1
|
Ronde E, van de Lücht VA, Lachkar N, Ubbink DT, Breugem CC. Stakeholders' Views on Information Needed in a Patient Decision Aid for Microtia Reconstruction. Cleft Palate Craniofac J 2024; 61:854-869. [PMID: 36604964 PMCID: PMC10981206 DOI: 10.1177/10556656221146584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To assess which information about microtia and the possible reconstructive options health care providers (HCPs), patients and parents believe should be included in a patient decision aid (PtDA). DESIGN A mixed-methods study comprised of an online survey of HCPs and focus group discussions with patients and parents. PARTICIPANTS Survey respondents were members of the International Society for Auricular Reconstruction (ISAR). Focus group participants were patients with microtia and their parents, recruited through the microtia outpatient clinic at Amsterdam UMC, and through a Dutch patient organization for cleft and craniofacial conditions. METHODS An online, investigator-made survey was sent to ISAR members in December 2021. Semi-structured focus group discussions were held in February 2022. Quantitative results were summarized, and qualitative results were thematically grouped. RESULTS Thirty-two HCPs responded to the survey (response rate 41%). Most respondents (n = 24) were plastic surgeons, who had a median of 15 years of experience (IQR: 7-23 years). Two focus groups were held with a total of five patients and two parents. HCPs, patients and parents generally agreed on the information needed in a PtDA, emphasizing the importance of realistic expectation management. Patients and parents also considered psychosocial and functional outcomes, patient experiences, as well as patients' involvement in decision-making important. CONCLUSIONS A PtDA for microtia reconstruction should target all patients with microtia, and include information on at least technique-related information, expected esthetic results, possible adverse effects, psychosocial and functional outcomes and patient experiences. Preference eliciting questions should be developed for both pediatric patients and their parents.
Collapse
Affiliation(s)
- E.M. Ronde
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development, Amsterdam, the Netherlands
| | - Veronique A.P. van de Lücht
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - N. Lachkar
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Dirk T. Ubbink
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Personalized Medicine, Amsterdam Public Health, Amsterdam, the Netherlands
| | - Corstiaan C. Breugem
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development, Amsterdam, the Netherlands
| |
Collapse
|
2
|
Jorgensen SCJ, Athéa N, Masson C. Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:1941-1956. [PMID: 38565790 PMCID: PMC11106199 DOI: 10.1007/s10508-024-02850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of "the child's right to an open future," which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.
Collapse
Affiliation(s)
- Sarah C J Jorgensen
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Céline Masson
- Département de Psychologie, Université de Picardie Jules-Verne, Amiens, France
| |
Collapse
|
3
|
Ravindranath O, Perica MI, Parr AC, Ojha A, McKeon SD, Montano G, Ullendorff N, Luna B, Edmiston EK. Adolescent neurocognitive development and decision-making abilities regarding gender-affirming care. Dev Cogn Neurosci 2024:101351. [PMID: 38383174 DOI: 10.1016/j.dcn.2024.101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 01/10/2024] [Accepted: 01/26/2024] [Indexed: 02/23/2024] Open
Abstract
Recently, politicians and legislative bodies have cited neurodevelopmental literature to argue that brain immaturity undermines decision-making regarding gender-affirming care (GAC) in youth. Here, we review this literature as it applies to adolescents' ability to make decisions regarding GAC. The research shows that while adolescence is a time of peak risk-taking behavior that may lead to impulsive decisions, neurocognitive systems supporting adult-level decisions are available given deliberative processes that minimize influence of short-term rewards and peers. Since GAC decisions occur over an extended period and with support from adult caregivers and clinicians, adolescents can engage adult-level decision-making in this context. We also weigh the benefits of providing GAC access during adolescence and consider the significant costs of blocking or delaying GAC. Transgender and non-binary (TNB) adolescents face significant mental health challenges, many of which are mitigated by GAC access. Further, initiating the GAC process during adolescence, which we define as beginning at pubertal onset, leads to better long-term mental health outcomes than waiting until adulthood. Taken together, existing research indicates that many adolescents can make informed decisions regarding gender-affirming care, and that this care is critical for the well-being of TNB youth. We highlight relevant considerations for policy makers, researchers, and clinicians.
Collapse
Affiliation(s)
- Orma Ravindranath
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA; Center for Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Maria I Perica
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ashley C Parr
- Center for Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA; Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amar Ojha
- Center for Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shane D McKeon
- Center for Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gerald Montano
- Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Naomi Ullendorff
- Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Beatriz Luna
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA; Center for Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA; Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
| | - E Kale Edmiston
- Department of Psychiatry, University of Massachusetts Chan School of Medicine, USA
| |
Collapse
|
4
|
Salayev K, Aslanova U, Munir K. Evaluating the Decisional Capacity for Informed Consent of Transition age Children to Adolescents in Human Subject Research. J Empir Res Hum Res Ethics 2024; 19:28-36. [PMID: 38073174 PMCID: PMC10957319 DOI: 10.1177/15562646231219384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
This study aimed to evaluate children's capacity for informed consent. We translated into Azerbaijani language and adapted the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC). We enrolled four healthy groups: children aged 11, 12, and 13 years and adults. We provided the participants with information about the simulated research proposal and a related informed consent form. Subsequently, they were administered the UBACC. The mean total UBACC scores were 11.9 (11-year-olds), 12.7 (12-year-olds), 14.0 (13-year-olds), and 16.0 (adults). The gradual increase in the mean UBACC scores with age suggests the continuous maturation of the capacity to comprehend the informed consent process. There was no specific cutoff age to decide whether the children were competent enough to provide informed consent.
Collapse
Affiliation(s)
- Kamran Salayev
- Department of Neurology, Azerbaijan Medical University, Baku (Azerbaijan)
- Medina Medical Center, Baku (Azerbaijan)
| | | | - Kerim Munir
- Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts (USA)
- Departments of Psychiatry and Pediatrics, Harvard Medical School, Boston, Massachusetts (USA)
| |
Collapse
|
5
|
Berg KL, Mihaila I, Feinstein RT, Shiu CS, Gussin H, Acharya K, Gladstone TRG, Bernard L, Best M, Renz E, Abdallah G, Weldy S, Herrman D, Lynch E, Gerges M, Perez P, Buchholz KR, Msall M, Aaron S, Mutti M, Arnold C, Danguilan C, Argueta I, Hunter M, Pela E, Diviak K, Kuhn J, Berbaum ML, Van Voorhees BW. BEhavioral Health Stratified Treatment (B.E.S.T.) to optimize transition to adulthood for youth with intellectual and/or developmental disabilities. Contemp Clin Trials 2024; 136:107374. [PMID: 37898308 DOI: 10.1016/j.cct.2023.107374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/03/2023] [Accepted: 10/25/2023] [Indexed: 10/30/2023]
Abstract
Youth with intellectual and/or developmental disabilities (IDD) often struggle with depression and anxiety, which adversely impacts transition to adulthood. Integrated behavioral health care coordination, wherein care coordinators and behavioral health specialists collaborate to provide systematic, cost-effective, patient-centered care, is a promising strategy to improve access to behavioral health services and address factors that impact transition to adulthood, including depression/anxiety symptoms. Current care coordination models (e.g., Title V Maternal and Child Health Bureau [MCHB]) do not include behavioral health services. The CHECK (Coordinated HealthCarE for Complex Kids) mental health model, hereby refined and renamed BEhavioral Health Stratified Treatment (B.E.S.T.), is a behavioral health intervention delivery program designed for integration into care coordination programs. This study aims to determine whether an integrated behavioral health care coordination strategy (i.e., MCHB care coordination plus B.E.S.T.) would be more acceptable and lead to better youth health and transition outcomes, relative to standard care coordination (i.e., MCHB care coordination alone). Results would guide future investment in improving outcomes for youth with IDD. This study is a two-arm randomized clinical trial of 780 transition-aged youth with IDD (13-20 years) to evaluate the comparable efficacy of MCHB Care Coordination alone vs. MCHB Care Coordination plus B.E.S.T. on the following outcomes: 1) decreased symptoms and episodes of depression and anxiety over time; 2) improved health behaviors, adaptive functioning and health related quality of life; 3) increased health care transition (HCT) readiness; and 4) improved engagement and satisfaction with care coordination among stakeholders.
Collapse
Affiliation(s)
- Kristin L Berg
- Department of Disability and Human Development, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA; Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA.
| | - Iulia Mihaila
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Rebecca T Feinstein
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Cheng-Shi Shiu
- University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Helene Gussin
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Kruti Acharya
- Department of Disability and Human Development, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA; Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Tracy R G Gladstone
- Wellesley Centers for Women, Wellesley College, Wellesley, MA 02481, USA; Brown University, Providence, RI, 02912, USA
| | - Leah Bernard
- Department of Disability and Human Development, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Megan Best
- University of Illinois, Urbana-Champaign, Champaign, IL 61820, United States of America
| | - Ellie Renz
- Department of Disability and Human Development, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Ghada Abdallah
- University of Illinois, Urbana-Champaign, Champaign, IL 61820, United States of America
| | - Sarah Weldy
- Department of Disability and Human Development, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Deana Herrman
- Northern Illinois University College of Allied Health and Communicative Disorders, USA
| | - Emma Lynch
- The University of Chicago, Chicago, IL 60637, USA
| | - Michael Gerges
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Patricia Perez
- The University of Illinois Division of Specialized Care for Children, Chicago, IL 60607, USA
| | | | | | | | | | - Catherine Arnold
- Department of Disability and Human Development, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Chris Danguilan
- Department of Disability and Human Development, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Isai Argueta
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Madeline Hunter
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Emily Pela
- Institute of Health Research and Policy, University of Illinois, Chicago, IL 60608, USA
| | - Kathleen Diviak
- Institute of Health Research and Policy, University of Illinois, Chicago, IL 60608, USA
| | - Jocelyn Kuhn
- Emory University School of Medicine, Department of Pediatrics, USA
| | - Michael L Berbaum
- Institute of Health Research and Policy, University of Illinois, Chicago, IL 60608, USA
| | - Benjamin W Van Voorhees
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| |
Collapse
|
6
|
Wendler D. Pediatric Research without Parental Permission. J Pediatr 2023:113896. [PMID: 38154520 DOI: 10.1016/j.jpeds.2023.113896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 12/30/2023]
Affiliation(s)
- David Wendler
- Department of Bioethics, NIH Clinical Center, Building 10, Room 1C118, Bethesda, MD 20892-1156.
| |
Collapse
|
7
|
Mogensen N, Kreicbergs U, Albertsen BK, Lähteenmäki P, Heyman M, Harila A. Parental experiences of the informed consent process in randomized clinical trials-A Nordic study. Pediatr Blood Cancer 2023; 70:e30684. [PMID: 37728014 DOI: 10.1002/pbc.30684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Randomized clinical trials (RCTs) are an essential part of improving acute lymphoblastic leukemia (ALL) treatment. This population-based questionnaire study investigated parents' experiences of the informed consent process in the RCTs within the Nordic NOPHO (Nordic Society of Paediatric Haematology and Oncology) ALL2008 trial. PROCEDURE Parents in Sweden, Denmark, and Finland whose child was alive and in first remission after end of therapy and who were asked to participate in any RCT in the ALL2008 protocol, were asked to complete 15 questions/items regarding their experience of the RCT consent process. RESULTS A total of 483 parents of 279 children met the inclusion criteria and answered the study questionnaire. Most (91%) agreed/strongly agreed to having received sufficient information to make a well-informed decision, felt confidence in the study design (86%), and thought that the process was satisfactory (86%). Those who did not consent reported a generally more negative experience of the process. More than a third of all parents and over half of parents who had refused participation felt that it was burdensome to decide. Most parents (66%) in general, and one-third of those with children 8 years or older, reported that their child was not involved in the process. CONCLUSIONS Parents were in general satisfied with the informed consent process, although many parents, particularly those who refused participation, reported it as burdensome to make the decision concerning RCT. Fewer than expected of the school-aged children were involved in the decision process, which calls for attention on how children are included in the consent procedure in clinical trials.
Collapse
Affiliation(s)
- Nina Mogensen
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institute, Stockholm, Sweden
- Department of Pediatric Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrika Kreicbergs
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institute, Stockholm, Sweden
- Department of Health Care Sciences, Palliative Research Centre, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, Faculty of Health, University of Aarhus, Aarhus, Denmark
| | - Päivi Lähteenmäki
- Pediatric and Adolescent Hematology/Oncology, Turku University Hospital, Fican-West and Turku University, Turku, Finland
- Swedish Childhood Cancer Registry, Karolinska Institutet, Stockholm, Sweden
| | - Mats Heyman
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institute, Stockholm, Sweden
- Department of Pediatric Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Arja Harila
- Department of Women's and Children's Health, Uppsala University and Pediatric Oncology, Uppsala University Hospital, Uppsala, Sweden
| |
Collapse
|
8
|
Rodríguez-Domínguez FJ, Osuna-García T, Guillén A, Pérez-Cárceles MD, Osuna E. Involvement and Autonomy of Minors in Medical Settings: Perceptions of Children Undergoing Surgery and Parents. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1844. [PMID: 38136046 PMCID: PMC10742034 DOI: 10.3390/children10121844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/19/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023]
Abstract
Informed consent presupposes competence and represents a formal decision by an informed person who has the legal capacity to accept medical action or participate in research. Our aim was to analyze the perceptions of minors and their parents about the age at which they consider that a minor is competent for making health decisions. A descriptive observational study was carried out in 302 minors between 12 and 17 years of age undergoing elective surgery, and 302 parents (range 30 to 62 years). Two semistructured questionnaires were designed, one for the minors and the other, for the parents. A total of 20.1% of minors and 31.1% of parents believe that patients should not make decisions related to their health until they are 18 years old. A total of 74.9% of the minors surveyed consider that from 16 years of age, the minor is empowered to make decisions. In parents, this percentage is 60%. In the pediatric setting, each case and situation must be examined individually to determine if the minor meets the condition of maturity to decide. The ideal is to promote the minor's participation in decision-making, giving them the opportunity to participate in the process in a manner appropriate to their capacity.
Collapse
Affiliation(s)
| | - Teresa Osuna-García
- Service of Pediatrics, University Hospital of Caravaca de la Cruz (Murcia), 30400 Murcia, Spain;
| | - Alberto Guillén
- Service of Otorhinolaryngology, University Hospital of Cartagena (Murcia), 30202 Murcia, Spain; (F.J.R.-D.); (A.G.)
| | | | - Eduardo Osuna
- Department of Legal and Forensic Medicine, University of Murcia, 30120 Murcia, Spain;
| |
Collapse
|
9
|
Vrouenraets LJJJ, de Vries ALC, Arnoldussen M, Hannema SE, Lindauer RJL, de Vries MC, Hein IM. Medical decision-making competence regarding puberty suppression: perceptions of transgender adolescents, their parents and clinicians. Eur Child Adolesc Psychiatry 2023; 32:2343-2361. [PMID: 36115898 PMCID: PMC10576681 DOI: 10.1007/s00787-022-02076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022]
Abstract
According to international transgender care guidelines, transgender adolescents should have medical decision-making competence (MDC) to start puberty suppression (PS) and halt endogenous pubertal development. However, MDC is a debated concept in adolescent transgender care and little is known about the transgender adolescents', their parents', and clinicians' perspectives on this. Increasing our understanding of these perspectives can improve transgender adolescent care. A qualitative interview study with adolescents attending two Dutch gender identity clinics (eight transgender adolescents who proceeded to gender-affirming hormones after PS, and six adolescents who discontinued PS) and 12 of their parents, and focus groups with ten clinicians was conducted. From thematic analysis, three themes emerged regarding transgender adolescents' MDC to start PS: (1) challenges when assessing MDC, (2) aspects that are considered when assessing MDC, and (3) MDC's relevance. The four criteria one needs to fulfill to have MDC-understanding, appreciating, reasoning, communicating a choice-were all, to a greater or lesser extent, mentioned by most participants, just as MDC being relative to a specific decision and context. Interestingly, most adolescents, parents and clinicians find understanding and appreciating PS and its consequences important for MDC. Nevertheless, most state that the adolescents did not fully understand and appreciate PS and its consequences, but were nonetheless able to decide about PS. Parents' support of their child was considered essential in the decision-making process. Clinicians find MDC difficult to assess and put into practice in a uniform way. Dissemination of knowledge about MDC to start PS would help to adequately support adolescents, parents and clinicians in the decision-making process.
Collapse
Affiliation(s)
- Lieke Josephina Jeanne Johanna Vrouenraets
- Department of Medical Psychology, Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Emma Children's Hospital, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Marijn Arnoldussen
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ramón J L Lindauer
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Irma M Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
| |
Collapse
|
10
|
Michaud PA, Takeuchi YL, Mazur A, Hadjipanayis AA, Ambresin AE. How to approach and take care of minor adolescents whose situations raise ethical dilemmas? a position paper of the European academy of pediatrics. Front Pediatr 2023; 11:1120324. [PMID: 37351318 PMCID: PMC10282839 DOI: 10.3389/fped.2023.1120324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/22/2023] [Indexed: 06/24/2023] Open
Abstract
In the care of adolescents, health care providers often face situations raising ethical concerns or dilemmas, such as refusal of a treatment or hospitalization, or request of confidentiality while engaging in risky behaviors or facing unplanned pregnancy. This position paper provides concrete avenues as how to assess the adolescent's capacity for autonomous decision making, e.g. the patient's competence in a specific situation, and how to elicit informed choice or consent. To do so, professionals need to be sensitized and trained as how to assess the cognitive and socio-psychological development of the young patient. Another challenge for the health professionals is to balance the needs to support patient's autonomy while offering secure guidance and protection if needed. To optimize such a process, they establish a climate of trust and empathy that will allow the patient to participate freely in the decision. In addition, especially when the decisions have potentially important consequences on the health and life, the professionals include, with the adolescent's permission, parents, caregivers or other significant adults, as well as they may request the opinion of other members of the health care team or expert colleagues such as ethicists.
Collapse
Affiliation(s)
| | - Yusuke-Leo Takeuchi
- Division for Adolescent Health, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Artur Mazur
- Faculty of Medicine, University of Rzeszow, Rzeszow, Poland
| | | | - Anne-Emmanuelle Ambresin
- Division for Adolescent Health, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
11
|
Tanaka K, Hayakawa M, Mori M, Maeda N, Nagata M, Horibe K. Medical staff's sense of awareness of informed consent for adolescent cancer patients and the need for decision-making support practiced from the perspective of trauma-informed approach. BMC Med Ethics 2023; 24:28. [PMID: 37149683 PMCID: PMC10164311 DOI: 10.1186/s12910-023-00907-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 04/14/2023] [Indexed: 05/08/2023] Open
Abstract
It has not been established how to assess children's and adolescents' decision-making capacity (DMC) and there has been little discussion on the way their decision-making (DM). The purpose of this study was to examine actual situation and factors related to difficulties in explaining their disease to adolescent cancer patients or obtaining informed consent (IC). The cross-sectional questionnaire survey was conducted. Physicians who have been treating adolescent cancer patients for at least five years answered a self-administered questionnaire uniquely developed about clinical difficulties in explaining, IC and factors related patient's refusal of medical treatment (RMT). Descriptive statistics for each item and a polychoric correlation analysis of the problems and factors related to the explanation were conducted. As a result, fifty-six physicians were participated (rate of return: 39%). Explaining the disease and treatment to patients (83.9%), IC to patients (80.4%), and explaining the disease and treatment to parents (78.6%) was particularly problematic. Difficulties to provide support related with patient's refusal of medical treatment and to explain disease and treatment for patient and parents were related to difficulties obtaining IC for the patient. Conclusion: There are clinically difficult to explain for the patient or parents and to obtain IC for the patient. It is necessary to establish a disease acceptance assessment tool for the adolescence generation so that it can be applied in the field.
Collapse
Affiliation(s)
- Kyoko Tanaka
- National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan.
- Division of Consultation liaison Department of Psychosocial Medicine, 2-10-1 Okura, Setagaya- ku, Tokyo, 157-8535, Japan.
| | - Maoko Hayakawa
- National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
- Ochanomizu University Human Developmental Sciences, Bunkyo-ku, Tokyo, Japan
| | - Makiko Mori
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Saitama, Japan
| | - Naoko Maeda
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Aichi, Japan
| | - Masako Nagata
- Psychological Support&Research Center for Human Development, NAGOYA UNIVERSITY, Nagoya-shi, Aichi, Japan
| | - Keizo Horibe
- Department of Pediatrics, National Hospital Organization Nagoya Medical Center, Nagoya, Aichi, Japan
| |
Collapse
|
12
|
Knopf A, Draucker CB, Fortenberry JD, Ott MA, Arrington-Sanders R, Reirden D, Schneider J, Straub D, Ofner S, Bakoyannis G, Zimet G. Parental Engagement in Consent Processes for Enrollment in Biomedical HIV Prevention Trials: Implications for Minor Adolescents' Willingness to Participate. J Adolesc Health 2023; 72:703-711. [PMID: 36646563 PMCID: PMC11114099 DOI: 10.1016/j.jadohealth.2022.11.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/10/2022] [Accepted: 11/22/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Minor adolescents are often excluded from HIV prevention clinical trials due to unresolved ethical issues. Their under-representation in research leads to delayed access to new HIV prevention approaches. We examine the relationship between consent procedures, trial features, demographic and social characteristics, and minor adolescents' willingness to participate (WTP) in biomedical HIV prevention research. METHODS We recruited 14-17-year-olds at risk of HIV for this quasi-experimental study. Adolescents were randomly assigned to (1) self-consent, (2) adult permission required, or (3) parental permission required and underwent simulated consent procedures for two types of HIV prevention trials. They rated likelihood of participating in each study if offered the opportunity and completed a survey with demographic, social, and behavioral measures. RESULTS One hundred and twenty nine adolescents with diverse identities and socioeconomic status enrolled. Among the 58% of participants who identified as lesbian, gay, bisexual, transgender, or queer (LGBTQ), 76% were out to at least one parent/guardian (outness). Mean WTP was 3.6 (of 5; 5 = definitely would participate) across all participants and both trial types. We found no evidence of an association between WTP and consent condition, LGBTQ identity, or outness. However, medical mistrust, communication with parents, and concern about HIV were associated with WTP. DISCUSSION Our results suggest adolescents are willing to participate in HIV prevention trials and parental involvement in the consent process may not be the most important deciding factor. However, variation in WTP within consent groups, and variation in other significant variables, underscores the need for individualized approaches to recruitment and consent for these trials.
Collapse
Affiliation(s)
- Amelia Knopf
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana.
| | - Claire Burke Draucker
- Department of Community and Health Systems, Indiana University School of Nursing, Indianapolis, Indiana
| | - J Dennis Fortenberry
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mary A Ott
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Renata Arrington-Sanders
- Division of Adolescent and Young Adult Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Daniel Reirden
- Section of Adolescent Medicine & Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colorado
| | - John Schneider
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Diane Straub
- Section of Adolescent Medicine & Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colorado
| | - Susan Ofner
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Giorgos Bakoyannis
- Department of Biostatistics and Health Data Science, School of Medicine, Indiana University, Indianapolis, Indiana; Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
| | - Gregory Zimet
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
13
|
Stettner NM, Lavelle EN, Cafferty P. Who decides? Consent for healthcare decisions of minors in the United States. Curr Opin Pediatr 2023; 35:275-280. [PMID: 36647569 DOI: 10.1097/mop.0000000000001218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to examine when parents and legal guardians have the authority to make medical decisions on behalf of the minors in their care, when the decisions of healthcare professionals may supersede those of parents and guardians, and under what conditions minors can make healthcare decisions for themselves. RECENT FINDINGS The coronavirus disease 2019 (COVID-19) pandemic has reignited discussion of who should make healthcare decisions for minors. Though serious adverse reactions to COVID-19 vaccines are rare, hesitancy toward pediatric COVID-19 vaccination is prevalent among parents in the United States. This has contributed to large numbers of minors who are not up-to-date or not fully vaccinated against severe acute respiratory syndrome coronavirus 2 infection. Surveys reveal a majority of minors in the United States are willing to receive a COVID-19 vaccine. A number of scholars have recommended allowing adolescents the ability to consent to COVID-19 vaccination without parental approval. SUMMARY Allowing adolescents with a minimum age of 15 to consent to vaccination without parental or guardian approval will more quickly enable adolescents to receive new vaccines as they become available, such as the COVID-19 bivalent vaccine.
Collapse
|
14
|
Groff E, Orzechowski M, Schuetz C, Steger F. Ethical Aspects of Personalized Research and Management of Systemic Inflammatory Response Syndrome (SIRS) in Children. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:470. [PMID: 36612792 PMCID: PMC9819223 DOI: 10.3390/ijerph20010470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 06/17/2023]
Abstract
Systemic inflammatory response syndrome (SIRS) is a life-threatening condition with nonspecific symptoms. Because of that, defining a targeted therapy against SIRS in children and adults remains a challenge. The identification of diagnostic patterns from individualized immuneprofiling can lead to development of a personalized therapy. The aim of this study was to identify and analyze ethical issues associated with personalized research and therapy for SIRS in pediatric populations. We conducted an ethical analysis based on a principled approach according to Beauchamp and Childress' four bioethical principles. Relevant information for the research objectives was extracted from a systematic literature review conducted in the scientific databases PubMed, Embase and Web of Science. We searched for pertinent themes dealing with at least one of the four bioethical principles: "autonomy", "non-maleficence", "beneficence" and "justice". 48 publications that met the research objectives were included in the thorough analysis, structured and discussed in a narrative synthesis. From the analysis of the results, it has emerged that traditional paradigms of patient's autonomy and physician paternalism need to be reexamined in pediatric research. Standard information procedures and models of informed consent should be reconsidered as they do not accommodate the complexities of pediatric omics research.
Collapse
Affiliation(s)
- Elisa Groff
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, 89073 Ulm, Germany
| | - Marcin Orzechowski
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, 89073 Ulm, Germany
| | - Catharina Schuetz
- Paediatric Immunology, Medical Faculty “Carl Gustav Carus”, Technic University Dresden, 01307 Dresden, Germany
| | - Florian Steger
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, 89073 Ulm, Germany
| |
Collapse
|
15
|
Fons‐Martinez J, Ferrer‐Albero C, Diez‐Domingo J. Co-creation of information materials within the assent process: From theory to practice. Health Expect 2022; 26:429-439. [PMID: 36416386 PMCID: PMC9854296 DOI: 10.1111/hex.13675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 08/29/2022] [Accepted: 11/10/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The informed consent process is key to safeguarding the autonomy of the participant in medical research. For this process to be valid, the information presented to the potential participant should meet their needs and be understood by them. The i-CONSENT project has developed 'Guidelines for adapting the informed consent process in clinical trials' which aim to improve informed consent so that they are easier to understand and better adapted to the needs and preferences of the target population. The best way to tailor information to the characteristics and preferences of the target population is to involve the community itself. METHODS Following guidelines developed by i-CONSENT, assent materials were co-created for a mock clinical trial of the human papillomavirus vaccine in adolescents. During the process, two design thinking sessions were conducted involving a total of 10 children and 5 parents. The objectives of the sessions were to find out the children's opinion of the informed consent (assent in their case) process in clinical trials, identify the parts that were most difficult to understand and alternatives for their presentation and wording, identify the preferred formats for receiving the information and the main characteristics of these formats, design a video explaining the clinical trial and evaluate a tool for assessing comprehension. RESULTS Assent materials were co-created in three formats: a web-based material following a layered approach; a video in story format; a pdf document with an innovative way of presenting information compared to traditional assent documents. In addition, the Comprehension of Assent Questionnaire was co-designed, based on the Quality of Informed Consent questionnaire. CONCLUSION The design thinking methodology has proven to be an easy and useful tool for involving children in designing information tailored to their needs and preferences. PATIENT OR PUBLIC CONTRIBUTION A sample of the target population participated in the design and piloting of the materials created using design thinking methodology. In addition, patient representatives participated in the design and evaluation of the guidelines developed by the i-CONSENT project that were followed for the development of the materials in this study.
Collapse
Affiliation(s)
- Jaime Fons‐Martinez
- Vaccine Research AreaFoundation for the Promotion of Health and Biomedical Research of Valencia Region, FISABIOValenciaSpain
| | - Cristina Ferrer‐Albero
- Facultad de Medicina y Ciencias de la SaludUniversidad Católica de Valencia San Vicente MártirValenciaSpain
| | - Javier Diez‐Domingo
- Vaccine Research AreaFoundation for the Promotion of Health and Biomedical Research of Valencia Region, FISABIOValenciaSpain,Facultad de Medicina y Ciencias de la SaludUniversidad Católica de Valencia San Vicente MártirValenciaSpain
| |
Collapse
|
16
|
Kreniske P, Hoffman S, Ddaaki W, Nakyanjo N, Spindler E, Ssekyewa C, Isabirye D, Nakubulwa R, Proscovia N, Daniel L, Haba N, Maru M, Thompson J, Chen IS, Nalugoda F, Ssekubugu R, Lutalo T, Ott MA, Santelli JS. Capacity to Consent to Research Among Adolescent-Parent Dyads in Rakai, Uganda. J Pediatr 2022:S0022-3476(22)01020-4. [PMID: 36402433 DOI: 10.1016/j.jpeds.2022.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/11/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the cognitive capacity of early, middle, and late adolescents and their parents or guardians to provide informed consent to a population-based cohort study. STUDY DESIGN Adolescent-parent/guardian dyads including 40 early (n = 80; 10-14 years), 20 middle (15-17 years), and 20 late (18-19 years) adolescents were recruited from the Rakai Community Cohort Study, an open demographic cohort in Uganda. Participants were administered the MacArthur Competence Assessment Tool for Clinical Research, a structured open-ended assessment; interviews were recorded and transcribed. Twenty transcripts were scored independently by two coders; the intraclass correlation coefficient was 0.89. The remaining interviews were scored individually. We compared mean scores for early and middle/late adolescents using a one-sided t test and score differences between parent/guardian and adolescent dyads using two-sided paired t tests. RESULTS Early adolescents (mean score, 28.8; 95% CI, 27.1-30.5) scored significantly lower (P < .01) than middle/late adolescents (32.4; 31.6-33.1). In paired dyad comparisons, we observed no statistically significant difference in scores between parents/guardians and middle/late adolescents (difference, -0.2; 95% CI, -1.0-0.6). We found a statistically significant difference in scores between parents/guardians and early adolescents (difference, 3.0; 95% CI, 1.2-4.8). CONCLUSIONS The capacity of adolescents-of different ages and in diverse settings-to comprehend risks, benefits, and other elements of informed consent is a critical but understudied area in research ethics. Our findings support the practice of having middle and late adolescents provide independent informed consent for sexual and reproductive health studies. Early adolescents may benefit from supported decision-making approaches.
Collapse
Affiliation(s)
- Philip Kreniske
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY.
| | - Susie Hoffman
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | | | | | - Esther Spindler
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY
| | | | | | | | | | - Lee Daniel
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY
| | - Nao Haba
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY
| | - Mahlet Maru
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY
| | - Julia Thompson
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY
| | - Ivy S Chen
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY
| | | | | | - Tom Lutalo
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - Mary A Ott
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - John S Santelli
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY
| |
Collapse
|
17
|
Koonrungsesomboon N, Charoenkwan P, Natesirinilkul R, Fanhchaksai K, Sakuludomkan W, Morakote N. What information and the extent of information to be provided in an informed assent/consent form of pediatric drug trials. BMC Med Ethics 2022; 23:113. [DOI: 10.1186/s12910-022-00856-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background
This study aimed to determine the elements and the extent of information that child participants and their parents would like to read in an informed assent form (IAF)/informed consent form (ICF) of a pediatric drug trial.
Methods
A descriptive survey was conducted to determine the perceived importance of each element of the ICF content from child participants and their parents who underwent informed assent/consent of a multi-center pediatric drug trial. The respondents were asked to indicate the level of importance of each item in a questionnaire, by giving a rating scale from 1 (not important) to 5 (very important).
Results
A total of 22 families, 17 child participants with the diagnosis of hematology or oncology diseases and 27 parents, were enrolled. Among 30 items, risk–benefit aspects (i.e., direct health benefit [mean: 4.71 for child respondents, 4.89 for parent respondents], indirect/societal benefit [mean: 4.65, 4.85], major foreseeable risk [mean: 4.47, 4.78], post-trial benefit/provision [mean: 4.59, 4.74], and all adverse effects of the drug including uncommon adverse effects [mean: 4.53, 4.74]) were perceived to be of most concerning items from both child participants’ and parents’ viewpoint. None of the items were considered ‘slightly important’ or lower by more than 20% of the respondents.
Conclusions
For pediatric drug trials, risk–benefit information (including direct health benefit, indirect/societal benefit, and post-trial benefit/provision, as well as major foreseeable risk and adverse effects of the drug) should be made a salient feature of an IAF/ICF. This empirical data could help related stakeholders arrange essential information in order of importance and tailor an IAF/ICF to better suit child participants’ and parents’ needs, particularly for pediatric drug trials involving children with the diagnosis of hematology or oncology diseases.
Collapse
|
18
|
Casati S, Ellul B, Mayrhofer MT, Lavitrano M, Caboux E, Kozlakidis Z. Paediatric biobanking for health: The ethical, legal, and societal landscape. Front Public Health 2022; 10:917615. [PMID: 36238242 PMCID: PMC9551217 DOI: 10.3389/fpubh.2022.917615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/06/2022] [Indexed: 01/22/2023] Open
Abstract
Biobanks play a central role in pediatric translational research, which deals primarily with genetic data from sample-based research. However, participation of children in biobanking has received only limited attention in the literature, even though research in general and in clinical trials in particular have a long history in involving minors. So, we resolved to explore specific challenging ethical, legal, and societal issues (ELSI) in the current pediatric biobanking landscape to propose a way forward for biobanking with children as partners in research. Methodologically, we first established the accessibility and utilization of pediatric biobanks, mainly in Europe. This was supported by a literature review related to children's participation, taking into account not only academic papers but also relevant guidelines and best-practices. Our findings are discussed under five themes: general vulnerability; ethical issues-balancing risks and benefits, right to an open future, return of results including secondary findings; legal issues-capacity and legal majority; societal issues-public awareness and empowerment; and responsible research with children. Ultimately, we observed an on-going shift from the parents'/guardians' consent being a sine-qua-non condition to the positive minor's agreement: confirming that the minor is the participant, not the parent(s)/guardian(s). This ethical rethinking is paving the way toward age-appropriate, dynamic and participatory models of involving minors in decision-making. However, we identified a requirement for dynamic tools to assess maturity, a lack of co-produced engagement tools and paucity of shared best practices. We highlight the need to provide empowerment and capability settings to support researchers and biobankers, and back this with practical examples. In conclusion, equipping children and adults with appropriate tools, and ensuring children's participation is at the forefront of responsible pediatric biobanking, is an ethical obligation, and a cornerstone for research integrity.
Collapse
Affiliation(s)
- Sara Casati
- ELSI Services & Research Unit, BBMRI-ERIC, Graz, Austria
| | - Bridget Ellul
- Centre for Molecular Medicine & Biobanking, University of Malta, Msida, Malta
| | | | | | - Elodie Caboux
- Laboratory Services and Biobank, International Agency for Research on Cancer, IARC, WHO, Lyon, France
| | - Zisis Kozlakidis
- Laboratory Services and Biobank, International Agency for Research on Cancer, IARC, WHO, Lyon, France
| |
Collapse
|
19
|
Contrasting Comprehension of HIV Research by Adolescents, Young Adults, and Caregivers in Western Kenya: A Cross-sectional Analysis. J Assoc Nurses AIDS Care 2022; 33:542-549. [PMID: 35767728 DOI: 10.1097/jnc.0000000000000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT Adolescent participation in research is critical to inform interventions that improve outcomes for this group. Adolescents and young adults living with HIV often present to care without caregivers, yet caregiver permission is typically required for those younger than 18 years. We evaluated whether understanding of key consent information differed between adolescents (n = 1,393) and caregiver adults (n = 169). Compared with caregivers, adolescents aged 10-14 years showed significantly lower understanding, whereas understanding for older adults living with HIV did not differ significantly from caregivers. Risks were the least understood consent information for all age groups. Our findings suggest that for low-risk research, waiving caregiver permission requirements will not compromise the ethical need to ensure understanding of research before enrollment and may allow adolescents greater access to potential research benefits.
Collapse
|
20
|
Nicolì S, Benevento M, Ferorelli D, Mandarelli G, Solarino B. Little patients, large risks: An overview on patient safety management in pediatrics settings. Front Pediatr 2022; 10:919710. [PMID: 36186651 PMCID: PMC9523149 DOI: 10.3389/fped.2022.919710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/29/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Simona Nicolì
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
| | - Marcello Benevento
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
| | - Davide Ferorelli
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
| | - Gabriele Mandarelli
- Section of Forensic Psychiatry, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
| | - Biagio Solarino
- Section of Legal Medicine, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
| |
Collapse
|
21
|
Abstract
Child and adolescent psychiatry involves simultaneously balancing duties to various vulnerable parties. Balancing autonomy and protection for adolescents is complex; state laws governing these situations often add confusion. Common prescribing patterns in child psychiatry lack robust evidence, and utilization of stimulants, atypical antipsychotics, and polypharmacy has skyrocketed. Significant concerns about distributive justice arise from alarming patterns in psychiatric treatment of vulnerable populations, like those affected by poverty, racism, adverse childhood experiences, and certain legal statuses. Principles of justice and respect for persons support the need for safe, adequate, and appropriate psychiatric treatment, including psychosocial interventions and resources, for all children.
Collapse
Affiliation(s)
- Rachel Conrad
- Department of Psychiatry, Harvard Medical School, Harvard Medical School Center for Bioethics, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, USA.
| | | |
Collapse
|
22
|
Vrouenraets LJJJ, de Vries ALC, de Vries MC, van der Miesen AIR, Hein IM. Assessing Medical Decision-Making Competence in Transgender Youth. Pediatrics 2021; 148:183482. [PMID: 34850191 DOI: 10.1542/peds.2020-049643] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND According to international transgender care guidelines, an important prerequisite for puberty suppression (PS) is transgender adolescents' competence to give informed consent (IC). In society, there is doubt whether transgender adolescents are capable of this, which in some countries has even led to limited access to this intervention. Therefore, this study examined transgender adolescents' medical decision-making competence (MDC) to give IC for starting PS in a structured, replicable way. Additionally, potential associated variables on MDC, such as age, intelligence, sex, psychological functioning, were investigated. METHODS A cross-sectional semistructured interview study with 74 transgender adolescents (aged 10-18 years; 16 birth-assigned boys, 58 birth-assigned girls) within two Dutch specialized gender-identity clinics was performed. To assess MDC, judgements based on the reference standard (clinical assessment) and the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), a validated semistructured interview, were used. RESULTS Of the transgender adolescents, 93.2% (reference standard judgements; 69 of 74) and 89.2% (MacCAT-T judgements; 66 of 74) were assessed competent to consent. Intermethod agreement was 87.8% (65 of 74). Interrater agreements of the reference standard and MacCAT-T-based judgements were 89.2% (198 of 222) and 86.5% (192 of 222), respectively. IQ and sex were both significantly related to MacCAT-T total score, whereas age, level of emotional and behavioral challenges, and diagnostic trajectories duration were not. CONCLUSIONS By using the MacCAT-T and clinicians' assessments, 93.2% and 89.2%, respectively, of the transgender adolescents in this study were assessed competent to consent for starting PS.
Collapse
Affiliation(s)
- Lieke J J J Vrouenraets
- Department of Child and Adolescent Psychiatry, Leiden University Medical Center Curium, Leiden University Medical Center, Oegstgeest, the Netherlands.,Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center, Location VUmc, VU University, Amsterdam, the Netherlands.,Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, the Netherlands
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center, Location VUmc, VU University, Amsterdam, the Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, the Netherlands
| | - Anna I R van der Miesen
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center, Location VUmc, VU University, Amsterdam, the Netherlands
| | - Irma M Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center and University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
23
|
Boceta R, Martínez-Casares O, Albert M. The informed consent in the mature minor: Understanding and decision-making capacity. An Pediatr (Barc) 2021; 95:413-422. [PMID: 34782293 DOI: 10.1016/j.anpede.2020.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/09/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The informed consent of the minor is a fundamental requirement of paediatric research. There is a lack of harmonisation as regards the age of the mature minor to consent, and there are no systematic tools available to assess competence in decision-making capacity. The objective of this work is to analyse the ethical and legal situation of consent by minors, as well as studies that use an objective assessment tool in the mature minor. MATERIAL AND METHODS Systematic review of scientific articles in PubMed, Embase and the Grey Literature, published with keywords "informed consent minors", without date restriction until March 2019. Abstracts and a selection of complete articles were reviewed following a protocol including identification, screening, eligibility, and inclusion. RESULTS Of the 260 records identified, 139 were excluded. After categorising the resulting 121 publications, 13 were finally selected following the eligibility criteria, including 7 articles on international ethical and legal regulations and 6 on understanding and decision- making capacity assessment. The MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) semi-structured interview was used in 4 studies, including different age ranges (6-21 years) in healthy and sick children. CONCLUSIONS The semi-structured MacArthur interview adapted to adolescents could be an appropriate tool with robust psychometric measures for assessing competence for the informed consent of minors between 9 and 12 years of age. The regulation of informed consent in paediatric research should consider this evidence.
Collapse
Affiliation(s)
- Reyes Boceta
- Departamento de Epidemiologia y Salud Publica, Universidad Rey Juan Carlos, Móstoles, Madrid, Spain.
| | - Olga Martínez-Casares
- Departamento de Epidemiologia y Salud Publica, Universidad Rey Juan Carlos, Móstoles, Madrid, Spain
| | - Marta Albert
- Departamento de Epidemiologia y Salud Publica, Universidad Rey Juan Carlos, Móstoles, Madrid, Spain
| |
Collapse
|
24
|
Chahal N, Rush J, Manlhiot C, Delayun C, Sananes R, Runeckles K, Collins T, O'Shea S, McCrindle BW. Understanding the Educational Support and Psychosocial Needs of Parents and Adolescents With Kawasaki's Disease and Coronary Artery Aneurysms. J Pediatr Health Care 2021; 35:e21-e31. [PMID: 34238625 DOI: 10.1016/j.pedhc.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/13/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Kawasaki disease (KD) with coronary artery aneurysms (complex KD) presents relentless challenges for families. Psychosocial experiences and needs were explored. METHOD A descriptive, exploratory study of adolescents and parents using a needs survey and psychosocial instruments (anxiety, depression, and functional impairment). RESULTS Fifty-one parents and 38 adolescents participated. Predominant interests were for information sheets, newsletters, Web sites, and phone applications. Gaps in disease-specific knowledge and awareness of coronary artery aneurysms between parents and adolescents were identified. Psychosocial concerns for adolescents included symptoms of anxiety (22%), depression (13%), and functional impairment (22%). Multivariable analyses indicated higher depression scores associated with longer travel distance from specialists (p = .04). Parent-reported social concerns for their adolescent were associated with higher anxiety (p = .005) and functional impairment (p = .005). Written commentary complemented the findings. DISCUSSION Care protocols require psychosocial assessment/referral and the use of virtual platforms. The groundwork was laid for developing patient and family-centered strategies.
Collapse
|
25
|
Neilan AM, Salvant Valentine S, Knopf AS. Case 27-2021: A 16-Year-Old Boy Seeking Human Immunodeficiency Virus Prophylaxis. N Engl J Med 2021; 385:1034-1041. [PMID: 34496178 DOI: 10.1056/nejmcpc1909626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Anne M Neilan
- From the Departments of Medicine and Pediatrics, Massachusetts General Hospital, and the Departments of Medicine and Pediatrics, Harvard Medical School - both in Boston (A.M.N.); the Division of HIV-AIDS Prevention, National Center for HIV-AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention, Centers for Disease Control and Prevention, Atlanta (S.S.V.); and Community and Health Systems, Indiana University School of Nursing, Indianapolis (A.S.K.)
| | - Sheila Salvant Valentine
- From the Departments of Medicine and Pediatrics, Massachusetts General Hospital, and the Departments of Medicine and Pediatrics, Harvard Medical School - both in Boston (A.M.N.); the Division of HIV-AIDS Prevention, National Center for HIV-AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention, Centers for Disease Control and Prevention, Atlanta (S.S.V.); and Community and Health Systems, Indiana University School of Nursing, Indianapolis (A.S.K.)
| | - Amelia S Knopf
- From the Departments of Medicine and Pediatrics, Massachusetts General Hospital, and the Departments of Medicine and Pediatrics, Harvard Medical School - both in Boston (A.M.N.); the Division of HIV-AIDS Prevention, National Center for HIV-AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention, Centers for Disease Control and Prevention, Atlanta (S.S.V.); and Community and Health Systems, Indiana University School of Nursing, Indianapolis (A.S.K.)
| |
Collapse
|
26
|
Reetz J, Richter G, Borzikowsky C, Glinicke C, Darabaneanu S, Buyx A. Consent to research participation: understanding and motivation among German pupils. BMC Med Ethics 2021; 22:93. [PMID: 34271886 PMCID: PMC8283995 DOI: 10.1186/s12910-021-00661-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/07/2021] [Indexed: 11/28/2022] Open
Abstract
Background The EU’s 2006 Paediatric Regulation aims to support authorisation of medicine for children, thus effectively increasing paediatric research. It is ethically imperative to simultaneously establish procedures that protect children’s rights. Method This study endeavours (a) to evaluate whether a template consent form designed by the Standing Working Group of the German-Research-Ethics-Committees (AKEK) adequately informs adolescents about research participation, and (b) to investigate associated phenomena like therapeutic misconception and motives for research participation. In March 2016 a questionnaire study was conducted among 279 pupils (mean age 13.1 years) of a secondary school in northern Germany. Results A majority of participants showed a general good understanding of foundational research ethics concepts as understood from the AKEK consent form. Nevertheless, our data also suggests possible susceptibility to therapeutic misconception. Own health concerns and pro-social considerations were found to be significant motivational factors for participating in research, while anticipation of pain lessens likelihood of participation. Advice from trusted others is an important decisional influence, too. Furthermore, data security was found to be a relevant aspect of adolescents’ decision-making process. Conclusion Bearing in mind adolescents’ generally good understanding, we infer the lack of knowledge about medical research in general to be one source of therapeutic misconception. To further improve the quality of consent we propose a multi-staged approach whereby general research education is completed before an individual becomes a patient or potential participant. To the best of our knowledge this is the first German questionnaire-study addressing issues of informed consent in a large under-age sample. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00661-z.
Collapse
Affiliation(s)
- Jana Reetz
- Diakonissenkrankenhaus, Department of Paediatrics, Knuthstraße 1, 24939, Flensburg, Germany
| | - Gesine Richter
- Institute of Experimental Medicine, Division of Biomedical Ethics, Kiel University, University Hospital Schleswig-Holstein, UKSH, Campus KielArnold-Heller-Str. 3, Haus U35, 24105, Kiel, Germany.
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, Kiel University, University Hospital Schleswig-Holstein, Brunswiker Str. 10, 24105, Kiel, Germany
| | - Christine Glinicke
- Ethics Commission, University Hospital Schleswig-Holstein, Arnold-Heller-Straße 3; Haus U 27, 24105, Kiel, Germany
| | - Stephanie Darabaneanu
- Institute of Medical Psychology and Medical Sociology, Kiel University, University Hospital Schleswig-Holstein Kiel, Preußerstrasse 1-9, 24105, Kiel, Germany
| | - Alena Buyx
- Institute of History and Ethics in Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany
| |
Collapse
|
27
|
Cotrim H, Granja C, Carvalho AS, Cotrim C, Martins R. Children's Understanding of Informed Assents in Research Studies. Healthcare (Basel) 2021; 9:healthcare9070871. [PMID: 34356249 PMCID: PMC8307200 DOI: 10.3390/healthcare9070871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/03/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022] Open
Abstract
The assent procedure reflects an effort to enable the minor to understand, to the degree they are capable of, what their participation in the decision making process would involve. Aims: To evaluate the minors’ ability to understand the information provided to them when obtaining assent and to evaluate the opinion of the parents regarding the importance of asking the child’s assent. Methods: The sample included a total of 52 minors aged between 10 and 17 years who underwent exercise echocardiogram. The Quality of Informed Consent is divided into two parts: Part A was used to measure objective understanding and part B to measure subjective understanding. Results: The results show that the minors have a high capacity to understand the information given to them when asking for assent. A positive relationship was found between the two parts of the questionnaire. No statistically significant relationship was found between age and sex and part A and part B or between both age groups (<14 years old and ≥14 years old) and the measure. In the case of the parents, 96.6% of parents consider assent as an advantage for the child’s acceptance of health care. The opinion of the parents is not related to the age, sex or level of schooling. Conclusion: Minors showed a substantial level of understanding regarding the information provided to them. The parents considered the implementation of assent fundamental to the child’s acceptance of health care.
Collapse
Affiliation(s)
- Hortense Cotrim
- Nursing Department, Universidade Atlântica, Fábrica da Pólvora de Barcarena, 2730-036 Barcarena, Portugal
- Correspondence:
| | - Cristina Granja
- Anaesthesiology Department, Centro Hospitalar Universitário São João, 4200-319 Porto, Portugal;
| | - Ana Sofia Carvalho
- Associated Teacher with Aggregation, Institute of Bioethics, University of Portugal, 1649-023 Lisboa, Portugal;
| | - Carlos Cotrim
- Cardiology Department, Hospital da Cruz Vermelha, 1549-008 Lisboa, Portugal;
| | - Rui Martins
- Centro de Estatística e Aplicações da Universidade de Lisboa (CEAUL), Department of Statistics and Operational Research, Faculdade de Ciências, Universidade de Lisboa, 1549-008 Lisboa, Portugal;
| |
Collapse
|
28
|
Kasperbauer TJ, Halverson C. Adolescent Assent and Reconsent for Biobanking: Recent Developments and Emerging Ethical Issues. Front Med (Lausanne) 2021; 8:686264. [PMID: 34307413 PMCID: PMC8301072 DOI: 10.3389/fmed.2021.686264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/17/2021] [Indexed: 11/13/2022] Open
Abstract
Research biobanks that enroll minors face important practical, ethical, and regulatory challenges in reconsenting participants when they reach the age of 18. Federal regulations governing research in the United States provide minimal guidance and allow for a range of practices, including waiving the requirement to obtain reconsent. Some commentators have argued that institutional review boards should indeed grant such waivers, given the low risks of biobank-based research and the impracticality of contacting all participants when they turn 18. There is also significant ethical debate about the age at which adolescents can make authentic, autonomous decisions regarding their research participation. This paper reviews these issues in detail, describes the current state of the ethical discussion, and outlines evidence-based policies for enrolling minors into research biobanks.
Collapse
Affiliation(s)
- T J Kasperbauer
- Indiana University Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Colin Halverson
- Indiana University Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, United States
| |
Collapse
|
29
|
Fisher CB, Puri LI, Macapagal K, Feuerstahler L, Ahn JR, Mustanski B. Competence to Consent to Oral and Injectable PrEP Trials Among Adolescent Males Who Have Sex with Males. AIDS Behav 2021; 25:1606-1618. [PMID: 33247336 PMCID: PMC8052255 DOI: 10.1007/s10461-020-03077-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 01/16/2023]
Abstract
Adherence to oral pre-exposure prophylaxis (PrEP) is challenging for adolescent males who have sex with males (AMSM). Once adult trials comparing oral to longer lasting injectable PrEP are completed, there will be a need for adolescent studies. However, lack of data on adolescent consent capacity may sustain guardian permission requirements identified as a barrier to AMSM participation in prior PrEP trials. This online study assessed AMSM's (14-17 years) consent capacity for these trials, comparing performance to MSM (18-19 years) for whom guardian permission is not required. Applying the MacCAT-CR, participants (N = 214) viewed a video and mock consent form followed by open-ended and yes/no items. Cognitive diagnostic models and means testing analyses supported AMSM capacity to consent to these trials: 16-17 and most 14-15 year-olds, demonstrated consent understanding, appreciation and reasoning at 18-19 year-old levels. Data also identified vulnerabilities requiring attention during informed consent.
Collapse
Affiliation(s)
- Celia B Fisher
- Center for Ethics Education, HIV/Drug Abuse Prevention Research Ethics Institute, and Department of Psychology, Fordham University, Dealy Hall, Bronx, NY, 10458, USA.
| | | | - Kathryn Macapagal
- Institute for Sexual and Gender Minority Health and Wellbeing & Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - Brian Mustanski
- Institute for Sexual and Gender Minority Health and Wellbeing & Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| |
Collapse
|
30
|
Benfatto G, Drago F. Regulatory, scientific, and ethical issues arising from institutional activity in one of the 90 Italian Research Ethics Committees. BMC Med Ethics 2021; 22:40. [PMID: 33827541 PMCID: PMC8028767 DOI: 10.1186/s12910-021-00605-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 03/24/2021] [Indexed: 12/28/2022] Open
Abstract
Background This paper highlights the issues that one of the 90 Italian Research Ethics Committees (RECs) might encounter during the approval phase of a clinical trial to identify corrective and preventive actions for promoting a more efficient review process and ensuring review quality. Publications on the subject from Italy and the rest of Europe are limited; encouraging constructive debate can improve RECs’ service to the subject of the clinical trial. Methods We retrospectively reviewed a cohort of 822 clinical trial protocols, initially reviewed by REC, from June 2014 to December 2018. Data collected for each protocol were type of trial, sample size, use of placebo, number and kind of revisions requested by the REC before approval, and time taken for approval. Data for each protocol were collected by a trained clinical research assistant using the REC’s files and electronic archives. Results Almost 45% of the reviewed studies (374/822) required clarifications, significant changes to the documentation, or minor changes before final approval. Conclusions Preventive measures are needed to reduce the number of requested corrections and thus also the time required for approval, while maintaining review quality. All critical points and proposals presented in this paper require harmonization through updates to European regulations, as regulatory harmonization produces better compliance with rules and reduces the number of changes required before the trials’ final approval. Such updates include the development of standardized formats for informed consent, the verification of any evidence in favor of using off-label treatments over placebo as comparators, using multidisciplinary staff in clinical trials with children and adolescents, improving the legal definition of RECs to assign responsibilities and ensure independence, and providing guidance for RECs to engage clinical research assistants in internal audits.
Collapse
Affiliation(s)
- G Benfatto
- Clinical Pharmacology and Pharmacovigilance Unit, Regional Pharmacovigilance Center of Catania, G Rodolico-San Marco University Hospital, Catania, Italy
| | | | | | - F Drago
- Clinical Pharmacology and Pharmacovigilance Unit, Regional Pharmacovigilance Center of Catania, G Rodolico-San Marco University Hospital, Catania, Italy. .,Ethics Committee, Catania 1, G Rodolico-San Marco University Hospital, Via Santa Sofia 78, 95125, Catania, Italy.
| |
Collapse
|
31
|
Mintz K, Jardas E, Shah S, Grady C, Danis M, Wendler D. Enrolling Minors in COVID-19 Vaccine Trials. Pediatrics 2021; 147:peds.2020-040717. [PMID: 33334920 PMCID: PMC7919110 DOI: 10.1542/peds.2020-040717] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 12/21/2022] Open
Abstract
It is widely agreed that an effective response to the coronavirus disease 2019 pandemic needs to include a vaccine that is safe and effective for minors. However, many current vaccine trials have no plans for when to enroll minors. Others have recently proposed enrolling minors as young as 12 years old. This lack of a systematic approach raises 2 concerns. Waiting too long to enroll minors could unjustly deny minors and their families the benefits of a vaccine and has the potential to delay an effective response to the pandemic by a year or longer. At the same time, enrolling minors too soon runs the risk of exposing them to excessive risks. With these concerns in mind, in the present article, we propose recommendations for when and how to enroll minors in vaccine trials for the coronavirus disease 2019.
Collapse
Affiliation(s)
- Kevin Mintz
- Department of Bioethics, National Institutes of Health, Bethesda, Maryland
| | - E Jardas
- Department of Bioethics, National Institutes of Health, Bethesda, Maryland
| | - Seema Shah
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois; and,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christine Grady
- Department of Bioethics, National Institutes of Health, Bethesda, Maryland
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, Maryland
| | - David Wendler
- Department of Bioethics, National Institutes of Health, Bethesda, Maryland;
| |
Collapse
|
32
|
Wijngaarde RO, Hein I, Daams J, Van Goudoever JB, Ubbink DT. Chronically ill children's participation and health outcomes in shared decision-making: a scoping review. Eur J Pediatr 2021; 180:2345-2357. [PMID: 33821341 PMCID: PMC8285312 DOI: 10.1007/s00431-021-04055-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/22/2021] [Accepted: 03/24/2021] [Indexed: 11/20/2022]
Abstract
Based on the United Nations Conventions on the Rights of the Child (CRC), it is a child's right to participate in all matters concerning its wellbeing. Little is known about chronically and/or critically ill children's participation in pediatric shared decision-making (SDM). We explored medical literature to see if and how these children participate in pediatric SDM. We searched relevant medical databases published between January 2008 and January 2020 for studies targeting children aged 4-18 years old, suffering from a chronic and/or critical disease. We found 9 relevant studies. SDM interventions mostly used were decision aids (n=8), questionnaires for caretakers/parents and children (n=4), and a SDM toolkit (n=2). Perceived involvement in SDM and knowledge increased amongst children, adolescents, and caretakers following these interventions. Decisional conflict measured using the 0-100 point DCS scale (higher scores indicate more decisional conflict) was reduced by 15.9 points in one study (p<0.01) and 17.8 points in another (95%CI: 13.3-22.9). Lower scores were associated with higher satisfaction with the decision aid by children, caretakers, and clinicians.Conclusion: Stakeholders should advocate initiatives to facilitate a child's participation preferences regarding pediatric SDM since decision support tools help chronically ill children to be more involved in SDM as they increase the children's knowledge and satisfaction and reduce decisional conflicts. What is Known: • Decision aids can help improve participation, knowledge, satisfaction, and health outcomes. • Quality and consistency of the information exchange impact quality and outcome of SDM. What is New: • Depending on a child's age, evolving capacities, and communication and participation preferences, more evidence is needed on which tools are suitable for chronically ill children to ensure their preferred participation in pediatric SDM. • Pediatricians adopt healthcare SDM tools and techniques that do not always take into account that a child's right to participate in pediatric SDM including the tendency to use interventions that are not specifically designed for pediatrics.
Collapse
Affiliation(s)
- R. O. Wijngaarde
- grid.7177.60000000084992262Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Room H8-247, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - I. Hein
- grid.5650.60000000404654431Child and Adolescent Psychiatry and de Bascule, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - J. Daams
- grid.5650.60000000404654431Medical Library, Amsterdam University Medical Centers, AMC, Amsterdam, The Netherlands
| | - J. B. Van Goudoever
- grid.7177.60000000084992262Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Room H8-247, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - D. T. Ubbink
- grid.5650.60000000404654431Department of Surgery, Amsterdam University Medical Centers, AMC, Amsterdam, The Netherlands
| |
Collapse
|
33
|
Sims JP, Nolen C. “I Wouldn’t Trust the Parents To ‘Do No Harm’ To a Queer Kid”: Rethinking Parental Permission Requirements for Youth Participation in Social Science Research. J Empir Res Hum Res Ethics 2020; 16:35-45. [DOI: 10.1177/1556264620983134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Obtaining parental consent for youth to participate in research is a standard requirement in the United States. However, the assumption that involving parents is the best way to protect youth research participants is untenable for some populations. This study draws on interviews with 19 LGBTQ+ mixed-race participants to examine lay views of parental consent requirements for LGBTQ+ youth research participants. Qualitative data analysis found concerns about potentially outing LGBTQ+ youth to intolerant parents. Interviewees also asserted that adolescents aged 16 and older are competent enough and should have the autonomy to consent themselves. Finally, interviewees raised several methodological concerns regarding the biased research that may result from parental consent requirements. We agree with others that U.S. Institutional Review Boards should end uncritical requirements for parental consent for older adolescents and should routinize the use and study of alternative protective measures.
Collapse
|
34
|
Abstract
Without a structure to address healthcare transition, adolescents and young adults with neurological disorders are likely to have disruptions in their care that result in a higher need for emergency care and hospitalization. There are numerous obstacles to implementing the existing transition guidelines: adequate numbers of skilled and willing adult providers, patient and family anxiety about transfer, changes in health insurance, inadequate reimbursement, and inefficient communication systems to pave the path for a smooth transition. The aim of this article is to provide practical information about developing a transition program, as well as a potential clinical model for transitioning care.
Collapse
Affiliation(s)
- Mary L Zupanc
- Department of Neurology and Pediatrics, Pediatric Comprehensive Epilepsy Program, University of California-Irvine, Children's Hospital of Orange County, Orange, CA..
| |
Collapse
|
35
|
Boceta R, Martínez-Casares O, Albert M. [The informed consent in the mature minor: Understanding and decision-making capacity]. An Pediatr (Barc) 2020; 95:S1695-4033(20)30453-7. [PMID: 33272846 DOI: 10.1016/j.anpedi.2020.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/28/2020] [Accepted: 10/09/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The informed consent of the minor is a fundamental requirement of paediatric research. There is a lack of harmonisation as regards the age of the mature minor to consent, and there are no systematic tools available to assess competence in decision-making capacity. The objective of this work is to analyse the ethical and legal situation of consent by minors, as well as studies that use an objective assessment tool in the mature minor. MATERIAL AND METHODS Systematic review of scientific articles in PubMed, Embase and the Grey Literature, published with keywords "informed consent minors", without date restriction until March 2019. Abstracts and a selection of complete articles were reviewed following a protocol including identification, screening, eligibility, and inclusion. RESULTS Of the 260 records identified, 139 were excluded. After categorising the resulting 121 publications, 13 were finally selected following the eligibility criteria, including 7 articles on international ethical and legal regulations and 6 on understanding and decision- making capacity assessment. The MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) semi-structured interview was used in 4 studies, including different age ranges (6-21 years) in healthy and sick children. CONCLUSIONS The semi-structured MacArthur interview adapted to adolescents could be an appropriate tool with robust psychometric measures for assessing competence for the informed consent of minors between 9 and 12 years of age. The regulation of informed consent in paediatric research should consider this evidence.
Collapse
Affiliation(s)
- Reyes Boceta
- Departamento de Epidemiologia y Salud Publica, Universidad Rey Juan Carlos, Móstoles, Madrid, España.
| | - Olga Martínez-Casares
- Departamento de Epidemiologia y Salud Publica, Universidad Rey Juan Carlos, Móstoles, Madrid, España
| | - Marta Albert
- Departamento de Epidemiologia y Salud Publica, Universidad Rey Juan Carlos, Móstoles, Madrid, España
| |
Collapse
|
36
|
Koechlin H, Locher C, Prchal A. Talking to Children and Families about Chronic Pain: The Importance of Pain Education-An Introduction for Pediatricians and Other Health Care Providers. CHILDREN (BASEL, SWITZERLAND) 2020; 7:E179. [PMID: 33053802 PMCID: PMC7599921 DOI: 10.3390/children7100179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/28/2020] [Accepted: 10/03/2020] [Indexed: 12/26/2022]
Abstract
Chronic pain in children and adolescents is a common and debilitating health problem. This narrative review will give a brief overview on what pediatric chronic pain is and what treatment options there are for children and adolescents. The specific emphasis will be on pediatric chronic pain education and communication: this narrative review aims to show how important a good patient-health care provider relationship is-it builds the foundation for successful communication-and how this relationship can be established. In addition, we will present five steps that health care providers can perform to explain pediatric chronic pain to patients and their parents and what to keep in mind in their clinical routine. Our review is intended for pediatricians and other health care providers who treat pediatric patients with chronic pain but might feel uncertain on how to best communicate with them.
Collapse
Affiliation(s)
- Helen Koechlin
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115 USA;
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, 4055 Basel, Switzerland
| | - Cosima Locher
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115 USA;
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, 4055 Basel, Switzerland
- School of Psychology, University of Plymouth, Plymouth PL4 8AA, UK
| | - Alice Prchal
- Department of Psychosomatics and Psychiatry and Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland;
| |
Collapse
|
37
|
Muñoz KA, Blumenthal-Barby J, Storch EA, Torgerson L, Lázaro-Muñoz G. Pediatric Deep Brain Stimulation for Dystonia: Current State and Ethical Considerations. Camb Q Healthc Ethics 2020; 29:557-573. [PMID: 32892777 PMCID: PMC9426302 DOI: 10.1017/s0963180120000316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Dystonia is a movement disorder that can have a debilitating impact on motor functions and quality of life. There are 250,000 cases in the United States, most with childhood onset. Due to the limited effectiveness and side effects of available treatments, pediatric deep brain stimulation (pDBS) has emerged as an intervention for refractory dystonia. However, there is limited clinical and neuroethics research in this area of clinical practice. This paper examines whether it is ethically justified to offer pDBS to children with refractory dystonia. Given the favorable risk-benefit profile, it is concluded that offering pDBS is ethically justified for certain etiologies of dystonia, but it is less clear for others. In addition, various ethical and policy concerns are discussed, which need to be addressed to optimize the practice of offering pDBS for dystonia. Strategies are proposed to help address these concerns as pDBS continues to expand.
Collapse
Affiliation(s)
- Katrina A. Muñoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | | | - Eric A. Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
| | - Laura Torgerson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Gabriel Lázaro-Muñoz
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| |
Collapse
|
38
|
Weithorn LA. When Does A Minor's Legal Competence To Make Health Care Decisions Matter? Pediatrics 2020; 146:S25-S32. [PMID: 32737229 DOI: 10.1542/peds.2020-0818g] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2020] [Indexed: 11/24/2022] Open
Abstract
In this article, I examine the role of minors' competence for medical decision-making in modern American law. The doctrine of parental consent remains the default legal and bioethical framework for health care decisions on behalf of children, complemented by a complex array of exceptions. Some of those exceptions vest decisional authority in the minors themselves. Yet, in American law, judgments of minors' competence do not typically trigger shifts in decision-making authority from adults to minors. Rather, minors' decisional capacity becomes relevant only after legislatures or courts determine that the default of parental discretion does not achieve important policy goals or protect implicated constitutional rights in a particular health care context and that those goals can best be achieved or rights best protected by authorizing capable minors to choose for themselves. It is at that point that psychological and neuroscientific evidence plays an important role in informing the legal inquiry as to whether minors whose health is at issue are legally competent to decide.
Collapse
Affiliation(s)
- Lois A Weithorn
- University of California, Hastings College of the Law, San Francisco, California
| |
Collapse
|
39
|
Knopf A, Ott MA, Draucker CB, Fortenberry JD, Reirden DH, Arrington-Sanders R, Schneider J, Straub D, Baker R, Bakoyannis G, Zimet GD. Innovative Approaches to Obtain Minors' Consent for Biomedical HIV Prevention Trials: Multi-Site Quasi-Experimental Study of Adolescent and Parent Perspectives. JMIR Res Protoc 2020; 9:e16509. [PMID: 32224493 PMCID: PMC7154935 DOI: 10.2196/16509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Despite the high burden of new HIV infections in minor adolescents, they are often excluded from biomedical HIV prevention trials, largely owing to the ethical complexities of obtaining consent for enrollment. Researchers and ethics regulators have a duty to protect adolescents-as a special category of human subjects, they must have protection that extends beyond those afforded to all human subjects. Typically, additional protection includes parental consent for enrollment. However, parental consent can present a risk of harm for minor adolescents. Research involving minor adolescents indicate that they are unwilling to join biomedical trials for stigmatized health problems, such as HIV, when parental consent is required. This presents a significant barrier to progress in adolescent HIV prevention by creating delays in research and the translation of new scientific evidence generated in biomedical trials in adult populations. OBJECTIVE This protocol aims to examine how parental involvement in the consent process affects the acceptability of hypothetical participation in biomedical HIV prevention trials from the perspectives of minor adolescents and parents of minor adolescents. METHODS In this protocol, we use a quasi-experimental design that involves a simulated consent process for 2 different HIV prevention trials. The first trial is modeled after an open-label study of the use of tenofovir disoproxil fumarate and emtricitabine as preexposure prophylaxis for HIV. The second trial is modeled after a phase IIa trial of an injectable HIV integrase inhibitor. There are 2 groups in the study-minor adolescents aged 14 to 17 years, inclusive, and parents of minor adolescents in the same age range. The adolescent participants are randomized to 1 of 3 consent conditions with varying degrees of parental involvement. After undergoing a simulated consent process, they rate their willingness to participate (WTP) in each of the 2 trials if offered the opportunity. The primary outcome is WTP, given the consent condition. Parents undergo a similar process but are asked to rate the acceptability of each of the 3 consent conditions. The primary outcome is acceptability of the consent method for enrollment. The secondary outcomes include the following: capacity to consent among both participant groups, the prevalence of medical mistrust, and the effects of the study phase (eg, phase IIa vs the open-label study) and drug administration route (eg, oral vs injection) on WTP (adolescents) and acceptability (parents) of the consent method. RESULTS Enrollment began in April 2018 and ended mid-September 2019. Data are being analyzed and dissemination is expected in April 2020. CONCLUSIONS The study will provide the needed empirical data about minor adolescents' and parents' perspectives on consent methods for minors. The evidence generated can be used to guide investigators and ethics regulators in the design of consent processes for biomedical HIV prevention trials. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/16509.
Collapse
Affiliation(s)
- Amelia Knopf
- Department of Community & Health Services, School of Nursing, Indiana University, Indianapolis, IN, United States
| | - Mary A Ott
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Claire Burke Draucker
- Department of Community & Health Services, School of Nursing, Indiana University, Indianapolis, IN, United States
| | - J Dennis Fortenberry
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Daniel H Reirden
- Children's Hospital Colorado, School of Medicine, The University of Colorado, Aurora, CO, United States
| | - Renata Arrington-Sanders
- Division of General Pediatrics & Adolescent Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - John Schneider
- Department of Medicine, The University of Chicago, Chicago, IL, United States
| | - Diane Straub
- Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Rebecca Baker
- Department of Community & Health Services, School of Nursing, Indiana University, Indianapolis, IN, United States
| | - Giorgos Bakoyannis
- Department of Biostatistics, School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Gregory D Zimet
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, United States
| |
Collapse
|
40
|
Petran M, Dragos D, Gilca M. Historical ethnobotanical review of medicinal plants used to treat children diseases in Romania (1860s-1970s). JOURNAL OF ETHNOBIOLOGY AND ETHNOMEDICINE 2020; 16:15. [PMID: 32204715 PMCID: PMC7092505 DOI: 10.1186/s13002-020-00364-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/12/2020] [Indexed: 05/17/2023]
Abstract
BACKGROUND Romanian ethnopediatrics has a long history of medicinal plant use. The main objective of the present review was to identify, collect, systematize, and prioritize the available bibliographical data related to medicinal plants traditionally used to treat various pediatric diseases in Romania during the 1860s-1970s. METHODS Information was mainly obtained by manual systematic search in various relevant historical works focused on the traditional use of medicinal plants in Romania (1860s-1970s), found in the Archives of Romanian Academy Library and National Romanian Library. RESULTS A total of 153 medicinal plants belonging to 52 families were identified as having ethnopediatric significance. The plant traditional indications, targeted body systems, parts used, and way of administration were provided. We have also proposed one index (expressed as percentage) in order to assess the ethnopediatric applicability area of species: ethnopediatric relative therapeutic versatility (ERTV), which was calculated on the basis of the number of distinct uses mentioned for a species. The species identified to have the highest ERTV scores were Dryopteris filix-mas (100%), Gratiola officinalis (85.71%), Allium sativum (71.42%), Eryngium planum (71.42%), Juglans regia (71.42%), Matricaria chamomilla (71.42%), Plantago major (71.42%). CONCLUSIONS The present study exposed for the first time to the international scientific community important ethnopediatric information contained in several local Romanian bibliographical resources that could guide the local and international researchers towards new directions of plant valorization.
Collapse
Affiliation(s)
- Madalina Petran
- Department of Functional Sciences I- Biochemistry, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Dorin Dragos
- Nephrology Clinic, University Emergency Hospital Bucharest, 050098, Bucharest, Romania
- Department of Medical Semiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Marilena Gilca
- Department of Functional Sciences I- Biochemistry, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
| |
Collapse
|
41
|
Brothers KB, Clayton EW, Goldenberg AJ. Online Pediatric Research: Addressing Consent, Assent, and Parental Permission. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2020; 48:129-137. [PMID: 32342755 DOI: 10.1177/1073110520917038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This article provides practical guidance for researchers who wish to enroll and collect data from pediatric research participants through online and mobile platforms, with a focus on the involvement of both children and their parents in the decision to participate.
Collapse
Affiliation(s)
- Kyle B Brothers
- Kyle B. Brothers, M.D., Ph.D., is an Associate Professor in the Department of Pediatrics at the University of Louisville, where he is also affiliated with the Institute for Bioethics, Health Policy, and Law. Ellen Wright Clayton, M.D., J.D., is the Craig-Weaver Professor of Pediatrics, Professor of Health Policy, and Member of the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center, and Professor of Law at the Vanderbilt University School of Law. Aaron J. Goldenberg, Ph.D., is an Associate Professor and Vice Chair for the Department of Bioethics at Case Western Reserve University (CWRU). He is also Co-Director of the Center for Genetic Research Ethics and Law at CWRU
| | - Ellen Wright Clayton
- Kyle B. Brothers, M.D., Ph.D., is an Associate Professor in the Department of Pediatrics at the University of Louisville, where he is also affiliated with the Institute for Bioethics, Health Policy, and Law. Ellen Wright Clayton, M.D., J.D., is the Craig-Weaver Professor of Pediatrics, Professor of Health Policy, and Member of the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center, and Professor of Law at the Vanderbilt University School of Law. Aaron J. Goldenberg, Ph.D., is an Associate Professor and Vice Chair for the Department of Bioethics at Case Western Reserve University (CWRU). He is also Co-Director of the Center for Genetic Research Ethics and Law at CWRU
| | - Aaron J Goldenberg
- Kyle B. Brothers, M.D., Ph.D., is an Associate Professor in the Department of Pediatrics at the University of Louisville, where he is also affiliated with the Institute for Bioethics, Health Policy, and Law. Ellen Wright Clayton, M.D., J.D., is the Craig-Weaver Professor of Pediatrics, Professor of Health Policy, and Member of the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center, and Professor of Law at the Vanderbilt University School of Law. Aaron J. Goldenberg, Ph.D., is an Associate Professor and Vice Chair for the Department of Bioethics at Case Western Reserve University (CWRU). He is also Co-Director of the Center for Genetic Research Ethics and Law at CWRU
| |
Collapse
|
42
|
Leung GK. The Narrative Coherence Standard and Child Patients' Capacity to Consent. AJOB Neurosci 2020; 11:40-42. [PMID: 32043927 DOI: 10.1080/21507740.2019.1704933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
43
|
Weisleder P. Helping Them Decide: A Scoping Review of Interventions Used to Help Minors Understand the Concept and Process of Assent. Front Pediatr 2020; 8:25. [PMID: 32117832 PMCID: PMC7020747 DOI: 10.3389/fped.2020.00025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/20/2020] [Indexed: 11/13/2022] Open
Abstract
For adults, understanding research protocols prior to consenting to participate can be demanding. For children, that challenge is likely amplified. Yet, the participation of minors as research subjects is necessary. Otherwise, the likelihood of improving healthcare for minors now and in the future is hampered. The risk that minors could be harmed by procedures and medicines that are ill-adapted to their age-group or lack adequate scientific basis is real. It is therefore necessary to identify age-appropriate models to help minors understand the concept and process of assent. For this scoping review the concepts of assent and dissent, tools to evaluate the capacity of minors to assent, and six empirically based methods that have been used to help minors understand the process of assent were reviewed. Helping minors become better decision-makers in a manner that is commensurate with their development, supports children's prerogative to participate as human subjects in research.
Collapse
Affiliation(s)
- Pedro Weisleder
- Division of Neurology and Center for Pediatric Bioethics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States
| |
Collapse
|
44
|
Hartsock JA, Schwartz PH, Waltz AC, Ott MA. Anticipatory Waivers of Consent for Pediatric Biobanking. Ethics Hum Res 2019; 41:14-21. [PMID: 30895753 DOI: 10.1002/eahr.500008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
As pediatric biobank research grows, additional guidance will be needed about whether researchers should always obtain consent from participants when they reach the legal age of majority. Biobanks struggle with a range of practical and ethical issues related to this question. We propose a framework for the use of anticipatory waivers of consent that is empirically rooted in research that shows that children and adolescents are often developmentally capable of meaningful deliberation about the risks and benefits of participation in research. Accordingly, bright-line legal concepts of majority or competency do not accurately capture the emerging capacity for autonomous decision-making of many pediatric research participants and unnecessarily complicate the issues about contacting participants at the age of majority to obtain consent for the continued or first use of their biospecimens that were obtained during childhood. We believe the proposed framework provides an ethically sound balance between the concern for potential exploitation of vulnerable populations, the impetus for the federal regulations governing research with children, and the need to conduct valuable research in the age of genomic medicine.
Collapse
Affiliation(s)
- Jane A Hartsock
- Faculty investigator with the Indiana University Center for Bioethics at the Indiana University School of Medicine and the director of clinical ethics for the Academic Health Center at Indiana University Health
| | - Peter H Schwartz
- Director of the Indiana University Center for Bioethics at the Indiana University School of Medicine and an associate professor of medicine at Indiana University School of Medicine
| | - Amy C Waltz
- Associate director of the Indiana University Human Subjects Office and an adjunct professor at the Indiana University Robert H. McKinney School of Law
| | - Mary A Ott
- Pediatric ethicist at the Indiana University Center for Bioethics at the Indiana University School of Medicine and an associate professor of pediatrics in the Indiana University School of Medicine
| |
Collapse
|
45
|
Ash P. Children Are Different: Liability Issues in Working With Suicidal and Dangerous Youths. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2019; 17:355-359. [PMID: 32047381 PMCID: PMC7011300 DOI: 10.1176/appi.focus.20190018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
While many of the principles of assessing risk to self and others in adults are applicable to risk assessments of children and adolescents, developmental and legal factors regarding youths give rise to some significant differences. This article highlights major differences in assessing and managing risk in working with suicidal and homicidal youths and gives suggestions for reducing clinicians' liability in these challenging cases.
Collapse
Affiliation(s)
- Peter Ash
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA
| |
Collapse
|
46
|
Béranger A, Bouazza N, de Haut de Sigy A, Foubert-Wenc AC, Davous D, Aerts I, Geoerger B, Auvrignon A, Brethon B, Leblond P, Corradini N, André N, Martinez H, Dupont JCK, Doz F, Chappuy H. Parents' and children's comprehension and decision in a paediatric early phase oncology trial: a prospective study. Arch Dis Child 2019; 104:947-952. [PMID: 30472665 DOI: 10.1136/archdischild-2018-315237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 08/15/2018] [Accepted: 10/10/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To analyse parents' and children's understanding of consent information and assess their decision-making process in paediatric oncology. DESIGN Prospective observational study. SETTINGS Eleven French paediatric oncology units. PATIENTS Parents and children who have been asked to give consent for participation in an early phase trial. INTERVENTIONS Thirty-seven children and 119 parents were questioned using an audio-recorded semistructured interview. MAIN OUTCOME MEASURES The participants' understanding of nine elements of the informed consent was assessed by comparing their answers with the informed consent leaflet. Their decision-making process was also evaluated. RESULTS Most parents and children had an excellent understanding regarding their participation in a clinical trial (respectively 88.2% and 48.6%), the right to withdraw (76.5% and 43.2%) and the prospects of collective benefits (74.8% and 48.6%). By contrast, less than half of the parents and few of the children correctly understood the alternatives (respectively 47.5% and 27%), the risks related to participation (44.5% and 10.8%), the prospects of individual benefits (33.6% and 10.8%) and the purpose of the clinical trial (12.6% and 2.7%). Twenty-six (70.3%) children participated in the decision-making process. Most parents and children felt they had no choice but to participate in the trial to have access to a new anticancer treatment. CONCLUSIONS What might appear to be a poor understanding of the research protocol may actually correspond to the families' interpretation of the situation as a coping mechanism. All children (except infants) should get age-tailored information in order for them to have a meaningful involvement in research.
Collapse
Affiliation(s)
- Agathe Béranger
- Unité de recherche clinique, hôpital Cochin-Necker, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, Île-de-France, France
| | - Naïm Bouazza
- Unité de recherche clinique, hôpital Cochin-Necker, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, Île-de-France, France
| | - Amélie de Haut de Sigy
- Unité de recherche clinique, hôpital Cochin-Necker, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, Île-de-France, France
| | - Anne-Charlotte Foubert-Wenc
- Unité de recherche clinique, hôpital Cochin-Necker, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, Île-de-France, France
| | - Dominique Davous
- CHU Saint Louis, Espace éthique région Ile-de-France, Paris, France
| | - Isabelle Aerts
- Centre Oncologie SIREDO (Soins, Innovation et Recherche pour enfants, adolescents et jeunes adultes atteints de cancer), Institut Curie, Paris, France
| | - Birgit Geoerger
- Département d'oncologie pédiatrique et pour adolescents, Gustave Roussy, Villejuif, France
| | - Anne Auvrignon
- Hémato-Immuno-Oncologie Pédiatrique, hôpital Armand Trousseau, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Benoît Brethon
- Hématologie immunologie pédiatrique, hôpital Robert Debré, AP-HP, Université Paris Diderot, Paris, France
| | - Pierre Leblond
- Oncologie pédiatrique, Centre Oscar Lambret, Centre régional de lutte contre le cancer, Lille, France
| | - Nadège Corradini
- Service d'hématologie et oncologie pédiatrique, hôpital Mère-Enfant, Nantes, France.,Institut d'hématologie et d'oncologie pédiatrique (IHOPe), Centre régional de lutte contre le cancer, Centre Léon Bérard, Lyon, France
| | - Nicolas André
- Hématologie et oncologie pédiatrique, hôpital de la Timone, AP-HM, Marseille, France.,INSERM UMR 911, Centre de recherche en oncologie biologique et en oncopharmacologie, Université Aix-Marseille, Marseille, France
| | - Hélène Martinez
- Institut d'hématologie et d'oncologie pédiatrique (IHOPe), Centre régional de lutte contre le cancer, Centre Léon Bérard, Lyon, France
| | - Jean-Claude K Dupont
- Hospinnomics, Paris School of Economics, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Doz
- Centre Oncologie SIREDO (Soins, Innovation et Recherche pour enfants, adolescents et jeunes adultes atteints de cancer), Institut Curie, Paris, France.,Université Paris Descartes, Université Paris Descartes, Paris, France
| | - Hélène Chappuy
- Unité de recherche clinique, hôpital Cochin-Necker, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, Île-de-France, France.,Urgences pédiatriques, hôpital Armand Trousseau, AP-HP, Université Pierre et Marie Curie, Paris, France
| |
Collapse
|
47
|
Marsh V, Mwangome N, Jao I, Wright K, Molyneux S, Davies A. Who should decide about children's and adolescents' participation in health research? The views of children and adults in rural Kenya. BMC Med Ethics 2019; 20:41. [PMID: 31200697 PMCID: PMC6570858 DOI: 10.1186/s12910-019-0375-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 05/22/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND International research guidance has shifted towards an increasingly proactive inclusion of children and adolescents in health research in recognition of the need for more evidence-based treatment. Strong calls have been made for the active involvement of children and adolescents in developing research proposals and policies, including in decision-making about research participation. Much evidence and debate on this topic has focused on high-income settings, while the greatest health burdens and research gaps occur in low-middle income countries, highlighting the need to take account of voices from more diverse contexts. METHODS Between January and March 2014, 56 community representatives and secondary school students were involved in eight group discussions to explore views on the acceptability of involving children and adolescents in research, and how these groups should be involved in decision-making about their own participation. Discussions were voice-recorded and transcriptions analyzed using Framework Analysis, combining deductive and inductive approaches. RESULTS Across these discussions, the idea of involving children and adolescents in decision-making about research participation was strongly supported given similar levels of responsibility carried in everyday life; existing capacity that should be recognized; the opportunity for learning involved; varying levels of parental control; and generational shifts towards greater understanding of science for adolescents than their parents. Joint decision-making processes were supported for older children and adolescents, with parental control influenced by perceptions of the risks involved in participation. CONCLUSIONS Moves towards more active involvement of children and adolescents in planning studies and in making decisions about their participation are supported by these findings from Kenya. Important emerging considerations include the need to take account of the nature of proposed studies and prevailing attitudes and understanding of research in identifying children's and adolescents' roles. More research is needed to expand diversity and develop approaches to joint assent and consent processes that would fairly represent children's and adolescents' wishes and interests, towards their long term benefit.
Collapse
Affiliation(s)
- Vicki Marsh
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Institute, PO Box 230, Kilifi, 80108 Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Peter Medawar Building, South Parks Road, Oxford, OX13SY UK
| | - Nancy Mwangome
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Institute, PO Box 230, Kilifi, 80108 Kenya
| | - Irene Jao
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Institute, PO Box 230, Kilifi, 80108 Kenya
| | - Katharine Wright
- UK Nuffield Council on Bioethics, 28 Bedford Square, London, WC1B 3JS UK
| | - Sassy Molyneux
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Institute, PO Box 230, Kilifi, 80108 Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Peter Medawar Building, South Parks Road, Oxford, OX13SY UK
| | - Alun Davies
- Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Institute, PO Box 230, Kilifi, 80108 Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Peter Medawar Building, South Parks Road, Oxford, OX13SY UK
| |
Collapse
|
48
|
Kebbe M, Perez A, Buchholz A, Scott SD, McHugh TLF, Richard C, Dyson MP, Ball GDC. Adolescents' involvement in decision-making for pediatric weight management: A multi-centre, qualitative study on perspectives of adolescents and health care providers. PATIENT EDUCATION AND COUNSELING 2019; 102:1194-1202. [PMID: 30791989 DOI: 10.1016/j.pec.2019.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To explore adolescents' and health care providers' (HCPs) perspectives on adolescents' involvement in decision-making within multidisciplinary clinical care for pediatric weight management. METHODS In this multi-centre, qualitative description study, we purposefully recruited 13-17-year-olds with overweight or obesity and HCPs from two pediatric weight management clinics in Edmonton and Ottawa, Canada. Participants completed one-on-one, in-person, semi-structured interviews (adolescents) or focus groups (HCPs), which were audio-recorded, transcribed verbatim, and managed using NVivo 11. Data were analyzed by two independent researchers using inductive thematic analysis and the congruent methodological approach for group interactions. RESULTS A total of 19 adolescents and 16 HCPs participated. Three themes were identified in relation to adolescents' decision-making for weight management, including (i) conditions for adolescent involvement, (ii) preferences for adolescent involvement, and (iii) extent of parental involvement. CONCLUSIONS Although adolescents and HCPs positively valued adolescents' involvement in making decisions regarding their weight and health, the extent to which adolescents wished to be involved in the decision-making process varied between individuals and families. PRACTICE IMPLICATIONS HCPs are encouraged to include adolescents and families in their health services delivery, including consulting individually with adolescents and tailoring care to their expectations regarding decision-making.
Collapse
Affiliation(s)
- Maryam Kebbe
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Arnaldo Perez
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Annick Buchholz
- Centre for Healthy Active Living, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | | | - Tara-Leigh F McHugh
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Canada
| | - Caroline Richard
- Department of Agricultural, Food, and Nutritional Science, University of Alberta, Edmonton, Canada
| | - Michele P Dyson
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Geoff D C Ball
- Department of Pediatrics, University of Alberta, Edmonton, Canada.
| |
Collapse
|
49
|
Expanding adolescent access to hormonal contraception: an update on over-the-counter, pharmacist prescribing, and web-based telehealth approaches. Curr Opin Obstet Gynecol 2018; 30:458-464. [DOI: 10.1097/gco.0000000000000497] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
50
|
Fukuda Y, Fukuda K. Parents' attitudes towards and perceptions of involving minors in medical research from the Japanese perspective. BMC Med Ethics 2018; 19:91. [PMID: 30463554 PMCID: PMC6249915 DOI: 10.1186/s12910-018-0330-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 11/08/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Children's intentions should be respected. Parents are the key persons involved in decision-making related to their children. In Japan, the appropriate ages and standards for a child's consent and assent, approval, and decision-making are not clearly defined, which makes the process of obtaining consent and assent for clinical research complex. The purpose of this paper is as follows: to understand the attitudes and motives of parents concerning children's participation in medical research and the factors influencing their decision-making. We also sought to clarify who has the right to be involved in decisions regarding children's participation in research. METHODS A semi-structured Internet survey on parents' opinions and attitudes and preferences concerning medical research involvement was conducted. Children were divided into three age groups (6-10-year-olds, 11-14-year-olds, and 15-18-year-olds), with three illness severity categories. Possible correlations between the number of children, children's ages, parents' educational levels, and parents' attitudes were examined. RESULTS Among the participants, 42.3% recognized the term "informed consent." The proportion of participants who understood "informed consent" increased with educational level. Four out of five participants did not know, or had not heard of, the term "informed assent." Furthermore, the percentage of those who understood the term "informed assent" increased with academic level. Participants generally believed in prioritizing parents' opinions over children's, and that parents and children would ideally reach a joint decision. Although many parents favored collaborative decision-making, they also wanted their own will reflected in the decision and felt they should receive important information before their children do. Decision-making was affected by the condition's severity and prognosis. This indicates that most Japanese parents believe that their children have the right to know their disease name and treatment; nonetheless, they should be protected. Parents' values and judgments regarding medical intervention involving their children varied. CONCLUSIONS Children's ability to consent to treatment and research believed to be in their best interests should be assessed appropriately. They should be permitted to provide consent or assent, and their views should be respected. Involving children in decision-making fosters more open communication and transparency between medical professionals, parents, and children.
Collapse
Affiliation(s)
- Yasue Fukuda
- General Medical Education and Research Center, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 174-8605 Japan
| | - Koji Fukuda
- School of Political Science and Economics, Waseda University, 1-6-1 Nishi Waseda Shinjyuku-ku, Tokyo, 169-8050 Japan
| |
Collapse
|