Current approaches and future directions for addressing ethics in infant and early childhood mental health

In this paper, we consider whether the field of infant and early childhood mental health (IECMH) needs its own code of ethics. We begin by describing unique features of infant and early childhood mental health (IECMH) and the diverse strategies that the field has developed to address complex clinical dilemmas, among them workforce development, clinical supports, policy statements, and statements of ethical values. Because of the field's interdisciplinary nature, we also consider how various contributing professions and organizations address ethical issues. While these are important resources that can inform ethical decision-making, we identify some of the limitations of the current approaches. We argue that it is time for the field of IECMH to take an intentional, systematic approach to directly address the complex and unique ethical dilemmas faced by infant and early childhood mental health practitioners, and we grapple with some of the challenges developing such a code might entail. We suggest several avenues for better understanding the scope of ethical issues and ethical decision-making processes in IECMH that could be used to support developing an ethics code that is responsive to the unique and challenging world of infant and early childhood mental health.

The ethics of infant and early childhood mental health practice

Ethics is concerned with the basis for moral judgments of "right" and "wrong" and is central to the clinical endeavor. Many clinicians integrate ethical estimations into their work without much conscious awareness. However, explicit use of ethical principles and frameworks can help navigate clinical decision-making when there is a sense of moral conflict or ambiguity about the "right" course of action. This article aims to highlight the key concepts and principles in clinical ethics as they apply to IECMH practice and stimulate a bigger conversation in the profession around how to support each other to maintain high ethical standards in working with young children and their families. Specifically, the authors consider the relevance of Beauchamp and Childress' four principles framework (respect for autonomy, beneficence, non-maleficence, and justice), and address some of the special ethical challenges in the field, namely, the vulnerability of the infant, the need for a competent workforce, caring for caregivers, and the problem of multiple patients. Finally, the role of infant rights is briefly explored, noting the significant interest and debate that has been generated by the publication of the World Association of Infant Mental Health's Position Paper on the Rights of Infants.

Introduction to special section doing the "right" thing: Ethical issues in infant and early childhood mental health

Introducción a la Sección Especial: Hacer lo ‘correcto:’ Asuntos éticos en la salud mental infantil y en la temprana niñez

ética, salud mental infantil y en la temprana niñez, código de ética

Ethical dilemmas in infant mental health: Examples from child protection, home visiting, and medical contexts

Infant mental health is explicitly relational and strengths based as a field. Ethical dilemmas in infant mental health have received insufficient attention at the level of infant mental health professionals (IMHP) and other professionals caring for infants who must grapple with questions of when caregivers and infants have conflicting interests. We present composite cases drawn from North American and Australian contexts, using three systems in which such conflicts may commonly manifest: child protection, home visiting, and medical settings. The field of infant and early childhood mental health (IECMH) should begin to discuss such dilemmas and how best to balance the needs of caregivers and infants when they are not well aligned.

Maternal beliefs about children's attachments to soft objects

Maternal practices, attitudes, and beliefs about children's attachments to soft objects were investigated via questionnaires and interviews completed by mothers of 58 children with such attachments, present or previous, and of 24 children who had never been thus attached. Mothers in the former group were generally more accurate and positive about the attachments and the characteristics of children with them than were mothers in the latter group. The role of parents in the development of soft-object attachments is discussed.

[Pregnancy, births and infants after in-vitro-fertilization in Norway, 1988-1991]

We studied 1,165 pregnancies after in vitro fertilization in six public hospitals in Norway in the years 1988-91. The annual number of pregnancies increased from 158 in 1988 to 365 in 1991. The mean number of replaced embryos was reduced from 3.7 to 2.7. The rate of multiple births was not significantly altered in the same period, 24.3% were twin births and 5.7% triplet births. 19.3% of the pregnancies ended in abortion and 8.4% were ectopic. 782 births were registered in the Medical Birth Registry of Norway and compared with all other births during the period. Gestational hypertension, bleeding and preterm birth were observed more often in pregnancies after in vitro fertilization. The proportion of infants with very low birth weight (> 1,500 g) after in vitro fertilization was 9.7%, and nearly 50% of these were triplets. The relative risk of stillbirth and death during the first year of life, adjusted for maternal age and birth order, was 3.1 (95% CI 2.4-4.0) and 2.3 (95% CI 1.5-3.5) for singletons alone. The proportion of multiple births should be reduced.

[Failed induced abortion. Pregnancy continuing after induced abortion]

Operations classified as induced abortion fail, i.e. the pregnancy continues, in approximately 0.05% of the cases. Termination procedures before 7-8 weeks of gestation and wrong assessment of the size of the uterus imply significantly increased risk of failed abortion. The article describes current methods for early termination of pregnancy, as well as preoperative procedures and postoperative advice aimed at avoiding or detecting failed induced abortions.

Clinical experience with a triphasic oral contraceptive

A triphasic combined oral contraceptive containing fluctuating amounts of ethinylestradiol and levonorgestrel was tested clinically in a multicenter trial at six hospitals in Norway. 367 women were included in the study, 3 588 cycles were studied, and the follow up period was 12 months. The one year continuation rate was 67%. Five pregnancies occurred during the study period. All of them had to be considered as patient failures. The causes for stopping medication were side effects in about 50% and the rest for personal reasons. The cycle control taking into account duration of bleeding, amount of flow, and intermenstrual bleeding was good and comparable to the low-dose monophasic combined pills. The incidence of side effects was low. One woman had an increase in systolic blood pressure to more than 140 mmHg. Thrombophlebitis was not registered. In conclusion the triphasic oral contraceptive was effective and had a good cycle control and low incidence of side effects.