre-school years. The complexity of multiple depressive disorders, their coexistence and comorbidity with anxiety disorders needs to be studied further, employing whenever possible a developmental perspective and a longitudinal design.