A major difficulty with the official American Psychiatric Association (APA) nomenclature, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (APA, 2000), and indeed with most current psychiatric nomenclatures, is that etiology is not usually taken into account in formulating a diagnosis. One reason for this is that, at our present state of knowledge, we do not know the etiologies of many conditions. Hence, we are often treating specific constellations of behavioral symptoms without adequately understanding their biological and genetic underpinnings and how they interact with their psychosocial and physical environments. For example, autistic disorder is not etiologically homogeneous but has a multitude of causes.

Theoretically, for a given psychiatric disorder, drugs may be effective by correcting the condition(s) leading to it (or them) or by influencing events somewhere along the usually complex pathways between the hypothesized abnormality(ies) and its subsequent psychological and/or behavioral consequences. Therefore, some psychoactive drugs may be effective in several dissimilar disorders because they influence or modify neurotransmitters and
psychoneuroendocrine events in the brain along or near the end of these interacting, partially confluent, or final common pathways. Current research suggests that there are genetic bases for these phenomena (Cross-Disorder Group, 2013).

Other psychoactive drugs appear to exert their therapeutic effects through entirely different mechanisms in different diagnostic entities—for example, imipramine in depression, attention-deficit/hyperactivity disorder (ADHD), and enuresis.

Some patients with a specific diagnosis (e.g., ADHD, autistic disorder, or schizophrenia) will not have a satisfactory clinical response or will be refractory to a specific drug—even one known to be highly effective in statistically significant double-blind studies—or will even have a worsening of symptoms. This may reflect differences in genetic makeup or other biologically determined conditions, psychosocial environments, and/or internalized conflicts and the contributions each makes to the etiopathogenesis of each patient’s psychiatric disorder.

Although diagnostic issues are not discussed specifically in this book, it is emphasized that an accurate diagnosis is of critical importance in choosing the correct medication. At times, the lack of expected clinical response to a medication should suggest to the clinician the possibility of an incorrect diagnosis and that a careful diagnostic reconsideration should be undertaken.

Other unfortunate clinical consequences may result from incorrect diagnoses. For example, antidepressants may precipitate an acute psychotic reaction when given to some individuals with schizophrenic disorder. Stimulant medications, too, may precipitate psychosis when given in sufficient doses to some children or adolescents with borderline personalities or unrecognized schizophrenia.

Wender (1988) noted that clinical experience suggested that some children diagnosed with ADHD were treated with stimulants and rapidly developed tolerance to them but were actually suffering from a major depressive disorder and that they responded to treatment with tricyclic antidepressants with remarkable improvement.

Changing diagnostic criteria may also complicate matters. For example, some of the controversy regarding the efficacy of stimulants in patients with development disabilities may have resulted from diagnostic issues. Until the publication of DSM-II (APA, 1968), there was no specific APA diagnosis for what was commonly known as the hyperactive child. There were various labels for this condition, including hyperactive child, hyperkinetic syndrome, minimal brain dysfunction (MBD), and minimal cerebral dysfunction. Intellectual disability was considered evidence of more than “minimal” dysfunction, and the various etiologies were thought to be biological. Because of this concept, children with intellectual disabilities were excluded from the possibility of receiving a codiagnosis of MBD, hyperactive child, or an equivalent diagnosis, and some clinicians may not have tried stimulant medication in their patients who had even mild disabilities.

The situation changed with the publication of DSM-II, which noted that “in children, mild brain damage often manifests itself by hyperactivity, short attention span, easy distractibility, and impulsiveness” (APA, 1968, p. 31). It also suggested that unless there are significant interactional factors (e.g., between child and parents) that appear to be responsible for these behaviors, the disorder should be classified as a nonpsychotic, organic brain syndrome and not as a behavior disorder.

In DSM-III (APA, 1980a), the diagnosis of attention-deficit disorder with hyperactivity (ADDH) was based on the presence of a specific constellation of symptoms, and no etiology was hypothesized. Hence, children of any intelligence could exhibit such features. DSM-III additionally notes that mild or moderate mental retardation may predispose one to the development of ADDH and that the addition of this diagnosis to the severely and profoundly retarded child is not clinically useful because these symptoms are often an inherent part of the condition.

DSM-III-R redefines ADDH somewhat, renames it (ADHD), and refines its relation with mental retardation. It notes that many features of ADHD may be present in mentally retarded people because of the generalized delays in intellectual
development. DSM-III-R (APA, 1987), DSM-IV (APA, 1994), and DSM-IV-TR (APA, 2000) note that a child or adolescent with an intellectual disability should be additionally diagnosed with ADHD only if the relevant symptoms significantly exceed those that are compatible with the child’s or adolescent’s mental age. These changes in diagnostic criteria, although directed toward greater precision in identification and classification of disorders, have often complicated the process of treatment planning for clinicians.

The clinician should discuss the medication with the child or adolescent as appropriate to the patient’s psychopathology and ability to understand. Giving the patient an opportunity to participate in his or her treatment is helpful for many reasons.

The patient can feel like an active partner in the treatment. This can alleviate feelings of passivity (i.e., that treatment is something over which the patient has no control). Letting the patient know that he or she should pay attention to the effects of the medication in order to report them to the therapist, that the patient will be listened to, and that the information the patient conveys will be considered seriously in regulating the medicine also helps the therapeutic relationship. The patient can also be informed that although medication may provide some relief or help, it cannot do everything, and he or she must still contribute effort toward reaching the treatment goals. This can be particularly important during adolescence, when issues of autonomy and control over one’s own body are normal developmental concerns.

Because the patient is experiencing firsthand the disorder being treated, in many cases valuable information necessary for regulating the medication can be obtained directly. Some fairly young children can express whether the medicine makes them feel better, more calm, or quiet; less mad or less like fighting; happier or sadder; less afraid, upset, nervous, or anxious; or worse, sleepy, tired, more bored, “madder,” or harder to get along with; and so on. Although parents or caretakers can provide much useful information, they may be unaware of some information that the patient can provide if time is taken to learn the words or expressions that the child uses to communicate feelings and experiences.

Adverse effects should be explained so that the child or adolescent understands them. The patient’s awareness that adverse effects may be transient (e.g., that tolerance for sedation may develop) or reversible with dose reduction may be helpful in gaining cooperation during the titration period. Foreknowledge also increases the sense of control and can decrease fear of some adverse effects. For example, if an acute dystonic reaction is a possibility, it is important to realize how frightening this can be to some patients (and their parents). Explaining beforehand that if this reaction occurs, medicine will help, and the condition will go away can make the experience less frightening. Also, if a rapidly effective oral medication such as diphenhydramine, an antihistamine with anticholinergic properties, is made available and patients and parents are aware of what is happening, the medication may be administered earlier in the process, frequently aborting a potentially more severe reaction.

Children who ride bicycles and adolescents who drive a car, motor bike, or motorcycle, or operate potentially dangerous machinery should be cautioned if a medication may cause sedation or other impairment. They should be told to wait until they are sure how they are reacting to the medication before engaging in these activities. Similarly, if an adolescent is likely to use alcohol or other psychoactive drugs, he or she should be warned of possible additive or other adverse effects. Drugs like monoamine oxidase inhibitors are too risky to recommend except in very cooperative patients who are able to follow the necessary strict dietary restrictions to avoid a potential hypertensive crisis.

Medicolegal issues usually involve concerns about the clinician’s clinical competence or performance. These issues arise primarily when something goes wrong. Incidentally, that “wrong something” may have nothing to do with the clinician’s specific treatment or competence but may, for example, be an outcome that displeases the patient or guardian. Even then, for a medicolegal issue to arise, someone who has become aware of it must decide to pursue the matter legally.

The importance of these issues is that the clinician’s relationship with the patient and his or her family or caretakers can either increase or decrease the likelihood of legal proceedings. As a general rule, the better the quality of the relationship and rapport between the physician and the patient and his or her family, the less is the likelihood for legal proceedings to occur. Parents who are angry at their child’s physician, who feel neglected or not cared about, are more likely to institute legal proceedings. Taking time to explain what the medicine may and may not do is important; no medication can be guaranteed to be clinically effective and safe for every patient.

If there is a risk that a depressed patient may attempt suicide but the patient is not hospitalized, this should be discussed with all concerned parties. Public perception of the association of suicidal ideation with a number of psychotropic agents has intensified the importance of these concerns. The patient may be asked to commit verbally or in writing to a contract to contact the clinician before any attempt to take his or her own life. Legal guardians should be informed of and concur with the decision that their child or ward will not be hospitalized and that, although there is a risk, the degree of risk is acceptable to avoid hospitalization. The guardians should be asked to provide more formal supervision until the depression improves sufficiently. If such measures are carried out and documented and a working rapport established, the risk of legal action and/or liability will be lessened should a suicide attempt, successful or otherwise, occur.

The clinician should make a genuine effort to establish a working rapport with parents who have consented under duress to the treatment of their child or adolescent (e.g., if their child has been removed from their care by a governmental agency because of abuse or neglect or where medication may be a prerequisite for remaining in a particular educational program), although this is frequently difficult.

Holzer (1989) noted that most, if not all, malpractice claims occur in cases with either an unexpected clinical outcome or an event that is perceived by the patient (or parents) as avoidable or preventable. The aspects of psychopharmacotherapy that have potential for medicolegal implications parallel this book’s entire section on general principles of psychopharmacotherapy. Lawsuits are most frequently brought if something is omitted or if something goes wrong that could reasonably have been prevented. It should be emphasized that proper documentation in the clinical record is essential. If this is not done, the clinician’s position is precarious if legal difficulties arise. The ascendancy of electronic health records (EHRs) has made it possible for physicians to document more fully their assessments and interventions; but electronic health records have made every aspect of patient care easily discoverable. Particular areas of concern are discussed later.

For a comprehensive overview of malpractice issues in child psychiatric practice, see Benedek et al. (2010).

Ethical concerns are paramount in the practice of psychiatry, and especially with children, because of their inherent vulnerability and their special reliance upon others and their environment. Contemporary medical ethics rests upon a set of major principles (Veatch, 1991): beneficence, maleficence, autonomy, veracity, fidelity, and avoidance of killing. These principles are often designated consequentialist (beneficence and nonmaleficence—having to do with good outcome) and nonconsequentialist (having
to do with inherent morality—autonomy, fidelity, veracity, avoidance of killing, and justice). Although many today assign a higher lexical ranking to the nonconsequentialist principles, this stance may be questioned in view of the vulnerability of children and their inherent lack of autonomy. In any case, it is the duty of the practitioner to recognize and balance appropriately the application of these principles.

The consequentialist principles of beneficence and nonbeneficence are usually the instinctive first consideration of clinicians. All medications that we use have both desirable and adverse effects, and each prescription represents an attempt to balance these effects for an individual patient. The history of psychopharmacology is replete with misapprehensions of these. The neuromuscular and metabolic effects of neuroleptics compared with their limited effectiveness in many off-label uses are a prime example.

Another such example would be the use of a psychostimulant in the child whose inattentive behavior in school results not from an attention deficit disorder but from a language-based learning disability. The child would demonstrate less activity when receiving the medication to the possible satisfaction of adults; however, this child would not be adequately educated, and the occurrence of dysphoria or other adverse effects might hurt the child.

It is an intrinsic duty (based on the principle of fidelity) for a physician to pursue beneficence and avoid maleficence. It is obvious that a physician can do so only with a comprehensive biopsychosocial diagnostic understanding of the child patient. The physician must also have as full a familiarity as possible with the effects of any agents to be considered. Ignorance is unethical.

The consequentialist principles present a more nuanced challenge. Avoiding killing is a clearly defined and almost universally accepted principle among physicians, despite concerns about euthanasia. Fidelity, the adherence to behavioral and professional standards, in the context of a doctor-patient relationship based on a social contract, is universally accepted. Justice in the context of medical ethics refers to the allocation of resources among a larger population; its application involves a range of political and cultural issues that are constantly debated.

Veracity in today’s context requires not only the avoidance of falsehoods but the telling of the “whole truth.” Two complications arise here. First of all, doctors and patients considering pharmacologic treatment face an intimidating volume of information. The pages of fine print in the Physicians’ Desk Reference are intimidating to many patients and families and contain information of varying relevance to physicians. The full possibility of adverse effects from any agent can never be absolutely known. In this situation, physicians should offer as much information as they judge families can digest at a given time, with the added proviso that other information is available, that it can be acquired from the physician and other sources, and that no other information can be absolutely complete. At times, physicians fear that information may be daunting to families and will discourage the acceptance of beneficial agents. Parents almost always do have the autonomous right to refuse to give psychotropic agents to their children, despite the concerns of physicians. Coercion is usually unethical and seldom successful. These issues can be resolved only through communication, and the ability to communicate with authority, empathy, and clarity is as essential as skill and psychopharmacology as is scientific knowledge (Krener and Mancina, 1994).

The second complication of veracity is the cognitive level of the child patient. One must provide a clear and developmentally appropriate explanation of risks, benefits, and possible adverse effects of medication; this is important not only from an ethical standpoint but also to assure that the child can recognize positive and/or adverse effects and report them.

Autonomy is the most complicated ethical issue in child psychopharmacology. In general, parents have absolute authority in decisions related to the treatment of minor children. Concurrently, however, children, despite their intrinsically
limited autonomy, are seen as having the right to assent or refuse treatment. Assent is “agreement obtained from those who are unable to enter a legal contract” (Ford et al., 2007). Dockett and Perry (2011) describe assent as “a relational process whereby children’s actions and adult’s responses taken together reflect children’s participation in decisions”; this is an interactive process. In their masterful review, Krener and Mancina (1994) describe various models for decision making and demonstrate that autonomy in child patients, as well as compliance, is engendered by a communicative rather than an authoritative or prescriptive stance.

This same principle is obtained in addressing the autonomy of parents or guardians. In rare cases, this autonomy may be superseded by legal interventions as in overt abuse or neglect; however, this almost never occurs regarding issues of psychopharmacology. Consequently, for both ethical and pragmatic reasons, the clinician must respect the nearly total autonomy of parents. Krener and Mancina provide models and examples for decision making. In all of these cases, there is a framework of communication that is respectful, empathetic, and complete.

The most specific application of autonomy arises in informed consent. Today, most physicians are aware of the absolute necessity for documentation of informed consent to all treatments, for legal as well as ethical reasons. Informed consent involves information and voluntariness. Patients and families are provided with diagnosis, the nature and purpose of a treatment, and the risks and benefits of a proposed treatment versus alternative treatments or no treatment (AMA, 2012). These principles have become accepted throughout much of the world (Malhotra and Subodh, 2009).

A special problem that involves all the principles of ethics arises from the use of psychotropic agents in the face of inadequate or inappropriate psychosocial services and environmental settings. This most often occurs with the intent of managing or attenuating aggressive behavior. At this writing, massive public attention is being directed toward the alleged misuse or overuse of psychotropic agents, notably neuroleptics among children in foster care (Kutz, 2011). Similar concerns have been raised for children in other treatment settings (MMDLN, 2011). It is charged that these medications have been given involuntarily (autonomy) and without full information (veracity) to children. Adverse effects have arisen (non-maleficence) with few if any concurrent benefits (beneficence). Implicit and often explicit accusations are made that these agents are used for behavioral control in the absence of appropriate environments and psychosocial treatments (justice). Clinicians involved in these issues may be overwhelmed by massive numbers of needy children and very sparse treatment resources. In certain circumstances, they may opine that medications given even under the stated circumstances but in a resource-starved setting may constitute a more beneficent alternative than placement in more restrictive settings, multiple brief foster or residential placements, incarceration, or abandonment. The obvious answer to this ethical dilemma is the development of comprehensive environmental and treatment resources. In the absence of that blessed circumstance, clinicians must approach these questions with a broad awareness of all the ethical principles involved applying them with both rationality and sensitivity; this approach to ethics facilitates all medical practice. The Codes of Ethics and the Ethics Committees of the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry can provide assistance in assessing these dilemmas (Sondheimer and Klykylo, 2008).