Nutritional and Herbal Therapies for Children and Adolescents

A Handbook for Mental Health Clinicians

George M. Kapalka

• Editorial: Academic Press
• Año: 2009
• ISBN:
  9780080958019
• Categoría: Psychology
• Categoría: Developmental Psychology

This volume assists practicing mental health professionals in expanding their knowledge about nutritional and herbal interventions that can be attempted as alternatives to prescription medications. Designed to provide guidance for non-medical caregivers treating children and adolescents who present with emotional and/or behavioral difficulties such as such as depression, anxiety, ADHD, sleep difficulties, impulsivity, distractibility, and other psychological and psychiatric disorders, the volume provides a comprehensive discussion of naturopathic solutions based on existing research. In areas where research is not extensive, conclusions are provided about potentially beneficial effects based on the specific pharmacologic action of the compounds. Dosage for specific age groups, schedules of administration, dietary considerations (i.e., whether or not to take the supplement with food), monitoring for response and adverse effects, signs of dangerous reactions, and the need to control interactions with other compounds (i.e., prescription medications) are thoroughly reviewed with regard to each supplement discussed in the book.

• Reviews specific psychological disorders (i.e. ADHD, depression, mania, anxiety, sleep difficulties, tic behaviors and autism) and the available data about their treatment with the use of nutritional and herbal supplements
• Provides rationale for the use of every specific compound with detailed recommendations tailored for each age group with regard to the dosage, frequency of administration, possible dangers and monitoring for side effects
• Discusses claims of efficacy used to market various products and ground those claims within fully vetted scientific research
• Discusses neurobiology, pharmacodynamics and pharmokinetics in detailed but accessible language *Non-medical clinicians with limited knowledge of medicine and pharmacology come away with understanding of key issues involved in
• Fully covers assessment, diagnosis & treatment of children and adolescents, focusing on evidence-based practices *Consolidates broadly distributed literature into single source and specifically relates evidence-based tools to practical treatment, saving clinicians time in obtaining and translating information and improving the level of care they can provide
• Detailed how-to explanation of practical evidence-based treatment techniques *Gives reader firm grasp of how to more effectively treat patients
• Material related to diversity (including race, ethnicity, gender and social class) integrated into each chapter *Prepares readers for treating the wide range of youth they will encounter in practice

Chapter 1

Deciding Between Medications and Supplements

To medicate or not to medicate: that is the question that millions of parents ask themselves when faced with significant psychological or behavioral symptoms their child or teen exhibits. Parents who decide that a trial of prescription medications is a reasonable course of action usually see a medical professional (for example, a pediatrician or a pediatric psychiatrist). Those who want to avoid prescription medications seek non-medical mental health treatment. Many of these parents contact psychologists, professional counselors, marriage and family therapists, or social workers to try to address the symptoms through psychotherapy and behavioral interventions. At the onset of treatment, both medical and non-medical mental health professionals need to decide whether psychotherapy and behavioral interventions are likely to be sufficient to address the symptoms, or pharmacological interventions may also be needed.

When a patient comes in for mental health treatment, the clinician initially needs to assess the symptoms and their progression. Various factors must be considered, including symptom severity, onset, precipitating factors, associated features, and patient’s functioning in various settings – at home, in school or at work, and with peers. Proper history must also be gathered in order to understand the course of the symptoms.

Before a treatment plan is developed, an appropriate diagnosis should be made. The importance of a diagnosis lies in its ability to provide direction for treatment. Because various syndromes sometimes present with similar symptoms, differentiating them is needed, since each syndrome, despite apparent similarities, may need to be treated differently. Clinicians whose work is grounded in a knowledge base obtained from results of scientific studies understand that, for example, treatment of panic disorder must be different than treatment of generalized anxiety disorder, and treatment of major depression is not the same as treatment of dysthymia.

After a diagnosis is assigned, clinicians draw upon their expertise and experience in order to review various treatment options available to address the symptoms. Those who follow the biopsychosocial approach consider the contributions that each of its three constituents can make to the overall improvement, and discuss with the patient (and/or the family) how to implement interventions that address changes within each component.

Many of the disorders diagnosed in children and adolescents are candidates for biopsychosocial treatment. Following the diathesis-stress model (Zubin & Spring, 1977), most clinicians accept that when symptoms of a disorder become evident, those symptoms are the result of two factors – underlying biological vulnerability, and environmental factors that may have enacted upon it. Moreover, both occur on a continuum – in some cases, the underlying biological vulnerability is so significant that very little (or no) environmental stress is needed to produce symptoms, while in other cases the biological vulnerability is minimal and will only become enacted upon when stress or trauma are very significant.

Many disorders have been shown to be associated with biological changes in the brain. These include attention deficit hyperactivity disorder (ADHD), Tourette’s disorder, obsessive compulsive disorder (OCD), major depression, bipolar disorder, and schizophrenia. When a patient is diagnosed with one of those disorders, the first decision that faces the clinician is whether to suggest a psychosocial treatment, a psychopharmacological treatment, or a combination of both.

In some cases, when symptoms do not appear to be notably severe, a psychosocial approach may be more appropriate. As discussed in the Preface to this handbook, various factors need to be assessed when a decision is made whether or not to treat symptoms through psychotherapy. These include not only the severity of symptoms, but additional considerations such as the accessibility of psychological care, the family’s resources, and the availability of mental health insurance coverage. Clinicians need to remember that even if psychological treatment may be expected to reasonably alleviate the symptoms, factors pertaining to affordability and availability of care may still indicate that pharmacological treatment may be more practical.

When symptoms are more severe, psychological treatments may be insufficient. Psychosis, mania, and other forms of serious psychopathology often do not respond well to psychological care. In those cases, psychopharmacological approaches are likely to be needed.

When the decision has been made that pharmacological approaches will be utilized, whether as monotherapy or in addition to psychosocial treatments, the next question that needs to be considered is whether to use prescription medications or naturopathic supplements. As discussed in the Preface, misperceptions may drive this decision-making process, and clinicians need to be vigilant about dispelling misconceptions about medications and nutritional/herbal supplements. On the other hand, there are legitimate and well-founded reasons to consider, and these are discussed in this chapter.

WHEN TO USE MEDICATIONS

The decision to use medications or naturopathic supplements should be made after reviewing several crucial aspects of the effectiveness and accessibility of various compounds. The ideal situation exists when a method that is most likely to be effective in treating the symptoms is available and accessible, and the patient and/or family are receptive to the recommendations and supportive of such an approach. Clinicians should strive to maximize the likelihood that such a combination of factors exists in all cases.

Type of Symptoms

Some symptom groups are not likely to respond to non-medical treatments. Hallucinations, delusions, flight of ideas, pressured speech, and similar symptoms of more severe disorders (like schizophrenia or bipolar disorder) are less likely to diminish with naturopathic supplements. Although this book includes chapters about naturopathic treatment of these groups of symptoms, it is assumed that supplements in those cases may be utilized as an adjunct to other treatments, or when those symptoms are present in a mild variant, as an associated feature of another disorder. For example, it is not likely that naturopathic supplements will be sufficient to successfully treat symptoms of schizophrenia. However, milder psychosis that occasionally occurs with another disorder (for example, major depression) may be attempted to be controlled through the use of an appropriate naturopathic supplements.

Severity of Symptoms

The severity of symptoms should also be a top priority when a decision about whether to use medications or supplements is made. For most supplements, no head-to-head comparisons between the use of supplements and corresponding medications have been done. A few supplements have been researched in this manner, and those studies generally revealed that the supplement was better than placebo, but not as good as treatment with prescription medications (Lake & Spiegel, 2007). Consequently, when symptoms are severe, any improvement that is likely to be evident when supplements are administered will probably be minimal.

Patients need to consider this factor especially in light of data that suggests that even prescription medications are less effective when symptoms are severe. For example, mild or moderate symptoms of depression or ADHD tend to respond well to medications and mono-therapy with a single compound may be sufficient. However, when symptoms are severe, a single drug is less likely to be effective and several medications may be needed to control the symptoms (Barkley, 2006). Thus, symptoms of some disorders, in milder variants, may respond well to psychosocial and naturopathic interventions, but the same disorders in more severe versions, when symptoms are more debilitating, are not likely to respond to nutritional and herbal supplements.

Expectation of Efficacy

As discussed above, few head-to-head comparisons of medications and supplements have been performed, and those that have been done often reported that supplements are not as effective as medications. Clinicians, patients, and family members need to take this into consideration when attempting treatment with naturopathic supplements. When it is desirable to manage the symptoms as effectively as possible, and as quickly as possible, use of medications, rather than supplements, should be preferred.

Conversely, for symptoms that are mild-to-moderate and may have already responded to psychosocial interventions, at least in part, supplementation with nutrients or herbal extracts may be reasonable. Although expectation of improvement will be less dramatic, it may be sufficient, especially given the fact that another treatment is being utilized that will help maximize the overall improvement.

Cost

Almost all naturopathic and herbal supplements are available over the counter, rather than by prescription, and the vast majority of insurance plans do not cover treatment with such compounds. Consequently, patients who desire treatment with these supplements must pay the costs out of pocket. In some cases, the cost may be significant. For example, some preparations of herbal extracts and nutritional supplements cost several dollars per tablet, and at least one tablet per day must be administered. This means that a monthly supply may cost 30 dollars or more, especially if several pills per day must be taken. Many families may find this cost to be prohibitive.

Conversely, those families with good medical insurance are likely to be able to obtain prescription drugs at a cheaper price. This is especially true when generic preparations of the prescription compound are available. In those cases, a monthly supply of the medication may only cost a few dollars. Interestingly, although mental health care coverage is scant in many insurance policies (especially those where managed health care approaches are utilized), most plans do not have significant restrictions on prescription medications, especially those available in generic forms. Since all categories of psychotropic medications now have many generic compounds within them, treating a disorder with these medications, rather than naturopathic supplements, may often be less expensive.

Access to Medical Professionals

When a child or an adolescent is diagnosed with a psychological disorder, and a decision is made to utilize a psychopharmacological approach, it is necessary to locate medical professionals who will be able to prescribe the medications and monitor the response. Traditionally, this has been done by pediatric psychiatrists. However, in the United States, there is a nationwide shortage of psychiatrists (Goldman, 2001) that is especially evident among pediatric psychiatrists (Thomas & Holzer, 2006), and therefore psychiatrists often refuse new patients and require several months’ wait time for the initial appointment. Other medical professionals try to fill this gap. Throughout the country, nurse practitioners prescribe medications and some accept children and adolescents on their case loads. In some states, other medical professionals also prescribe, such as medical psychologists and doctoral-level pharmacists, and access has improved. However, in most other states, the availability of prescribers is insufficient, especially in rural settings.

This problem is compounded by managed health care practices that severely restrict the availability of medical specialists. In managed plans, pediatricians are established as primary medical practitioners for children and adolescents, and must approve all specialist care. In their day-to-day practice, pediatricians encounter a vast array of medical problems that may require specialized care. However, managed health care plans keep track of specialist referrals and often penalize those pediatricians who, in the opinion of gatekeepers employed by the insurer, overutilize specialist care. Thus, pediatricians must carefully weigh each referral and consider that, for example, each child referred to a specialist for a psychotropic medication may deprive another patient from the ability to receive needed cardiac care. Not surprisingly, research findings reveal that nowadays most psychotropic medications are prescribed to children by their pediatricians (for example, Olfson et al., 2002).

In sum, access to care may be a determinant of whether prescription medications or naturopathic supplements may be utilized. Those patients who need a psychopharmacological intervention and have access to a pediatric psychiatrist, and/or are treated by a pediatrician who is willing to prescribe medications to treat psychological disorders may be better off utilizing this option. However, those patients who have limited access to medical treatment and/or exhibit symptoms that lend themselves well to management with naturopathic stimulants may be good candidates for such treatment.

WHEN TO USE NATUROPATHIC SUPPLEMENTS

While in some cases it may be preferred to attempt a trial of medications, in other situations it is reasonable to try a naturopathic supplement and carefully monitor patient’s progress. The likelihood of a positive response is determined by many factors, some of which are discussed below. When a decision is made by considering these aspects, clients are selected that are more likely to exhibit a positive response, and a subsequent trial with a supplement is more apt to produce positive results.

Type of Symptoms

Generally speaking, symptoms that are likely to respond to psychosocial interventions, at least to some degree, are good candidates for naturopathic treatment. This means that symptoms of depression, anxiety, distractibility, impulsivity, or agitation may be good candidates for treatment with herbal and nutritional supplements. As discussed below, this may especially be the case with milder variants of these symptoms.

Conversely, when the above symptoms are accompanied by manic of psychotic features, naturopathic supplements are less likely to be effective. While some supplements have been shown to occasionally be effective in lessening such symptoms, response rates are inconsistent. When these symptoms are present, naturopathic supplements should only be utilized as a last resort (when other treatment approaches are not available), and a positive response to naturopathic supplements is more likely when level of severity is low and those symptoms constitute associated, rather than core, features of the disorder. For example, supplements are less likely to control psychosis that is a core symptom of schizophrenia than psychotic symptoms that are associated features of major depression.

Severity of Symptoms

The severity of symptoms should also be a top priority when a decision about whether to use medications or supplements is made. Mild or moderate symptoms are generally good targets for naturopathic supplements. In accordance with the diathesis-stress model, milder symptoms generally indicate a lesser degree of underlying biological vulnerability, and therefore biological disturbances in the function of various brain parts are likely to be less pronounced. In those cases, where dramatic changes in brain functions are not sought, an approach that utilizes nutritional and herbal supplements instead of medications seems appropriate. Of course, if the supplements do not prove effective and further interventions are needed to manage the symptoms, use of medications may still need to be considered.

Cost

Although families with medical insurance may be able to obtain prescription drugs at an affordable price (especially when generic formulations are prescribed), millions of Americans have no health insurance. For them, the out-of-pocket costs of prescription drugs may be higher than they can afford. Although generic preparations are cheaper, a 1 month supply of the medication may still cost about the same as a 1 month supply of a naturopathic supplement, and in some cases, vitamins or other nutrients may be cheaper.

Another factor must also be considered in the cost. Since naturopathic and herbal supplements are available over the counter, no prescription is needed. Thus, when supplements are utilized, the only associated cost is the price of the pills, whereas the price of prescription drugs (even if generics are used) must also include the cost of a doctor’s visit. For individuals with no health care coverage, this may be a tipping point that will turn them toward a naturopathic substance.

Access to Medical Professionals

As discussed above, most areas in the US experience a significant shortage of child psychiatrists. Although some other prescribers may be available, major portions of the country have limited access to pediatric prescribers. Consequently, pediatricians have now become the primary medical practitioners that prescribe psychotropic medications.

However, although highly knowledgeable about medicine and medications in general, most physicians complete only 6 weeks of exposure to psychiatry during medical training (Serby et al., 2002) and receive no further required training in psychiatry during pediatric residency (Kersten et al., 2003). Thus, pediatricians often limit the type of medications they are willing to prescribe. While most pediatricians are familiar with psychostimulants and some antidepressa...