Alternative and Complementary Therapies for Children with Psychiatric Disorders, Part 2
Preface
Deborah R. Simkin, MD, DFAACAP Editors
Charles W. Popper, MD
This is the second of a two-part series on alternative and complementary therapies for psychiatric disorders published in the Child and Adolescent Psychiatric Clinics of North America. In Part 1, issued in 2013, the articles were organized to describe the current treatment research on several of the major psychiatric disorders of children and adolescents, including attention deficit hyperactivity disorder (ADHD), mood disorders, autism, and learning disorders. Overviews were also offered regarding the national research effort in complementary and alternative medicine (CAM), translating these treatments into clinical practice, and legal issues regarding CAM treatments that are relevant to child and adolescent psychiatrists. In Part 2, the emphasis is shifted to specific CAM treatment techniques and the research developments pertaining to their use in treating child and adolescent psychiatric disorders. There are an enormous number of CAM treatments, many that have been proposed for treating psychiatric disorders, and each of these CAM treatments has potential applications for managing a range of psychiatric disorders. Some of the methods are already widely utilized by patients and clinicians, but research on these techniques is limited in psychiatry, especially in child and adolescent psychiatry. The selection of treatments in this issue was based on the availability of systematic research on the treatments specifically in children and adolescents, and also on the general public interest in these approaches. These selected interventions include neurofeedback, mindfulness/meditation, music therapy and music medicine, essential fatty acids, and micronutrients (vitamins and minerals). Neurofeedback is a relatively new intervention that has been built on modern science and technology. Several neurofeedback techniques have been developed, and the clinical research on youth is described in two articles. One article reports on surface neurofeedback, which is the most commonly studied neurofeedback technique in children and adolescents, particularly for youth with attention deficit disorder, autism, epilepsy, and learning disorders. The second article discusses the few research studies using surface neurofeedback for children and adolescents with depressive disorders, anxiety disorders, comorbid addiction/ADHD disorders, and traumatic brain injury. The second article also explains the science behind the use of quantitative EEG and describes a newer neurofeedback approach that has so far received little
Child Adolesc Psychiatric Clin N Am 23 (2014) ix–xii http://dx.doi.org/10.1016/j.chc.2014.04.002 childpsych.theclinics.com 1056-4993/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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study in youth: low-resolution electromagnetic tomography (LORETA) neurofeedback. LORETA targets deeper neuronal hubs, modules, and circuits. Clinically, LORETA holds promise as a novel intervention for addressing the central dysregulation associated with psychiatric disorders in youth by normalizing brain function at the level of neuronal circuits and by improving symptom clusters based on connectivity between specialized neuronal populations. This approach of targeting functions that are based on neuronal dysregulation is consistent with the “transdiagnostic” approach exemplified by the Research Domain Criteria of the National Institute of Mental Health. Although the best evidence for the use of neurofeedback concerns ADHD (and to a lesser extent, autism and learning disorders), there remains some degree of controversy regarding the suitability of neurofeedback for general clinical application, due to the time demands, cost, and (at present) lack of insurance reimbursement. Neurofeedback treatment requires referral to a clinician who has received significant training in the appropriate protocols and technologies. In contrast to neurofeedback, mindfulness and meditation approaches are derived from several ancient traditions that originated centuries ago, and their powers have often been viewed as mystical or mysterious. Modern neuroimaging and EEG technology have helped scientists and clinicians understand the powerful effects that these techniques have on the brain and their benefits for patients with psychiatric disorders. With so many distinct techniques used in mindfulness/meditation, these techniques are presented in five categories: focused attention, open monitoring, transcendental meditation (automatic self-transcending), mind-body techniques, and body-mind techniques. Both mind-body and body-mind techniques often utilize many mindfulness/meditation methods; however, mind-body also includes relaxation components, and body-mind also uses movement techniques (such as Tai Chi) or body postures (such as yoga). Several mindfulness and meditation techniques have been examined for medical indications, but only transcendental medicine has been recognized by the American Heart Association as effective in reducing hypertension in adults. There are few well-conducted randomized controlled trials in children and adolescents for medical and/or psychiatric indications, but the minimal adverse effects make them particularly appealing despite the scarce scientific support. These techniques can be applied in schools and clinics, but the methods should be taught by highly trained personnel. Differences in therapeutic effectiveness among these methods are likely to be uncovered when used as adjunctive treatments for various psychiatric indications, and the effectiveness of the different methods may differ from adults in youth at different ages. Music has been used as a clinical treatment in medicine for more than three decades, especially with youth and the elderly. In the past, music medicine involved mainly passive listening and did not require trained specialists. More recently, several techniques of actual music therapy have been developed and have been shown to decrease pain and anxiety in adults and youth with cancer. Music therapy has also been used for mental and emotional problems in children and adolescents, with some studies suggesting benefits for intellectual disabilities, emotional and behavioral conditions, and learning disorders. Preliminary data have also examined youth with autism, mood and anxiety disorders, substance abuse, and eating disorders. Music therapy for brain-injured patients became publically prominent when it was employed in the recovery and rehabilitation of former US Congresswoman Representative Gabrielle Gifford. Music therapy has been shown to induce physiological changes in youth and adults as well as hormonal changes in adults, giving credence to the neurobiological legitimacy of this intervention. To acquire clinical sophistication in this field, music therapists receive 2 to 4 years of comprehensive training to become eligible for board
Preface
certification. Despite the scarcity of substantive data on music therapy as an adjunctive treatment for youth with psychiatric disorders, this promising field deserves clinicians’ attention, especially in view of its low risks. Essential fatty acids are well-established to be critical for proper brain development, and nutritional deficiencies of omega-3 fatty acids appear to have significant effects on neurodevelopmental outcomes. Psychiatric research in youth is not extensive, but available data suggest their value as adjunctive treatments for youth with ADHD, depression, and possibly bipolar disorder. The effect on ADHD appears small but sufficient to justify its use as an adjunctive agent. Some studies of essential fatty acids (when combined with micronutrients) have shown clear-cut and clinically significant benefits for youth (and young adults) with violent, aggressive, and antisocial behaviors associated with conduct disorder in school settings and even in young adult prisoners. It is unclear whether these improvements in conduct disorder are related to symptomatic improvements in ADHD or in mood disorders, and current studies are insufficient to determine what effect essential fatty acid treatments might have in children and adolescents with major depression or bipolar disorder. Further research is needed as well to assess which of the essential fatty acids (and in what relative ratios) may be most relevant for different psychiatric disorders in youth. While treatment outcome data are gathering, the easiest justifications for the clinical use of omega-3 fatty acids are their minimal profile of adverse effects and their broadranging (although still debated) benefits to general health. Micronutrient (vitamin and mineral) supplements have been investigated for their potential for treating psychiatric disorders, especially mood disorders. Certain vitamins, such as folate and perhaps chromium, show significant potential as adjunctive psychiatric treatments in adults. An alternative treatment approach is the use of a broad spectrum of micronutrients, rather than single vitamins or minerals. Although few randomized controlled trials have been conducted, a series of publications on broad-spectrum micronutrient treatments has described clinically significant improvements in youth and adults with mood disorders and ADHD. Based on the preliminary findings in the literature, it appears that broad-spectrum micronutrient approaches may be comparable in clinical effectiveness to psychiatric medications for treating mood disorders, but with much fewer adverse effects than conventional psychiatric medications. Drug-nutrient interactions are surprisingly extensive and complex. Clinicians who wish to employ these treatments will need to become savvy in some aspects of nutritional pharmacology before applying the broad-spectrum treatments, and patients would need to provide well-informed consent in view of the dearth of controlled trials. Broad-spectrum micronutrient treatment appears to have the potential to eventually become a primary monotherapy for bipolar disorder (and probably for non-bipolar major depression as well) and an adjunctive therapy for ADHD, based on currently available studies in youth and adults. The data are limited, but impressive, and justify further research in youth as well as in adults. In comparing these very different approaches, our authors have employed the US Preventive Service Task Force system to grade the quality of available research supporting the different treatments. This element of continuity will allow clinicians to sense the relative strengths and weaknesses of the evidence base for the different approaches, and it is hoped, will guide researchers toward fruitful areas of investigation. All of these CAM treatments illustrate the abundance of new directions that are being explored with a new openness and inquisitiveness in medicine. Novel “alternative” treatments of yesterday (eg, cognitive behavior therapy) can become the conventional treatments of today, and a bit ironically, some conventional treatments of today become “alternative” treatments as they are replaced by newer methods. What counts
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Preface
as “alternative” is time-based and culture-based. The current culture of psychiatry is increasingly exhibiting the curiosity and imagination that have been hallmarks of the best of medical research and innovative care. By shedding light on new and promising “CAM” research and the neuroscience underlying these approaches, it is hoped that newer and more diverse interventions will become available to support the health and development of children and adolescents. We want to again express our gratitude to our series editor, Dr Harsh Trivedi, for granting two issues of the Child and Adolescent Psychiatric Clinics of North America to present this unorthodox side of our field, and to Joanne Husovski and Stephanie Carter, our editors at Elsevier, whose devoted work, kindness, prudence, intellect, and grace have been a vital force for us. Deborah R. Simkin, MD, DFAACAP American Academy of Child and Adolescent Psychiatry Attention, Memory and Cognition Center, LLC 4641 Gulfstarr Drive, Suite 106 Destin, FL 32541, USA Charles W. Popper, MD* Child and Adolescent Psychiatry McLean Hospital and Harvard Medical School Belmont, MA 02478, USA E-mail addresses: [email protected] (D.R. Simkin) [email protected] (C.W. Popper) *385 Concord Avenue, Suite 204 Belmont, MA 02478-3037, USA
Preface
Deborah R. Simkin, MD, DFAACAP Editors
Charles W. Popper, MD
This is the second of a two-part series on alternative and complementary therapies for psychiatric disorders published in the Child and Adolescent Psychiatric Clinics of North America. In Part 1, issued in 2013, the articles were organized to describe the current treatment research on several of the major psychiatric disorders of children and adolescents, including attention deficit hyperactivity disorder (ADHD), mood disorders, autism, and learning disorders. Overviews were also offered regarding the national research effort in complementary and alternative medicine (CAM), translating these treatments into clinical practice, and legal issues regarding CAM treatments that are relevant to child and adolescent psychiatrists. In Part 2, the emphasis is shifted to specific CAM treatment techniques and the research developments pertaining to their use in treating child and adolescent psychiatric disorders. There are an enormous number of CAM treatments, many that have been proposed for treating psychiatric disorders, and each of these CAM treatments has potential applications for managing a range of psychiatric disorders. Some of the methods are already widely utilized by patients and clinicians, but research on these techniques is limited in psychiatry, especially in child and adolescent psychiatry. The selection of treatments in this issue was based on the availability of systematic research on the treatments specifically in children and adolescents, and also on the general public interest in these approaches. These selected interventions include neurofeedback, mindfulness/meditation, music therapy and music medicine, essential fatty acids, and micronutrients (vitamins and minerals). Neurofeedback is a relatively new intervention that has been built on modern science and technology. Several neurofeedback techniques have been developed, and the clinical research on youth is described in two articles. One article reports on surface neurofeedback, which is the most commonly studied neurofeedback technique in children and adolescents, particularly for youth with attention deficit disorder, autism, epilepsy, and learning disorders. The second article discusses the few research studies using surface neurofeedback for children and adolescents with depressive disorders, anxiety disorders, comorbid addiction/ADHD disorders, and traumatic brain injury. The second article also explains the science behind the use of quantitative EEG and describes a newer neurofeedback approach that has so far received little
Child Adolesc Psychiatric Clin N Am 23 (2014) ix–xii http://dx.doi.org/10.1016/j.chc.2014.04.002 childpsych.theclinics.com 1056-4993/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
x
Preface
study in youth: low-resolution electromagnetic tomography (LORETA) neurofeedback. LORETA targets deeper neuronal hubs, modules, and circuits. Clinically, LORETA holds promise as a novel intervention for addressing the central dysregulation associated with psychiatric disorders in youth by normalizing brain function at the level of neuronal circuits and by improving symptom clusters based on connectivity between specialized neuronal populations. This approach of targeting functions that are based on neuronal dysregulation is consistent with the “transdiagnostic” approach exemplified by the Research Domain Criteria of the National Institute of Mental Health. Although the best evidence for the use of neurofeedback concerns ADHD (and to a lesser extent, autism and learning disorders), there remains some degree of controversy regarding the suitability of neurofeedback for general clinical application, due to the time demands, cost, and (at present) lack of insurance reimbursement. Neurofeedback treatment requires referral to a clinician who has received significant training in the appropriate protocols and technologies. In contrast to neurofeedback, mindfulness and meditation approaches are derived from several ancient traditions that originated centuries ago, and their powers have often been viewed as mystical or mysterious. Modern neuroimaging and EEG technology have helped scientists and clinicians understand the powerful effects that these techniques have on the brain and their benefits for patients with psychiatric disorders. With so many distinct techniques used in mindfulness/meditation, these techniques are presented in five categories: focused attention, open monitoring, transcendental meditation (automatic self-transcending), mind-body techniques, and body-mind techniques. Both mind-body and body-mind techniques often utilize many mindfulness/meditation methods; however, mind-body also includes relaxation components, and body-mind also uses movement techniques (such as Tai Chi) or body postures (such as yoga). Several mindfulness and meditation techniques have been examined for medical indications, but only transcendental medicine has been recognized by the American Heart Association as effective in reducing hypertension in adults. There are few well-conducted randomized controlled trials in children and adolescents for medical and/or psychiatric indications, but the minimal adverse effects make them particularly appealing despite the scarce scientific support. These techniques can be applied in schools and clinics, but the methods should be taught by highly trained personnel. Differences in therapeutic effectiveness among these methods are likely to be uncovered when used as adjunctive treatments for various psychiatric indications, and the effectiveness of the different methods may differ from adults in youth at different ages. Music has been used as a clinical treatment in medicine for more than three decades, especially with youth and the elderly. In the past, music medicine involved mainly passive listening and did not require trained specialists. More recently, several techniques of actual music therapy have been developed and have been shown to decrease pain and anxiety in adults and youth with cancer. Music therapy has also been used for mental and emotional problems in children and adolescents, with some studies suggesting benefits for intellectual disabilities, emotional and behavioral conditions, and learning disorders. Preliminary data have also examined youth with autism, mood and anxiety disorders, substance abuse, and eating disorders. Music therapy for brain-injured patients became publically prominent when it was employed in the recovery and rehabilitation of former US Congresswoman Representative Gabrielle Gifford. Music therapy has been shown to induce physiological changes in youth and adults as well as hormonal changes in adults, giving credence to the neurobiological legitimacy of this intervention. To acquire clinical sophistication in this field, music therapists receive 2 to 4 years of comprehensive training to become eligible for board
Preface
certification. Despite the scarcity of substantive data on music therapy as an adjunctive treatment for youth with psychiatric disorders, this promising field deserves clinicians’ attention, especially in view of its low risks. Essential fatty acids are well-established to be critical for proper brain development, and nutritional deficiencies of omega-3 fatty acids appear to have significant effects on neurodevelopmental outcomes. Psychiatric research in youth is not extensive, but available data suggest their value as adjunctive treatments for youth with ADHD, depression, and possibly bipolar disorder. The effect on ADHD appears small but sufficient to justify its use as an adjunctive agent. Some studies of essential fatty acids (when combined with micronutrients) have shown clear-cut and clinically significant benefits for youth (and young adults) with violent, aggressive, and antisocial behaviors associated with conduct disorder in school settings and even in young adult prisoners. It is unclear whether these improvements in conduct disorder are related to symptomatic improvements in ADHD or in mood disorders, and current studies are insufficient to determine what effect essential fatty acid treatments might have in children and adolescents with major depression or bipolar disorder. Further research is needed as well to assess which of the essential fatty acids (and in what relative ratios) may be most relevant for different psychiatric disorders in youth. While treatment outcome data are gathering, the easiest justifications for the clinical use of omega-3 fatty acids are their minimal profile of adverse effects and their broadranging (although still debated) benefits to general health. Micronutrient (vitamin and mineral) supplements have been investigated for their potential for treating psychiatric disorders, especially mood disorders. Certain vitamins, such as folate and perhaps chromium, show significant potential as adjunctive psychiatric treatments in adults. An alternative treatment approach is the use of a broad spectrum of micronutrients, rather than single vitamins or minerals. Although few randomized controlled trials have been conducted, a series of publications on broad-spectrum micronutrient treatments has described clinically significant improvements in youth and adults with mood disorders and ADHD. Based on the preliminary findings in the literature, it appears that broad-spectrum micronutrient approaches may be comparable in clinical effectiveness to psychiatric medications for treating mood disorders, but with much fewer adverse effects than conventional psychiatric medications. Drug-nutrient interactions are surprisingly extensive and complex. Clinicians who wish to employ these treatments will need to become savvy in some aspects of nutritional pharmacology before applying the broad-spectrum treatments, and patients would need to provide well-informed consent in view of the dearth of controlled trials. Broad-spectrum micronutrient treatment appears to have the potential to eventually become a primary monotherapy for bipolar disorder (and probably for non-bipolar major depression as well) and an adjunctive therapy for ADHD, based on currently available studies in youth and adults. The data are limited, but impressive, and justify further research in youth as well as in adults. In comparing these very different approaches, our authors have employed the US Preventive Service Task Force system to grade the quality of available research supporting the different treatments. This element of continuity will allow clinicians to sense the relative strengths and weaknesses of the evidence base for the different approaches, and it is hoped, will guide researchers toward fruitful areas of investigation. All of these CAM treatments illustrate the abundance of new directions that are being explored with a new openness and inquisitiveness in medicine. Novel “alternative” treatments of yesterday (eg, cognitive behavior therapy) can become the conventional treatments of today, and a bit ironically, some conventional treatments of today become “alternative” treatments as they are replaced by newer methods. What counts
xi
xii
Preface
as “alternative” is time-based and culture-based. The current culture of psychiatry is increasingly exhibiting the curiosity and imagination that have been hallmarks of the best of medical research and innovative care. By shedding light on new and promising “CAM” research and the neuroscience underlying these approaches, it is hoped that newer and more diverse interventions will become available to support the health and development of children and adolescents. We want to again express our gratitude to our series editor, Dr Harsh Trivedi, for granting two issues of the Child and Adolescent Psychiatric Clinics of North America to present this unorthodox side of our field, and to Joanne Husovski and Stephanie Carter, our editors at Elsevier, whose devoted work, kindness, prudence, intellect, and grace have been a vital force for us. Deborah R. Simkin, MD, DFAACAP American Academy of Child and Adolescent Psychiatry Attention, Memory and Cognition Center, LLC 4641 Gulfstarr Drive, Suite 106 Destin, FL 32541, USA Charles W. Popper, MD* Child and Adolescent Psychiatry McLean Hospital and Harvard Medical School Belmont, MA 02478, USA E-mail addresses: [email protected] (D.R. Simkin) [email protected] (C.W. Popper) *385 Concord Avenue, Suite 204 Belmont, MA 02478-3037, USA
