Physicians have been using psychotropic drugs in children increasingly, probably because of the successful results of methylphenidate (Ritalin®) with hyperactive children who have an associated attention deficit disorder.
Parents and child advocates have been simultaneously concerned, however, about accuracy of diagnosis, over-labelling of the child, long-term side-effects, and providing a quick “fix” while neglecting other therapies that require long-term commitment. Consumer complaints in Ontario resulted in unique legislation, the Child and Family Services Act (CFSA) of 1985, which defines psychotropic drugs; formally states the physician’s responsibility to obtain informed consent; defines informed consent to include drug dosage and risks; requires caretakers other than the parents to be informed about the medication; and sets limitations on the emergency use of psychotropic drugs with adolescents older than 16.
This article will address common questions from parents and guardians about the use of psychotropic drugs, will provide a brief guide to use of three common psychotropic drugs used with children, and will list the common conditions in children and adolescents for which psychotropic drugs might be considered.
Legal and Ethical Issues
Although the CFSA applies only to children and adolescents in programs of the Ontario Ministry of Community and Social Services, the principles of obtaining informed consent have been endorsed by the Ontario College of Physicians and Surgeons and the Canadian Medical Protective Association. There have been myriad articles aimed at physicians following the 1980 Supreme Court of Canada “Reibl versus Hughes” case, which established the precedent of a physician’s obtaining informed consent.
Assessment of the case’s impact, however, has shown that it has been ignored for the most part by physicians, much to the dismay of the Ontario Hospital Association (and likely the Canadian Medical Protective Association). All that is legally required now, even under the Ontario CFSA, is a note in the doctor’s record that he or she has discussed the purpose of drug treatment and the risks associated with this treatment. The Ministry of Community and Social Services has, however, recently considered requiring formal, written consent forms signed by children receiving their services. The Ontario Medical Association will be asked to participate in developing potential regulations.
The Biomedical Ethics Committee of the Royal College of Physicians and Surgeons of Canada has urged a higher standard of informed consent than the law requires and has recommended the concept of shared responsibility. This recommendation entails good communication with the patient or surrogate, provision of reasonable data, noting and discussing any indecision on the part of the patient or surrogate, consulting legal authority if the physician believes that serious harm may befall the patient without treatment, and finally, avoiding delegation of this important medical act to others.