Ethical and Clinical Considerations During the Coronavirus Era.

The practice of child and adolescent psychiatry is evolving during an unprecedented global health catastrophe, the coronavirus disease 2019 (COVID-19) pandemic. As child and adolescent psychiatrists grapple with COVID-19's enormous medical, educational, social, and economic toll, a mental health crisis is co-occurring. Pre-existing disparities are recognized as contributors to the disproportionate impact of the COVID-19 pandemic on racial and ethnic minorities.1 The magnitude of COVID-19's effects on child and family mental health has yet to be fully revealed. child and adolescent psychiatrists are in a unique position to address this mental health crisis. Child and adolescent psychiatrists must stay up-to-date regarding federal, state, local, and institutional mandates, regulations, and policies informed by the Centers for Disease Control and Prevention2 and other public health institutions, while also navigating the ethical dilemmas unique to child and adolescent psychiatry during the coronavirus era.

Cuestiones bioéticas en la psiquiatría evolutiva / Bioethical issues in evolutionary psychiatry / Qüestions bioètiques en la psiquiatria evolutiva

En este artículo, se esbozan y discuten algunos temas rela­cionados con la bioética del cuidado en la Neuropsiquiatría de la Infancia y la Adolescencia (NPIA). Se pone de relieve el concepto de hacerse cargo del niño en edad de desarrollo y las raíces históricas de la bioética infantil. Se abordan las cuestiones relacionadas con la privacidad, el respeto de la confidencialidad y la protección de los menores, así como el concepto de estigma relacionado con la enfermedad y el cuidado de la mente. Se describe la cuestión ética del uso de fármacos psicoactivos en edad de desarrollo. Se destaca el problema del consenti­miento informado y de la elección del método de tratamiento para las enfermedades en las que el conocimiento es incompleto y los resultados no están garantizados. Se aborda la cuestión de la comunicación del diagnóstico, de la necesidad de una intervención oportuna, de métodos apropiados y de la elección del camino en los casos de patología grave y diagnóstico temprano. Por último, se habla de la cuestión ética de las psicoterapias en el servicio público y en centros privados reconocidos por el Sistema Nacional de Salud

In this article, some issues related to the bioethics of care in Child and Adolescent Neuropsychiatry (NPIA) are outlined and discussed. We highlight the concept of looking after a child in his/her developmental age and the historical roots of child bioethics. Issues of privacy, respect for confidentiality and protection of minors are addressed, as well as the concept of stigma related to illness and care. The ethical issue of the use of psychoactive drugs at a developmental age is described. The problem of informed consent and choice of treatment method for diseases where knowledge is incomplete and results are not guaranteed is highlighted. The issue of communication of diagnosis, the need for timely intervention, appropriate methods and choice of path in cases of severe pathology and early diagnosis is addressed. Finally, the ethical issue of psychotherapies in the public service and in private centres recognised by the National Health System is discussed

En aquest article, s'esbossen I discuteixen alguns temes rela­cionats amb la bioètica de la cura en la Neuropsiquiatria de la Infància I l'Adolescència (NPIA). Es posa en relleu el concepte de fer-se càrrec de l'infant en edat de desenvolupament I les arrels històriques de la bioètica infantil. S'aborden les qüestions relacionades amb la privacitat, el respecte de la confidencialitat I la protecció dels me­nors, així com el concepte d'estigma relacionat amb la malaltia I la cura de la ment. Es descriu la qüestió ètica de l'ús de fàrmacs psicoactius en edat de desenvolupament. Es destaca el problema del consentiment informat I de l'elecció del mètode de tractament per a les malalties en les quals el coneixement és incomplet I els resultats no estan garantits. S'aborda la qüestió de la comunicació de la diagnosi, de la necessitat d'una intervenció oportuna, de mètodes apropiats I de l'elecció del camí en els casos de patologia greu I diagnòstic precoç. Finalment, es par­la de la qüestió ètica de les psicoteràpies en el servei públic I en centres privats reconeguts pel Sistema Nacional de Salut

[Appreciating COVID-19 as a child and adolescent psychiatrist on the move]. / Appréhender le COVID-19 au fil de l'eau en tant que psychiatre d'enfant et d'adolescent.

COVID-19 is a multi-organ disease due to an infection with the SARS-CoV2 virus. It has become a pandemic in early 2020. The disease appears less devastating in children and adolescents. However, stress, quarantine and eventually mourning have major impacts on development. It is difficult to describe what this pandemic implies for a child psychiatrist, other than by giving a first-hand account. I propose to go through the main ethical questions that have arisen; to describe how my hospital team has reorganized itself to meet the new demands and questions, in particular by opening a unit dedicated to people with autism and challenging behaviors affected by COVID-19; and to address, in a context of national discussion, how the discipline has sought to understand the conditions of a certain well-being during quarantine. Finally, I will try to conclude with more speculative reflections on re-opening.

Justifications for coercive care in child and adolescent psychiatry, a content analysis of medical documentation in Sweden.

BACKGROUND: There has been considerable interest in normative ethics regarding how and when coercive care can be justified. However, only a few empirical studies consider how professionals reason about ethical aspects when assessing the need for coercive care for adults, and even less concerning children and adolescents. The aim of this study was to examine and describe how professionals document their value arguments when considering the need for coercive psychiatric care of young people. METHODS: All 16 clinics that admitted children or adolescents to coercive care during one year in Sweden were included in the study. These clinics had a total of 155 admissions of 142 patients over one year. Qualitative content analysis with a deductive approach was used to find different forms of justification for coercive care that was documented in the medical records, including Care Certificates. RESULTS: The analysis of medical records revealed two main arguments used to justify coercive care in child and adolescent psychiatry: 1) the protection argument - the patients needed protection, mainly from themselves, and 2) the treatment requirement argument - coercive care was a necessary measure for administering treatment to the patient. Other arguments, namely the caregiver support argument, the clarification argument and the solidarity argument, were used primarily to support the two main arguments. These supportive arguments were mostly used when describing the current situation, not in the explicit argumentation for coercive care. The need for treatment was often only implicitly clarified and the type of care the patient needed was not specified. Few value arguments were used in the decision for coercive care; instead physicians often used their authority to convince others that treatment was necessary. CONCLUSIONS: One clinical implication of the study is that decisions about the use of coercive care should have a much stronger emphasis on ethical aspects. There is a need for an ethical legitimacy founded upon explicit ethical reasoning and after communication with the patient and family, which should be documented together with the decision to use coercive care.

Child and adolescent depression: psychotherapeutic, ethical, and related nonpharmacologic considerations for general psychiatrists and others who prescribe.

Depression is a common, recurring disorder affecting millions of youth at some point before they reach mature adulthood. Given the shortage of and uneven distribution of psychiatrists who have completed specialized fellowships in child and adolescent psychiatry, a significant number of depressed youth will receive their pharmacotherapy from general psychiatrists and other prescribers with varying degrees of interest, training, and even willingness to treat children and adolescents. For general psychiatrists who will prescribe antidepressants for minors, knowledge of the training and expertise of nonphysician mental health professionals, the psychotherapies they may employ, and familiarity with school services are essential. Physicians who typically work only with adults will also need familiarity with differing ethical, legal, and regulatory issues and standards applicable to pediatric psychopharmacology. General psychiatrists, pediatricians, family physicians, nurse practitioners, and others contribute greatly to the care of depressed children, adolescents, and their families, and many find this work to be a very rewarding part of their professional practices.

[Autonomy, care and justice: ethical aspects of the psychiatric treatment of adolescents]. / Autonomie, Fürsorge und Gerechtigkeit1.

What is the right and good action in dealing with young patients in child and adolescent psychiatry? To answer this question, we have to consider professional standards, legal rules, and ethical reflections. With reference to the latter, four bioethical principles were proposed by Beauchamp and Childress to identify and to deal with ethical problems and conflicts. On the basis of this scheme we reflect on the legal aspects and discuss the following topics: (1) self-determination of adolescents concerning their own psychiatric treatment, (2) conflicts between autonomy and care, which occur relatively often, whenever restrictions to personal liberty are indicated, and (3) admission of adolescents in adult psychiatric wards. The bioethical principles facilitate a reliable decision-making process in individual cases. The standards of right and good action have to be implemented in the field of distributive justice. We find evidence that prioritization decisions for inpatient admission are already established in German child and adolescent psychiatry.

The emerging role for repetitive transcranial magnetic stimulation in optimizing the treatment of adolescent depression.

Major depressive disorder (MDD) in adolescents is a common illness and significant public health problem. Treatment is challenging because of recurrences and limited modalities. Selective serotonin reuptake inhibitors and cognitive behavioral therapy are considered the standard of care in severe or treatment-resistant MDD in this age group. However, responses to these interventions are often suboptimal. A growing body of research supports the efficacy of repetitive transcranial magnetic stimulation (rTMS) for the treatment of MDD in adults. Induced seizures are a primary safety concern, although this is rare with appropriate precautions. There is, however, limited experience with rTMS as a therapeutic intervention for adolescent psychiatric disturbances. This review will summarize the rTMS efficacy and safety data in adults and describe all published experience with adolescent MDD. Applications in other adolescent psychiatric illnesses such as schizophrenia and attention-deficit/hyperactivity disorder are reviewed. Safety and ethical issues are paramount with investigational treatments in adolescent psychiatric illnesses. However, further research with rTMS in adolescent MDD is imperative to establish standards for optimal stimulation site, treatment parameters, and its role in treatment algorithms. These may diverge from adult data. Early intervention with neuromodulation could also hold the promise of addressing the developmental course of dysfunctional neurocircuitry.

Ethics and risk management in administrative child and adolescent psychiatry.

This article examines ethics (the philosophic study of "doing the right thing") and risk management (the practice that seeks to manage the likelihood of "doing the wrong thing") and the relationship between them in the context of administrative child and adolescent psychiatry. Issues that affect child and adolescent psychiatrists who manage staff and business units and clinical practitioners who treat and manage individual patients are addressed. Malpractice, budgeting, credentialing, boundaries, assessment, documentation, treatment, research, dangerousness, and confidentiality are among the topics reviewed.

When, why, and how to conduct research in child and adolescent psychiatry: practical and ethical considerations.

Changes in the clinical research enterprise to involve practicing psychiatrists in gathering evidence in real-world settings are truly exciting. The CAPTN breaks important ground as a PBRN in psychiatry. The authors anticipate that more practical clinical trials will come. These changes challenge psychiatrists to reach an entirely new level of understanding and appreciation of the ethical and practical challenges of commingling clinical practice and research. It is time that all practicing psychiatrists prepare to meet these challenges.

[Off-label use in child and adolescent psychiatry. An ongoing ethical, medical and legal problem]. / Off-Label-Use von Psychopharmaka in der Kinder- und Jugendpsychiatrie. Ein andauerndes ethisches, medizinisches und rechtliches Problem.

Off-label use is an ongoing problem in child and adolescent psychiatry. Except methylphenidate and atomoxetine for attention-deficit/hyperactivity disorder (ADHD), most substances used to treat children and adolescents with psychiatric disorders are prescribed off-label. In additional to aspects of drug safety and efficacy the widespread off-label use raises issues of liability in the case of adverse events. In Germany off-label use also poses problems of reimbursement by the health insurance. In the future we expect, driven by written request of the FDA, numerous new indications for novel antipsychotics in the USA for the treatment of so-called childhood bipolar disorders. Given another diagnostic framework in context in Europe, these so-called bipolar disorders in children are very rarely diagnosed. Anyhow, antipsychotics are widely used in the USA and in Europe to treat impulsivity or aggressiveness in children and adolescents. There is still a lack of European labelling of novel antipsychotics for the treatment of schizophrenia. In clinical practice given the risk of liability and other forensic issues in the treatment of schizophrenic patients, this is still one of the major hindrances in the treatment of young schizophrenic patients in Europe. Whereas these drugs may urgently be needed for treatment of psychotic disorders and of impulsivity or aggressiveness, the indication of bipolar as used in the USA leads to a misconception and does not increase availability of licensed modern antipsychotics for minors.

Ethical issues in psychopharmacology of children and adolescents.

PURPOSE OF REVIEW: This summary of the literature published over recent years focuses on the ethical aspects of interventions with psychotropic medication in child and adolescent psychiatry. Ethical issues of pharmacotherapy concern aspects of research, safety, indicated use, enhancement, information and evidence-based practice. RECENT FINDINGS: The literature on pharmacological interventions suggests changes in prescribing patterns for some substance classes owing to regulatory authorities' warnings. For most of the commonly used medications in children and adolescents no sound database about efficacy and safety is available and knowledge about adverse events and long-term safety remains poor. This is due to a general lack of clinical trials in this population. Legislative efforts have tried to improve safety and labelling of medicines for children. Ethical issues of enhancement in minors have been increasingly discussed over recent years. SUMMARY: The ethical aspects of psychopharmacotherapy in minors are still rarely discussed in the literature. Practical questions of research and treatment ethics such as a need for information for children and parents are pointed out; conflicts of evocation and access to care for special populations in need are identified in a field lacking adequate ethical and clinical research.

Ethical challenges in mental health services to children and families.

Mental health practitioners working with children and families must attend to several ethical concerns that do not typically come into play with adult clients. The challenges for practitioners usually involve attention to four subsets of concerns that all begin with the letter c: competence, consent, confidentiality, and competing interests. Using the 4-C model, this article focuses on ethical aspects of practitioner competence, consent and assent, confidentiality, and the incongruence of interests that occurs when different people organize and set goals for psychological services. After explicating these issues, I provide recommendations for addressing them in the course of clinical practice.