Unique Ethical Dilemmas for Mental Healthcare of Infants, Young Children
Infant and early childhood mental health practitioners face complex and unique ethical issues. “But there has been little explicit attention to the ethical dilemmas that emerge when taking care of vulnerable infants and their families,” says Paula Zeanah, PhD, research director at the Cecil J. Picard Center for Child Development & Lifelong Learning at University of Louisiana at Lafayette. Zeanah and colleagues argue that a code of ethics is urgently needed.1 “Ethical codes for the involved professional disciplines fail to provide guidance about when caregivers and infants’ needs diverge,” according to Zeanah. Currently, ethical guidance in the field is limited to general statements on values, principles, or professional comportment from professional societies and specialty organizations. These do not provide enough detail to guide clinicians’ actions, the authors argue.
An infant’s needs may conflict with those of the caregiver. “This is a common ethical challenge,” says Zeanah. Some caregivers are unable or unwilling to consider the infant’s needs over their own. In other cases, the parent’s needs require attention before the infant’s needs can be addressed. “Thus, there is the dilemma of beneficence for one and potentially maleficence for the other,” explains Zeanah.
Laws protect children from abuse and neglect, but situations are often not so clear-cut. Some cases are more of a gray zone, leaving clinicians unclear on whether, when, or how to act. For example, an infant’s caregiver may have a substance use problem, or suffer from depression — both treatable conditions. “But the caregiver can choose whether to participate in treatment, or the treatment response may be slow,” says Zeanah. The caregiver’s symptoms may hinder the ability to recognize and respond to the infant’s needs, risking behavioral or developmental delays. The ethical question then becomes: At what point does the infant’s need for safe, nurturing care take priority over the caregiver’s right to determine their own health?
“Another common challenge is an ‘eye of the beholder’ question,” says Zeanah. A young child with a speech delay initially may be evaluated by a speech therapist, pediatrician, early education provider, or child protection worker. Each of those providers evaluates the child through a specific “lens” — thus, the level of concern can vary considerably. “The ethical concern with this is beneficence and nonmaleficience,” says Zeanah. A child in this situation could end up with a missed or wrong diagnosis, inappropriate treatment, or delayed treatment.
Hospital-based professionals encountering these dilemmas can turn to ethics committees and clinical ethicists. Such resources are not available in community-based settings. Zeanah argues that ethicists and clinicians have an obligation to be sure that identified ethical concerns are addressed post-discharge. For example, clinicians can connect families with appropriate community programs. “Ethical issues do not disappear after discharge — and may be exacerbated by the infant and family’s experience during the hospitalization,” says Zeanah.
- Zeanah PD, Steier A, Lim I, et al. Current approaches and future directions for addressing ethics in infant and early childhood mental health. Infant Ment Health J 2023;44:625-637.
Infant and early childhood mental health practitioners face complex and unique ethical issues. Experts argue that a code of ethics is urgently needed.
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