Partnering With Parents: Difficult Decisions About CAM

In a calm and reasonable discussion in the Brown University Child and Adolescent Behavior Letter, Dr. Margaret Klitzke has commented on the difficulties pediatricians and child psychiatrists encounter when parents want to use CAM (complementary and alternative medicine) treatments for their children’s mental health problems. In this article (“CAM in child mental health: Partnering with parents”, CABL, August 2010, p. 1, pp. 5-6), Dr. Klitzke defines CAM as “those healing modalities that provide supplemental treatments in addition to conventional treatments”, but she suggests that parents may consider CAM out of concern that conventional treatments are ineffective or have too many side effects, which impliess that the CAM treatments in question are seen as alternatives, not actually as “complementary” additional methods.

Dr. Klitzke’s discussion focuses on dietary supplements like flax oil and herbal remedies like St.John’s wort as well as on melatonin. She also notes the use of special diets, for example a gluten-free casein-free diet, and points out that the findings on the effectiveness of any of these are “equivocal”. With respect to these treatments, Dr. Klitzke suggests that practitioners need to be informed, be open to families’ inquiries, cultivate a partnership with families , and know their professional limitations.

It’s clear that practitioners are worried that apparent rejection of CAM treatments may cause parents to abandon conventional methods and commit their children to exclusive CAM care. As a result of this worry, they are inclined to seek ways to stay on good terms with parents, and to follow the methods parents want as far as they can ethically and scientifically justify this. And there would be little reason to criticize this approach as long as the CAM treatments are harmless, and as long as conventional treatment is also ongoing. (With respect to harmlessness, by the way, Dr. Klitzke points out the lack of FDA supervision of dietary supplements and herbal remedies, and the related issues of possible contamination or dosage problems.)

But what happens when CAM treatments for child mental health problems are demonstrably harmful? Not just ineffective, not just fraught with side effects, but potentially harmful treatments in and of themselves? A number of CAM treatments for child mental health issues come into this category. For example, there have been examples recently of parents advised to make their children’s food largely contingent on desirable behavior, and associated weight loss, in some cases producing permanent physical effects. I recently had a conversation with a young woman who as a four-year-old had been subjected to almost daily “holding therapy” over the course of a year; she is now being treated for serious anxiety, a reaction that may well be based on that early “therapeutic” experience. Child deaths have been associated with physically-intrusive treatments such as forced consumption of food or liquid, claimed by CAM practitioners to be effective with Reactive Attachment Disorder or any behavior problem of an adopted child.

At a more obviously physical level, avoidance of immunization, argued by CAM practitioners to prevent autism, does not prevent autism but does make children vulnerable to potentially fatal diseases. Chelation, a treatment with oral or infused medication, can have minor or occasionally serious side effects, and has not been shown to be an effective method of treating mental health problems.

How can conventional practitioners “partner” with parents who have committed to these types of treatments? No doubt criticism of dangerous CAM techniques is likely to cause some parents to leave conventional treatment and never come back, or to withhold accurate information about CAM treatments from a psychologist or pediatrician. (Because CAM treatments may in some cases interact with conventional treatments such as anti-depressant medication, the absence of accurate information may in itself create a dangerous situation. ) Nevertheless, there are several real problems that can result from failing to criticize CAM methods when it is appropriate to do so. One is that lack of criticism may be read by parents as actual approval of methods that are known to be dangerous, or ineffective, or both; parents may pass on to others this piece of “information”, thus making it more probable that other families will become engaged with CAM. Another is that it is conceivable that parents’ commitment to CAM is shaky. Criticism by a knowledgeable person might carry enough weight to alter a decision that would be maintained if left uncriticized. Finally, there is the point that professions involving responsible stewardship of others’ lives all have some ethical requirement for active engagement to prevent harm.

No one expects practitioners to partner with parents and facilitate abusive or neglectful treatment where it is not defined as part of a CAM treatment. Why is this “partnering” expected when harmful treatments are given the CAM label? It seems to be time for professionals working with children and families to re-think this matter and to differentiate between tolerating the harmless and encouraging the harmful.