Josephine Johnston

Controversies concerning the diagnosis and treatment of bipolar disorder in children

This commentary grows out of an interdisciplinary workshop focused on controversies surrounding the diagnosis and treatment of bipolar disorder (BP) in children. Although debate about the occurrence and frequency of BP in children is more than 50 years old, it increased in the mid 1990s when researchers adapted the DSM account of bipolar symptoms to diagnose children. We offer a brief history of the debate from the mid 90s through the present, ending with current efforts to distinguish between a small number of children whose behaviors closely fit DSM criteria for BP, and a significantly larger number of children who have been receiving a BP diagnosis but whose behaviors do not closely fit those criteria. We agree with one emerging approach, which gives part or all of that larger number of children a new diagnosis called Severe Mood Dysregulation or Temper Dysregulation Disorder with Dysphoria.Three major concerns arose about interpreting the DSM criteria more loosely in children than in adults. If clinicians offer a treatment for disorder A, but the patient has disorder B, treatment may be compromised. Because DSMs diagnostic labels are meant to facilitate research, when they are applied inconsistently, such research is compromised. And because BP has a strong genetic component, the label can distract attention from the family or social context.Once a BP diagnosis is made, concerns remain regarding the primary, pharmacological mode of treatment: data supporting the efficacy of the often complex regimens are weak and side effects can be significant. However, more than is widely appreciated, data do support the efficacy of the psychosocial treatments that should accompany pharmacotherapy. Physicians, educators, and families should adopt a multimodal approach, which focuses as much on the childs context as on her body. If physicians are to fulfill their ethical obligation to facilitate truly informed consent, they must be forthcoming with families about the relevant uncertainties and complexities.

Cryopreserved Human Embryos in Canada and Their Availability for Research

OBJECTIVE To determine the number of cryopreserved human embryos at all Canadian in vitro fertilization (IVF) clinics, the number of these embryos that have been donated to research, and the consent processes regarding the disposition of embryos no longer required for reproductive purposes. METHODS A questionnaire was mailed to 24 fertility clinics identified as conducting IVF and cryopreservation, inviting completion of the questionnaire by telephone. Thirteen clinics (response rate 54%) completed the survey. RESULTS As of August 2003, all 13 clinics cryopreserve embryos not required for intrauterine transfer; in total, 15,615 embryos are currently in storage in these clinics. Nine clinics specifically offer patients the option of donating embryos to research; in total, 299 embryos have been allocated for research, about 2% of all embryos stored by these 13 clinics. All 9 clinics routinely seek consent for research use of embryos, with 7 clinics currently using such embryos for research to improve clinic practices. CONCLUSION The results highlight the difficulties of gathering accurate data on assisted human reproduction and related research in a context where there is no legislation governing these practices. Nonetheless, the data suggest there are very few cryopreserved embryos in Canada available for research and that even fewer of these may be potentially eligible for research due to incomplete or inadequate consent processes.

Embryology policy: Revisit the 14-day rule.

On 4 May, two groups reported that they had sustained human embryos in vitro for 12–13 days. Embryos normally implant in the wall of the uterus at around day seven. Until now, no one had reported culturing human embryos in vitro beyond nine days, and rarely have they been sustained for more than seven. This latest advance comes only 21 months after the researchers at the Rockefeller University in New York City (some of whom are involved in the latest embryo-culturing work) announced that, under certain conditions, individual human embryonic stem cells can self-organize into structures akin to the developmental stages of embryos soon after implantation (see ‘Two advances in human developmental biology’). The cells were obtained from pre-existing stem-cell lines (derived from 4–5-day-old embryos donated through fertility clinics). In principle, these two lines of research could lead to scientists being able to study all aspects of early human development with unprecedented precision. Yet these advances also put human developmental Revisit the 14-day rule

Pediatric mental health care dysfunction disorder

One of the most talked-about features of the draft revisions for the DSM-V is a new diagnostic category for children: temper dysregulation disorder with dysphoria (TDD). Erik Parens and colleagues argue that this new diagnosis may not help troubled children unless we get serious about reforming pediatric mental health care.

Does it make sense to speak of neuroethics?: Three problems with keying ethics to hot new science and technology

The field of bioethics has been split into subspecialties over the past few decades. In some cases, it was divided in terms of social domains, such as clinical ethics, research ethics and public‐health ethics. In other cases, it was separated in terms of methodological approaches, including principle‐based bioethics, virtue ethics and narrative ethics. Yet more divisions were made in terms of medical specialties, such as paediatric ethics, surgical ethics and psychiatric ethics. A more recent trend is to identify subfields in terms of new lines of scientific or technological investigation, such as genethics, nanoethics and neuroethics. > …the basic ethical concerns about threats to identity are not different in the context of neuroscience or genetics… Given the rich history of bioethics, we would not suggest that there is only one correct way forward or that speaking of new subfields is completely wrong. Indeed, Adina Roskies recently made a strong case specifically for neuroethics: “although neuroethics may appear to consist of a collection of diverse and unrelated concerns, the various issues emerging from the confluence of neuroscience and ethics are so densely interconnected that it is defensible, and may even be profitable, to consider them as a unified whole” (Roskies, 2006). Because no one has the infinite energy necessary to consider all aspects of bioethics, limiting oneself to a quasi‐discrete scientific arena can help to focus attention. Moreover, because studying ethics requires a firm grip on the science—and it will take ethicists time to catch up with the latest research in fields as complex as genetics, nanoscience and neuroscience—we can appreciate the case for speaking of bioethical subfields. Nevertheless, although we grant that speaking in such terms can be reasonable, we also want to call attention to some of the dangers associated with carving up bioethics into ever more specialized subfields that …

Do We Need "Synthetic Bioethics"?

As we address ethical issues in emerging fields, ethicists, funders, and policy-makers should resist balkanization.

Why We Should All Pay for Fertility Treatment: An Argument from Ethics and Policy

Since 1980, the number of twin births in the United States has increased 76 percent, and the number of triplets or higher-order multiples has increased over 400 percent. These increases are due in part to increased maternal age, which is associated with spontaneous twinning. But the primary reason for these increases is that more and more people are undergoing fertility treatment. Despite an emerging (but not absolute) consensus in the medical literature that multiples, including twins, should be a far less frequent outcome of fertility treatment, American clinicians currently practice fertility medicine in ways likely to result in twins and, occasionally, triplets—often, they tell us, at the request of their patients. At first blush, one might conclude that these practice patterns show that patients and their doctors have weighed the risks associated with twins against the benefits of swiftly completing their families and decided that the risks are worth taking. That is, their requests for twins must represent their free and informed choices. But there are reasons to be skeptical of this interpretation, including that the preferences of many patients seem to be very strongly shaped, if not sometimes completely constrained, by concerns about costs—costs that mainly result from the routine exclusion of in vitro fertilization from health insurance coverage. It is quite possible, we believe, that these cost concerns actually undermine the autonomy of fertility patients, pushing many of them to take risks with their health and the health of their hoped-for future children.

The NIH Stem Cell Registry: An Absence of Gamete Donor Consent

The URL for data presented herein is as follows:NIH Guidelines for Human Stem Cell Research, http://stemcells.nih.gov/policy/2009guidelines.

Seeing Responsibility: Can Neuroimaging Teach Us Anything about Moral and Legal Responsibility?

As imaging technologies help us understand the structure and function of the brain, providing insight into human capabilities as basic as vision and as complex as memory, and human conditions as impairing as depression and as fraught as psychopathy, some have asked whether they can also help us understand human agency. Specifically, could neuroimaging lead us to reassess the socially significant practice of assigning and taking responsibility? While responsibility itself is not a psychological process open to investigation through neuroimaging, decision-making is. Over the past decade, different researchers and scholars have sought to use neuroimaging (or the results of neuroimaging studies) to investigate what is going on in the brain when we make decisions. The results of this research raise the question whether neuroscience-especially now that it includes neuroimaging-can and should alter our understandings of responsibility and our related practice of holding people responsible. It is this question that we investigate here.

Neuroimaging: Beginning to Appreciate Its Complexities

For over a century, scientists have sought to see through the protective shield of the human skull and into the living brain. Today, an array of technologies allows researchers and clinicians to create astonishingly detailed images of our brains structure as well as colorful depictions of the electrical and physiological changes that occur within it when we see, hear, think and feel. These technologies-and the images they generate-are an increasingly important tool in medicine and science. Given the role that neuroimaging technologies now play in biomedical research, both neuroscientists and nonexperts should aim to be as clear as possible about how neuroimages are made and what they can-and cannot-tell us. Add to this that neuroimages have begun to be used in courtrooms at both the determination of guilt and sentencing stages, that they are being employed by marketers to refine advertisements and develop new products, that they are being sold to consumers for the diagnosis of mental disorders and for the detection of lies, and that they are being employed in arguments about the nature (or absence) of powerful concepts like free will and personhood, and the need for citizens to have a basic understanding of how this technology works and what it can and cannot tell us becomes even more pressing.