ETHICAL MINDFULNESS - A Reflective Checklist for Child Mental Health Professionals who Prescribe Psychotropic Medicines Endorsed by the DECP Committee of the British Psychological Society - June 2016 and Prof Allen Frances again in March 2018.

A Reflective Checklist for Child Mental Health Professionals who Prescribe Psychotropic Medicines Endorsed by the Division of Educational and Child Psychology Division Committee of the BPS  in June 2016 and subsequently by Professor Peter Kinderman, the then President of the British Psychological Society (See enclosed letter)

This year’s chairperson of the DECP, Brian Apter, as expressed in his ‘Chair’s Notes feels an article outlining the rationale underpinning the development of this Reflective Checklist by the Medicalisation Subcommittee of the Division of Educational and Child Psychology is needed at this stage to inform our members and all psychologists of its development so as to help them effectively challenge practice in cases where they have ethical and long term health concerns about the children with whom they co-work.

The idea for this Reflective Checklist for Mental Health practitioners is for prescribers of psychotropic medications to children in the U.K. to use as an aide-memoire on their desks 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 which is an international bestseller and has provoked radical approaches in many fields.

The rapidly increasing prescription rates of psychotropic drugs for children by Child Psychiatrists and Paediatricians in the U.K. over the last two decades  has alarmed many mental health practitioners and professional bodies alike such as the Division of Educational and Child Psychology 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 which most professionals would want to avoid in the U.K.

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 endeavoured to produce a positive contribution to this critical area of multi-professional debate and good practice. We hope that applying the much celebrated above approach of using simple and thought provoking question prompts could significantly improve the Safeguarding of vulnerable groups in society such as children.

The checklist went through many stages of generating suitable questions and consultation with colleagues about their suitability.The questions were then further refined to improve their face validity and effectiveness at making practitioners consider the importance of midfully making the decision to medicate a child in their often very busy working day. It is still our hope that child psychiatrists and paediatricians, themselves, through consideration by their professional bodies could 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. This would act as a significant additional safeguard we feel.

 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 pause where they take stock with a period of reflection may in the long term benefit the client group we all serve.  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.

The common-sense and reflective nature of the questions we have posed are, we feel, both practical and ethical in nature .  Sadly despite our best efforts and success at drawing it to the attention of the appropriate professional bodies which initially showed a lot of promise at  high levels within the organisations it seems that the inevitable committee considerations has not reached any positive conclusion at this stage. This in some way mirrors the consideration of new NICE Guidelines that we have also been involvedribers from potential complaint rather than  better Safeguarding Children from what the President of the Royal College of Psychiatry, Sir Simon Wessely has refe in in the intervening period. The worrying trend seems to be a tendancy to protect prescrred to as, ‘over-zealous prescribing.’

We must persist with trying to influence good practice in this regard at both a personal interaction level with the medical colleagues we work with supporting children on our caseloads and at a professional collaboration level in setting up NICE’s preferred model of multi-agency pathways for child behaviour.

Some of the many endorsements received since it has received international coverage in articles include:

1)From the Psychiatric Times website - 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 and his colleagues in the United Kingdom, have come up with a terrific suggestion to help contain the epidemic of careless medication in kids. They have developed a checklist of questions doctors should think about before prescribing psychoactive drugs to children."

Prof Allen Frances Psychiatrist 2018:This checklist is the best way to stop doctors from over-prescribing psych meds for kids.Forces them to do more thorough evaluation & to consider the many safer alternatives. LINK: 
https://t.co/unJicQf5r2 (https://twitter.com/AllenFrancesMD/status/978989855655931904?s=03)

Thanks Allen.

2)“ I saw the 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. Medical Editor for Mental Health, The Huffington Post.

3)"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 , 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.  

4) Professor Peter Kinderman - President of the BPS 2016-17 stated -

I am happy personally to endorse the Reflective Checklist that the Division of Educational and Child Psychology approved for limited dissemination at their June Committee meeting, following their consultation with some interested partners and to thank you all for your work on this issue.

The Reflective Checklist having been duly endorsed by the DECP, as well as a range of significant external partners, including the General Secretary, Kate Fallon, of the Association for Educational Psychologists, means I am very happy to join with them in this regard. I agree with your hope and that of Professor Allen Frances (Editor in Chief of DSM-IV) expressed a couple of weeks ago on his blog that, were the Checklist to be used by the two main groups of prescribers for children and young people i.e. child and adolescent psychiatrists and specifically trained paediatricians, that the number of prescriptions of psychotropic medication would become more reasonable over time.

You mentioned that you would also be pleased to remain involved in this initiative and to liaise with me and the DECP Committee where appropriate and to start a conversation with the President of the Royal College of Psychiatrists, Sir Simon Wesseley who is already aware of this initiative, with a view to the RCP using it as a stimulus for meaningful discussion amongst their membership of the concept.

5) Caroline Martin, Chief of the ETB in the City of Dublin as feedback on this post: "This Reflective Checklist designed by Dave Traxson endorsed by the BPS Division of Educational & Child Psychology (amongst several notable others) is an excellent resource. It is targeted for use by those who prescribe psychotropic meds to children. However, I suggest it can also be used by educational & psychological professionals who are responsible for determining and/or implementing interventions for children. We need to stop assuming the source of the problem lies within the child and checklists like this challenge this assumption. Granted, this will make for some more uncomfortable conversations."

AND NOW THE CHECKLIST - DISCUSS ITS BENEFITS

A Reflective Checklist for Child Mental Health Professionals who Prescribe Psychotropic Medicines Endorsed by the Division of Educational and Child Psychology Division Committee 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 up the 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 you still be prepared to prescribe this drug?