Is Electroconvulsive Therapy Unsuitable For Children And Adolescents?

Adolescence, Fall, 1998 by Steve Baldwin, Yvonne Jones

ABSTRACT

Electroconvulsive therapy (ECT) as a treatment option for adults with affective disorders has a long history. ECT with children and adolescents, however, has not been widely used, and no empirical studies or controlled evaluations have been conducted. A review of the literature on ECT with minors reveals that it has an unknown mechanism of action, with a domain of applicability diminished yearly by legislation, litigation, and a wide range of intervention alternatives.

HISTORICAL REVIEW

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 (Abrains & 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.