Informed consent instead of assent is appropriate in children from the age of twelve: Policy implications of new findings on children's competence to consent to clinical research

Lack of assent to dental examination in children with intellectual disabilities: Dentists' practices in Europe and ethical issues

AIM

(1) To determine the repartition of criteria which can be considered as marks of lack of assent by the child with intellectual disabilities from the dentist's point of view and whether that influences the decision to examine the patient or not. (2) To explain the decision of practitioners and determine the ethical implications of these practices.

METHODS

An anonymous and structured questionnaire was distributed online using the scenario of a 9-year-old child with moderate cognitive impairment with eight different oppositional behaviours. The practitioners were asked about their perception of the patient's lack of assent and about their decision to perform the dental examination or not.

RESULTS

The proportion of them who performed a dental examination despite the patient's refusal represented between 13% and 28.8% of the population of respondents.

CONCLUSION

There was an ambivalence among the practitioners who carried out a dental consultation when children were uncooperative. They adopted a teleological point of view. It calls for us to reflect on the ethical principles of autonomy and beneficence.

Standards for the care of people with cystic fibrosis (CF); Planning for a longer life

This is the final of four papers updating standards for the care of people with CF. That this paper "Planning a longer life" was considered necessary, highlights how much CF care has progressed over the past decade. Several factors underpin this progress, notably increased numbers of people with CF with access to CFTR modulator therapy. As the landscape for CF changes, so do the hopes and aspirations of people with CF and their families. This paper reflects the need to consider people with CF not as a "problem" to be solved, but as a success, a potential and a voice to be heard. People with CF and the wider CF community have driven this approach, reflecting many of the topics in this paper. This exercise involved wide stakeholder engagement. People with CF are keen to contribute to research priorities and be involved in all stages of research. People with CF want healthcare professionals to respect them as individuals and consider the impact of our actions on the world around us. Navigating life presents challenges to all, but for people with CF these challenges are heightened and complex. In this paper we highlight the concerns and life moments that impact people with CF, and events that the CF team should aim to support, including the challenges around having a family. People with CF and their care teams must embrace the updated standards outlined in these four papers to enjoy the full potential for a healthier life.

Sedation Research in Critically Ill Pediatric Patients: Proposals for Future Study Design From the Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research IV Workshop

OBJECTIVES

Sedation and analgesia for infants and children requiring mechanical ventilation in the PICU is uniquely challenging due to the wide spectrum of ages, developmental stages, and pathophysiological processes encountered. Studies evaluating the safety and efficacy of sedative and analgesic management in pediatric patients have used heterogeneous methodologies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) IV hosted a series of multidisciplinary meetings to establish consensus statements for future clinical study design and implementation as a guide for investigators studying PICU sedation and analgesia.

DESIGN

Twenty-five key elements framed as consensus statements were developed in five domains: study design, enrollment, protocol, outcomes and measurement instruments, and future directions.

SETTING

A virtual meeting was held on March 2-3, 2022, followed by an in-person meeting in Washington, DC, on June 15-16, 2022. Subsequent iterative online meetings were held to achieve consensus.

SUBJECTS

Fifty-one multidisciplinary, international participants from academia, industry, the U.S. Food and Drug Administration, and family members of PICU patients attended the virtual and in-person meetings. Participants were invited based on their background and experience.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Common themes throughout the SCEPTER IV consensus statements included using coordinated multidisciplinary and interprofessional teams to ensure culturally appropriate study design and diverse patient enrollment, obtaining input from PICU survivors and their families, engaging community members, and using developmentally appropriate and validated instruments for assessments of sedation, pain, iatrogenic withdrawal, and ICU delirium.

CONCLUSIONS

These SCEPTER IV consensus statements are comprehensive and may assist investigators in the design, enrollment, implementation, and dissemination of studies involving sedation and analgesia of PICU patients requiring mechanical ventilation. Implementation may strengthen the rigor and reproducibility of research studies on PICU sedation and analgesia and facilitate the synthesis of evidence across studies to improve the safety and quality of care for PICU patients.

The psychology, legality, ethics and medical aspects of organ donation by minors

Any individual who has not attained the chronological age of legal majority as per national law is termed a minor. The concept of living donation (LD) has always been a subject of ethical debate and further compounding the controversy is the question of LD by minors. The decision for a minor to donate poses a special challenge as it involves a close family unit of parent-child relationship. Such an emotionally loaded situation wherein questions of attachment, perceived duties, moral obligation are likely to cloud a truly informed consent on the part of the minor to donation, who may find themselves in a vulnerable position. Furthermore, a minor's cognitive ability to comprehend the gravity of LD and when required defy parental coercion need to be elucidates before a minor is accepted for LD. Experts have set out stringent conditions which need to be met prior to the exceptional circumstance that a minor is considered for organ donation. Such donations should require parental permission, child's assent and the involvement of a paediatric-trained donor advocacy team. This article debates the question of minors acting as live donors from ethical, medical, psychosocial and legal viewpoints with an aim to present internationally defined circumstances when a minor may morally participate as a LD, thereby laying the foundation for future deliberations in this regard using traditional metrics to juxtapose divergent courses of action.

Consent and Assent in Pediatric Research

Research involving pediatric populations has important ethical and regulatory considerations. As children generally cannot consent to research, there are special protections put in place to ensure that the decisional vulnerability is protected, including parental permission and often the child's assent. Assent is an ethically important part of the research because it allows the child to participate in the process of agreeing to research, develop their autonomy, and express their values. This article explores a case where the child and parent disagree about the child's participation. In doing so, the regulatory requirements of pediatric research are outlined and the process and product of obtaining assent from a minor is described.

The effect of virtual reality on pain, fear and emotional appearance during blood draw in pediatric patients at the hematology-oncology outpatient clinic: A randomized controlled study

OBJECTIVE

Invasive attempts can be very painful and stressful for pediatric patients. Virtual Reality (VR) can be used to distract patients undergoing such procedures in pediatric hematology oncology patients.

METHODS

A parallel trial design approach was adopted for this randomized controlled trial, guided by the CONSORT checklist. The study sample (n = 69) was divided into a VR group (n = 34) and a control group (n = 35) using stratified randomization. For the blood draw attempt, no distraction method was applied to the control group, while the children in the VR group were distracted from the procedure with the Epic Roller Coasters VR application. The primary variable assessed was pain, while secondary variables were fear and emotional appearance. The scores of emotional appearance, fear, and pain were compared with a Mann-Whitney U Test.

RESULTS

The pre-procedure emotional appearance score was 11.3 ± 4.3 in the VR group and 11.0 ± 5.0 in the control group, and the post-procedure score was 6.5 ± 3.3 in the VR group and 11.8 ± 5.3 in the control group, indicating a difference in emotional appearance after the procedure. VR group had lower negative emotional appearance, lower pain, and lower fear scores after procedure compared to the control group.

CONCLUSION

VR can be considered an effective approach to reducing the negative emotional appearance and for relieving pain and fear in children aged 4-12 years undergoing blood draw procedures in pediatric hematology and oncology outpatient unit (ClinicalTrials.gov: NCT05675358).

Generative Language Models and Open Notes: Exploring the Promise and Limitations

Patients' online record access (ORA) is growing worldwide. In some countries, including the United States and Sweden, access is advanced with patients obtaining rapid access to their full records on the web including laboratory and test results, lists of prescribed medications, vaccinations, and even the very narrative reports written by clinicians (the latter, commonly referred to as "open notes"). In the United States, patient's ORA is also available in a downloadable form for use with other apps. While survey studies have shown that some patients report many benefits from ORA, there remain challenges with implementation around writing clinical documentation that patients may now read. With ORA, the functionality of the record is evolving; it is no longer only an aide memoire for doctors but also a communication tool for patients. Studies suggest that clinicians are changing how they write documentation, inviting worries about accuracy and completeness. Other concerns include work burdens; while few objective studies have examined the impact of ORA on workload, some research suggests that clinicians are spending more time writing notes and answering queries related to patients' records. Aimed at addressing some of these concerns, clinician and patient education strategies have been proposed. In this viewpoint paper, we explore these approaches and suggest another longer-term strategy: the use of generative artificial intelligence (AI) to support clinicians in documenting narrative summaries that patients will find easier to understand. Applied to narrative clinical documentation, we suggest that such approaches may significantly help preserve the accuracy of notes, strengthen writing clarity and signals of empathy and patient-centered care, and serve as a buffer against documentation work burdens. However, we also consider the current risks associated with existing generative AI. We emphasize that for this innovation to play a key role in ORA, the cocreation of clinical notes will be imperative. We also caution that clinicians will need to be supported in how to work alongside generative AI to optimize its considerable potential.

Involvement and Autonomy of Minors in Medical Settings: Perceptions of Children Undergoing Surgery and Parents

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.

Aflatoxicosis outbreak and its associated factors in Kiteto, Chemba and Kondoa Districts, Tanzania

Tanzania had experienced hundreds of cases of aflatoxicosis in the districts of Kiteto, Chemba, and Kondoa for the three consecutive years since 2016. Cases may end up with liver cancer. Aflatoxin-induced liver cancer had resulted in the demise of roughly three persons per 100,000 in the country during the same year, 2016. We investigated to characterize the latest outbreak of 2019 and identify its risk factors. This case-control study enrolled all patients presented with acute jaundice of unknown origin and laboratory test results confirmed an acute liver injury with or without abdominal pain, distension, vomiting, or fever during the period of June to November 2019 and had epidemiological link with cases confirmed with Aflatoxin-B1-Lysine. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were used to identify independent factors associated with aflatoxicosis. We analyzed 62 cases with median age of 7 years (0.58-50 years) and 186 controls with median age of 24 years (range 0.42-55) with onset of symptoms ranging from 1st June 2019 to 16th July 2019. Case-parents had higher serum aflatoxin-B1-lysine adduct concentrations than did controls; 208.80 ng/mg (n = 45) vs. 32.2 ng/mg (n = 26); p<0.01. Storing foods at poor conditions (AOR 5.49; 95% CI 2.30-13.1), age <15 years (AOR 4.48; 95% CI 1.63-12.3), chronic illness (AOR 3.05; 95% CI 1.19-7.83) and being male (AOR 2.31; 95% CI 1.01-5.30) were significantly associated with the disease, whereas cleaning foods before milling decreased the risk of getting the disease by 88% (AOR 0.12; 95% CI 0.05-0.29). According to the results, the outbreak resulted from a globally highest-ever recorded aflatoxin-B1-lysine that originated from a common source. To prevent future outbreaks, it is crucial to store and clean food crops safely before milling. We recommend strict regulations and enforcement around aflatoxin levels in food products.

Between Autonomy and Paternalism: Attitudes of Nursing Personnel Towards Jehovah's Witnesses' Refusal of Blood Transfusion

Objectives: The study describes the attitudes of Polish nursing personnel towards Jehovah's Witnesses' (JWs') refusal to receive blood and blood products. Methods: We developed an online survey assessing nurses' knowledge and attitudes towards JWs' refusal of blood transfusion in a life-threatening condition. It also examined nurses' attitudes towards ethical and legal issues associated with JWs' refusal of blood transfusions. These questions were explored using a sample of 202 Polish nurses. Results: Nurses' knowledge of JWs' stance towards blood transfusions is inadequate and they tended to be ill-disposed towards JWs' refusal of blood transfusions. Although most nurses respected adult JW patients' autonomy and supported their right to refuse blood, in the case of JW children they are guided by paternalism. Nurses' attitudes were affected by whether they had children, whether they declared themselves religious, their level of education and prior experience with patients who had refused a blood transfusion. Conclusion: Since most nurses felt unprepared to care for JW patients, this study reveals an urgent need to train nurses in transcultural nursing and increase nurses' cultural competencies, and that this should be incorporated into medical curricula .

Approaches to consent in public health research in secondary schools

OBJECTIVES

We assess different approaches to seeking consent in research in secondary schools.

DESIGN

We review evidence on seeking active versus passive parent/carer consent on participant response rates and profiles. We explore the legal and regulatory requirements governing student and parent/carer consent in the UK.

RESULTS

Evidence demonstrates that requiring parent/carer active consent reduces response rates and introduces selection biases, which impact the rigour of research and hence its usefulness for assessing young people's needs. There is no evidence on the impacts of seeking active versus passive student consent but this is likely to be marginal when researchers are directly in communication with students in schools. There is no legal requirement to seek active parent/carer consent for children's involvement in research on non-medicinal intervention or observational studies. Such research is instead covered by common law, which indicates that it is acceptable to seek students' own active consent when they are judged competent. General data protection regulation legislation does not change this. It is generally accepted that most secondary school students age 11+ are competent to provide their own consent for interventions though this should be assessed individually.

CONCLUSION

Allowing parent/carer opt-out rights recognises their autonomy while giving primacy to student autonomy. In the case of intervention research, most interventions are delivered at the level of the school so consent can only practically be sought from head teachers. Where interventions are individually targeted, seeking student active consent for these should be considered where feasible.

A Novel Scale to Assess Parental Satisfaction of Dental Local Anesthetic Techniques in Children: A Cross-Sectional Study

Background

Pain control is one of the most important aspects that can affect parental satisfaction of the dental care provided for children. Dental local anesthesia has the highest impact on pain sensation of the children. However, there is no scale in the literature to assess parental satisfaction of dental local anesthetic techniques.

Objectives

This study was aimed to assess the parental satisfaction with dental local anesthetic techniques for their children through designing a scale that reflects satisfaction and to study the validity and reliability of this scale.

Methods

A cross-sectional observational study was conducted on 150 parents (102 mothers and 48 fathers). Two techniques of local anesthesia were used for each child participated in this study (inferior alveolar nerve block and computerized intraosseous anesthesia). The developed scale consisted of 20 items in a 5-point Likert scale. Half of the items were written in a negative format. Internal consistency, validity, and factor analysis were performed in this study. Independent t-test was used to compare between the two techniques of anesthesia, between boys and girls and among fathers and mothers.

Results

Parental satisfaction mean values were higher in the computerized intraosseous anesthesia group in comparison to inferior alveolar nerve block (P value <0.05). The T-test showed that there was no difference between boys and girls regarding parental satisfaction (P value >0.05). Furthermore, fathers show lower satisfaction in the computerized interosseous anesthesia group (P value <0.05). Excellent internal consistency of this scale was resulted as Cronbach's alpha reliability coefficient was 0.985. After factor analysis, seven factor components were retained by using varimax rotation.

Conclusions

Findings of this study reported that the designed parental satisfaction of dental local anesthetic techniques scale (PSLAS) is a valid and reliable scale to be used. Moreover, this study showed that parental satisfaction was higher when computerized intraosseous anesthesia was used in comparison to inferior alveolar nerve block.

Ethical Aspects of Personalized Research and Management of Systemic Inflammatory Response Syndrome (SIRS) in Children

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.

Psychosocial and bioethical challenges and developments for the future of vascularized composite allotransplantation: A scoping review and viewpoint of recent developments and clinical experiences in the field of vascularized composite allotransplantation

Vascularized Composite Allotransplantation (VCA) has evolved in recent years, encompassing hand, face, uterus, penile, and lower extremity transplantation. Accordingly, without centralized oversight by United States Organ Procurement and Transplantation Network (OPTN) or European Programs, centers have developed their own practices and procedures that likely vary, and accordingly, present different levels of rigor to the evaluation process, internationally. The importance of psychosocial factors in the selection process and treatment course has been widely recognized, and therefore, several approaches have been developed to standardize and guide care of VCA candidates and recipients. We propose to develop an international multidisciplinary platform for the exchange of expertise that includes clinical, patient, and research perspectives. Patient perspectives would derive from peer education and the assessment of patient-reported outcomes. To establish a foundation for such a platform, future research should review and combine current VCA protocols, to develop the ethical framework for a standardized psychosocial evaluation and follow-up of VCA candidates and recipients. This review presents a comprehensive overview of recent results in the field of VCA, developments in structural aspects of VCA, and provides viewpoints driven from clinical experience.

Assent, parental consent and reconsent for health research in Africa: thematic analysis of national guidelines and lessons from the SickleInAfrica registry

The enrolment of children and adolescents in health research requires that attention to be paid to specific assent and consent requirements such as the age range for seeking assent; conditions for parental consent (and waivers); the age group required to provide written assent; content of assent forms; if separate assent and parental consent forms should be used, consent from emancipated young adults; reconsent at the age of adulthood when a waiver of assent requirements may be appropriate and the conditions for waiving assent requirements. There is however very little available information for researchers and ethics committees on how to navigate these different issues. To provide guidance to research initiatives, the SickleInAfrica consortium conducted a thematic analysis of a sample of research ethics guidelines and procedures in African countries, to identify guidance for assent requirements in health research. The thematic analysis revealed that 12 of 24 African countries specified the age group for which assent is required. The minimum age for written assent varied across the countries. Five countries, Algeria, Botswana, Cameroon, Nigeria and The Democratic Republic of Congo require consent from both parents/family council in certain circumstances. Botswana, Nigeria, South Africa and Uganda have specific assent/consent requirements for research with emancipated minors. South Africa and Algeria requires re-consent at onset of adulthood. Five countries (Botswana, Cameroon, Nigeria, South Africa and Tanzania) specified conditions for waiving assent requirements. The CIOMS and the ICH-GCP guidelines had the most comprehensive information on assent requirements compared to other international guidelines. An interactive map with assent requirements for different African countries is provided. The results show a major gap in national regulations for the inclusion of minors in health research. The SickleInAfrica experience in setting up a multi-country SCD registry in Africa highlights the need for developing and harmonising national and international guidelines on assent and consent requirements for research involving minors. Harmonisation of assent requirements will help facilitate collaborative research across countries.

Fertility preservation for transgender children and young people in paediatric healthcare: a systematic review of ethical considerations

BACKGROUND

While fertility preservation is recommended practice for paediatric oncology patients, it is increasingly being considered for transgender children and young people in paediatric care. This raises ethical issues for clinicians, particularly around consent and shared decision-making in this new area of healthcare.

METHODS

A systematic review of normative literature was conducted across four databases in June 2020 to capture ethical considerations related to fertility counselling and preservation in paediatric transgender healthcare. The text of included publications was analysed inductively, guided by the Qualitative Analysis Guide of Leuven.

RESULTS

Twenty-four publications were identified for inclusion. Four key ethical considerations emerged from this literature: access to fertility preservation, conscientious objection, decision-making capacity of children and young people, and shared decision-making.

CONCLUSION

In the identified literature, there is consensus that transgender children and young people should not be refused access to fertility preservation services solely due to their gender identity, and that clinicians with conscientious objections to fertility preservation for this group have an obligation to refer on to willing providers. Factors that create ethical complexity in this area of paediatric care include the child's age, mental health, and parents' views.

Electronic informed consent criteria for research ethics review: a scoping review

Background

The research shows a growing trend in using an electronic platform to supplement or replace traditional paper-based informed consent processes. Instead of the traditionally written informed consent document, electronic informed consent (eConsent) may be used to assess the research subject’s comprehension of the information presented. By doing so, respect for persons as one of the research ethical principles can be upheld. Furthermore, these electronic methods may reduce potential airborne infection exposures, particularly during the pandemic, thereby adhering to the beneficence and nonmaleficence principle. This scoping review aims to identify the ethics related criteria that have been included in electronic informed consent processes and to synthesize and map these criteria to research ethics principles, in order to identify the gaps, if any, in current electronic informed consent processes.

Methods

The search was performed based on internet search and three main databases: PubMed, SCOPUS and EBSCO. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation guideline was used to report this work.

Results

Of 34 studies that met the inclusion criteria, 242 essential original constructs were collated, and 7 concepts were derived. Digital content showed the highest percentage of collated original constructs (27%, n = 65) followed by accessibility (24%, n = 56), comprehension engagement (18%, n = 43), autonomy (14%, n = 34), confidentiality (11%, n = 25), language (5%, n = 13), and parental consent (1%, n = 2). Twenty-five new items were synthesized for eConsent criteria which may provide guidance for ethical review of research involving eConsent.

Conclusion

The current study adds significant value to the corpus of knowledge in research ethics by providing ethical criteria on electronic informed consent based on evidence-based data. The new synthesized items in the criteria can be readily used as an initial guide by the IRB/REC members during a review process on electronic informed consent and useful to the future preparation of a checklist.

What information and the extent of information to be provided in an informed assent/consent form of pediatric drug trials

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.

Operationalization of assent for research participation in pre-adolescent children: a scoping review

BACKGROUND

Seeking assent from children for participation in medical research is an ethical imperative of numerous institutions globally. However, none of these organizations provide specific guidance on the criteria or process to be used when obtaining assent. The primary objective of this scoping review was to determine the descriptions of assent discussed in the literature and the reported criteria used for seeking assent for research participation in pre-adolescent children.

METHODS

Medline and Embase databases were searched until November 2020 using the term "assent" in the title or abstract. Inclusion criteria were (1) studies enrolling children which specifically described operationalization of the assent process and (2) studies of the assent process which provided a description of assent. Data collected included participant information, patient criteria for seeking assent, guidelines referenced, description of assent reported, how assent was obtained and assent information presented, and reported assent rate. For qualitative articles focusing on the assent process, important themes were identified.

RESULTS

A total of 116 articles were included of which 79 (68.9%) operationalized assent and 57 studies (%) described the assent process. The most commonly reported criterion used to determine the ability of a child to assent was age (35.4%, 28/79). The reported minimal age for obtaining pediatric assent varied considerably across and within jurisdictions (5-13 years; median 7.5 years, IQR 7.0, 9.75). Cognitive ability was reported as a criterion for obtaining assent in 5.1% (4/79) of studies. Assent rates were only reported in 17.7% (14/79) of citations and ranged from 32.0 to 100%. Analysis of the 57 studies describing the assent process identified several themes, including age thresholds, assessment of capacity, variable knowledge of pediatric assent and parental roles.

CONCLUSION

We found significant variation in criteria used for assessment of patient capacity, delivery of information used to obtain assent and documentation of the assent process. While we acknowledge that individual children, settings and jurisdictions may require different approaches to obtaining assent, there should be agreement on important principles to be followed with resulting common guidance on assessing capacity, delivering information and documentation of the assent process for publication.

From Human Papillomavirus to COVID-19: Adolescent Autonomy and Minor Consent for Vaccines

Adolescent minors in every state can give their own consent for some health care. Although parent consent is generally required for vaccination, there are exceptions in some states. Completion rates are low for recommended adolescent vaccines; allowing adolescents to consent may improve coverage, although more study is needed on barriers to vaccine completion and the feasibility of changes in consent laws. The COVID-19 pandemic highlights the importance of vaccines and related challenges. This policy brief reviews laws governing adolescent consent for health care, including vaccines, and recommends advocacy to support increased adolescent access to vaccines and improved public health.

Three Kinds of Decision-Making Capacity for Refusing Medical Interventions

According to a standard account of patient decision-making capacity (DMC), patients can provide ethically valid consent or refusal only if they are able to understand and appreciate their medical condition and can comparatively evaluate all offered treatment options. We argue instead that some patient refusals can be capacitated, and therefore ethically authoritative, without meeting the strict criteria of this standard account-what we call comparative DMC. We describe how patients may possess burdens-based DMC for refusal if they have an overriding objection to at least one burden associated with each treatment option or goals-based DMC for refusal if they have an overriding goal that is inconsistent with treatment. The overridingness of a patient's objections to burdens, or of their commitment to a goal, can justify the moral authority of their refusal, even when a patient lacks some of the cognitive capacities that standard accounts of DMC involve.

Paediatric biobanking for health: The ethical, legal, and societal landscape

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.

How to deal with moral challenges around the decision-making competence in transgender adolescent care? Development of an ethics support tool

Background

Decision-making competence is a complex concept in the care for transgender and gender diverse adolescents, since this type of care concerns one’s developing gender identity and involves treatment options that often lack international consensus. Even despite competence assessments, moral challenges arise in the decision-making process. Here, traditional forms of clinical ethics support such as moral case deliberation might not fit as these do not provide thematic guidance. This study therefore aimed to develop a practice-oriented ethics support tool to assist care providers when dealing with moral challenges around decision-making competence in transgender adolescent care.

Methods

The study followed a participatory design to develop a tool in close collaboration with care providers; they had a say in all phases of development and dissemination. Firstly, nine care providers were interviewed about experienced moral challenges and needs for ethics support. Based on this, the structure and content of the tool was constructed and discussed in two focus group meetings, after which four care providers tested the tool and additional feedback was collected from the team and an advisory board. The final tool was presented to all Dutch care providers in transgender adolescent care.

Results

Care providers expressed a need for guidance in defining and assessing decision-making competence. Main moral challenges concerned discussing fertility options with young clients, dealing with co-occurring mental health difficulties and the decision-making role of parents. The final tool, named the Competence Consultant, is an interactive pdf containing four parts: (1) Clarify information; (2) Identify doubts and moral questions; (3) Guidance for conversations and (4) Overview and Conclusions.

Discussion

Developing an ethics support tool in a controversial care setting is highly relevant as it aims to help individual care providers in defining, discussing and dealing with their moral challenges in actual practice. The ‘Competence Consultant’ for transgender care providers contributes to their moral sensitivity and moral competence. It is an example of the development of innovative and integrative forms of thematic ethics support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00837-1.

Guideline for the management of pediatric off-label use of drugs in China (2021)

BACKGROUND

The "Law on Doctors of the People's Republic of China," which was officially implemented on March 1, 2022, emphasizes the requirements for rational drug use and the necessity for appropriate management of off-label drug use. The safety and ethical considerations related to off-label drug use are different in children than in adults. There is so far no management guideline for pediatric off-label use of drugs in China, and the applicability of foreign guidelines is limited. Establishing a localized evidence-based management guideline for pediatric off-label use of drugs to support the national legislation and clinical practice is of critical importance.

METHODS

We established a guideline working group, including experts from a broad range of disciplines and developed recommendations following the guidance of the World Health Organization Handbook and the Chinese Medical Association. The following themes were identified by questionnaires and expert interviews to be of great concern in the management of off-label drug use in children: general principles and characteristics of management of pediatric off-label drug use; establishment of expert committees; evidence evaluation; risk-benefit assessment; informed consent; monitoring and assessment of the risk; and monitoring and patient education. Two rounds of Delphi surveys were organized to determine the final recommendations of this guideline. We graded the recommendations based on the body of evidence, referring to the evaluation tool of the Evidence-based management (EBMgt) and the Oxford Center for Evidence-Based Medicine: Level of Evidence (March 2009).

RESULTS

We developed the first guideline for the management of pediatric off-label use of drugs in China.

CONCLUSIONS

The guideline is to offer guidance for pediatricians, pharmacists, medical managers, policymakers, and primary care physicians on how to manage off-label drug use in pediatrics and to provide recommendations for Chinese healthcare policy in the future.

Les tests et le dépistage génétiques chez les enfants

Les tests génétiques, qui ont évolué rapidement depuis vingt ans, deviennent monnaie courante en pédiatrie. Le présent document de principes procure un aperçu des récents développements qui peuvent avoir des répercussions sur les tests génétiques chez les enfants. La génétique est un domaine en constante évolution, et le présent document de principes s'attarde tout particulièrement au dépistage néonatal élargi, au séquençage de nouvelle génération, aux découvertes fortuites, aux tests commercialisés directement auprès des consommateurs, aux tests d'histocompatibilité et aux tests génétiques dans le contexte de la recherche.

Genetic testing and screening in children

Genetic testing has progressed rapidly over the past two decades and is becoming common in paediatrics. This statement provides an overview of recent developments that may impact genetic testing in children. Genetics is a rapidly evolving field, and this statement focuses specifically on expanded newborn screening, next generation sequencing (NGS), incidental findings, direct-to-consumer testing, histocompatibility testing, and genetic testing in a research context.

Adolescent decision making: A decade in review

Research in the past decade has highlighted the nuances of adolescent decision making. In this review article, we summarize several themes evident in the field of developmental science including the redefinition of adolescence and the ways in which adolescent decision-making capabilities converge with or diverge from those of adults. While the decision-making process is similar for adolescents and adults in contexts that encourage deliberation and reflection, adolescents and adults differ in contexts which preclude deliberation vis-à-vis high emotional arousal. We also discuss the reconceptualization of adolescent behavior, including risk taking, as adaptive. That is, characteristics of adolescence, including impulsivity, the importance of peers, and novelty seeking, are normative, evolutionarily advantageous, and essential for positive development. While these features manifest in negative, health-compromising ways (e.g., risky driving and criminal behavior), they also foster growth and exploration. We conclude with a discussion of potential avenues for future research.

Adolescents' and Young Adults' Ability to Self-Screen for Contraindications to Hormonal Contraception and the Role of Chronic Illness

PURPOSE

Multiple states allow pharmacists to prescribe hormonal contraception but can have age restrictions. The study objective was to examine how age influences adolescents' and young adults' (AYAs) ability to self-report potential contraindications to hormonal contraception compared with physician reports (our "gold standard").

METHODS

Between February 2017 and August 2018, girls aged 14-21 years and their physicians were recruited in outpatient adolescent primary and subspecialty care clinics. Screeners were completed separately for medical conditions that are potential contraindications to hormonal contraception as defined by the Centers for Disease Control Medical Eligibility Criteria. Overall, discordance was defined as differences between the patient's and provider's answers, and potential unsafe discordance was defined as AYAs underreporting of contraindications. Multivariable logistic regression was used to examine predictors of overall and unsafe discordance.

RESULTS

Of 394 AYA/physician pairs, 45% were from subspecialty clinics, 35% identified as African American, the mean age was 16.7 ± 1.9 years, and 38% were sexually active. Fifty percent of patients reported potential contraindications to hormonal contraception. There was only an 18% rate of unsafe discordance, with no statistical difference by age but a higher rate in subspecialty clinics (28% vs. 10%). No variables were predictive of higher rates of unsafe discordance in general or subspecialty clinics.

CONCLUSIONS

Potential overall and unsafe discordance between AYAs' and physicians' reports of medical contraindications to combined hormonal contraception were not related to younger age and thus support expansion of pharmacy access to adolescents. Pediatric subspecialists need to proactively address hormonal contraceptive needs and safety as pharmacy access expands.

Perceived facilitators of and barriers to mental health treatment engagement among decision-making competent adolescents in Greece

BACKGROUND

A subset of adolescents with mental disorders are likely to have decision-making capacity that facilitates their therapy engagement. However, there are high rates of drop-out in mental health settings.

AIM

This study aims to identify perceived barriers to or facilitators of mental health care engagement among adolescents with decision-making competence in Greece.

METHODS

A qualitative study was conducted using semi-structured interviews of adolescents with a wide range of mental health problems. In addition, two psychometric assessment measures were used to define who to include or exclude from the study sample.

RESULTS

Positive attitudes and experiences with therapy were reported as strong ("major") facilitators of therapy engagement for adolescents with mental disorders, whereas negative experiences with therapy were reported as strong barriers to it. Furthermore, and most importantly, a "good" adolescent-therapist relationship was reported as a strong facilitator, whereas negative experiences of participants with their therapist were reported as strong barriers. Moreover, goals such as getting rid of symptoms, improving personal well-being, and improving social skills and relationships (especially with peers) emerged as strong facilitators of therapy engagement. Importantly, the early remission of symptoms emerged from the study as a strong barrier to therapy engagement for participants. Among the weaker ("minor") perceived facilitators were goals such as confessing to a trustworthy person, becoming able to achieve personal expectations and life goals, enhancing independence and self-esteem, and developing a positive self-image. The (active or supportive) role of family emerged as a facilitator. The stigma related to mental health emerged as both a ("minor") facilitator of and barrier to therapy engagement for participants. Friends were reported as having a role ranging from neutral to mildly supportive.

CONCLUSION

A number of more or less strong barriers and facilitators were identified that, for the most part, were consistent with prior literature. However, the authors identified some nuances that are of clinical importance. For instance, adolescents are most likely to terminate the treatment prematurely if they experience early symptom remission. Highlighting the role of therapy in achieving their goals or improving their families' well-being might be used by therapists to reduce the attrition rate.

The CAMP study: feasibility and clinical correlates of standardized assessments of substance use in a youth psychiatric inpatient sample

BACKGROUND

To determine: (a) the feasibility and acceptability of administering a standardized electronic assessment of substance use and other mental health concerns to youth admitted to an inpatient psychiatric unit, and (b) the prevalence and clinical correlates of substance use in this sample.

METHODS

The sample included 100 youth between the ages of 13 to 17 years admitted to an inpatient psychiatric unit in Ontario, Canada between September and November 2019 (78% response rate). Youth data were comprised of electronic self-reported assessments (during hospitalization and 6-months following) and chart reviews (99% consented; historical and prospective). Frontline staff completed a self-report survey assessing their perceptions of the need for standardized substance use assessments, training, and interventions on the unit (n = 38 Registered Nurses and Child and Youth Workers; 86% response rate). Analyses included descriptive statistics, correlations, regression, and qualitative content analysis.

RESULTS

Feasibility of standardized youth self-reported mental health and substance use assessments was evident by high response rates, little missing data, and variability in responses. 79% of youth had used at least one substance in their lifetime; 69% reported use in the last 3 months. Substance use was positively correlated with severity of psychiatric symptoms (τb 0.17 to 0.45) and number of psychiatric diagnoses (τb 0.17 to 0.54) at index. Based on prospective and retrospective data, substance use was also positively related to mental health symptom severity at follow-up and repeat mental health related hospital visits. Frontline staff reported a need for standardized assessment, training, and interventions on the unit, indicative of acceptability.

CONCLUSIONS

This study demonstrated the feasibility, acceptability and clinical importance of administering a standardized mental health and substance use assessment among youth experiencing psychiatric hospitalization.

Digital Mega-Studies as a New Research Paradigm: Governing the Health Research of the Future

'Digital Mega-Studies' are entirely or extensively digitised, longitudinal, population-scale initiatives, collecting, storing, and making available individual-level research data of different types and from multiple sources, shaped by technological developments and unforeseeable risks over time. The Australian 'Gen V' project exemplifies this new research paradigm. In 2019, we undertook a multidisciplinary, multi-stakeholder process to map Digital Mega-Studies' key characteristics, legal and governance challenges and likely solutions. We conducted large and small group processes within a one-day symposium and directed online synthesis and group prioritisation over subsequent weeks. We present our methods (including elicitation, affinity mapping and prioritisation processes) and findings, proposing six priority governance principles across three areas-data, participation, trust-to support future high-quality, large-scale digital research in health.

Chronically ill children's participation and health outcomes in shared decision-making: a scoping review

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.

Using a cartoon questionnaire to improve consent process in children: a randomized controlled survey

OBJECTIVE

The aim of the study was to evaluate the effectiveness of an audio and animated cartoon questionnaire (AACQ) at improving consent process in child for biospecimen donation.

METHODS

A multi-center randomized and controlled survey was performed at two pediatric hospitals in China from 2019 to 2020. Children aged from 7 to 18 years in the pediatric surgery wards were invited to investigate the participants' willingness and attitudes for donating biospecimens. A total of 264 children, including 119 in the AACQ group and 145 in the TQ group, and 67 parents of children were analyzed. A separate knowledge test was acquired in the questionnaires.

RESULTS

Our findings showed that the response rate of the AACQ group (89.85%) was significantly higher than that of the TQ group (68.44%; p < 0.001). AACQ can improve the child's understanding, increase children's engagement in biospecimen donation, reduced the differences in selected characteristics affecting children understanding, and enhanced their risk awareness of donating biospecimens. We also found that increasing pain and privacy disclosure were the most popular concern among children for the refusal to donate biospecimens.

CONCLUSIONS

AACQ is an effective and standardized tool of content delivery to children from the surgical wards. Children who fully understood of biospecimen donation are suggested to participate in the consent signing.

IMPACT

Using audio and animated cartoon questionnaire is a more effective and standardized tool of content delivery to children. This study expanded the use of an animated cartoon to a children's survey. Audio and animated cartoon questionnaire (AACQ) can improve the child's understanding, increase children's engagement in biospecimen donation compared to text questionnaire (TQ) group, and enhanced their risk awareness of donating biospecimens. More AACQ should be used with children in the future to effectively deliver content to children and improve children's participation in the survey.

Identifying Issues in Fertility Preservation for Childhood and Adolescent Patients with Cancer at Pediatric Oncology Hospitals in Japan

Purpose: We conducted a questionnaire survey in 15 pediatric oncology hospitals in Japan to better understand the current status of fertility preservation in childhood and adolescents. Methods: The survey period was from September 2020 to December 2020. We mailed questionnaires to 64 departments involved in pediatric cancer treatments at the 15 hospitals. The primary outcomes were the timing of providing explanations on fertility preservation, presence of health care provider while providing explanations, cooperation between medical staff, and cooperation between hospitals. Results: The response rate was 100% (64/64). Regarding the time at which this information was provided, 79.6% of patients (43/54) received it before cancer treatment; 5.6% (3/54), after remission; and 14.8% (8/54), both time points. Nurses were mostly in attendance (70%) when oncologists provided information to patients. Nine (60%) hospitals did not have a reproductive department. Among these, 28.6% of the respondents referred patients to a reproductive facility that performed fertility preservation. Providing information about fertility preservation was challenging owing to the shortage of specific explanatory materials (35.1%) and the lack of cooperation between pediatric oncologists and reproductive endocrinologists (24.6%). Conclusion: Based on this survey, educational activities regarding fertility preservation centered on pediatric oncologists and nurses are needed. Furthermore, a system for providing explanatory materials for fertility preservation and encouraging cooperation at the physician and hospital levels is also needed (IRB No. H2020-111).

Consent to research participation: understanding and motivation among German pupils

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.

Children's Understanding of Informed Assents in Research Studies

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.

Adolescent Assent and Reconsent for Biobanking: Recent Developments and Emerging Ethical Issues

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.

[Intellectual disability and cancer in children: An analysis of the decision-making process]

AIM

The aim was to describe and to analyze the ethics of decision-making in situations involving children with intellectual disability and cancer, from the referent-doctor's point-of-view, in pediatric oncology units in France.

METHODS

Pediatricians working in pediatric oncology units were interviewed through an online questionnaire and a semi-directive interview was systematically proposed. We analyzed the ethical issues that arose during the process of decision-making and we made suggestions in order to address them.

RESULTS

Sixteen doctors reported twenty-one clinical cases. Of these cases, one third of the children had a change in their oncologic treatment, with a risk of pejorative outcome on the prognosis. Despite the fact that ethical issues appeared in 80 % of the cases, there were few consultations with ethical committees. Decision-making process showed no difference compared to children without intellectual disability, thus raising ethical issues in the medical team. Our study showed discrepancy between frequently reported ethical issues, high consensus rate regarding treatment decision and lack of consultation with ethical committees.

DISCUSSION

We propose three steps to guide the decision-making process in situations involving children with intellectual disability and cancer: 1/deeper understanding of the child through reinforced interactions with their caregivers, 2/better cross-boundary discussions, to improve the effectiveness of the multidisciplinary staff, and 3/more systematic ethical committees consultation.

Take the T out, put the T in: Gender-affirming hormones in youth

BACKGROUND

An increasing number of adolescents are seeking gender care at clinics and hospital programs, and requesting gender-affirming hormonal treatment. The interventions can either include suppression of testosterone and introduction of estrogen, or suppression of estrogen and introduction of testosterone.

AIMS

This review article focuses on the psychosocial experiences of youth who have completed their endogenous puberty and are now requesting one of these two forms of gender-affirming hormonal treatment. We investigate the comparative profiles of these two subgroups of transgender/gender-expansive youth.

MATERIALS AND METHODS

Review of research data, established standards of care and practice guidelines, and clinical observations.

RESULTS

Differences and similarities are noted and discussed in several realms: gender-related experiences prior to receiving hormonal treatment; the relationship between the physical changes and psychological experiences that accompany the introduction of testosterone or suppression of testosterone with replacement with estrogen; the intrapersonal and interpersonal implications of the treatment; considerations of fertility preservation for future family building; the role of the family in the decision-making process prior to starting a course of hormone therapy; and the capacity of youth to make informed decisions about these partially irreversible medical interventions.

DISCUSSION

Medical providers who offer gender-affirming hormonal care to youth should work with the family and allied professionals to assure that the youth's gender health is enhanced, barriers to care are removed, and mental health risks are reduced, whether the T is coming out or going in.

CONCLUSION

The cohort of youth who come to medical providers after completing puberty, and request gender-affirming hormones in the form of increases or reductions in T have a great deal in common, and also extensive variation among them.

Competence to Consent to Oral and Injectable PrEP Trials Among Adolescent Males Who Have Sex with Males

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.

Avoiding fights on social media: Strategies youth leverage to navigate conflict in a digital era

AIMS

Emerging qualitative work documents that social media conflict sometimes results in violence in impoverished urban neighborhoods. Not all experiences of social media conflict lead to violence, however, and youth ostensibly use a variety of techniques to avoid violent outcomes. Little research has explored the daily violence prevention strategies youth use on social media, an important gap given the omnipresence of social media in youth culture. This paper examines youth strategies and factors that avoid violence resulting from social media conflict.

METHOD

Four focus groups with 41 teenagers of color solicited strategies to prevent violence resulting from social media conflict. Three coders analyzed data in Dedoose, guided by systematic textual coding using a multi-step thematic analysis.

RESULTS

Four approaches emerged to avoiding violence from social media conflict: avoid, de-escalate, reach out for help, and bystander intervention.

CONCLUSION

Our findings position youth as key players in efforts to prevent violence from resulting from social media conflict.

Adolescent perceptions of pharmacogenetic testing

Background: Despite the expansion of pharmacogenetics (PGx), the views of pediatric patients remain unknown. This study explores adolescents' understanding and perceptions of PGx testing. Methods: Adolescents who had PGx testing were interviewed and their electronic health records were reviewed. Results: Adolescents accurately described reason for testing and most felt the results impacted their current and future care. None perceived risks to securing future employment or insurance. All felt PGx would benefit their peers. Conclusion: Adolescents understand the reasons for PGx and perceive testing to be useful, low risk and applicable to peers. Findings from this study advocate for the inclusion of adolescents in shared decision-making regarding testing and for active engagement in the discussion of results.

Recommendations on Youth Participation in Ultra-Endurance Running Events: A Consensus Statement

Participation in ultra-endurance running (UER) events continues to grow across ages, including youth athletes. The 50- and 100-km are the most popular distances among youth athletes. Most youth athletes are between 16-18 years; however, some runners younger than 12 years have successfully completed UER events. Parents, athletes, coaches, race directors, and medical professionals often seek advice regarding the safety of youth athletes participating in these events, especially with regard to potential short and long-term health consequences. UER may impact key organ systems during growth and development. We propose a decision-making process, based on current knowledge and the experience of the consensus group that addresses age regulations, medical and psychological well-being, training status and race-specific factors (such as distance, elevation change, remoteness, ambient temperatures, level of medical assistance, and type of provisions provided by the race organizers) to use until evidence of long-term consequences of UER in youth athletes is available. These recommendations are aimed at safe participation in UER events for youth athletes with a proper and individualized assessment.

Addressing the psychosocial needs of young people with thalassaemia undergoing bone marrow transplantation

Beta thalassaemia major is an inherited condition that causes severe anaemia. Patients with the condition require regular blood transfusions. One curative treatment option available is bone marrow transplantation, but a bone marrow transplant is a high-risk, painful procedure requiring prolonged hospitalisation. Undergoing such a disruptive treatment can be a source of great anxiety for young people and their families, who will need honest, sensitive and empathetic communication, person-centred care, support to socialise and access education, involvement in decision-making and signposting to financial support. This article discusses the role of children's nurses in addressing the psychosocial needs of young people with thalassaemia who undergo bone marrow transplantation and in supporting young people's families.

Assent for Orthognathic Surgery: Features, Challenges, and Benefits

The ideal age to undergo orthognathic surgery approximates the age of majority, and as a result a considerable portion of the patient population undergoing orthognathic surgery are legal minors. When a patient cannot legally provide consent, assent is often sought. Assent for surgical orthodontics is complicated by particular changes in cognitive variables during adolescence, the multiphased and multi-provider treatment course, and the intervention's elective nature. Ultimately, inclusion of a high-quality assent process can help identify patients most likely to benefit from orthognathic surgery and increase patient satisfaction.

When Does A Minor's Legal Competence To Make Health Care Decisions Matter?

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.

Improving assent in health research: a rapid systematic review

Background

Enrolment in a research study requires the participant’s informed consent. In the case of minors, informed consent of the respective legal guardian is obtained in conjunction with informed assent of the underage p

articipant. Since comprehension of the information provided may be limited, effective interventions to improve understanding should be identified. Thus, it is the objective of this study to review quantitative studies that tested interventions to improve the understanding of information provided during assent processes in health research. The studied population consisted of minors that participated or were willing to participate in research. The primary outcome was the level of comprehension after intervention.

Methods

A systematic search was conducted in eleven databases including regional databases: PubMed, Web of Science, ERIC, PsycINFO, CINAHL, POPLINE, AIM, LILACS, WPRIM, IMSEAR, and IMEMR and included references from inception of the database until July 2018 except PubMed which spanned the period from May 2013 to July 2018. Search terms focused on Informed Consent/Assent, Minors, and Comprehension. To complement the search, reference lists of retrieved publications were additionally searched. We included all quantitative studies that were conducted in minors, tested an intervention, covered assent processes in health research, and assessed comprehension. One reviewer screened titles, abstracts, and full-texts to determine eligibility and collected data on study design, population, intervention, methods, outcome, and for critical appraisal. Interventions comprised enhanced paper forms, interspersed questions, multimedia format, and others.

Results

Out of 7089 studies initially identified, 19 studies comprising 2805 participants and conducted in seven countries were included in the review. Fourteen studies (74 %) tested an intervention against control and ten (53 %) were randomized controlled trials. Heterogeneous methodology as well as incomplete outcome and statistical reporting impaired the reliability of the collected data. Positive effects were suggested for use of enhanced paper forms, interspersed questions, use of pie charts, and organizational factors.

Conclusions

Improving assent in health research is an under-researched area with little reliable evidence. While some interventions are proposed to improve understanding in assent processes, further investigation is necessary to be able to give evidence-based recommendations.

Trial registration

PROSPERO ID: 106808.

Ethical Challenges of Pediatric Cancer Care: Interviews With Nurses in Saudi Arabia

Despite rapid and successful development in pediatric cancer treatment, many ethical challenges remain. These challenges have been, and continue to be, the subject of much research, but few qualitative studies have explored the views of nurses, especially in the Middle East. This study, therefore, seeks to fill a knowledge gap in this area and to better understand the concerns of nurses-particularly those in Saudi Arabia and the Middle East. Face-to-face, in-depth interviews were conducted with 17 male and female nurses working in pediatric units at 2 hospitals in Saudi Arabia to explore their views on the ethical challenges in caring for children with cancer. All interviews were recorded and transcribed, then line-by-line encoded, merged, and categorized into themes. Our results show that pediatric cancer is perceived as being "different" from other diseases, and from cancer in adults. Nurses are an integral part of the medical care team and are aware of the importance of their role, as well as the special relationships that they develop with the children. Consent is mandatory and necessary and can be signed by any parent. Assent is important when children become able to give it. Pediatric cancer is seen as a different disease by nurses for various reasons. Their roles and relationships with children and families pose many challenges. Though parental consent and child assent are essential, nurses' collaboration is important for shared decision-making. Our study paves the way for broader studies to understand the concerns of nurses and other health-care providers about treating children with pediatric cancer.