Ethical Challenges in Child Mental Health

Every day physicians deal with patients who could improve their health by engaging in some behavior change, but want instead to be prescribed a pill. A patient might say for example “Yes, I know it would be good for my cardiovascular system if I lost 10 pounds, ate more fruits and vegetables and went for a brisk walk each evening. But I don’t feel like doing those things so give me the statins and the antihypertensives I heard about on that TV ad”.

There are a range of ethical issues for the care provider here, including balancing the need to take care of people while at the same time not enabling poor health behaviour, weighing the risk of side-effects with the benefits of medication, and recognizing that sometimes medications are best but if everyone refuses to change their health behaviour it puts more strain on already strained social programmes (e.g., Medicare), and so forth.

But what doesn’t arise is the “split decision” ethical problem common in child mental health treatment. By “split decision”, I mean when someone is faced with a choice not between changing their behaviour or taking a pill, but changing their behaviour or making someone else take one. Here are some examples of such conundrums:

A 14-year old boy is brought in by his parents, who report that he has low self-esteem and cries a lot. They want him on an anti-depressant. When the doctor observes the family and does a private interview with the boy, s/he discovers that the mother constantly tells the boy that he is fat and stupid, and that it’s his fault that his parents got divorced. The father has visitation rights every weekend, but more than half the time, he doesn’t show up, repeatedly disappointing his son. When these issues are raised with the parents, they say angrily “We told you to fix him, not us!”.

A 9-year old girl is engaging in strange ritual behaviours (e.g., compulsively re-arranging her room) and has difficulty concentrating. Her parents want her on an ADHD or anxiolytic medication. Her mother is concerned while the father seems angry to even have to come in to the clinic. You smell alcohol on his breath, and it’s noon. As you watch them leave the clinic the father brushes against another patient and screams “Watch where you are going, you moron!”, leading his child to cover her ears and start sobbing. When you come out to intervene the father tells you to mind your damn business, and that if you don’t put his kid on a medication he will find another doctor who will.

Everything about these situations is terrible, most of all of course for the children concerned. But they are also rough on the treatment provider. To really help the child would require a change in someone else’s behavior, and that person refuses to do anything other than consent to have the child medicated. If you refuse to sign on to this arrangement, the child receives no help at all. If you agree to help the child adapt, you are reinforcing the destructive family myth that the only thing wrong is that the child is defective for a reason at which no one can guess.

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College London. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over thirteen thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

19 thoughts on “Ethical Challenges in Child Mental Health”

  1. Is it just documentable suspicions of physical or sexual abuse that fit the mandatory-reporting category? The first hypothetical appears to be pretty clear emotional abuse, and the second raises strong suspicions of physical abuse (as well as constituting assault of a third party). Obvious massive escalation is no fun either, but is it even an option?

    Speaking entirely as a layperson, this kind of case also seems ripe for engaging the children, who both need and deserve to know that other adults recognize that their parents are being dysfunctional jerks (even if that makes for more trouble in the short term). In general, recruitment of supportive figures outside the family is reported to be correlated with better outcomes for such kids.

  2. @paul

    If emotional abuse at the level in the examples was cause for mandatory report, all mental health care providers would do all day is make mandatory reports (adding to an already overwhelmed and dysfunctional mandatory report receiving system) — this sort of stuff is even more prevalent than sexual abuse of children.

    You are quite right that supportive adults outside the family (or in the family but outside the home, for example a loving grandparent or uncle or aunt) can help children survive in stressful family environments.

    1. That’s a good point, and also I wonder, if usually the point of “reporting” is to get the child put somewhere better, then that probably won’t work, since we probably don’t magically have some other, better parents available.

      Otoh, these two kids were affected enough that someone dragged them to a doctor. I wonder if schools might not somehow provide a third space or option, in the sense that teachers are sort of considered authority figures (at least before the current “reform” anyhow) and people who have a legitimate interest in children’s behavior. And no doubt, they already know which children are struggling at home. Even if you can’t “fix” the parents, the child could still be taught very useful coping strategies. (I am big on therapy, especially CBT.) I bet Eli would know something about this.

      Further, why not a placebo in this situation? Give the kid a sugar pill? I don’t think it would be wrong, if their parent is really determined to drug them and the doctor thinks it would harm the child. Ethically, you’ve got to side with the kid, right?

  3. Wow, what an excellent insight. This is a profound issue that goes to the core of so much of how we view society: how to separate the behavioral dynamics of the parent from child. I often think of this problem in terms of education, where the context is a larger, systemic issue of building human capital in children from disadvantaged families. The task of an educator is to teach the child, yet in terms of providing an equal education, the real problem is at home and in the community.

    In a way, there is a sort of black hole in our thinking about social development and the transmission of human capital. We can all look at parents and blame them for making poor choices, and we can look at kids as victims. But few of us I think understand the dynamic in which parents drive capital formation of children. So when a kid has a problem, we have a bias to treating it in isolation from the family dynamic.

    Much of this, I think speaks to the lack of a properly defined and designed social service network, likely owing to a larger issue of the fragility of our healthcare system. Currently, there is no robust, integrated system that connects the provision of healthcare, education, childcare, drug/alcohol treatment, criminal justice, etc. in a way that could begin to provide effective intervention in situations where there are numerous issues involved. A doctor ought to be able to “plug” a family into a larger support system. A teacher ought to be able to see the struggles of a student in the context of a homelife that may be driving the underlying problem. Often times, a teacher or health provider only sees one child, when there are no doubt multiple siblings involved.

  4. In these cases, a referral to a multidisciplinary mental health practice is in order. The doctor should frame the referral by indicating to the parents that treatment by specialists is the best way to go. There should be skilled clinicians at the practice who can deal with the “fix him, not us,” response.

    The parents may still refuse, but the doctor has done his/her ethical duty.

  5. Keith–

    Thank you for raising this issue. The fundamental problem in child mental health services is the question of who the client is. Is it the person who is suffering from the mental condition, or is it the person(s) who have the free choice of accepting or rejecting proposed treatments? There is, frankly, no way to contravene the will of the parents. And there are plenty of practitioners who will simply take the easy route of the scapegoating of the child (not that there aren’t plenty of cases where the child initiates the problems). So it is most likely that the conscientious practitioner will be ignored and the parents will go get medication somewhere else.

    Some strategies of persuasion that may be of use:

    Using teacher reports of the child’s behavior. These provide something of a discriminant between what is truly problem behavior and what is specific to the family situation. I find them to be generally more useful for the purposes of diagnosis and more consistent across reporters (i.e. multiple teachers agree with each other more than two parents do).

    Citing the family history of behavioral problems in the context of the fairly strong genetic basis of most mental disorders. Putting the emphasis on genetics that it’s nobody’s fault (not even the parents’) but is everyone’s problem.

    Showing a genuine appreciation for the suffering of the parents. They have gotten enough blame from family and thoughtless acquaintances. And at least one of them will have similar behavioral tendencies to that of the child. Let them know that family-based interventions are for them, too.

    1. “Showing a genuine appreciation for the suffering of the parents. ”
      This is an important piece. Even so-called “bad parents” are doing the best they know how to do.

    2. @calling all toasters: Very well said indeed. Thanks for these wise suggestions.

  6. I don’t know anything about the medical side of this, but in a perfect world, we’d have funding so both these kids could have school-based therapy. It could help them learn to cope with their family, since they’re stuck there until they’re 18.

    I don’t see a downside to it. The therapist could explain to them that being in therapy in no way means there is even a problem with them — it’s just learning tools to help them get through life with their non-ideal parents. I think children are smarter than adults think and they could handle it just fine. They probably already know which subjects to avoid around their folks.

    1. Those kids are stuck with their families WAY past 18. They’re so broken that there’s no way they’re going to get out of that situation until both parents are dead or in prison. This makes me very sad, and if I turn out to be wrong, I’ll be very glad.

      1. Well, I don’t think you’re wrong, at all. Growing up with difficult parents is a huge handicap. I do think there’s hope though.

  7. My insurance will cover pills, but try getting full coverage for therapy.
    Do try, please. Find the one guy/gal in your city who is covered by your insurance, has space, that you have a good feel for.

  8. Thank you Dr. Humphreys for sharing your thoughts with us whether about a favorite movie (Charlie Muffin) or about these kinds of unhappy and frequently unsolvable clinical dilemmas practitioners are faced with. Your discussion frequently lights up the clinical aspects of the issue making it much more interesting for me. Regarding this problem: How about the three year old who is on steroid medication for asthma which results in a level of restlessness that causes the child’s caretaker to pursue medication for ADHD? Often difficult to resolve easily especially if the child is being cared for by a state agency and does not have a “family” physician.

    1. Thanks alnval, for the kind words. And you are right of course that if there is not a single provider or coordinated providers, medication side effects can often be mistaken as independent disorders.

  9. There have been some promising trials of multi-agency partnerships that help families in this sort of situation (typically, they begin by having the school identify at risk children, and then involve the school, social services, police, housing and so on). One of the ones I heard about was run by John Toumborou in Melbourne. I think one of the funadamentals is to frame the rationale for intervention – it’s not ‘how can we fix this problem”, it’s “what’s needed to get this family to a point where they won’t need our services”. Always hard to get funding and to maintain this approach, though.

    As a loving grandparent in one of these situations, I have to say that one frustration is powerlessness. The parents have all the rights until and unless there is some really major problem, and the process for for addressing these is drawn out, messy and likely very harmful to the children. You learn to patiently negotiate and influence, but there’s always the fear that the parents will cut you off, or move away on a whim, and there’s nothing much you can do about it. It’s a long walk on eggshells.

  10. One other thing to consider in such cases (especially if there’s more than one kid) is that when you’re dealing with a designated patient, until/unless you get at the larger dynamic there *is* going to be a designated patient. At most there may be a choice about who is shoved into that role.

    It’s sort of ironic that there should be coverage for drugs but not other forms of therapy (and in some areas finding a therapist who will be acceptable to the parents and not do more harm than good may be a problem); 20 years ago it was conventional wisdom that non-pharmacalogical interventions were both expensive and interminable, whereas now it’s the drug cocktails that are hugely expensive and often require longterm consumption.

  11. I face these issues every working day. I am both a child psychologist and a child/adolescent/young adult psychiatric nurse practitioner. I can think of 2 cases like this from just the last 2 weeks. What I try to do is to be clear with both the parents and child about what medications can and can’t do. Things that medications can’t do include fix maladaptive behaviors, or change dysfunctional relationships. Medications can sometimes assist in those processes, e.g. a child with ADHD and oppositional-defiant disorder who becomes easier to work with after being medicated, leading the parents to be less stressed and feel more confident in their dealings with him, thus leading to improvements in the relationships. I sometimes do refuse to prescribe (I did in both the recent cases), usually when I my judgment is that the child does not have a condition that medications can help. In those cases medications are at best useless and at worst harmful, as in the situation where a child gains a lot of weight on atypical antipsychotics that he/she should never have been prescribed in the first place(I see that one almost every day also). Also, agreeing to prescribe when the problem really isn’t a clinical condition in the child risks ratifying the inaccurate belief systems of the family (e.g. that the child is sick and the parents don’t need to change), which also isn’t ethical IMHO. I know that in many of those situations the parents will simply find a more amenable prescriber; there’s nothing I can do about that. I also put a lot of effort into gaining the trust of both the children and the parents. I’m very aware that parents are likely to see me as an expert, in part because I am licensed to prescribe, and that I can sometimes can use that belief to assist them in starting to see the situation in a new way. In my view, very few parents are sociopathic; most bad parents are trying to do the best they can, with the resources that they have. If I can gain their trust I increase the likelihood that they will begin to work on changing their own behavior. Of course that takes a lot of time. I am fortunate enough to work in a setting in which I have 90 minutes for intake appointments and 60 minutes for follow-up appointments. That’s almost unheard-of in the prescribing world, where 30-60 minute intakes and 15-30 minute follow-ups are the norm. A lot of my fellow practitioners don’t have the time to do the relationship work, so they just write the script. Unfortunately that’s a bad model that often leads to bad outcomes. People are very complicated, and families even more so; this work just can’t be done on an assembly line.

    1. @beckya57 — Thanks for these very thoughtful comments, and even moreso of course for being in the trenches with these struggling families.

  12. In re Anval’s comment above: the analogous situation that I’ve seen is the child who has been prescribed benzodiazapines, which can cause children to hallucinate, and then the child is given antipsychotics for his/her iatrogenic psychotic disorder. Integrated medical record systems (which I am also very fortunate to have access to in my setting) can help prevent a lot of these problems.

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