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ORIGINAL
ARTICLE
Focus on Alternative and
Complementary Therapies
Volume 17(2) June 2012 97–102
© 2012 The Authors
FACT © 2012
Royal Pharmaceutical Society
DOI 10.1111/j.2042-7166.2012.01144.x
ISSN 1465-3753
Parental interest in comprehensive care for children with
attentional concerns
Ben Banasiewicz, Kathi J Kemper
Abstract
Many families seek natural therapies for children. We describe what families want when they seek consultation for natural
therapies for children with attention deficit hyperactivity disorder (ADHD). Our objective was to: a) describe the kinds of
problems and therapies used by patients presenting with a concern about ADHD; b) assess interest in counselling about
health promotion; and c) describe physician recommendations at the initial consultation about conventional and CAM
therapies. We reviewed intake forms, physician reports and laboratory studies for new patients seen in an integrative
paediatric clinic between January 2010 and June 2011. Of the 75 new patients, 23 (31%) families had concerns about
ADHD. Of these, 70% were boys; the average age was 11.2 ⫾ 3.1 years, and 80% received care from specialists. Eleven
patients (48%) were taking a prescription medication, but only three (13%) were taking medicine for ADHD; dietary
supplements were taken by 12 patients (52%). Most families were interested in health promotion information about diet
(87%), exercise (78%), stress management (74%), and sleep (74%). Of 11 patients tested, 82% had low ferritin.
Recommendations focused on health promotion (100%), dietary supplements, such as multivitamins/minerals (71%) and
omega-3 fatty acids (82%), and specialist referrals (30%). Families seeking natural therapies for children with ADHD have
needs for health promotion and care coordination, which are well addressed using tools and skills already present in the
medical home.
Keywords
Clinical • complementary and alternative medicine • integrative health care • paediatrics
Introduction
Attention deficit hyperactivity disorder (ADHD) is
one of the most common behavioural problems in
paediatrics, affecting 3–10% of youth in the USA.1
Increasingly, families are using complementary and
alternative therapies, such as dietary supplements, to
improve their child’s attention and behaviour.2–5
The growing field of integrative paediatrics covers
not only complementary therapies, but ideally
includes an orientation towards patient-centred care
and communication skills, an orientation towards
health promotion and disease prevention, effective
lifestyle coaching, a comprehensive array of therapies
for human health, including complementary therapies, and coordinated team care.6–10 Continuing
medical education offerings in CAM for practising
professionals have become increasingly common
both at professional meetings and online.11–17
However, little is known about what parents who
seek natural remedies for their child’s ADHD are
actually using or interested in from an integrative
paediatrician.
In the USA in November 2009, in collaboration
with the Pediatric Working Group of the Consortium
of Academic Health Centers for Integrative Medicine
97
98
Focus on Alternative and Complementary Therapies
(based in Minneapolis), the Brenner Children’s Hospital (BCH) Pediatric Second Opinion Clinic (PSOC),
North Carolina, revised its standard intake form for
patients seeking care from an integrative paediatrician. The PSOC was established in 2003 to provide
consultations to primary care and specialist physicians whose patients were interested in natural therapies. Most referrals were for children with complex or
chronic conditions. Onsite services are available from
a registered dietician as well as the paediatrician. The
BCH also offers care from psychologists, physical
therapists, social workers, pastoral care, paediatric
medical specialists, psychiatrists and massage therapists. When indicated, referrals are made to community providers for acupuncture and other therapies.
This study was conducted to: a) describe the kinds
of problems and therapies already used by patients
presenting with a concern about ADHD; b) assess
interest in counselling about health promotion
(nutrition, activity, sleep, stress management and
lifestyle issues, such as the use of TV, electronic media,
music and time in nature); and c) describe physician
recommendations at the initial consultation about
conventional and CAM therapies in order to improve
the quality of service provided at the PSOC and to
inform others caring for similar patients.
Methods
Subjects were included if the patient-intake form
indicated a concern about ADHD, attention deficit
disorder (ADD), or attention. Subjects were excluded
if the intake form was missing.
The intake form, which is mailed to parents when
initial appointments are made, asks parents about
their chief concerns, and provides an opportunity
to identify health goals as well as problems. For
example, a parent who lists ADHD as a concern
might check priorities, such as ‘better concentration’,
‘less impulsivity’, or ‘more patience’ from among
more than 40 common physical, mental, emotional,
spiritual and social health goals. In order to focus
discussions during the visit on the kinds of strategies
of greatest interest to families, parents are asked to
note whether or not they are interested in discussing
lifestyle factors, such as diet, activity/exercise, sleep
and stress management. The form also asks parents to
list all current therapies and therapists, and includes
a section about specific interest in a list of complementary and conventional therapies. It also asks
about psychosocial factors that may affect symptoms,
such as TV, activity, family meals, recent moves,
meals together, religious participation, pride in the
child’s skills or actions and risks such as guns, substance abuse and domestic violence concerns in the
household. Finally, the intake form asks families to
bring all medications, herbs, vitamins, and other
supplements used by the child to the clinic appoint-
June 2012 17(2)
ment for careful review, and to list all other professionals involved in the child’s health care.
The intake form and materials used for education
(i.e. handouts on ADHD, commonly used dietary
supplements, tracking symptoms, and tracking
behaviour change) are available on the website for
the PSOC (accessed via: <http://www.wakehealth.
edu/cim>).
In addition to reviewing and extracting data from
the intake form, we reviewed the physician notes,
including laboratory test results from the visit, and
referrals to other clinicians.
This study was approved by the Wake Forest School
of Medicine Institutional Review Board, WinstonSalem, North Carolina, USA.
Results
Of the 75 new patients seen in the PSOC between
January 2010 and June 2011, 23 (31%) noted a
concern about ADHD. Of these, the average age was
11.2 ⫾ 3.1 years, and 70% were boys. Most (87%)
were referred by the patients’ primary physician,
with the remaining referred by specialists (neurology,
developmental/behavioural paediatrics, and gastroenterology). Parents of 21 (91%) children reported
additional health concerns. The most common of
these concerns were anxiety and other emotional or
behavioural problems, but also included a variety of
physical and behavioural issues (Table 1). There was
an average of 4.9 concerns per patient, with a range
of one to 14 problems per patient.
Health goals
The most frequently noted health goals for the 23
children presenting with a parental concern about
Table 1 Other health concerns among children seeking natural
therapies for attention problems
Other health concerns
Percentage of
23 patients
Anxiety
Other emotional or behavioural problems
Nutrition/diet
Fatigue
Sleep problems
Allergies
Constipation or diarrhoea
Autism spectrum disorder
Eczema or rash
Other pain
Headache
Other: Asthma, frequent infections, defiance,
medication side effects, nausea, nosebleeds,
obsessive compulsive disorder, orthostatic
intolerance, pneumonia, poor social skills,
seizures, self-injury, stress, tics, Tourette’s
syndrome and weight concerns
61
48
40
35
35
30
22
22
17
17
13
<10% each
Original Article
Table 2 Parents’ health goals for children seeking natural therapies
for attention problems*
Health Goals
Percentage of
23 patients
Better concentration
More restful sleep
Less worried or anxious
Better listener
Less impulsive
More self-discipline
More vitality or energy
More empathetic
More confidence
More flexible or adaptable
Better balance or coordination
Calmer
Better relationships with friends/family
Less pain
Other: more cheerful, less isolated, less
irritable, fewer allergies, more patience,
fewer infections, better weight, more
hopeful, more present, less nausea,
fewer tics
65
35
30
30
26
26
22
22
17
17
17
17
17
17
<15% each
*Parents could list more than one health goal for their child.
ADHD were better concentration and more restful
sleep (Table 2). Parents listed a variety of physical,
mental, and behavioural goals for their children.
Care at time of initial consultation
At the time of the initial consultation, 20 (80%)
patients were receiving care from other specialist
physicians or health professionals in addition to their
primary paediatrician. These clinicians included:
allergist, cardiologist, chiropractor, dentist, gastroenterologist, haematologist, massage therapist,
neurologist, nutritionist, orthodontist, orthopaedic
specialist, otolaryngologist, physical therapist, psychiatrist, psychologist, pulmonologist, recreational
therapist, social worker, speech therapist, spiritual
adviser and yoga teacher. Most patients received care
from more than one kind of specialist.
Eleven patients (48%) were taking one or more
medications, most commonly allergy/asthma medications (39%; e.g. antihistamines, inhaled steroids, or
bronchodilators), gastrointestinal medications (17%;
i.e. for constipation); and mental health medications
(17%; e.g. tricyclic antidepressants, selective serotonin reuptake inhibitors or antipsychotics). Of the
11 patients taking medication, seven (64%) were
also taking a dietary supplement other than a
multivitamin/mineral. Only three (13%) patients
were taking stimulant medications, though several
had been prescribed medications and had stopped
taking them due to side-effects or lack of efficacy.
Dietary supplements other than multivitamins
were taken by 12 (52%) patients altogether, most
99
commonly omega-3 fatty acid supplements (26%),
probiotics (13%), melatonin (13%), calcium (9%),
magnesium (9%), herbal combination products (9%),
iron (4%), amino acids (4%), B-complex vitamins
(4%) and vitamin D3 (4%).
Family interest in health promotion
Most parents were interested in discussing nutrition
(87%), exercise/activity (78%) and/or sleep (74%).
When asked to rate the child’s stress level on a 0–10
scale, with 0 being no stress and 10 being extreme
stress, parents reported an average child’s stress level
of 5.3 ⫾ 2.3, with a range from 1 to 8. Parents of
17 children (74%) wanted to learn additional stress
management strategies to help their child manage
stress, although nearly all reported using one or more
stress management strategies such as hitting a pillow,
talking with a family member, listening to music,
sleeping, eating, spending time in nature, playing, or
taking a break.
Family history and psychosocial risk and
protective factors
Several psychosocial factors may increase the risk of
problems with attention, behaviour and other symptoms. The intake forms of 74% of patients reported a
family history of problems with learning, mental
health, and/or substance abuse. Nine parents (39%)
reported that the child watched more than 2 h of
television daily. Three (13%) families reported having
moved in the previous 12 months; 13% reported that
the child also lived at least part of the time in another
household (e.g. with father or grandparents); 13%
reported that there was a smoker in the child’s household; and 13% reported having a gun in the home
(all said that guns were locked away). There were also
positive screens for household alcohol misuse (9%),
domestic violence (4%) and/or drug abuse (4%).
Other factors, such as regular family meals
together, regular participation in groups such as
church, and seeing positive traits in the child, may
be protective for children with behavioural problems.18–22 Most (87%) families reported moderate or
strong religious participation or practice, 78% had at
least four meals together as a family each week, and
74% of parents listed at least three things they were
proud that the patient had done in the past week.
Recommendations and referrals
Basic health promotion information was reviewed
with all families using tools and techniques from
motivational interviewing. The PSOC website has an
Action Plan Tracker for Successful Change, which
helps families identify their primary goal, pick a strategy to try for 1 week, choose a number of days that
week to use that strategy, track success, and plan a
100
Focus on Alternative and Complementary Therapies
celebration for success. Families are encouraged to
make copies of the form and revise the strategies each
week after reflecting on the experiences of the prior
week. Pros and Cons of Change worksheets are available for those who are ambivalent.
Families that had not previously completed a validated rating scale were given copies of the parent and
teacher versions of the Vanderbilt Rating Scale to
complete and review with their primary physicians.
After discussing optimal diet (emphasising fruits, vegetables, whole grains, nuts, seeds, low-fat milk and
fish), suggestions were made to some families about
supplemental omega-3 fatty acids, such as fish oil
(82%), and vitamins/minerals (71%). For example, of
the 11 patients for whom ferritin levels were checked
at the initial consultation, 82% had low levels according to the BCH laboratory standard; all received
recommendations for iron supplements (Table 3).
New referrals were made to psychologists (13%),
community agencies offering social skills and
mental health support (17%) and developmental/
behavioural paediatric clinics (4%). Referrals were
also made to allergists (9%), endocrinologists for
evaluation of possible thyroid problems (9%), rheumatologists (4%), neurologists for seizures and tics
(4%) and paediatric sleep specialists for evaluation of
possible obstructive sleep apnoea syndrome (4%).
Due to parental concerns about out-of-pocket costs,
referrals were less common to massage therapists
(9%) and acupuncturists (4%) for help with sleep or
pain (Table 3).
Table 3 Recommendations at initial consultation
Recommendation
Percentage
Continue current care with primary and
specialist physicians
Health promotion (diet, exercise, and/or sleep)
Continue current medications (one change in
oral contraceptive pills)
New referrals to mental health professionals
New referrals to specialist physicians
Dietary supplements
Omega-3 fatty acids
Multivitamins/minerals, including iron
Caffeine in coffee, tea, or green tea on a trial
basis
Tryptophan or 5-hydroxytryptophan
Melatonin
Probiotics
More time in nature
Mind/body – stress management
Gratitude journal
Yoga/tai chi
Biofeedback
Massage
Acupuncture
100
100
97
30
22
91
71
26
23
18
9
17
17
13
9
9
4
June 2012 17(2)
Discussion
This is the first study to describe patients with ADHD
seeking care from an integrative paediatric clinic. The
data suggest that such children often suffer from
multiple chronic health conditions, receive care
from multiple, diverse specialists as well as primary
care clinicians, and take a variety of medications
and supplements while avoiding ADHD medications.
Their families articulate reasonable health goals for
their child (including better concentration and more
restful sleep) and are highly interested in basic health
promotion information on diet, exercise and stress
reduction. Thus, the families share many characteristics of children with special healthcare needs best
served by care in a medical home that provides
ongoing coordinated, comprehensive care.23
These findings need to be considered in the context
of previous studies on the use of complementary
and alternative medical therapies by children with
ADHD.2,3,5 As with earlier studies, many families are
interested in dietary supplements, but fewer patients
in this North Carolina sample were interested in
expressive therapies than reported in the Boston,
USA, study by Chan et al.3 Families’ interest in
omega-3 fatty acid supplements reflect emerging
research on their role in mental health.24–33 In addition to parental values, such as therapies that are
natural or empowering, and concerns about medication side-effects, the data in this study suggest that
parents may have multiple health goals in addition
to their concerns about ADHD.5
Although this study enriches and updates our
information about families seeking natural care for
children with ADHD, it has limitations. It includes
data from just one practice, with patients referred
to just one paediatrician who, during the time period
of the study, published two books on natural
approaches to paediatric mental health. Thus, the
sample may over-represent children with ADHD seen
in paediatric integrative clinics due to response bias.
Because the study focused on describing families’
interests at the initial visit, we did not contact families to collect outcome data. Future studies should
include a larger, more diverse, sample and consider
comparing the interests and outcomes of those with
ADHD to those with other health concerns.
Despite these limitations, these data are reassuring
for clinicians caring for children with ADHD whose
parents are interested in natural therapies. Such
parents are very interested in the kind of health promotion advice that paediatricians can offer about
diet, exercise, sleep, stress and behaviour management. Furthermore, their reluctance to use medications for ADHD does not appear to generalise to all
medications, which means that dialogues about
N-of-1 trials and other innovative approaches to considering medication in the context of health promo-
Original Article
tion are feasible.34,35 Clinicians should be aware that
families interested in natural therapies may already
be administering dietary supplements, often based
on emerging science, and should ask and advise
patients routinely on these products using evidencebased resources.36 Patients with ADHD may well
have multiple additional health concerns, optimally
treated with a team approach involving generalist
and specialist physicians, psychologists, social
workers, nutritionists, and community clinicians. In
short, the care of children whose families seek natural
therapies for ADHD requires an integrated approach
to the whole child in the context of family and community, which is the hallmark of good care in the
medical home.
Funding
No external funding was received for this project.
Conflict of interest None declared.
Acknowledgements
We are grateful to Paula Stant for accessing the
medical records, our colleagues at the Brenner Children’s Hospital, the Section on Complementary and
Integrative Medicine of the American Academy of
Pediatrics, Winston-Salem, North Carolina, USA, and
all the patients and families who inspire and educate
us.
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Ben Banasiewicz, Pediatrics and Social Science/Health
Policy, Wake Forest University School of Medicine, WinstonSalem, North Carolina 27157, USA.
E-mail: [email protected]
Kathi J Kemper, MD, MPH, Pediatrics and Social
Science/Health Policy, Wake Forest University School of
Medicine, Winston-Salem, North Carolina 27157, USA.
E-mail: [email protected]