Nutritional and Herbal Therapies for Children and Adolescents A Handbook for Mental Health Clinicians 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 AMSTERDAM • BOSTON • HEIDELBERG • LONDON NEW YORK • OXFORD • PARIS • SAN DIEGO SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO Academic Press is an imprint of Elsevier Academic Press is an imprint of Elsevier 32 Jamestown Road, London NW1 7BY, UK 30 Corporate Drive, Suite 400, Burlington, MA 01803, USA 525 B Street, Suite 1900, San Diego, CA 92101-4495, USA Copyright © 2010 Elsevier Inc. All rights reserved No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the publisher. 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Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN : 978-0-12-374927-7 For information on all Academic Press publications visit our website at www.elsevierdirect.com Typeset by Macmillan Publishing Solutions www.macmillansolutions.com Printed and bound in the United States of America 10 11 12 13 14 15 10 9 8 7 6 5 4 3 2 1 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