Nutritional and Herbal Therapies for Children and Adolescents: A Handbook for Mental Health Clinicians

428 Pages·2009·6.62 MB·English

by  George M. Kapalka

Nutritional and Herbal Therapies
for Children and Adolescents
A Handbook for Mental Health Clinicians
http://avaxho.me/blogs/ChrisRedfield
Nutritional and Herbal
Therapies for Children
and Adolescents

A Handbook for Mental Health Clinicians
George M. Kapalka
Associate Professor, Monmouth University
West Long Branch, NJ
and
Director, Center for Behavior Modifi cation
Brick, NJ

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Preface
Many years ago, when symptoms of most psychological disorders were
just beginning to be identified, the prevailing belief was that these symp-
toms were the result of deeply embedded psychogenic conflicts that
required psychoanalysis to work through. Over the past five decades,
however, a plethora of research revealed that many individuals with these
disorders exhibit structural and functional differences in their brains.
According to our current knowledge of the neuropsychiatric aspects of
psychological disorders, attention deficit hyperactivity disorder (ADHD),
Tourette’s disorder, obsessive compulsive disorder (OCD), panic disor-
der, depression, bipolar disorder, and schizophrenia are characterized by
significant changes in the brain. Moreover, the earlier the onset of the
symptoms, the more significant those brain differences appear to be.
Since brain changes are likely to be reflected in feelings and behav-
iors, psychopharmacological approaches were developed to try to
address some of the biological factors that may be responsible, at least
in part, for the symptoms. Indeed, many of these have proven effective
in reducing (and, sometimes, eliminating) the symptoms of some psy-
chological disorders, and intervening pharmacologically may be ben-
eficial, and in some cases is indispensable, since without medications
some symptoms (for example, psychosis) are not likely to resolve.
As advances in psychopharmacology continued, a biopsychosocial
approach developed and aimed to conceptualize effective mental health
treatment as falling across three dimensions – biological (use of medica-
tions), psychological (counseling and psychotherapy), and social (group
and family counseling, development of social supports). Over time, med-
icine (especially, psychiatry) began to favor the biological aspects and
pharmacological interventions. However, the biopsychosocial approach
was developed to balance the three aspects of mental health care, and
many mental health professionals continue to approach psychological
care from the biopsychosocial perspective, utilizing pharmacological
approaches in conjunction with psychosocial treatment, especially when
treating individuals with disorders that are known to be associated with
significant changes in the brain.
ix
x Preface
Biological vs. Psychosocial TreaTmenT
When treating disorders with known biological etiology, many non-
medical mental health professionals seek to minimize pharmacological
approaches and initially try psychosocial treatment. This is a reasonable
approach, especially with children. However, many factors may contrib-
ute to the decision to utilize pharmacological approaches, in conjunc-
tion with or instead of psychotherapy.
Type of symptoms
Some symptoms may lend themselves well to psychotherapy. For exam-
ple, depression or generalized anxiety generally respond well to psy-
chosocial treatment, and results of numerous research studies reveal
that individuals who undergo psychotherapeutic treatment for such
symptoms exhibit statistically significant improvement (for example,
see Beck, 1995). Of course, improvement does not necessarily mean the
elimination of symptoms, so in many cases conjoint psychopharmaco-
logical treatment may offer additional benefits.
Conversely, some symptoms do not seem to respond well to psycho-
therapy. For example, delusions, hallucinations, racing thoughts, and
other symptoms associated with severe psychopathology do not tend to
significantly diminish with psychosocial interventions. True, concur-
rent psychotherapy may help the patient’s overall adjustment, but the
core symptoms are not likely to resolve without the use of at least some
pharmacological interventions.
severity of symptoms
Even those symptoms that may often be manageable without medications
may sometimes require a pharmacological approach. For example, milder
forms of depression, impulsivity, anxiety, or agitation may respond well to
psychotherapy. However, severe variants of these symptoms may be diffi-
cult to treat with talk therapies, and intense symptoms are likely to require
psychopharmacological treatment. For example, it may be very difficult to
communicate with a severely depressed or agitated patient, and a severely
anxious patient may have difficulties coming in for psychotherapy. Thus,
most clinicians find that symptoms that are very impairing usually require
an approach that includes pharmacological treatment.
onset of relief
When psychotherapy is effective, progression of improvement is gradual
and requires several sessions to become evident. Even those variants that
Preface xi
are called ‘brief therapy’ generally require 8–15 sessions before signifi-
cant improvement is expected. When the patient is very uncomfortable,
and when the symptoms debilitate the patient and significantly interfere
with normal functioning, waiting this long for improvement may not be
prudent.
Although this is not always the case, many pharmacological treat-
ments produce at least some improvement within days of the onset of
treatment, although a few weeks (in some cases, 4–6) may be needed
for more comprehensive response. However, this is still faster than psy-
chotherapy, and the amount of improvement seen with medications may
be greater than the improvement seen with psychotherapy over the same
period of time. Especially when symptoms are severe, it may be more
appropriate to initiate pharmacological treatment immediately, perhaps
conjointly with psychosocial interventions. Relief is likely to be faster
when such a strategy is utilized.
Time and effort
When pharmacological and non-pharmacological approaches are likely to
be equally effective, as is the case with pharmacological or psychothera-
peutic treatment of depression, non-medical mental health professionals
prefer to utilize non-medical treatments, and pharmacological interven-
tions are seen as a ‘last resort’ when therapy does not seem to produce
sufficient relief. While this may be reasonable in some situations, pro-
fessionals need to be sensitive to other reasons that may drive the use of
pharmacological interventions.
In order for psychotherapy to be effective, patients need to attend ses-
sions regularly. If rapid progress is needed, sessions need to be scheduled
at least weekly. However, driving to the therapist’s office once per week,
and spending an hour in the office, may be difficult for some patients (or
families) with significant time obligations. When the patient is a child or
adolescent, psychotherapy must be done outside of school hours, since
missing school 1 day per week to attend psychotherapy is neither practical
for the family nor beneficial to the student. However, it may be difficult to
find therapists with significant amount of evening hours to accommodate
the patient’s schedule, especially when weekly treatment is needed.
In addition, geographic considerations also affect the decision to enter
psychotherapy. In urban or suburban areas, child and adolescent psy-
chotherapists may be prevalent. In rural areas, however, this situation is
much more likely to be problematic, and patients may not live in reason-
able proximity of qualified and competent pediatric mental health pro-
fessionals. Thus, even when a family may prefer to try psychotherapy
xii Preface
instead of pharmacy, their ability to get to the therapist’s office may be
limited.
cost of care
The cost of weekly psychotherapy for 8–15 weeks is likely to constitute
a significant expense for many families, and few are able to cover such
costs out of pocket. In the United States, most children and adolescents
who have health care coverage are covered by private plans, usually pur-
chased through the parent’s employer. The quality of this coverage varies
widely. Unfortunately, mental health care is often considered to be the
‘step-child’ of the health care industry, and levels of coverage for men-
tal health treatment are often much lower than they are for medical care.
Although laws on the federal and state levels have been passed to close
that gap, many exclusions exist and the disparity between medical and
mental health coverage continues.
Limiting the patient’s access to care is one common method of con-
taining health care costs. Many individuals with managed health care
coverage have benefits that primarily are evident ‘on paper’ and virtually
disappear when the insured seeks treatment. Gatekeepers are assigned
that review the need for care, and these reviews delay sessions and inter-
rupt the continuity of care. Usually, four to six sessions may initially be
authorized, and additional reviews are needed for each subsequent block.
It is up to the discretion of the gatekeeper to authorize further treatment,
and when the gatekeeper feels that sufficient progress was attained, or
that sufficient progress is not evident, further authorization may not be
issued. Although every insurer has appeals procedures that may be uti-
lized, these appeals are internal to the insurer, and usually no external
review exists that may be invoked if the insurer continues to refuse to
authorize care. To make matters worse, appeals often take months, and
meanwhile the patient is getting no care.
In addition, millions of children and adolescents in the US have no
health care coverage. While federal and state authorities are striving to
close this gap, there continues to be a significant portion of our soci-
ety that cannot afford mental health care and has no insurance cover-
age. Various agencies exist that may service these individuals, including
networks of community mental health centers (CMHCs) that provide
care to those who need it, sometimes without (or with minimal) cost.
However, in many states, CMHCs are overextended and long wait times
are necessary (in some cases, up to 8 weeks) before the agency is able
to provide care. Meanwhile, patients are suffering and are receiving no
Preface xiii
treatment. In addition, in rural states, the nearest CMHC may be quite a
distance away.
For all of the reasons reviewed above, patients and/or their families
may choose to utilize psychopharmacological treatment either instead
of, or in addition to, psychosocial interventions.
medicaTions vs. nuTriTional and herBal suPPlemenTs
When patients decide to use pharmacological interventions, they must
consider whether to use prescription medications or over-the-counter
compounds. Once again, patients are likely to consider many factors
when making such a decision. Many patients are skeptical about the use
of prescription drugs. There are complex reasons for this perception,
some of which are more legitimate than others. It is important for mental
health professionals to understand the reasons that drive these percep-
tions, and help their clients separate truth from fiction when considering
naturopathic interventions.
distrust in Pharmaceutical companies
One reason for skepticism about prescription drugs is the availability of
information that continues to come to light about the influence of the
drug industry on studies that investigate the effectiveness of medications.
The process of bringing a medication to market is more convoluted in
the US than in the vast majority of countries around the world. Overtly,
this may imply that medications marketed in the US are safer than those
marketed elsewhere, and the Federal Drug Administration (FDA) seeks
a greater amount of safety data before the drug is approved. In practice,
however, drug manufacturers have a significant amount of influence over
various portions of this process. Although the FDA requires three stages
of studies to investigate the safety and efficacy of medications, there are
no requirements that compel drug manufacturers to report all research
findings to the FDA, and it is becoming increasingly evident that drug
manufacturers perform many studies and only choose to release to the
FDA the findings of those studies that support the drug’s safety and effi-
cacy. Consequently, the public is losing confidence in widely publicized
claims of effectiveness, and drug manufacturers have lost a lot of credit-
ability with the American public.
As a result, people are turning to nutritional and herbal supplements.
Often, these are perceived as viable alternatives that have been around
for thousands of years, and have been used for various purposes in many
xiv Preface
cultures through many centuries. Thus, they must be effective. However,
this assumption is often inaccurate. Although the efficacy of medica-
tions must be established through empirical studies, no such requirement
is placed on nutritional and herbal supplements, unless they are being
specifically marketed to treat an existing illness or disorder. Since nutri-
tional and herbal supplements are not usually marketed in this way, they
are exempt from this requirement, and the vast majority of supplements
have undergone a miniscule amount of research. Thus, frequently, the
efficacy of a naturopathic compound is presumed, rather than estab-
lished. A major goal for this book is to help readers determine which
supplements have been shown to be effective, and which are only pre-
sumed or expected to be (with little research support).
marketing
Medications can only be advertised to treat the specific condition for
which they are FDA approved (the so-called ‘on-label’ use). Although
medications are brought to market to treat a specific condition, in sub-
sequent research they are sometimes shown to be effective for another
disorder. Because of the staggering cost involved in filing another appli-
cation with the FDA, most drug manufacturers do not do so, knowing
that any prescriber can potentially prescribe any medication to treat any
disorder so long as in the prescriber’s professional opinion there is good
likelihood that the medication will be effective. This ‘off-label’ use is
usually based on the availability of research studies that support the use
of the medication for a specific purpose, even though the original FDA
approval was issued to treat a different disorder.
The situation is different with nutritional and herbal supplements.
While these compounds cannot be marketed to, for example, ‘treat
symptoms of ADHD’ without submitting evidence of efficacy to treat
this disorder, they can be advertised to ‘improve attention’ or provide
other similar benefits, as long as no specific claim is being made to treat
ADHD. This is exemplified by the marketing practices of Focus Factor,
a vitamin compound that lacks any objective efficacy in treating symp-
toms of ADHD, and yet it is commonly sold to ‘improve attention.’
Obviously, this loophole in current regulations is successfully exploited
by the manufacturers of nutritional and herbal supplements, and clients
must understand that they have to be even more skeptical about claims
of efficacy of nutritional compounds than about similar claims made
regarding medications, for which advertising practices are more tightly
regulated.