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Ethical and Moral Lens of Non-Invasive Brain Stimulation on Children
“If I Only Had a Brain,” the Scarecrow sang in the Wizard of Oz as he strolled down the yellow brick road. The scarecrow wasn’t the only individual who dreamt of modifying his cognitive abilities-- neural technology has taken the world by storm. The advance of neural technology has made rapid progress in treating congenital neural disorders, like dyslexia and autism spectrum disorder (11). Non-invasive brain stimulation (NIBS) is one of the many techniques currently used to treat congenital neural disorders in children. However, neural development is extremely complex: over 90% of cerebral development occurs before a child reaches the age of six, and during this time, children’s intelligence, judgment, and emotions are highly sensitive to environmental factors such as nicotine, alcohol, and caffeine (11). Due to neural development’s complexity, the use of NIBS in children has raised moral concerns within the medical community, both in the short and long term (7). Additionally, the lack of regulations and restrictions regarding NIBS usage on young patients has also raised several ethical concerns such as side effects, trade-offs, and dosage requirements, all of which must be addressed to safely use NIBS.
NIBS is a relatively new technique, developed in the second half of the twentieth century, used to monitor neural activity and analyze the physiology of the brain. NIBS includes two different techniques known as transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS). The difference being that tDCS passes direct currents through the skull while TMS utilizes electromagnetic fields to modify neural activity (7). Due to its utilization of signals, NIBS can treat a broad spectrum of neurological diseases such as epilepsy, depression, and ADHD. As a matter of fact, this technique has already been proven to reduce seizures by stimulating the areas seizures arise from (4). However, because NIBS targets specific regions of the brain, its interference can cause adverse effects, including fatigue, nausea, anxiety, tingling, abnormal muscle contractions, and in serious cases may even cause seizures (4). Notably, a recent study conducted with control groups reported 83% of adult participants having adverse events and 67% with minor adverse events occurring after being induced with TMS (4).
Ethical issues regarding NIBS are raised when this technology is applied to children, though NIBS is still used when brain targeting medications fail to target severe mental illnesses and neurological diseases. There has always been a common misconception that children are simply “miniature” adults; this misconception has led to doctors prescribing young patients NIBS with doses equivalent to that of an adult, which is problematic given the lack of scientific evidence (4). From one experiment conducted, scientists estimated that 0.14% of children could develop life-threatening seizures (4). In such situations, the potential side effects may be more harmful than advantageous. As a result, NIBS testing on children would be greatly beneficial, yet there are challenges; notably, certain neural conditions such as childhood-onset schizophrenia rarely arise in children. Thus, research centers lack funding and governments put fewer efforts into developing situations for rare conditions (2). In addition, the coherent risks of NIBS on children have brought several interesting issues, specifically regarding the potential trade-offs and permanent effects (7), which further delays testing.
In reality, ethical and moral concerns are only one of the reasons contributing to the insufficiency of raw data on NIBS: the lack of government funding and standardized dosage procedures also account for the scarcity of clinical research. Increased study of adolescent neural development and dosage guidelines for NIBS could arise with an upsurge of government funding. Researchers such as Dr. Davis NJ has already pointed out several dangers of NIBS, he suggests only treating patients over the age of six with neural enhancements and calls for the development of dosage guidelines corresponding to a patient’s age (3). With strict regulations in place, the use of NIBS could be monitored and potential harms reduced.
When examining potential avenues for more NIBS restrictions, it is helpful to consider the neural technology restrictions that hold patient safety as the highest priority; this is found in the United Kingdom as proposed by the British Medical Association and Medicines (BMA) and Healthcare Products Regulatory Agency (MHRA). Regulations in the US are more lenient as manifested in how products are marketed; for example, herbal enhancements (e.g. Rhodiola Rosea, Ginkgo biloba) are marked as dietary supplements, whereas in the UK it is marked as Traditional Herbal Medicinal Products (8). In addition, the BMA put the risks, purpose, and socioeconomic status of cognitive enhancement devices into considerations (9). The BMA has discussed policies specifically regulating pharmaceutical cognitive enhancers due to how it is misused to improve cognitive domains (9). Likewise, the MHRA has passed strict regulations on invasive products and similar implants (9). Henceforth, countries around the world should use the UK’s regulations as a reference for tightening restrictions; ultimately, this could be beneficial to the use of NIBS in all populations, especially children.
With neural technology developing rapidly around the world, the rules and regulations that bind to it must keep up with the progress. We have already seen the innumerable ethical and moral concerns such technology brings, and how countries are stepping up and developing regulations. Children are a vulnerable population when it comes to science; clinical trials are almost always adult-oriented because of the potential harmful treatments. Therefore, testing and understanding the risks NIBS brings to children is essential. With these obstacles tackled, this astounding technology could soon pave the path to be applied to treat central nervous system disorders and psychological disorders.
1. Brown, T. T., & Jernigan, T. L. (2012). Brain development during the preschool years. Neuropsychology review, 22(4), 313–333. doi.org/10.1007/s11065-012-9214-1
2. Caldwell, P. H., Murphy, S. B., Butow, P. N., & Craig, J. C. (2004). Clinical trials in children. Lancet (London, England), 364(9436), 803–811. doi.org/10.1016/S0140-6736(04)16942-0
3. Davis, N. J. (2014). Transcranial stimulation of the developing brain: A plea for extreme caution. Frontiers in Human Neuroscience, 8, Article 600. doi.org/10.3389/fnhum.2014.00600
4. Gillick, B. T., Gordon, A. M., Feyma, T., Krach, L. E., Carmel, J., Rich, T. L., Bleyenheuft, Y., & Friel, K. (2018). Non-Invasive Brain Stimulation in Children With Unilateral Cerebral Palsy: A Protocol and Risk Mitigation Guide. Frontiers in pediatrics, 6, 56. doi.org/10.3389/fped.2018.00056
5. Konrad, K., Firk, C., & Uhlhaas, P. J. (2013). Brain development during adolescence: neuroscientific insights into this developmental period. Deutsches Arzteblatt international, 110(25), 425–431. doi.org/10.3238/arztebl.2013.0425
6. Lord, C., Risi, S., DiLavore, P. S., Shulman, C., Thurm, A., & Pickles, A. (2006). Autism from 2 to 9 years of age. Archives of general psychiatry, 63(6), 694–701. doi.org/10.1001/archpsyc.63.6.694
7. Maslen, H., Earp, B. D., Cohen Kadosh, R., & Savulescu, J. (2014). Brain stimulation for treatment and enhancement in children: an ethical analysis. Frontiers in human neuroscience, 8, 953. doi.org/10.3389/fnhum.2014.00953
8. Maslen, H., Savulescu, J., Douglas, T., Levy, N., & Cohen Kadosh, R. (2013). ‘Regulation of devices for cognitive enhancement, The Lancet, 382(9896), 938-939. doi.org/10.1016/S0140-6736(13)61931-5
9. Maslen, H., Douglas, T., Cohen Kadosh, R., Levy, N., & Savulescu, J. (2015). The regulation of cognitive enhancement devices: refining Maslen et al.'s model. Journal of law and the biosciences, 2(3), 754–767. doi.org/10.1093/jlb/lsv029
10. Nickels, K. C., Grossardt, B. R., & Wirrell, E. C. (2012). Epilepsy-related mortality is low in children: a 30-year population-based study in Olmsted County, MN. Epilepsia, 53(12), 2164–2171. doi.org/10.1111/j.1528-1167.2012.03661.x
11. Ross, E. J., Graham, D. L., Money, K. M., & Stanwood, G. D. (2015). Developmental consequences of fetal exposure to drugs: what we know and what we still must learn. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 40(1), 61–87. doi.org/10.1038/npp.2014.147
12. Vicario, C. M., & Nitsche, M. A. (2013). Non-invasive brain stimulation for the treatment of brain diseases in childhood and adolescence: State of the art, current limits and future challenges. Frontiers in Systems Neuroscience, 7, Article 94. doi.org/10.3389/fnsys.2013.00094