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Friday, 12 August 2016

A Commentary on the ‘Reflective Checklist’ to help moderate the rate of prescribing psychotropic drugs for children using Atul Gawande's work. Courtesy of Linkedin 11-08-16





The idea for this Reflective Checklist for Mental Health practitioners is for prescribers of psychotropic medications to children in the U.K. to better safeguard the Wellbeing of Children they work with and came from Atul Gawande’s inspirational and practical work on checklists applied to the fields of surgery and neo-natal emergencies in the U.K. which have had profoundly beneficial outcomes on client survival rates. Atul Gawande is a Professor of Surgery at Harvard Medical School and believes that incredibly complex processes and decisions can be improved and made safer by simple prompt questions and common sense practical procedures. His seminal book was 'The Checklist Manifesto.' 2009.
The rapidly increasing prescription rates of psychotropic drugs for children by Child Psychiatrists and Paediatricians in the U.K. over the last decades  has alarmed many mental health practitioners and professional bodies alike such as the Division of Educational and Child Psychology (DECP) within the British Psychological Society and the Association of Educational Psychologists (AEP) as well as colleagues in America where the situation is even more extreme. In some States the prescription rate for Methylphenidate alone is 16% of the total school population.
As reflective practitioners and being ‘Ethically Mindful’ of the Paramount Principle of the Safeguarding Children in our shared care the DECP Medicalisation of Childhood Subcommittee has endeavored to produce a positive contribution to this critical area of multi-professional debate. We hope that applying the much celebrated above approach of using simple and thought provoking question prompts could significantly add to the Safeguarding of vulnerable groups in society such as children.
The checklist has gone through many stages with the final one, prior to obtaining a Presidential endorsement from Professor Peter Kinderman (BPS), being the refinement of some of the questions to improve their face validity and effectiveness at making practitioners consider the importance of making the decision to medicate a child in their often crammed working day. The idea is that the final version which has to be further refined by the two groups of prescribers, child psychiatrists and paediatricians, themselves through their professional bodies could hopefully then be distributed as a desk top aide-memoire which could be situated next to their prescription pad or indeed combined with it as one item.





A Reflective Checklist for Child Mental Health Practitioners Approved by the Division of Educational and Child Psychology Division of the BPS in June 2016.
                              PAUSE  –  REFLECT  -  REVIEW


  • Are the child’s behavioural differences pervasive, occurring in a wide range of social settings and observed by a range of different individuals in the community?
  • Are the child’s difficulties severe, enduring, and significantly impairing?
  • Have there been any stresses in the child’s relationships, social context, and recent history which might explain this pattern of behaviours?
  • Does the child have presenting behaviours that closely conform to an approved usage for the particular medication being considered at this time?
  • Is there research evidence on the efficacy and safety of this specific medication with children of the same age, gender, and social grouping?
  • Are the child’s presenting behaviours significantly impairing in a range of settings to acceptably balance the possible impact on the child’s developing brain and body from the evidence based side effects of the specific medications being considered?
  • Do the child’s parents and involved professionals see the child’s differences as significant enough to require this medication?
  • Has a psychological intervention, such as a talking therapy (CBT etc.); a social intervention such as ‘Circle of Friends’ / ‘Buddy System’ or a physical intervention such as participation in sport been tried prior to prescribing this particular psychotropic medication being considered?
  • Have there been any reported significant adverse side effects from this specific medication with children of the same age, gender and social grouping ?
  • Have you carefully weighed short- and long-term risks and balanced them against possible benefits?

  • Have you received valid consent from the parent and the child?
And perhaps the most searching question:
  • If a child in your immediate family or circle of friends had the same presenting behaviours that are in front of you now, would it still be right to prescribe this drug?



Obviously we do not want to unnecessarily duplicate procedures, such as the excellent NICE Guidelines for specific conditions for well trained and informed professionals but we do believe that a brief taking stock and period of reflection may in the long term benefit the client group we all serve. This Reflective Checklist is intended as a more generic approach which when the necessary consultation is completed will be a short but effective additional protective safeguard for the children in our joint care regardless of the medication being considered. We hope as many colleagues in the field have already indicated that a few minutes well spent may enhance the decision making at the point of prescription and moderate unnecessary overprescribing to children who may well on reflection fall within the normal range of children experiencing higher levels of mental distress for whatever causal combination of environmental, social and biological factors.
Other endorsements include:
  • From Psychiatric Times - July 2015 - Professor Allen Frances, ex- editor in chief of DSM-IV states, "Overwhelmed teachers often recommend that parents take their kids to doctors for medicine when the problem may be more in the classroom than in the kid. Dave Traxson, a child and educational psychologist in the United Kingdom, has come up with a terrific suggestion to help contain the epidemic of careless medication in kids. He has developed a Checklist of questions doctors should think about before prescribing psychoactive drugs to children."

  • “Dear Mr. Traxson, I saw your proposed checklist re: child psych medications in Psychiatric Times.It seems clear, thoughtful and feasible. Thank you, Lloyd Sederer, MD."
  • Medical Director, NYS Office of Mental Health, Adjunct Professor, Columbia/Mailman School of Public Health

  • "Thanks for the check list. I wonder how many children would really need medications after working through this check list? I am a child and adolescent psychiatrist (Denmark), and as the years go by I find fewer and fewer children really need medications, and more and more do so much better without the meds that didn´t really help in the first place. But it is not popular talk around the block."                        Lisbeth Kortegaard - Consultant Child and Adolescent Psychiatrist at Child and Adolescent Psychiatry in Hoejbjerg,Central Region, Denmark.

  • “Great Input ! Thanks.”- regarding proposed checklist,Jose Miguel, Psychiatrist. California.

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