In the treatment of children, and in a different way also in the treatment of mentally retarded people or people suffering from dementia, questions of patient choice will become increasingly important as already discussed in the example of atypical neuroleptics. Who can, and should, consent to treatment? How important is the assent of the person who has to tolerate the treatment? Can parents decide on preventative interventions or on enhancement in children whilst the children are still too young to articulate their wishes or recognise the problems the parents have with their behaviour? Who defines the problems? Who decides about the cure and who has to take the pill? These are the standard questions in the triangle of parent, child and doctor or legal guardian, patient and doctor. Where autonomy is concerned, an additional dimension is important: that of society. Restraint of aggressive or dangerous psychiatrically ill patients has always been one of the historical tasks of psychiatry. In the context of intervening in the psyche, the interests of the society may conflict with the personal interests of a subject. For example: is so-called "chemical restraint" acceptable to avoid harm to self or others? Individual rights of freedom and autonomy are sometimes overruled by mechanical or chemical interventions in psychiatrically ill patients, in the interests of protecting either themselves or others. These classical ethical questions will be discussed in this chapter against the background of examples from different substance classes. This will provide a framework for possible future discussions that will accompany the introduction of new forms of interventions in the brain.
The term "chemical restraint" in itself bears some potential for dispute (Crumley 1990) and is still not accepted by the American Psychiatric Association (APA), which considers this term imprecise, inaccurate and pejorative, and prefers to use the phrase "drug used as restraint" (Riordan 1999). Nevertheless, this term is widely used within the literature concerning restraint of children and adolescents and is well defined in the "Practice parameters" of the American Academy of Child and Adolescent Psychiatry (AACAP):
A drug used as a restraint is a medication used to control behavior or to restrict a patient's freedom of movement and is not standard treatment for the patient's medical or psychiatric condition. Chemical restraint is different from the ongoing use of medication for the treatment of symptoms of underlying illness. (Masters et al. 2002)
Similar definitions can be found in the existing literature (Sorrentino 2004; Wynn 2002) and in the definition of the Health Care Financing Administration (Department of Health and Human Services 1999).
Discussion of different types of restraint (including mechanical, physical and chemical) and seclusion began about 200 years ago and led to dispute between European and American psychiatrists (or "alienists" as they were called at that time) throughout the 18th century, with a British group led by
John Conolly opposing mechanical restraint on the one side, and American alienists emphasising the need for mechanical control as the only means of controlling the "liberty-loving American" (Deutsch 1949) on the other.
The synthesis of chloralhydrate (which entered the American market in 1870) by a German pharmaceutical company, along with the use of opiates, bromides, alcohol and (later on) barbiturates, opened new possibilities in the management of agitated and psychotic patients by the turn of the century (Colaizzi 2005), thus ending the debate about the pros and cons of mechanical restraint.
Nowadays, different (psycho)pharmacological substances are used to control problematic behaviour and restrain patients. They include antihistamines (e.g. Diphenhydramine and Hydroxyzine), benzodiazepines (e.g. Diazepam, Lorazepam, Midazolam), opiates (e.g. Fentanyl), barbiturates (e.g. Pentobarbital), beta blockers (e.g. Propanolol), Lithium, Carba-mazepine, atypical antipsychotics (e.g. Olanzapine, Ziprasidone, Quetiap-ine) and typical antipsychotics (e.g. Chlorpromazine, Fluphenazine, Haloperidol, Perphenazine, Thiothixene, Trifluorperazine; the butyrophe-none Droperidol received a black box warning from the FDA due to its QT-prolongation and torsades de pointes dysrhythmias). Combinations, for example Haloperidol with Lorazepam (Battaglia et al. 1997; Bieniek et al. 1998), have also been tried.
Dorfman and Kastner (2004) evaluated the use of both mechanical and chemical restraint in paediatric psychiatric patients within an emergency medicine residencies and paediatric emergency medicine fellowships setting. They found that the most commonly drugs recently used to restrain children and adolescents were benzodiazepines, butyrophenones and antihistamines, followed by phenothiazines, opiates, barbiturates and others. Vitiello et al. (1991) found no significant difference in the efficacy of pro re nata (PRN, meaning according to need) medication when compared to placebo in a study of 21 boys between 5 and 13 years to whom medication was administered for the control of physical aggression, disruptive behaviour and temper tantrums.
According to Sorrentino (2004), an ideal drug for chemical restraint would have 1) efficacy in children; 2) multiple routes of administration; 3) non-addictive properties and no induction of tolerance; 4) minimal side effects with a good safety record and 5) cost-effectiveness. So far, such a drug does not exist. When it comes to indications for the use of seclusion and restraint, the "Practice parameters" of the AACAP (Masters et al. 2002; Barnett et al. 2002) points out that the application of these methods is only indicated "to prevent dangerous behavior to self or others and to prevent disorganisation or serious disruption of the treatment programme including serious damage to property". This, unfortunately, leaves considerable room for personal interpretation. Possible goals of chemical restraint suggested by Sorrentino (2004) are:
1. Decreasing the patient's anxiety and discomfort
2. Minimising disruptive behaviour
3. Preventing escalation of behaviour
4. Reversing the underlying cause, if identifiable
It is crucial that chemical restraints should always be offered first to the patient as voluntary treatment before involuntary measures are instituted, in order to emphasise the self-directedness of the applied pharmaceutical measures (Sorrentino 2004). Pharmacological substances often seem to be used as an aid where seclusion is not feasible. Sufficient data exists that an "unlocked seclusion policy" leads to an increased use of "as needed" tran-quilising medications (Antoinette et al. 1990).
When we start to discuss chemical restraint and its potential impact on children, we always need to consider the possible alternatives in managing aggressive behaviour. "Time-out" is often used at psychiatric wards as a means of giving a child the opportunity to "cool down" by him- or herself. It is defined by the AACAP as "a process in which a child or adolescent can calm down usually by being quiet and disengaging from current stressors. The time-out may be conducted without removing a child from peers (inclusionary) or with the child's removal (exclusionary). It may be staff-directed or at the child's request (self-directed)" (Masters et al. 2002). It has been shown that seclusion in a time-out room can be problematic for children and adolescents with a history of physical or sexual abuse, as it has potential for re-traumatisation (Barnett et al. 2002). We need to know how patients themselves feel about different treatment modalities offered in an "out of control" situation. Miller (1985) showed within a sample of 40 children, that young patients perceived time-out as a punishment and not as a self-regulated aid to lower their aggression level. Kazdin (1984) found that although mothers of hospitalised children found time-out to be the most acceptable method, children in fact preferred medication. In adults, Wynn (2002) noted that different studies suggest that both patients and staff prefer the use of pharmacological restraint to the use of physical restraint and seclusion, as the first is perceived more as "treatment" whereas the latter more as some sort of "punishment".
When we look at this topic from an ethical viewpoint, we should ask whether the child who presents with acute aggressive problems that clearly require management either physically or pharmaceutically has had comparable difficulties in his former (which in this context is understood as "pre-hospital") life, indicating an inherent need; or whether the behavioural problems stem from the surrounding environment at a psychiatric ward. It is well known in the literature that aggression among children at psychiatric wards peaks during unstructured times (Measham 1995) and Wynn (1996) described a peak in the afternoon and early evening for aggression at an adult psychiatric ward.
There is a probable lack of recognition of the need to change staffing factors associated with an increase of violence in psychiatric units, such as inappropriate nursing staff-to-patient ratios, too many non-nursing staff on planned leave, staff becoming involved in cycles of aggression and coercion, staff sadism, staff conflicts, lack of boundary-setting by staff in response to patient limit-testing and emotions amongst staff of fear and anger. Finally, staff must demonstrate competent therapeutic approaches (Masters 2002). In a nutshell: we must always ask whether pharmaceutical control of behaviour is necessary in itself, or in order to compensate for deficits within a hospital or parental or school environment which promote "artificial" aggressive behaviour.
To sum up, the possible conclusions that can be drawn include the following three points:
- First, the administration of chemical restraints must always be questioned in terms of necessity, and possible amelioration which can be achieved by changing the hospital environment.
- Second, (psycho)pharmaceutical substances should only be used after several attempts to offer the aggressive child support in controlling their violent behaviour have failed.
- Third, and most important, a distinction between a child's behaviour problems and himself/herself (Masters 2002) should be made by the staff, in order to use chemical restraint not as some sort of punishment, but as an appropriate step to help the patient regain self-control.
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