PMHNP Care Across the Lifespan I

Instructions: Respond to at least two of your colleagues on 2 different days by sharing cultural considerations that may impact the legal or ethical issues present in their articles.



Ethical Consideration Child Autonomy

The prevalence of attention-deficit hyperactivity disorder (ADHD) among US children has increased two to three times in the last 20 years, and a growing number of preschool-aged children are being prescribed stimulant medications. With approximately 9% of children in the USA between 9 years and 17 years of age being diagnosed with ADHD and 2.7 million children prescribed stimulant medications annually, ADHD is considered the most prevalent and most treated mental health diagnoses in US children. The increase of stimulant use in children has caused controversy and concern about the potential medicalization of typical, albeit challenging, childhood behaviors. These concerns are often implicitly related to the perception that stimulants will have a deleterious effect on the child’s emerging sense of self and their sense of authenticity. By using stimulant medications, some argue, children may become an ersatz though socially manageable version of themselves. Thus, when prescribing psychotropic medications for treatment of ADHD assent is a necessary component of providing high quality healthcare. Assent can help avoid negative misperceptions regarding the overprescribing of stimulants and the specific concern that stimulants present a risk to the child’s authentic sense of self. By engaging in an ongoing assent conversation with each patient about the physical, psychological, and existential effects of their treatment is necessary and feasible with present day clinical time constraints. Assent is a way to respect the nascent autonomy of young persons. By obtaining assent for stimulant medication, clinicians incorporate the child’s perspective into their mental health treatment decisions and thereby demonstrate respect for the young person. Respect for persons can be viewed as recognizing a person as an autonomous agent that has the right to make choices based upon a set of personal beliefs and values. Assent-related conversations enhance communication between the child and all adult parties (parents and physician) involved in the medical decision-making process. Assent therefore promotes the principle of respect for persons which grounds contemporary ideals of shared decision-making, patient-centered care, and supporting the transition of care into adulthood (Koshy,2015).



Ethical Consideration Adult Autonomy

Psychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients’ opportunities to be heard and participate in the process. They identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients, paternalism, autonomy, and reciprocity. The aim of the study was to describe and analyze statements describing real work situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics: paternalism, autonomy, and reciprocity. The idea of autonomy was clearly expressed in the first version of The International Code of Medical ethics adopted in 1949. The code states that the physician is obliged to respect a competent and well-informed patient’s right to accept or refuse treatment. A key idea in this perspective is that the competent and well-informed patient has the right to make a decision, even if this is contrary to her/his best interest from a professional perspective. The participants emphasized the need to respect the patient’s right to self-determination and information. Several threats to patient autonomy were reported. One was lack of resources, which sometimes resulted in limitations on patient autonomy. Being permitted to go outdoors and other activities could be limited if staff members lacked the time to assist. Another risk was that ward practices, routines and rules were often extensive, and patients and staff were expected to respect them. Relatives could request information about the patient, which was problematic if the patient did not wish to inform them. Occasionally the staff decided to withhold information from patients, for example incoming mail or details about their care planning, in order not to create anxiety on the ward. Ward routines included conducting diagnostic tests, and at times management demanded tests, but it could happen that patients refused to participate (Pelto-Piri,2013).




Legal Considerations Adult Autonomy

Consent is a process that allows for free expression of an informed choice, by a capable person to participate in a treatment or a study. The primary purpose of consent is to uphold an individual’s autonomy and the right to choose by rational decision-making. It is one of the most important components of healthcare delivery and biomedical research today. Informed consent involves clinical, ethical, and legal dimensions pertaining to all the medical interventions. Consent is a process of communication between two parties, in which a person grants permission for the proposed treatment or research intervention based on realistic expectations of the potential risks and benefits. It is an obligation on a service provider to communicate to service seeker about the need for such medical intervention, and other alternate options, realistic expectations of each intervention, based on the potential risks and benefits and helping the service seeker to choose an appropriate intervention without undue influence or coercion. Consent is believed to improve the autonomy of the individual, the therapeutic alliance and treatment compliance (Ali,2019)




Legal Considerations Child Autonomy

Waiving parent permission can be an option in some epidemiological and social research with adolescents. However, exemptions have not been uniformly considered or applied. The aim is to critically assess the different factors that could be considered when making decisions about waiving active parental permission in observational research with adolescents. The current problem is that exemptions are not uniformly considered or applied. In some countries, there is no clear set of rules regarding when it is required to obtain parental permission for minors in observational research. Regulation in the US allows the consideration of a waiver of parental permission when it is not a reasonable requirement to protect subjects. However, even in these cases there is some controversy and contradictory assessments from Research Ethics Committees can be found. This variability can be explained by multiple factors that can determine decisions regarding adolescents’ participation in research. In each case the assessment should consider the topic of the research, the context in which it is implemented and the developmental level and age of the participants (Ruiz-Canela,2013).

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Discussion Response

Your discussion post offers an informative analysis on ethical considerations in child autonomy and relevance to PMHNP. I like that your discussion highlights the prevalence of attention-deficit hyperactivity disorder (ADHD) as a mental health concern among children. The presence of statistical figures shows how much ADHD is a problem and the proportion of the population that is diagnosed with the condition and medicated. In addition, I like that you focus concern on the use of medication. The concern is understandable since the medication for ADHD is taken for the long-term with a focus on controlling the symptoms. Besides that, I like that you highlight the fact that children are typically not consulted when prescribing medication such that their autonomy as patients is not really recognized. Moreover, I like your idea that children should be consulted when prescribing medication and their assent acquired to ensure that children autonomy is not violated. Furthermore, I like that your discussion also explores adult patient autonomy with reference made to the relevant ethical codes supporting patient autonomy. Additionally, I like that you discuss the legal considerations in adult autonomy with a focus on consent process, informed choice, and autonomy. Although your discussion is informative, I feel that you may have overlooked the influence of culture on the issue. While it is right to recognize the autonomy of children, most cultures do not recognize that children have an autonomy since they are immature and inexperienced, and therefore, incapable of consistently making the best decisions (Novalis, Singer & Peele, 2020). Both culture and the law recognize that children are incapable, and instead recognize the right of parents and guardians to act as proxies and make decisions for children. If children are incapable of making decisions, then consulting them during decision making may be a redundant practice. Still, consulting them can make them feel involved in the decision making so that they are more supportive of the outcomes (McCormick & Sherer, 2018). Overall, I feel that your discussion is well presented, but could be improved by including the mentioned points.


McCormick, C. B., & Sherer, D. G. (2018). Child and adolescent development for educators (2nd ed.). The Guilford Press.

Novalis, P. N., Singer, V., & Peele, R. (2020). Clinical Manual of Supportive Psychotherapy (2nd ed.). American Psychiatric Association Publishing.