Original Publication
Open Access

Teaching Ethics in Child and Adolescent Psychiatry: Vignette-Based Curriculum

Published: June 17, 2016 | 10.15766/mep_2374-8265.10418

Appendices

  • Ethics Vignette Student Version.pdf
  • Ethics Vignette Curriculum Teacher Version.pdf
  • Ethics Curriculum Overview.pdf
  • AACAP Code of Ethics 2014.pdf

All appendices are peer reviewed as integral parts of the Original Publication.

To view all publication components, extract (i.e., unzip) them from the downloaded .zip file.


Abstract

Introduction: Ethics is an integral component of child and adolescent psychiatry. While ethics can seem abstract or philosophical, its tenets are fundamental to the practice of medicine. Understanding relevant ethical principles shapes how practitioners make decisions in all activities, including clinical, administrative, research, and scholarly. Methods: Using the American Academy of Child and Adolescent Psychiatry (AACAP) Code of Ethics as the framework, these vignettes serve as stimulus material to help teach the ethical principles relevant to child and adolescent psychiatry practice. Each vignette briefly describes a clinical situation in practice, followed by questions and possible appropriate responses. The teacher’s guide includes a discussion of the relevant ethical principles and perspectives on how to think about the issues involved. A supplementary overview of ethical issues in child and adolescent psychiatry and a list of resources are also provided. Results: We and other child and adolescent psychiatrists have used this curriculum at professional organizational meetings, in residency programs, and in teaching medical students with positive learner responses. Discussion: This curriculum was developed by members of the AACAP Ethics Committee with input from the entire committee in an effort to produce material that was easy to use and provided valuable content about an essential aspect of practice that is relevant to all practitioners at all levels. While designed for child and adolescent psychiatrists, the content is relevant to all physicians working with children, adolescents, and families.


Educational Objectives

After participating in this activity, the learner will be able to:

  1. Identify and describe the ethical principles relevant to clinical practice with children, adolescents, and families as delineated in the American Academy of Child and Adolescent Psychiatry Code of Ethics.
  2. Identify and explain the ethical issues that arise when working with children, adolescents, and families.
  3. Utilize the relevant ethical principles to understand, discuss, and manage ethical dilemmas that occur in practice.

Introduction

The discipline of ethics focuses on moral principles and values that guide attitudes and behaviors. Being an ethical and professional practitioner has been a fundamental tenet of medical practice throughout its history and remains an essential aspect. The ability to understand and abide by ethical principles relevant to the practice of child and adolescent psychiatry is an essential aspect of being a competent and professional child and adolescent psychiatrist. Learning and maintaining an ability to identify, analyze, and make decisions about ethical dilemmas are key skills for all medical students, residents, and physicians. Ethical child and adolescent psychiatrists have to have the knowledge of ethical principles and how to use them but also have to consider the application of ethical principles an essential aspect of professional practice. Maintaining ethical behavior in practice requires self-awareness and self-monitoring regarding one’s own beliefs and actions, both as an individual and as a practitioner, and assessing the impact of these beliefs and actions on one’s position and practice.1 The available literature indicates that trainees and practitioners often are uncomfortable with the ethical aspects of care and would like more targeted education in this area.2-6

To facilitate ongoing ethics education of trainees and practitioners working with psychiatrically ill children and adolescents, the American Academy of Child and Adolescent Psychiatry (AACAP) Ethics Committee has developed an interactive curriculum to provide concise overviews of essential ethics topics with relevant references. While prior knowledge of children and adolescents is helpful, learners can be at any level of experience. This curriculum is designed to be used in interactive forums in which all participants can join the discussion. It can be used in full or in part. Certain vignettes can be selected to supplement other didactic and clinical material. The material covered is based on the principles laid out in the AACAP Code of Ethics,7 which broadly covers the essential ethical tenets relevant to working in mental health with children, adolescents, and families. The resource summary8 was developed from current relevant literature, and the vignettes are composites of relevant clinical situations we have experienced that highlight essential aspects of the material.

Methods

Ethics is an integral aspect of medical practice but often is viewed by practitioners as a content area that is difficult to understand and apply. This curriculum was developed using the AACAP Code of Ethics and various real-life scenarios to illustrate the code’s principles. The vignettes are intended to be easily accessible to practitioners at all levels, from medical students through practicing child psychiatrists. Using an interactive, discussion group–based approach allows different perspectives to be voiced and participants to have the opportunity to explore their understanding of the relevant ethical principles and how they might apply to future events. Providing a teacher’s version with suggested discussion points allows faculty to feel more confident in leading these types of discussions.

Using the AACAP Code of Ethics as the framework, the Ethics Vignette Student Version (Appendix A) and Teacher Version (Appendix B) are stimulus material to help teach the ethical principles relevant to child and adolescent psychiatric practice. Each vignette briefly describes a clinical situation in practice, followed by questions. The teachers’ guide has additional material that includes a discussion of the relevant ethical principles and perspectives on how to think about the issues involved.

The Ethics Curriculum Overview (Appendix C) provides an overview of the principles of the AACAP Code of Ethics and additional summaries of ethical issues relevant to the practice of child and adolescent psychiatry. Annotated references are provided. This summary can be read in its entirety to provide a brief overview or used as a reference to review concise overviews of specific topics.

The AACAP Code of Ethics (Appendix D) describes the code of ethics for practicing child and adolescent psychiatrists. The basic 10 principles are described. This document is also available on the AACAP website in the transparency portal.

There two different types of vignettes. The first set focuses on a single principle per vignette. Though the vignettes bring up issues relevant to more than one principle, a single principle is emphasized to highlight one specific concept and its applications. The second set discusses multiple principles per vignette, more closely mirroring real-life practice.

The issues raised in these vignettes are potentially complex. They are designed to capture the interface of multiple, sometimes competing approaches, including clinical judgment, ethical principles, and the law. The goal is to develop a thorough, deliberate process for analysis, discussion, and review rather than to reach a definitive answer for each vignette. For any given situation, practitioners should consider all relevant ethical principles and then prioritize, depending on the specific situation, their assessment of the child or adolescent, and their understanding of the involved adults. Child development, the best interest of the child, and doing no harm are always primary considerations. The goal of these vignettes is to prompt and facilitate the analysis and discussion of relevant child and adolescent psychiatry ethical principles; however, often no single correct answer exists. A key concept for teaching is that while some ethical choices are absolute, ethical principles often need to be applied flexibly in accordance with the clinician’s understanding of the context in which the ethical dilemma occurs and the values of those involved.

While designed for child and adolescent psychiatrists, these vignettes can be useful to any practitioner who works with children, adolescents, and families. It is suggested that prior to using these vignettes, both learners and teachers review the AACAP Code of Ethics and that the teacher review the Ethics Curriculum Overview as well as the teacher version of the vignettes. Expectations for prior preparation vary depending on the intent and goals of the sessions. Minimal preparation (i.e., just reviewing the AACAP Code of Ethics) tends to produce discussions in which participants identify their baseline reactions, articulate their general values, and review how these factors influence patient care, usually using personal experiences. More involved prework tends to produce comments by the participants that reference the germane literature, include a wider range of possible relevant situations (not just those personally experienced), and utilize ethical concepts and principles more systematically. One approach that has been positive in helping trainees to have both types of experiences is to first discuss the single-principle vignettes with minimal advance work and then do the multiprinciple vignettes, with requirements that participants read assigned texts and do independent research in order to lead the discussion and present on a specific ethical issue.

This curriculum can be used as a whole as well as in parts. It can be a stand-alone ethics educational activity or an aspect of other courses, for example, treatments or research. Selected segments have been used in onetime seminars of 90 to 180 minutes. The entire curriculum also has been taught in hour-long seminars over a period of time. To ensure mastery of the material, adequate time must be allowed to discuss the ethical issues brought up by each vignette. Depending on the participants and the goals of the activity, vignettes can be read in advance or during the class.

Time allotment depends on the number of vignettes covered as well as what the goals of the activity are. The minimal time to adequately discuss one vignette in reasonable depth generally is 45-60 minutes. If the teaching session is covering both clinical and ethical issues relevant to the vignette, including alternate scenarios (e.g., changing the child’s age, level of severity, etc.), then sessions of at least 90 minutes would be optimal. When participants are expected to prepare by reading the vignettes and/or additional relevant resource material, class time can be shortened. If participants are expected to review and present additional relevant outside information, 2-hour sessions are probably best. Reviewing and discussing all of the vignettes would require approximately 15 sessions of 60-90 minutes each.

When used for beginning trainees, it is recommended that the vignettes be done in order so that they mirror the AACAP Code of Ethics, with the more complicated scenarios implemented last. Teachers are encouraged not to provide the supplied discussion points to the learners before they arise in discussion. In addition to using paper-based versions of the vignettes in small-group discussions, these vignettes have been used in larger groups, using slides with audience response technology, and as stimuli for debates and role-plays. This curriculum has been utilized to help teachers develop more interactive approaches to teaching this content area and to help learners develop knowledge and skills about how to think about and manage ethical issues in practice.

Results

Both teachers and learners have been positive about using this curriculum. It has been presented at professional meetings and used with medical students, psychiatry residents, and child and adolescent psychiatry residents. The overall feedback has been positive, with requests for additional vignettes. This curriculum has been presented at the annual meetings of the AACAP and the American Association of Directors of Psychiatry Residency Training, where the audience included mostly educators. Feedback from the AACAP 2014 Annual Meeting included a rating of 4.64 out of 5 for “presentation was effective,” 4.50 out of 5 for “acquired useful knowledge and skills,” and 4.21 out of 5 for “information from session will change practice.” Ninety percent stated that the presentation should be offered again, with the remaining 10% not having answered the question. A 2015 presentation discussing cross-cultural variations in ethical interpretations yielded feedback that included a rating of 4.48 out of 5 on having well-balanced perspectives, 4.47 out of 5 for being interactive and allowing audience participation, and 4.30 out of 5 on meeting the educational objectives.

Discussion

This curriculum was developed by members of the AACAP Ethics Committee with input from the entire committee in an effort to produce material that was easy to use and provided valuable content about an essential aspect of practice that is relevant to all practitioners at all levels. While designed for child and adolescent psychiatrists, the content is relevant to all physicians working with children, adolescents, and families. Those who have used the curriculum have found it helpful and easy to implement. Current efforts include trying to disseminate the curriculum more widely and to continue to encourage educators that the ethics of medical practice need to be integrated systematically throughout the medical curriculum. The major barrier to implementation that has been expressed in feedback is the amount of time that the curriculum takes since it is an interactive, discussion-based activity. Potential users have been encouraged to use selected segments of the vignettes as time in their curricula allows. Future plans include developing additional vignettes to provide expanded content (e.g., professionalism) as well as developing complementary videos.

Familiarity with the AACAP Code of Ethics is now a requirement of the Accreditation Council of Graduate Medical Education requirements for child and adolescent psychiatry training. One hour of ethics education annually is required by AACAP for all its members. These requirements reflect a growing concern nationally about awareness of ethical principles among physicians, including child and adolescent psychiatrists. Yet training programs often find it difficult to teach applied ethics, in part due to lack of perceived expertise and also due to lack of resources. During presentations on this curriculum, a number of faculty from different institutions expressed frustration with the lack of teaching resources in this content area and indicated their interest in using the vignettes. This curriculum captures everyday ethical dilemmas very familiar to the seasoned practitioner and delineates the ethical issues and potential resolutions of these issues in a clear and explicit way. Thus, the vignettes both heighten awareness of potential ethical issues and model a thought process for clinicians to use when they confront ethical issues in practice.

In teaching these vignettes locally and nationally, we have recognized the great need for explicit ethics education, particularly as it pertains to everyday practice.


Author Information

  • Arden Dingle, MD: Professor of Psychiatry, University of Texas Rio Grande Valley School of Medicine
  • Sandra DeJong, MD: Assistant Professor of Psychiatry, Harvard Medical School
  • Vishal Madaan, MD: Assistant Professor of Psychiatry, University of Virginia School of Medicine
  • Lee Ascherman, MD: Professor of Psychiatry, University of Alabama at Birmingham

Disclosures
None to report.

Funding/Support
This activity was done as an AACAP Ethics Committee activity; AACAP provided some travel funds since a portion of the work occurred during committee meetings.

Ethical Approval
Reported as not applicable.


References

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  2. Sondheimer A. Teaching ethics and forensic psychiatry: a national survey of child and adolescent psychiatry training programs. Acad Psychiatry. 1998;22(4):240-252. http://dx.doi.org/10.1007/BF03340025
  3. Lehrmann JA, Hoop J, Hammond KG, Roberts LW. Medical students’ affirmation of ethics education. Acad Psychiatry. 2009;33(6):470-477. http://dx.doi.org/10.1176/appi.ap.33.6.470
  4. Jain S, Lapid MI, Dunn LB, Roberts LW. Psychiatric residents’ needs for education about informed consent, principles of ethics and professionalism, and caring for vulnerable populations: results of a multisite survey. Acad Psychiatry. 2011;35(3):184-190. http://dx.doi.org/10.1176/appi.ap.35.3.184
  5. Jain S, Dunn LB, Warner CH, Roberts LW. Results of a multisite survey of U.S. psychiatry residents on education in professionalism and ethics. Acad Psychiatry. 2011;35(3):175-183. http://dx.doi.org/10.1176/appi.ap.35.3.175
  6. Silverman HJ, Dagenais J, Gordon-Lipkin E, et al. Perceived comfort level of medical students and residents in handling clinical ethics issues. J Med Ethics. 2013;39(1):55-58. http://dx.doi.org/10.1136/medethics-2011-100300
  7. Code of ethics. American Academy of Child and Adolescent Psychiatry Web site. http://www.aacap.org/App_Themes/AACAP/docs/about_us/transparency_portal/Code_Of_Ethics_2014.pdf. Published September 2014. Accessed December 23, 2015.
  8. Dingle AD, Dell ML, Hamoda H. Ethics overview. American Academy of Child and Adolescent Psychiatry Web site. https://www.aacap.org/App_Themes/AACAP/docs/member_resources/ethics/in_action/code_in_action/aacap_ethics_overview_2012.pdf. Published December 31, 2011.


Citation

Dingle A, DeJong S, Madaan V, Ascherman L. Teaching ethics in child and adolescent psychiatry: vignette-based curriculum. MedEdPORTAL. 2016;12:10418. https://doi.org/10.15766/mep_2374-8265.10418

Received: January 7, 2016

Accepted: May 13, 2016