CHAPTER 24 Complementary Health Approaches in Developmental and Behavioral Pediatrics Thomas D. Challman, MD, FAAP Justin is a 4-year-old boy who was diagnosed with autism spectrum disorder (ASD) at the age of 2 years, when he presented with severe communication impairments, joint attention deficits, and repetitive behaviors. His parents come to your office with information they found on the Internet regarding a special diet that other parents have reported to be helpful for children with ASD. They also have some questions about the value of certain vitamins and other supplements. Justin is in a well-designed preschool program and is receiving intensive applied behavior analysis services. How should you address their concerns? Primary pediatric health care professionals and caregivers should consider several important questions when evaluating the merits of a particular treatment that is being promoted for children with developmental-behavioral disorders. What is the scientific rationale and evidence regarding the use of these therapies individually or in combination for children with developmental-behavioral concerns? What are the potential risks of these therapies? Is it plausible that these approaches should be expected to have efficacy in improving the symptoms of a developmental-behavioral disorder based on what we already know about neuroscience and how the body works? How does one balance the desire of a parent to pursue a particular treatment with the right of a child not to be subjected to unsubstantiated therapies that may be ineffective or even harmful? And importantly, how do we help caregivers learn the skills they need to critically evaluate the large number of remedies popularized on the Internet and social media? Complementary Health Approaches: Definition and Background One of the challenges of assessing therapies that fall outside mainstream or standard medical care is the ill-defined and shifting boundary that differentiates these treatments from accepted medical practices. Many definitions for this group of therapies have been used over the years. Complementary and alternative medicine has been defined as “a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period,”1 and as practices “not presently considered an integral part of conventional medicine.”2 The term complementary medicine has been used to describe nonstandard approaches that are used with conventional medicine, and the term alternative medicine has been used to refer to therapies that are a replacement for mainstream medical practices. The National Center for Complementary and Integrative Health (NCCIH), an NIH center, currently uses the term complementary health approaches (CHAs) when referring to treatments that fall outside the mainstream of standard medical care, and integrative health to convey the idea of using standard and nonstandard therapies in a coordinated manner.3 NCCIH categorizes CHAs into 2 main domains: natural products and mind-body practices. Natural products include botanical agents, vitamins, minerals, and special diets, whereas mind-body practices include such approaches as massage therapy, yoga, chiropractic, and acupuncture. The diversity and varied scientific plausibility of practices included under the umbrella of CHAs highlights the importance of evaluating the specific merits of individual therapies and methods (some of which, eg, vitamin supplements, may be considered either CHAs or conventional depending on the context in which they are being used). The use of CHAs is common among adults,4–6 and population-based data indicate that the use of these therapies is as high as 12% in the general pediatric population.7–9 CHAs are used more commonly in children of parents who use these therapies themselves and are associated with higher levels of parental education.10–13 Significant variability has been reported among selected outpatient and inpatient pediatric groups.11,12,14–20 The use of CHAs does appear to be widespread among children with chronic medical conditions.21–27 High rates of use have also been reported among children with developmental and behavioral disorders, including ASD, attention-deficit/hyperactivity disorder (ADHD), and other developmental-behavioral disorders.13,28–40 There has been increased interest in research into CHAs over the past 20 years. The National Center for Complementary and Alternative Medicine (renamed NCCIH) was created in 1998 for the purpose of investigating complementary and alternative practices using the methods of rigorous scientific study and disseminating authoritative information regarding CHAs to the public and professionals. Unfortunately, few NIH-funded projects related to CHAs have been directed at issues relevant to pediatrics, and limited information has been developed proving or disproving the value of specific complementary health approaches. How to Evaluate Therapies Families of children with developmental and behavioral disorders, and the clinicians caring for these children, should ask certain questions to help them identify therapies that have an insufficient evidence base or are scientifically implausible. These questions can be grouped into 3 main categories that pertain to the theoretical basis of the therapy, the evidence base of the therapy, and the tactics used to promote the therapy (Table 24.141,42).
Scott M. Myers, MD, FAAP
Table 24.1. Twelve Questions to Ask About a Complementary or Alternative Therapies(41,42) |
Questions related to the underlying theoretical basis for the therapy |
1. Is the treatment based on a theory that is overly simplistic? |
2. Is the treatment based on proposed forces or principles that are inconsistent with accumulated knowledge from other scientific disciplines? |
3. Has the treatment changed little over a very long period of time? |
Questions related to the scientific evaluation of the therapy |
4. Is it possible to test the treatment claim? |
5. Have well-designed studies of the treatment been published in the peer-reviewed medical literature? |
6. Do proponents of the treatment cherry-pick data that support the value of the treatment, while ignoring contradictory evidence? |
7. Do proponents of the treatment assume a treatment is effective until there is sufficient evidence to the contrary? |
8. Do proponents claim that a particular treatment cannot be studied in isolation but only in combination with a package of other interventions or practices? |
Questions related to the promotion and marketing of the therapy |
9. Is the treatment promoted as being free of adverse effects? |
10. Is the treatment promoted primarily through the use of anecdotes? |
11. Do proponents of the treatment use scientific-sounding but nonsensical terminology to describe the treatment? |
12. Is the treatment promoted for a wide range of physiologically diverse conditions? |
Evaluating the Theoretical Basis of a Therapy
Therapies considered complementary and alternative have diverse origins and arise from a variety of theoretical frameworks. The following questions can help identify therapies that have a weak theoretical foundation:
1.Is the treatment based on a theory that is overly simplistic?
2.Is the treatment based on proposed forces or principles that are inconsistent with accumulated knowledge from other scientific disciplines?
3.Has the treatment changed little over a very long period of time?
Many of the nonstandard therapies used in children with developmental-behavioral disorders are based on hypotheses that do not account for much of what we already know about the neurobiology of these disorders. For example, the belief that ASD is caused by a discrete toxic environmental insult has gained traction, facilitated by the rapid spread of misinformation on the Internet. While environmental factors that modify disease expression certainly should be explored even in disorders that have a strong genetic basis, therapies (eg, chelation therapy) based in a belief about the role of some environmental trigger are unjustified in the absence of good evidence that the particular environmental factor is actually etiologically related to the disorder. There should also not be a blind leap to link associated medical issues to the etiology of a particular developmental-behavioral disorder. For example, even if medical issues, such as gastrointestinal dysfunction, occur more commonly in children with ASD, it does not necessarily follow that these issues are causally related to the core neurobehavioral features—to contend otherwise necessitates that a body of evidence about the neurobiology of ASD be disregarded. While treating a GI problem, or any other associated medical problem, is certainly important for the overall health and comfort of a child with a developmental-behavioral disorder, the claim that treatment of these associated medical issues should ameliorate core neurobehavioral features is currently not supported by available evidence. One should look no further than trisomy 21 to find a disorder in which various gastrointestinal and immune abnormalities are common but not related in a cause-effect manner to the fundamental neurodevelopmental issues.
Certain complementary health approaches also appear to be quite disconnected from what we already understand about how the natural world works. Therapeutic touch, for example, is based on the belief that an energy “biofield” exists in proximity to the human body and that imbalances in this energy field are responsible for human disease (including developmental disturbances). Practitioners of therapeutic touch believe that this energy field can be manipulated manually and can result in objective improvements in some aspect of physical functioning. This theory is fundamentally inconsistent with much of the accumulated knowledge in biology and physics. While people may certainly experience subjective improvement in some symptom after undergoing therapeutic touch, the mechanism for this improvement is likely based in placebo effects and not in the adjustment of “energy” imbalances. Another energy-based practice, acupuncture, also illustrates the principle that therapies remaining unchanged for many years (or centuries) may not be undergoing the error correction that is a necessary element of scientific practices.
While the scientific investigation of novel therapies is an important pursuit and is a primary mission of NCCIH, some therapies do not merit any further study given that their underlying theoretical basis is so implausible or at odds with an accumulation of reliable, reproducible knowledge from other scientific disciplines. The appropriateness of considering plausibility in determining which novel therapies are worthy of formal investigation is especially relevant when research resources are limited.
Evaluating the Evidence Base for a Therapy
The question of whether a particular treatment can actually do what it claims to do is a fundamental issue that should concern clinicians who care for children with developmental-behavioral disorders. Several questions can shed light on whether there is an adequate evidence base to support the use of a specific therapy. Is it possible to test the treatment claim? Have well-designed studies of the treatment been published in the peer-reviewed medical literature? Do proponents of the treatment cherry-pick data that support the value of the treatment while ignoring contradictory evidence? Do proponents of the treatment assume a treatment is effective until there is sufficient evidence to the contrary? Do proponents claim that a particular treatment cannot be studied in isolation but only in combination with a package of other interventions or practices?
The evidence base for CHAs in developmental-behavioral disorders remains quite limited, and some of the most widely used therapies are not supported by any published studies. Summary recommendations for the use of various complementary health approaches in developmental-behavioral disorders are outlined in Table 24.2. There is insufficient evidence to indicate any broad value for the various alternative medical systems (traditional Chinese medicine, Ayurvedic medicine, naturopathy, and homeopathy) in the treatment of developmental-behavioral disorders. There have been efforts to test traditional Chinese medicine methods in developmental-behavioral disorders including ADHD, cerebral palsy, and intellectual disabilities, although significant methodological deficiencies limit any conclusions that can be drawn from these studies. Homeopathy, which has a highly questionable scientific basis, has not been shown to be beneficial in the treatment of ADHD.43
Mind-body practices, including sensory integration therapy, massage, auditory integration training, and chiropractic manipulation, have a similar lack of supporting evidence. Although sensory integration therapies enjoy widespread use among children with developmental-behavioral disorders, there is limited evidence supporting the therapeutic value of these methods,44 and further rigorous research is needed. A number of studies of massage in infants have been published, but there is not convincing evidence of measurable developmental benefits in preterm or low birth weight infants or in children with ASD.45,46 Similarly, there have been several trials of auditory integration training (which is based on the hypothesis that abnormal auditory perception contributes to various developmental and behavioral symptoms) in children with ASD, but there is not sufficient evidence to support its use.47 Other manipulative or body-based practices, including optometric visual training, craniosacral therapy, and chiropractic manipulation, lack scientific plausibility and do not have any current role in the treatment of children with developmental-behavioral disorders. Children with trisomy 21 and atlantoaxial instability may be particularly susceptible to injury from chiropractic manipulation.
Table 24.2. Summary Recommendations for the Use of Selected Complementary and Alternative Therapies in Developmental-Behavioral Disorders Based on Available Evidence |
Not recommended: insufficient or absent empiric support (or strong evidence of inefficacy), low plausibility |
• Homeopathy |
• Chiropractic |
• Auditory integration therapy |
• Vestibular stimulation |
• Vision therapy, visual perceptual training |
• Reflexology |
• Craniosacral therapy |
• Patterning, Doman-Delacato method |
• Acupuncture |
• Therapeutic touch |
• Magnet therapy |
• Reiki, Qi gong |
• Hypnosis |
• Pharmacological doses of vitamins (except in known metabolic disorders) |
• Herbal remedies |
• Chelation therapy |
• Secretin in ASD |
• Hyperbaric oxygen |
• Antifungal agents |
• Antiviral agents |
• Antioxidants |
• Immunoglobulins |
• Stem cell therapy |
• Gluten-free, casein-free diet in ASD |
More research needed: limited empiric support, limited plausibility |
• Biofeedback, EEG/EMG biofeedback |
• Meditation, relaxation techniques |
• Music therapy |
• Massage |
• Sensory integration therapy |
• Omega-3 fatty acids |
• Oxytocin |
• Transcranial magnetic stimulation |
Adequate empiric evidence to support current use |
• Melatonin for prolonged sleep latency |
Abbreviations: ASD, autism spectrum disorder; EEG, electroencephalogram; EMG, electromyogram.
Electroencephalographic biofeedback has been promoted for the treatment of children with ADHD and remains under investigation. However, it is not yet a well-validated treatment approach in this population. Meditation and relaxation training have been investigated in children with ADHD, cerebral palsy, and intellectual disabilities, and short-term improvements in certain behavioral measures have been observed in some studies.
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