Is electroconvulsive therapy unsuitable for children and adolescents?

Baldwin, Steve; Jones, Yvonne
Vol. 33, Adolescence, 09-22-1998, pp 645(1).

Few treatment approaches have caused as much controversy as electroconvulsive therapy (ECT). Since its first documented use in the 1940s (Cerletti, 1956; Slater, 1951), there has been ongoing discourse about its effectiveness. This debate has generated much heat but insufficient light to permit conclusive recommendations about the limits of its application.

In the 1950s, ECT was viewed by many physicians as harm-free and potentially useful for a wide range of disorders and client populations. It was considered helpful in the treatment of affective disorders, in particular chronic depression - "cases in which the clear-cut, dynamically understandable and approachable neurosis has been overlaid by a serious depressive affect" (Gallinek, 1952). In the treatment of neurotic disorders, ECT was viewed by some psychiatrists as of decisive benefit; it often marked a turning point from therapeutic failure to perceived therapeutic success. Other clinical problems, such as anorexia nervosa, were also considered potentially resolvable by ECT. Similarly, client populations with schizo-affective disorders, narcotic addiction, and obsessive-compulsive behavior were included in many early clinical trials. The literature on ECT with minors was sparse, although some children and young adults were included in treatment populations (e.g., Gallinek, 1952).

ECT research and practice during the 1960s was characterized by efforts to understand how it produced results, with further attempts to specify optimum client populations (Abrams & Fink, 1969; Mendels, 1967; Sargent & Slater, 1963). Although there was more interest in the establishment of experimental designs to evaluate the effectiveness of ECT, many of these were unsophisticated trials with poor methodologies, producing inconclusive results. Most studies were based on ad hoc variations of normal clinical practice.

In the 1970s, increasing concern in the mental health field about client rights prompted a series of surveys and studies about ECT and its applications. This closer examination of ECT was associated with a narrowing of clinical focus to specific disorders with more discrete populations.

The seminal task force report on ECT in Massachusetts influenced a generation of clinicians. It found that "most authoritative publications appear to be in agreement that symptoms associated with the depressed phase of manic-depressive illness or involutional melancholia are treated most effectively by ECT" (Frankel, 1973). Nonetheless, the report noted continuing disagreement in the field with regard to the use of ECT with adults who had schizophrenia, its combined use with psychotropic drugs, and questions about subsequent brain damage. The use of ECT in childhood and adolescent disorders similarly was viewed as an area of unresolved debate.

An analysis of responses to the task force questionnaire (from which the report was written) indicated that all respondents assigned some value to ECT in the treatment of severe depression, especially when risk for suicide was present.

Some practitioners stated that it would be appropriate to consider ECT when psychotherapy or use of medication had been unsuccessful, or when a poor response to other therapies had rendered the person nonfunctional. Most respondents indicated the need to complete extensive pretreatment examinations (typically including an ECG, a chest x-ray, an EEG, a spine x-ray, a brain scan, and additional neurological tests) to determine the suitability of ECT for individual clients. About a third of the respondents (17 of 56) emphasized the inadvisability of ECT with children or adolescents, or to persons with neurotic/addictive behavior problems. Other contraindications were noted, and: for patients who are angrily dismayed or frustrated by disappointing events in their lives but who are still able to function adequately in other spheres, in whom there is no evidence of recognizable psychosis or serious suicidal thought or action, skilled psychotherapy should be energetically and adequately administered, with or without the assistance of medication. ECT is not the treatment of choice in such conditions, as it can neither remove nor resolve life-situational problems (Frankel, 1973).

With regard to adverse effects of ECT, the task force report focused on memory loss. Although no respondents offered incontrovertible proof of deterioration, nearly 18% (10 of 56) indicated irrecoverable gaps in memory, intellectual deterioration, or blunting in individual clients after multiple administrations. In contrast, other practitioners claimed never to have seen adverse effects, despite extensive use of ECT.

Concerning legal and ethical considerations, there was widespread agreement about the need for informed consent prior to ECT. A "treatment request," describing the procedure and stating that all questions had been answered, should be read and signed. If the person was unable to grant consent, the consent of a relative or guardian should be obtained; commitment laws could also provide the legal machinery for an in lieu agreement.

The task force was unanimous regarding the treatment of young persons: "administration of ECT to children who have not yet reached puberty has no established usefulness and that therefore such treatment on a routine basis cannot be justified" (Frankel, 1973). However, if ECT was offered as a treatment procedure for prepubertal children, then (1) it must be explained to parents/guardians that effectiveness of ECT for psychiatric disorders in preadolescent children is not proven, and that such use is not generally accepted; (2) that following a rigorous investigation of the case, explicit indications for an experimental trial should be recorded, and that the quality of the study should ensure publishable results; and that (3) it would be prudent before proceeding to have concurrence by a colleague from another hospital, providing additional clinical justification for the experimental use of ECT with a particular child. The problems posed by diagnosis and treatment of persons aged 13 to 16 prompted unanimity that consultation with a colleague be encouraged when ECT is contemplated. Many respondents were in favor of recommending mandatory consultation with a colleague in another hospital before administration of ECT to young clients.

The report also recommended conducting unbiased follow-up studies to evaluate the effectiveness of ECT. In addition, all persons who administer it should familiarize themselves with other treatment methods, allowing long-term comparative studies. The report concluded: "we believe that the onus is now on those whose views differ markedly from the recommendations expressed here to report their findings" (Frankel, 1973).

In the United Kingdom, ECT with children and adolescents generally was viewed during the 1970s as an unusual but not exceptional treatment. It was available as a treatment option to "control an acute psychotic or depressive illness," and was considered "if all drug treatments have failed after proper and prolonged use to control the illness" (Frommer, 1972). In some psychiatric clinics, it was viewed as an option for adolescents who were persistently suicidal and was made available as an inpatient treatment, prior to outpatient administration. As in treatment with adult populations, ECT was continued as long as the client showed improvement. Some physicians recommended that ECT should not be withheld on the basis of age alone, but rather should be a pragmatic treatment decision following nonresponse to pharmacotherapy (Frommer, 1972).

This scenario was complicated, however, by controversy over the diagnosis (and treatment) of affective disorders (i.e., depressive or manic behavior) in children. Indeed, the very existence of some depressive disorders in this population was questioned (Warneke, 1974). Disagreement about nosology and diagnosis even extended to the definition of the term "children"; some clinicians had recommended that this category be reserved for young persons who had not developed secondary sexual characteristics (Anthony & Scott, 1960). Diagnostic criteria for manic-depressive disorders often were based on circular definitions (e.g., "evidence of abnormal psychiatric state" or "positive family history"), which sometimes veered toward tautology (e.g., "evidence of severe illness as indicated by a need for inpatient treatment, heavy sedation, and ECT") (Warneke, 1974). based on a physical pathological model, the presence of an endogenous condition was clinically determined by the nonappearance of other environmental indicators. The supposed existence of illness/disease states thus often hinged on the absence, not presence, of clinical data.

Even by the mid-1970s, the literature on ECT with minors was still minimal. Many standard texts on child psychiatry omitted any reference to the applications of ECT with children or adolescents. Other psychiatric texts included brief references to possible clinical indications for its administration, such as "when a severe and handicapping affective disorder fails to respond to an adequate dose of antidepressants together with appropriate psychotherapeutic measures and environmental modification" (Rutter & Hersov, 1976). Such recommendations included the proviso that ECT should be used only if the affective disorder showed the characteristics associated in adults with a good response; failure to respond to other treatments was not considered to be a sufficient indication on its own.

Toward the end of the 1970s, other reports confirmed the narrowing of focus to specific clinical populations and disorders. A survey of New York hospitals in 1975/76 indicated primary use by physicians for endogenous depression, and secondary use with clients who had previously failed to respond to psychotropic drugs (Asnis, Fink, & Saferstein, 1978). All reported occasional use with adolescents; one physician (from a sample of 30) reported use of ECT with children under the age of 13. For all 30, a medical history, a physical examination, a chest x-ray, an ECG, and blood and urine tests were required prior to treatment. Written consent was obtained for all voluntary clients; procedures were different for people who refused consent. Sixty percent (18 of 30) of the physicians had written guidelines for the administration of ECT.

The training and experience of psychiatric staff influenced the choice of treatment (Asnis, Fink, & Saferstein, 1978). Where nonmedical mental health workers held responsible clinical or administrative positions, a lack of sympathy or experience with medical aspects of psychiatric problems may have biased treatment choices toward social, rather than medical, approaches. Alternatively, ECT may have been reserved for people who had failed to respond to other therapies. The study noted variations in consent procedures, infrequent modification of ECT, minimal record-keeping, and paucity of training courses for ECT administration; it was concluded that improved monitoring of the ECT process was necessary.

In Britain, a contemporaneous review of ECT suggested there were "plenty of testimonies to the value of ECT in all manner of psychological and behavioural troubles, but a dearth of scientific inquiries into efficacy" ("ECT forty years on," 1979). The review noted that the biological mechanism of action was still unclear, and that more information had been obtained about how ECT did not work.

There was also a powerful civil rights lobby emerging that was concerned with the safety of ECT and its possible side effects. In particular, a popular view among mental health reformers was that ECT was experimental, hazardous, and irreversible; it should never be used with compulsorily detained persons without the consent of an independent, multidisciplinary review body (Gostin, 1975).

The topic of consent (and competency to give it) came to the forefront. In the most celebrated ruling, an Alabama state judge ruled that before ECT could be administered (even when consent had been obtained), confirmation from four psychiatrists and one neurologist, as well as monitoring by two attorneys, was required. By the end of the 1970s, the prevailing ethos in the United Kingdom was to seek a second, independent psychiatric opinion whenever ECT was considered for compulsorily detained persons, with a multidisciplinary review panel to reach a decision in these circumstances (Clare, 1978).

At the beginning of the 1980s, several reviews of the clinical use of ECT suggested a shift toward greater consensus about use (and nonuse) with specific disorders and client populations. It was advocated mainly as an effective treatment for adults with severe mood disorder, and also for people with sleep disturbance, loss of appetite/weight, retardation, morbid guilt, and some delusional states. No evidence was presented for the use of ECT with chronic schizophrenia, psychoneurotic or obsessive- compulsive conditions, delirium tremens, or narcotic withdrawal. Risks were identified (e.g., mortality/morbidity via cardiac arrest from vagal inhibition, coronary thrombosis, cerebral hemorrhage, and pulmonary thrombosis). No absolute contraindications for ECT were reported, however (McKenna & Pratt, 1983). The proven existence of amnesia/memory loss after ECT was considered by practitioners to be offset by its advantages.

It was noted that, as part of "valid consent," a full explanation of ECT should be given to the client, including information about risks, benefits, and side effects. The consent form should state that this information had been provided, and be signed by both the psychiatrist and the client. Moreover, although valid consent should precede ECT treatment, it could be withdrawn at any stage. Also, it was affirmed that next of kin or other close relatives were not allowed to give consent should the client refuse ECT; relatives had no legal right to give consent on behalf of another person.

The following were considered essential for practitioners in the United Kingdom if the client was unwilling to accept or did not understand ECT after it was recommended: (1) consider whether there are grounds for compulsory treatment; if not, ECT cannot be given; (2) obtain the opinion of two other consultants to advise about the necessity of compulsory ECT; (3) invoke Section 26 of the Mental Health Act (Section 24 in Scotland); (4) obtain written consent of nearest relative; (5) record that relative's objections if he or she disagrees with treatment (and reasons for deciding to proceed); and (6) consult with other staff involved in the client's treatment. Although children and adolescents were not specifically included in this category, young persons were considered unable to understand fully what was asked of them.

In another review from the United Kingdom (Pippard & Ellam, 1981), analysis of a survey of 2,755 [Image]psychiatrists suggested that 1% were opposed to the use of ECT; 87% regarded ECT as at least "occasionally useful" with adult clients with some problems. Such problems included depressive psychosis, melancholia, and endogenous depression.

In child psychiatry, the use of ECT was "even more restricted; it was rarely used and mostly, if not only, in post-pubertal children with adult- type psychotic illness. . . . A minority opposed its use in children under any circumstances" (Pippard & Ellam, 1981).

The survey indicated that the physician usually explained ECT to both the client and relatives. Nurses were often (and social workers rarely) involved with this process. No written explanation of ECT was given in 87% of the cases. For those people unable to give valid consent, the decision was viewed as the responsibility of the psychiatrist. While multidisciplinary staff were viewed as acceptable for consultation, final decision-making remained with the physician.

Wide variation in recording the process of ECT was noted; some clinics used special forms to record details, while others kept only case notes. The survey produced many recommendations to improve administration of ECT in clinics, through either procedural reforms or revision of codes of practice.

Another review of the status of ECT in psychiatric practice confirmed many of these findings, in particular that ECT could be an effective treatment for severe depression in adult populations (Kendall, 1981). Benefits of ECT for chronic schizophrenia and mania were less clear, with a range of evidence to support both use and nonuse with such psychiatric problems. Some evidence was presented for impairment of memory (or new learning) after ECT administration, although its extent or severity in adults remained unknown.

Kendall (1981) noted an overall reduction in the use of ECT among clinical populations after legislative restrictions and adverse publicity. The range of clients, problems, and settings at the beginning of the 1980s became more limited, often restricted to adults with severe endogenous depression. However, situations where it was necessary to alter or prevent problem behaviors as quickly as possible, such as refusal to eat or drink or suicide risk, were deemed appropriate for ECT. Despite occasional reports of its use in the treatment of anorexia nervosa, obsessional illness, organic confusional states, psychogenic pain, and other conditions (unless there was evidence for depression), "such use has neither theoretical justification nor empirical support and is therefore inappropriate" (Kendall, 1981).

Findings regarding consent indicated that some people who had been given ECT claimed never to have received an adequate explanation of what the treatment involved (e.g., Freeman & Kendell, 1980; Hughes et al., 1981). Kendall (1981) concluded that ECT would eventually be supplanted by some kind of pharmacotherapy.

A more recent review noted the comparative rarity of the use of ECT with children (Black, Wilcox, & Stuart, 1985). Although ECT has been used with adolescents (e.g., for affective disorders, schizophrenia, and eating disorders), it has seldom been used to treat disorders occurring before puberty.

STUDIES OF ECT WITH MINORS

Research on the use of ECT with children and adolescents consists mainly of single-case reports and uncontrolled studies (Baldwin & Oxlad, 1996). Although some older texts have identified ECT as an option in the treatment of childhood schizophrenia (e.g., Freedman et al., 1972; Redlich & Freedman, 1966), others have been less positive (Kanner, 1966). Some clinicians have been enthusiastic (Bender, 1947, 1973); other investigators have been less sanguine and have declared the use of ECT with children exhibiting psychotic behavior of scant value (Clardy, 1951; Hift et al., 1960).

Few clinicians have been directly involved in either the administration or evaluation of ECT with children and adolescents (El-Sharif, 1993). Although practitioners often employ psychological interventions with a physical component (e.g., behavior modification), many view ECT with minors as outside their professional province.

The literature on ECT with children and adolescents offers no controlled studies, no reliably applied criteria, and no valid assessment scales (Black, Wilcox, & Stuart, 1985). Also, use of ECT with children has been relatively unpopular. Because endogenous depression is rare in prepubertal children, practitioners should not need to consider the use of ECT. In short, the literature indicates that ECT has an unknown mechanism of action, with a domain of applicability diminished yearly by legislation, litigation, and a wide range of intervention alternatives.

CLINICAL DILEMMAS

It is not unusual for psychological interventions to receive both praise and criticism; "time out," for example, has avid supporters and fierce opponents. Drug treatments, such as lithium therapy, have been the subject of vitriolic attacks. Pharmacological treatment of hyperkinetic behavior among children and adolescents in the 1980s subsequently faced a strong backlash.

In the 1990s, increased malpractice litigation against physicians has influenced treatment approaches (Monrad Aas, 1991). In the United Kingdom, where ECT has been given to minors against their wishes, criminal assault charges have been filed in some cases (Baldwin & Jones, 1990, 1991; Jones & Baldwin, 1992). There has been more litigation in the United States, although increased activity by advocacy organizations and consumer groups has irreversibly altered the legal climate in the United Kingdom.

The contemporary interdisciplinary team approach to psychiatric care has promoted the use of a range of effective, tested intervention alternatives. However, interprofessional contact has increased the probability of disagreement about optimum treatment. One source or professional conflict that has emerged during the 1990s has not yet been satisfactorily resolved. Different professional codes require psychiatrists, psychologists, and nurses to react differently to the administration of ECT with children and adolescents (Oxlad & Baldwin, 1995). Problems generally have occurred when there was doubt about the capacity of the young person to give valid consent. In the United Kingdom, the professional obligations of clinical psychologists are clear, according to the British Psychological Society' s (1987) code of conduct. Clinical psychologists should: recognise and uphold the rights of those whose capacity to give valid consent to interventions may be diminished, including the young, the mentally handicapped or the elderly, those in care of an institution or detained under the provisions of the law, and: where interventions are offered to those in no position to give valid consent, after consulting with experienced professional colleagues, establish who has legal authority to give consent and seek consent from that person or those persons.

Similarly, in exceptional circumstances where there is sufficient evidence to raise serious concern about the safety or interests of recipients of services... take such steps as are judged necessary to inform appropriate third parties without prior consent.

Thus, in a context where some applications of ECT with minors have previously led to charges of negligence, professional misconduct, or criminal assault, practitioners should be aware of their professional obligations. If this results in conflict among professionals, third- party nonmedical intermediaries may need to become involved.

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Yvonne Jones, Dip. Occ. Ther., Edinburgh, United Kingdom.