In this context, another important issue that may arise would be when a mental health professional feels compelled to take up an important component of treatment that really comes in the purview of the medical professional’s care. In this kind of scenario, the suggestion would be to gently urge the medical professional to deal with the issue while, at the same time, be available to the child and family tofill in the gaps. Sometimes, working in tandem will be an even better option.
few minutes as the mother had to run an errand and the child’s clothes had caughtfire from a lamp lit in the prayer room. The mother was inconsolable as she felt very guilty at having left her alone at home. At the outset, the doctors had warned the family about the poor prognosis.
For Case4.2, the sessions were had in the counselling room in the Burns ward with the parents and at the bedside wearing mask and gown with the child.
Although I had only four sessions over four days before the child died, I could really communicate with her coherently only on thefirst day as she was in and out of consciousness on the other days. She did ask me whether she would live several times on the first day. She appeared frightened to be by herself in the ward and swathed in bandages.
Sessions with the mother served to allow her to vent her feelings and share her sorrow. She felt she could not share with her husband as he was being‘practical and unemotional’. She would repeatedly ask the medical team for hope. When the child finally died, she was just not ready to accept it.
The ethical issues in this case were—should I tell the child the truth? Although it was very difficult, after speaking to her parents, I did convey this to the child with her mother by her side. The child appeared to understand what was conveyed to her.
She was, however, in no physical state to plan closure. I was left with an uncomfortable feeling that I had not got all the messages from the child as she was attached to so many tubes and I could not adequately convey my emotions with the mask on my face.
Case 4.3
A referral from paediatrics was made for a 5-year-old girl who was admitted with organophosphorus poisoning. The child was in the intensive care unit for a day but had recovered and was now in the general ward. Her older sister who was nine years old was still in the ICU on ventilator while her younger sister who was three years old was evaluated in the ward and found to have very minimal traces. The father was the only earning member and there was no other family support. He reported that he had brought the poison to use for the plants and had left it in their garden. He claimed the children drank it without knowing what the bottle contained. At thefirst contact, this child had told the paediatric resident that her father had given them the poison to drink but after that, had vehemently denied it.
In Case4.3, as the child was not forthcoming when spoken to, I decided to see the child in the play room. Given the fact that the treating team was suspecting that the children had been poisoned, daily sessions were planned. Although she wanted her parents to be in the room in thefirst session, she settled down and, from the second session onwards, she would come by herself. Due to the older sister’s condition, the family stayed in the ward without asking for discharge. She would
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not talk much but played with the available toys, especially the animals and the sand pit. She only started verbalizing around the seventh session. She suddenly said
“My father gave that to us to drink”. When I started to probe, she did not elaborate further.
We then planned family sessions and included the grandparents after obtaining consent from the parents. They denied any marital of family issues in this family but agreed to take the children to the village and take care of them there for the rest of the academic year. We could not ascertain the manner in which the children had consumed poison.
The ethical issue here was—what do I do with the information given by the child? After obtaining consent from the child, I discussed this with my medical colleagues and we all decided that protection of the child was the primary goal. The parents would be curious to know what the child had told me and I had to keep this information confidential as the child did not want me to discuss this with her parents. The only way around this was to bring the grandparents into the picture and involve them in the care of the children. The child would want to sit on my lap often but I had to resist the urge to offer comfort and would ask child to sit in a chair close by and talk to me.
Case 4.4
A 12-year-old boy was referred from paediatric nephrology with complaints that he was not cooperative for the treatment regimen which included thrice a week dialysis. He would also not take the oral medication as advised. Due to this, his creatinine did not come down at all. Any plans for transplant had to be stalled due to his unstable physical condition. The child appeared listless and‘depressed’.
The first plan was to draw up a contract wherein he would come for regular dialysis and attend sessions with me. He honoured the contract and the next four to five weeks, I managed to have about 12 sessions with him. During the individual sessions with the child, he expressed distress at the diagnosis and the chronic nature of the treatment and, more importantly, the costs involved. He reported hearing discussions at home as his parents discussed the source of money for his regular dialysis. He, in one session, broke down and confided that the reason he did not comply with the treatment was because he had lost the will to live and his treatment was causing the family especially his brother and sister to forego basic needs.
The ethical issue I was faced with was‘what do I do with this information the child has confided in me?’When I asked him, he refused to let me discuss this with his parents. I had to respect this and continued to speak with the child about the cognitive errors he may be making in deciding that he was a burden to his family.
Over the next few sessions, we discussed other ways of looking at the situation and came up with the idea that we would have a family session wherein this would be brought up and the family’s views obtained. His mother broke down when she heard the child relate his anxieties and fears and told him he would never be a 4 Ethical Issues in Working with Children in the Consultation… 67
burden to them and they would do anything to keep him healthy and happy. His siblings were also involved in this meeting and that proved really therapeutic for the child. Arrangements for financial help for the treatment were made using the medico-social work department’s contacts. Following this, the child has been compliant with the treatment and has since also had a transplant.
Case 4.5
A 14-year-old boy was referred from the Department of Paediatric Surgery with complaints of repeated injuries needing sutures. This was the fourth time he had needed sutures and the doctor suspected abuse. On speaking to the child and mother together, both denied any problems at home and school.
However, on speaking to his mother alone, it transpired that his father had been hitting the child for not following instructions and doing poorly in studies. His father had reportedly come up the hard way and had done his PhD as a scholarship student. He wanted his son to learn to appreciate all that he had and focus on his studies. The child was not forthcoming in the initial session.
In Case4.5, during the next few sessions, both the mother and the child opened up and spoke about the difficulties at home. I then evaluated the child for his academic difficulties and found him to have significant mixed learning difficulties along with attention deficit hyperactivity disorder (ADHD). He was started on medication and plans for his academics were also made. His father was also counselled and both the mother and the child reported subsequently that his father no longer hit him. The child was also keen on knowing whether I would reply if he sent me messages over the phone or on Facebook.
The ethical issues faced here were—does this constitute a medico-legal case? In a strict sense, any suspicion of abuse needs to be reported. However, since the father had desisted from hitting the child after being counselled, I decided against this. The other issue was about recording confidential information in his hospital folder. I decided to keep the notes of my sessions with the child and mother separate from the general folder which could be accessed by all the departments. The child’s request for access to the therapist by phone or Facebook is definitely a challenge that I may face in the future.
Case 4.6
A 10-year-old boy whose parents were medical professionals and worked in a hospital nearby was brought to the hospital with pain in the legs and not being able to walk for the prior 15 days. He had been refusing to go to school as he found it difficult to go due to this pain. The doctors in Orthopaedics had investigated the child in detail and found no medical problems. On detailed evaluation, the child revealed that he was being bullied in school and was
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very anxious about going to school. He was against my discussing this with his parents or his school as the child who was bullying him had threatened him and also, this child’s mother was a teacher in the same school.
For Case4.6, the ethical issues were—how could this child be helped without disclosing the bullying to his parents and to the school? If the child did not give permission to discuss this, could I speak to the parents nevertheless? Was the child old enough to not give permission? Does confidentiality take a backseat when a child’s wellbeing is concerned?
The issues became further complicated to resolve as his parents also wanted to be seen after working hours, wanted to know if the therapist would visit their home or would see them in the therapist’s home as the child may feel most comfortable.
They also did not want to come to the hospital in case they were recognized by other colleagues at the hospital.
Finally, I decided to talk to the child and emphasize the need to protect him from the bully and how, in the long run, it is necessary to learn the skills to deal with such children. After several weekly sessions spread over 8 weeks, during which time the child did not attend school, the child agreed to allow me to talk to his parents in his presence. After this discussion, I also made some boundaries clear to the parents—like the venue and time of meetings—though I did agree to have my sessions with them on a day other than the usual clinic days. These seemed to help and the parents were more cooperative with the plan for the discussion with the school which really helped to clear all the problems the child reported. The child was involved in all the discussions and this helped him realize the importance of confiding.
This ethical issue is an important one—we constantly have to deal with col- leagues, family members as well as other professionals who may have a personal connection with the therapist.