IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

J.2

MISCELLANEOUS

TRADITIONAL AND
ALTERNATIVE MEDICINETREATMENTS IN CHILD AND
ADOLESCENT MENTAL HEALTH
2019 edition
Nerissa L Soh, Garry Walter

Nerissa L Soh B Med Sc, M
Nutr Diet, PhD, APD.
Honorary Associate, The
University of Sydney Northern
Clinical School, Sydney,
Australia.
Conflict of interest: None
declared.

Garry Walter MD, PhD,FRANZCP

Blood letting

Honorary Professor, The
University of Sydney Northern
Clinical School, Sydney,
Australia & Adjunct Professor,
Department of Psychiatry,
Faculty of Medicine, Dalhousie
University, Canada.
Conflict of interest: None
declared.

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the editors or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2019. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Soh NL, Walter G. Traditional and alternative medicine treatments in child and adolescent mental health. In Rey
JM, Martin A (eds), JM Rey’s IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Childand Adolescent Psychiatry and Allied Professions 2019.

Traditional and alternative medicine J.2

1

IACAPAP Textbook of Child and Adolescent Mental HealthTraditional medicine is defined by the World Health Organization(WHO) as “the sum total of the knowledge, skills and practices
based on the theories, beliefs and experiences indigenous todifferent cultures, whether explicable or not, used in the maintenance of
health, as well as in the prevention, diagnosis, improvement or treatmentof physical and mental illnesses” (p15) (World Health Organization,2013). Traditional medicine spans a wide range of therapies, from herbal
or medicinal treatments to physical and procedural treatments such as
massage, acupuncture, yoga, and spiritual and mind-body therapies.
When traditional medicine is used in populations for which it is notindigenous—such as in a developed country—it becomes known ascomplementary and alternative medicine (CAM). In this chapter, we will
use traditional medicine and CAM interchangeably and refer to Western
conventional treatments, which have a scientific basis, as orthodox orscientific medicine.
The reasons people choose to use CAM vary widely by country andcommunity and the consumer profile also varies by age, socio-economic
status and gender (WHO, 2013). CAM is popular with the generalpublic in developed countries, although the level of scientific evidence for
efficacy is at best modest. In the case of child and adolescent psychiatry,the evidence is particularly scarce, partly due to ethical concerns in
conducting trials in this age group. In some Asian and African countries
traditional medicine forms the primary mode of health care for 80% of
the population (World Health Organization, 2008). Often, a patient
will have already used CAM treatments before seeing a psychiatrist and,
although much of the literature focuses on adults, children from such
cultural backgrounds may well have been treated with the same remedies
before presenting for clinical assessment.
In many countries, traditional and scientific medicine often go hand in
hand, with scientific medicine used to suppress symptoms and traditional
medicine to restore the body to its “natural balance.” This chapter will
review evidence for the efficacy of traditional medicine and note traditional
treatments which, effective or not, a psychiatrist or other mental healthprofessional working in such environments is likely to encounter.
Traditional beliefs or interpretations of psychiatric disorders are importantto the psychiatrist who aims to provide culturally sensitive and acceptable
therapy: some practices described in this chapter may be antiquated, but
are included for historical purposes and because there may be pocketsof traditional practice in those countries. These examples also serve tohighlight some of the challenges associated with combining traditionaland orthodox treatments, or transitioning from one form of treatment toanother. The chapter is organised by treatment type (herbal medicines,
meditation, trance, sorcery, religious healing, and acupuncture) and whereappropriate by condition (e.g., anxiety, depression, schizophrenia). Safety
and adverse events are also presented where relevant.

Traditional and alternative medicine J.2

Click on the picture to hear
Simon Singh talk aboutalternative medicine.

“Decoction is a methodof extraction, by boiling,of dissolved chemicals or
herbal or plant material,
which may include stems,roots, bark and rhizomes.
Decoction involves firstmashing, and then boiling inwater to extract oils, volatileorganic compounds, andother chemical substances.”(Wikipedia)

2

Traditional and alternative medicine J.2

Depression

Anxiety

ADHD

•

•

•

Indications

As an extract. Active
compounds are thought
to be hypericin and/or
hyperforin

Administration/mechanism••

RCT in children and adolescents with
ADHD found no difference between St
John’s wort and placebo

Open label trials have indicatedchildren with (mostly mild) depression
improve significantly. More rigorous
larger trials showed no significant
benefit.

Evidence of efficacy

•

•
•

•

•
•

Well tolerated
Potentiate serotonergic effects of selective
serotonin reuptake inhibitors and triptans
Reduces anticonvulsive effects of carbamazepine
and phenytoin
Reduces bronchodilator effects of theophylline
Interactions with many other drugs andmedications, including non-psychotropic drugs
Seizures from overdose

Comments and adverse effects

Long-chain omega-3 fatty•
A few RCTs have been undertaken
acids (eicosapentaenoic•
Well tolerated and safe even at high doses
in children with depression or bipolarand docosahexanenoic)•
Relatively mild side effects:
disorder, but used biologically active
improve cell membrane• Depression•
Gastrointestinal problems (e.g., diarrhoea)
placebos. Modest improvements in
fluidity, are precursors•
Fishy breath or aftertaste
those taking omega-3 supplements
to less-inflammatory• ADHD•
Skin rashes and urinary problems are rare•
RCT in youths at risk of psychotic
cytokines, and may
Omega-3 fatty•
At high doses, can increase the risk ofdisorder: those treated with omega-3
alter expression of• Bipolar
acids
bleeding
had significantly reduced symptoms
neurotransmitter
disorder•Careshould be taken in patients with a pre-existingand improved functioning comparedreceptors.
haematological condition• Schizophrenia Children with ADHD havewith placebo•
Concerns of heavy metal contaminants from•
Most data showed no benefit forlower blood levels ofmarine sources of omega-3
ADHD
long-chain omega-3s thanchildren without ADHD
*Rey et al, 2011; Soh & Walter, 2008; Arnold et al, 2013; Clayton et al, 2007; Müller et al, 2006; Millward et al, 2008; Feucht & Patel, 2011.

St John’s Wort
(Hypericum
perforatum)

Treatment

Table J.2.1. Summary of Common Herbal Complementary and Alternative Treatments Used in Developed Countries for
Psychiatric Conditions in Children and Adolescents*

IACAPAP Textbook of Child and Adolescent Mental Health3

Traditional and alternative medicine J.2

ADHD

ADHD

Vitamins
and Minerals(MicroNutrients)

Autistic spectrum
disorderADHD

Anxiety

Anxiety

Indications

Gingko biloba

Eliminationand exclusion
diets

Lemon balm
(Melissa
officinalis)

Valerian(Valeriana
officinalis)

Kava (Pipermethysticum)

Treatment

Oral

Oral

Removal of gluten andcaseinRemoval of dietary
substances (mostly
artificial flavours andcolours, salicylates)
which are associated withhyperactivity

Valerian root extract
combined with lemonbalm leaf extract

As an extract

Administration/mechanism

•

•

•

•
•

•

•

•

No evidenceNo effect on ADHD

Conflicting results from two studies
assessed in Cochrane review

Trials show conflicting results
Some children may be sensitive toparticular food chemicals and thus
benefit from those chemicals being
removed from their diets

In combination, low doses reduced
state anxiety in healthy young adults,
in a cross-over study
Open-label study in children withrestlessness and dyssomnia showed
improvement in symptoms, but tests ofsignificance were not conducted

In adults, RCTS showed kava reduced
anxiety symptoms but other RCTS
found no improvement

Evidence of efficacy

Table J.2.1 (cont.)

•

•

•

•

•

•

•
•

Vitamins and minerals only needed to meet
nutritional requirements in children with ADHD

Risk of subdural or anterior eye bleeds

Depending on which foods or nutrients are
removed, the restrictions of an elimination dietmeans a child can be put at risk of other nutritional
deficiencies
The diet places a burden on parents and children,in terms of time, lifestyle changes and finances
Exclusion diets not recommended as standard
treatment in autistic spectrum disorder

Inadequate evidence to recommend use in children

Hepatotoxicity
Not recommended for use in children

Comments and adverse effects

IACAPAP Textbook of Child and Adolescent Mental Health4IACAPAP Textbook of Child and Adolescent Mental Health

EVIDENCE FOR COMPLEMENTARY AND
ALTERNATIVE MEDICINES
Herbal and Dietary Therapies
In Western, high income societies, CAM used in treating child and adolescent
psychiatric conditions include St John’s wort for depression, kava for anxiety,omega-3 fatty acids for attention deficit hyperactivity disorder (ADHD) anddepression, elimination diets for autism and ADHD, and valerian and lemonbalm for anxiety. This is not exclusive to high income countries and avoidanceof some foods as a means of managing autistic behaviours has also been usedin Kenya (Gona et al, 2016). The evidence or lack thereof for these treatments’efficacy has been reviewed and discussed elsewhere (Rey et al, 2011; Soh &Walter, 2008; Arnold et al, 2013) and is summarised in Table J.2.1. Additionally,
homeopathy may be considered an herbal treatment. Homeopathy uses serial
dilutions of source materials with succussion (shaking) at each stage. Considering
the resulting, extremely diluted solutions, there would not be any of the source
substances remaining in the tincture or decoctions administered. Homeopathy
has been used to treat ADHD, but a Cochrane review found “no evidence that
homeopathy has a significant impact on the overall severity, core symptoms
or related outcomes of children diagnosed with attention deficit hyperactivity
disorder” (p12) (Heirs & Dean, 2007).
While it is likely a psychiatrist will find that patients from such backgrounds
have used herbal treatments before presenting for assessment, this does not meanthat the traditional medicines are (or are not) effective.

Schizophrenia
A number of herbal remedies from China and India have been traditionallyused to treat schizophrenia. In China, traditional medicine, including herbal
medicines, was the main treatment for psychiatric illnesses until the adventof antipsychotic medications. A review of Chinese herbal medicines foundno evidence that herbs on their own were more effective than antipsychotic
medications, but there was a possibility of benefit by adding the herbs to an
antipsychotic regimen (Rathbone et al, 2010). Herbal remedies may also attenuate
the adverse effects of antipsychotic drugs, such as constipation, thus promoting
compliance. None of the seven RCTs reviewed trialled herbs against placebo.
The studies were conducted in adults and used a range of herbal medicines: twodifferent versions of dang guicheng qi tang (five or seven different herbs) with anadditional 17 herbs used as needed for “blood stagnation” and hallucinations,
restlessness, and insomnia; xiaoyao san (a mixture of 10 herbs); ginkgo biloba;
xingshen (containing seven herbs); or a combination of Hirudo seu Whitmania
and the rhizoma of Rheum palmatum. When gingko biloba was combined with
antipsychotic medication, it yielded greater improvement in schizophrenia
patients’ mental state compared with the combined results of the other herbal
data, though the reviewers cautioned that trials were very small. The studies ofChinese herbal medicine for schizophrenia assessed in that review were publishedfrom 1987 to 2001. Their quality was modest at best: not all studies provided the
dosages for herbs or antipsychotic drugs and not all studies were double blind.
Another issue is that only one of the studies followed the traditional Chinese

Traditional and alternative medicine J.2

Click on the image to hear
Drs Steven Novella, Harriet
Hall, David Gorski, andRachel Dunlop discuss socalled “alternative” medicine.
What kinds of treatments
does that term include? Are
these treatments effective
or even ethical? How
can practitioners be held
accountable for the services
they provide? (58:48)

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IACAPAP Textbook of Child and Adolescent Mental Health

Table J.2.2. Summary of Traditional Treatments
Traditional
treatment

Examples

Indications

Herbal medicine•••

Indian Ayurvedic
ChineseJapanese••••

Schizophrenia
Bipolar disorder
Tourette disorder
Depression

Meditation••

Concentrative
Mindfulness

•
•
•

ADHD
Anxiety
Depression•

Both cause and treatment;
illnesses not specified but
includes spirits and deities ascause

TranceSorcery

•
•
•
•
•
•
•

Animal sacrifices
Confessions
Exorcism
Purification ceremonies
Herbal treatments
Charms and markings
Witchcraft•

Both cause and treatment;
illnesses not specified but
includes evil spirits as cause

Astrology•

Astrologer recommends
rituals as cure•Planets’ alignment as cause;
illnesses not specified

Religious healing••

Shamanism

•
•
•
•
•
•

Faith healing (egKoranic)
Rituals and prayers
Talismans and amulets
Devil dancers
Pilgrimages
Exorcism
CharmsIncludes evil spirits anddemons as cause; illnesses
not specified

Acupuncture••

Depression
Autistic spectrum disorder

medicine’s “pattern differentiation,” where patients were assigned to one of two
herbal medicine regimens in line with traditional customizing of treatment to
the individual. Nevertheless, the potential efficacy shown by this preliminary
data indicates the need for better-quality and larger studies for these herbal
medicines.
Another traditional Chinese herbal remedy, Wendan decoction, is used forschizophrenia-like symptoms, and the herb Huperzia serrate for memory loss inschizophrenia. Deng and Xu’s (2017) review of 15 randomised controlled trials inparticipants aged 15-71 years showed that the short-term global state improved
with Wendan decoction when compared with placebo or no treatment. There
was no difference in short-term mental state when compared with antipsychotic
drugs, although the decoction was associated with fewer extrapyramidal effects.
When combined with normal- or low-dose antipsychotics there was a greater
short-term improvement than when using normal-dose antipsychotics alone.

Traditional and alternative medicine J.2

Rauwolfia serpentina
Rauwolfia serpentina is
one of the fundamental
herbs used in traditional
Chinese medicine, where
it has the name shégēn
mù (Chinese: 蛇根木) or yìndù shémù
(Chinese: 印度蛇木). It
was also used in India for
centuries to treat a varietyof conditions. Rauwolfia
serpentina contains several
bioactive chemicals,
including yohimbine, andreserpine. The alkaloid
reserpine was introduced
into Western medicine
as an antipsychotic in
1954. Although effective,
side effects lessened
its popularity. The
ability of reserpine toinduce depression (nowquestioned) and deplete
brain amines became
one of the pillars of themonoamine theory of mooddisorders.

6IACAPAP Textbook of Child and Adolescent Mental Health

A variety of materials,
vegetable and animal, areused in traditional Chinese
medicine. In this picture, lingzhi mushrooms, dried snake,turtle shells, luo han guo (atype of fruit) and ginseng.

Toxic effects ofa Chinese herbal
medicine in children– when a herb issubstitutedThus, there is a suggestion that Wendan decoction may benefit people withschizophrenia but the overall quality of the evidence is moderate to poor. The
herb Huperzia serrata (qianceng ta) contains the active ingredient, HupA, astrong reversible inhibitor of acetylcholinesterase. Ma et al’s (2007) review cited
one study related to schizophrenia, where HupA significantly improved memory
function in patients with schizophrenia.
Ayurvedic medicine, a traditional Indian medicine system, is similar in its
philosophy to traditional Chinese medicine (Agarwal et al, 2010). A Cochranereview of three RCTs, all conducted in India, found weak support for one
herbal medicine (brahmyadiyoga) being more effective in treating schizophrenia
than placebo, but it does not appear to be more effective than chlorpromazine.
Brahmyadiyoga was also associated with nausea and vomiting. The studies were old(one published in 1976 and two in 1992) and short term. Psychiatrists working
with patients from Indian subcontinent backgrounds should be aware that theirpatients may have used such traditional treatments prior to presentation or may
continue using them.
The above studies of Chinese and Indian herbal medicines were conducted in
adults, and schizophrenia is less commonly diagnosed in children and younger
adolescents. Thus, caution is warranted in extrapolating such preliminary results
to the younger population.

Depression and Anxiety
A range of herbal treatments in both high- and low-income countries havebeen used for treating depression and anxiety, for example, St John’s wort
(hypericum perforatum) (see also table J.2.1). Other herbal medicines in Japanand Persia are also traditionally used to treat depression and anxiety.
Sarai (1992) reviewed herbal medicines used in Japan, among them: saikokaryukotu-borei-to for anxiety and depression; yokukan-san-ka-chinpi-hange foragitated depression and nightmares; choto-san for headaches; and hoch-ekki-to for

Traditional and alternative medicine J.2

In 1993, the Centres for
Disease Control (US)published a report of threecases of jin bu huan toxicity
in children in Colorado,
US (Horowitz et al, 1993).
Jin bu huan is a Chinese
herbal medicine used as
an analgesic. In all threecases, the children (aged
13 months to 2 ½ years)
presented with lethargy:
two had low respiratory
rates and were initiallyunresponsive. Analysesof the jin bu huan tablets
showed they contained 36%
levo-tetrahydropalmatine
by weight. This substanceis found in the plantgenus Stephania, not
Polygala (Polygala being
the genus of the plantingredient listed in thetablets’ packaging). The
children’s reactions to thetablets were also consistent
with those observed inanimals exposed to levotetrahydropalmatine andsuggests that a herb
substitution had occurred.
In one case, the child hadingested 60 of the tablets,
prompting the authors torecommend child-proof
packaging for herbal
medicines.

7

IACAPAP Textbook of Child and Adolescent Mental Health“exhausted depression”. Each of these herbal medicines is a complex combinationof herbs. A novel aspect of Sarai’s paper is that the ingredients for each medicine
are listed, including quantities and dosages. However, Sarai also noted that no
double blind controlled trials were available to test for efficacy. Further, thestudies cited were in vitro and animal studies and the mechanism of action ofthese medicines are mostly unknown. Thus, efficacy in humans is not known.
Akhondzadeh et al (2005) investigated the efficacy of saffron (dried stigmas of
Crocus sativus flowers), a traditional Persian treatment for depression. A doubleblind RCT in 40 adults with mild to moderate depression found those taking acapsule of 15g dried saffron extract/day had significantly improved at six weeks
and this improvement was greater than that experienced by the placebo group.
The participants were free of psychotropic medications for at least four weeks
before the start of the study. Side effects reported were mild. This is the firstclinical trial of saffron as a treatment for mild to moderate depression and thesample size is small. Thus, larger trials are required. A practical issue is the costof treatment as saffron is the most expensive spice in the world.

Borderline Personality Disorder (BPD)
While BPD is not generally diagnosed in adolescents, borderline featuresoften emerge at this age. The Chinese herb yi-gan san was originally used for
restlessness and agitation in children in the 16th century and more recently has
been used in Japan to treat behavioural and psychological symptoms in dementia.
A 12-week open-label study investigated yi-gan san as a monotherapy in adults
with BPD (Miyaoka et al, 2008). There were significant reductions in a variety ofsymptoms at week 2 and 12. Side effects were mild and few. The study was single
blind—the authors conceded a double blind study could not be conducted as
the herbal powder mixture had a distinctive taste and smell and an appropriate
placebo could not be developed.

Ayurveda
Ayurvedic medicine (alsocalled Ayurveda) is one of
the world's oldest medical
systems. It originated inIndia and has evolved
there over more than 3,000
years. The term "Ayurveda"
combines the Sanskrit
words ayur (life) and veda
(science or knowledge).
Thus, Ayurveda means "theknowledge of life" (Agarwal
et al, 2010). The aim of
Ayurvedic medicine is tointegrate and balance thebody, mind and spirit. Thisbalance is believed to leadto happiness and health,and to help prevent illness.
Ayurvedic medicine also
treats specific physical andmental health problems.
A chief aim of Ayurvedic
practices is to cleanse thebody of substances thatcan cause disease, thus
helping to re-establish
harmony and balance.

Attention Deficit Hyperactivity Disorder (ADHD)
A quick internet search reveals that a multitude of herbs and home remedies
are promoted as “natural” treatments for ADHD (see Chapter D.1.1 of theeBook). Gingko biloba, St John’s wort, valerian, kava-kava, and chamomile do
not improve ADHD symptoms (Arnold et al, 2013). A small trial of Pycnogenol(US registered trademark name for a product derived from the pine bark of
the tree Pinus pinaster) improved some symptoms of ADHD when comparedto placebo, but the safety of Pycnogenol has not been established (Arnold et al2013).

Adverse Effects of Traditional Herbal Treatments
In terms of safety, caution is warranted for herbal medicines overall. That an
herbal remedy has been used for centuries for religious or medicinal purposes does
not necessarily mean it is safe, and apparent lack of toxicity in the short term does
not guarantee the herb is not toxic with chronic use. Also, contaminants suchas heavy metals, pesticides and herbicides, may be significant toxins themselves(Gardiner & Kemper, 2000; Arnold et al, 2013). Drug-herb interactions are also
cause for concern, St John’s wort being a case in point. In other examples, kava,
which is not recommended for paediatric use (Rey et al, 2011), may potentiatebenzodiazepines, alcohol and central nervous system depressants, and valerian

Traditional and alternative medicine J.2

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IACAPAP Textbook of Child and Adolescent Mental Healthmay potentiate sedatives and barbiturates (Gardiner & Kemper, 2000).
Quality control of herbal medicines should also be considered as the quantityof active compounds may vary from dose to dose and according to the quality of
the herbs used in their preparation. Thus, a dose of traditional herbal medicine
may contain levels of active compounds too low to have an effect, or so highas to be toxic. There are situations where herbs within a prescribed mixture
have been substituted with another which is toxic (see Box), or conventional
pharmaceutical compounds have been included in a herbal medicine mixture(see Box ) (Kenny et al, 2001). These concerns make it necessary for clinicians
to ask patients and their families about the use of any herbal medicine. Patients
will not necessarily disclose use. Reasons for not doing so include fears theirclinician will disapprove or not want to know about it (Walter & Rey, 1999),
although a survey of Australian psychiatrists regarding St John’s wort shows thisis not necessarily the case, and that very few psychiatrists would be dismissive of
the information (Walter et al, 2000).

Conclusion
Overall, there is inadequate evidence that herbal remedies are effective
as primary treatments for mental conditions, particularly in the paediatricpopulation.

PHYSICAL AND PROCEDURAL THERAPIES
Apart from herbal and medicinal CAM, there are also procedural CAM
therapies used to treat psychiatric disorders. Music therapy, hypnosis andacupuncture are the better known examples in Western countries; other traditional
therapies that may be considered procedural include yoga, meditation, Qi Gong
and Tai Chi.

Hypnosis

In the case of hypnosis, Cochrane reviews found insufficient evidence tosupport its efficacy in the treatment of schizophrenia. Nevertheless, hypnosis
does not appear to have adverse effects and some patients found that it provided
short-term benefits. However, the studies reviewed were conducted in adults
only and are quite old, being published in 1973, 1983 and 1980 (Izquierdo deSantiago & Khan, 2009). Hypnosis has been used to treat conversion disorder, inboth inpatient and outpatient settings. There is weak evidence that hypnosis may
be more beneficial than harmful, but effects on social functioning, interpersonal
relationships and quality of life, and long term efficacy, are not known (Ruddy& House, 2005).

Music therapy
A Cochrane review assessed five RCTs of music therapy, but there weredistinct differences in the type of music therapy used. Only one study was
conducted in adolescents and the rest were conducted in adults. Four of the fivestudies (including the one of adolescents) found that patients undergoing music
therapy had fewer depressive symptoms compared to those given standard care(hospitalisation and medication), psychotherapy, or wait-list controls, while thefifth study found music therapy yielded no significant change in mental state
when compared with standard care alone (Maratos et al, 2009). Overall, theTraditional and alternative medicine J.2

Music therapy is theplanned and creative useof music to attain andmaintain health. Music
therapy focuses on meetingtherapeutic aims, which
distinguishes it frommusical entertainment ormusic education. Music
therapists seek to help
patients improve theirhealth across various
domains (e.g., cognitive
functioning, motor skills,
emotional and affective
development, behaviourand social skills, and qualityof life) by using musicexperiences (a diverse
range, e.g., singing, songwriting, listening to anddiscussing music, moving
to music) to achieve
treatment goals.

9IACAPAP Textbook of Child and Adolescent Mental Healthstudies were of low quality and had small sample sizes. Also, there was great
heterogeneity in the delivery of music therapy, such as a structured program
compared with a more passive and unstructured approach of simply listening
to music. The reviewers concluded that music therapy has at least short term
benefits in improving mood above those of standard care alone but it is still not
clear whether music therapy is an effective treatment for depression.

AutismA Cochrane review found music therapy could significantly improve bothverbal and non-verbal communicative skills in children with autism spectrum
disorder in the short term, although there was no significant improvement inbehavioural problems when compared to placebo treatment (Gold et al, 2006).
Only three studies met the criteria for inclusion in the review, all had very small
sample sizes and it is not known whether improvements in communication skills
were maintained in the long term. Gold and his colleagues cautioned that music
therapy should be conducted by individuals who have academic and clinicaltraining in this field.

Psychosis
A quasi-randomised controlled trial of a two-week active music therapy
program for patients during an acute psychotic episode was conducted as an
adjunct to medication. This trial found significantly reduced Brief PsychiatricRating Scale scores (total and subscale scores) in both treatment and control
groups, with the treatment group’s scores significantly lower than that of thecontrols (Morgan et al, 2011). The difference in improvement was not sustainedat follow-up, although both groups’ scores decreased significantly over time.
The length of hospital stay was reduced by two days in patients receiving music
therapy but this was not statistically significant.

Dance Therapy

Dance therapy has been defined as “the psychotherapeutic use of movement as
a process which furthers the emotional, social, cognitive, and physical integrationof the individual.” One single blind RCT found no evidence to support, or notsupport, dance as an adjunct to routine care in adults with schizophrenia, whencompared with routine care alone (Ren & Xia, 2013).

Acupuncture

Acupuncture—a traditional treatment in the Far East (China, Japan)—has become popular worldwide. In acupuncture, fine needles are inserted into
different points on the body to correct energy imbalances.

Depression
A Cochrane review of acupuncture as treatment for depression in adults isavailable; it assessed seven trials but found insufficient evidence to support its
effectiveness (Smith & Hay, 2004).

Schizophrenia
A review of 30 RCTs of acupuncture as a treatment for schizophrenia – alone
or combined with antipsychotics – found limited evidence of acupuncture
having antipsychotic effects (Shen et al, 2014).

Traditional and alternative medicine J.2

Mindfulness:
modernized
meditation?
In recent decades,
mindfulness-based
therapies have become
fashionable in developed
Western countries. These
include mindfulnessbased stress reduction(developed in the late1970s) for managing
stress, mindfulness-based
cognitive therapy for
managing depression,
dialectic behaviour therapy(which includes mindfulness
as one of its elements) andacceptance commitment
therapy. These therapies
are based on Buddhism,
yoga and meditation andgenerally focus on positive
alternatives and nonjudgemental acceptanceof symptoms (Dryden &Still, 2006). Mindfulnessbased therapies also
attempt to utilize only the
essence of meditation
and remove the cultural,
traditional and/or religious
elements associated with it.
Research into mindfulnessbased therapies is still
preliminary in children
and adolescents, withsmall study samples
and heterogeneous
methodologies (Burke,2010). Studies haveinvestigated both clinical(e.g., ADHD, sleep
disorders, anxiety) andnon-clinical samples forthe impact of mindfulness
therapies on social
skills, anxiety, attention,
depression, sleep
quality, substance use,aggression, behaviour,
general mental health andacademic performance.
At this stage, researchshows the therapies canbe administered and are
well accepted by children
and adolescents, but theirefficacy in this population is
not yet known.

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IACAPAP Textbook of Child and Adolescent Mental Health

Yoga
Yoga, a spiritual practice originating in India, is also used in Western societies
for relaxation and as exercise. While there has been interest in yoga in thetreatment of schizophrenia, a systematic review of six RCTs found yoga was not
more effective than other forms of exercise when used as adjunctive treatments
for schizophrenia (Broderick et al, 2017). This included no greater effectivenessin terms of mental state, social functioning, quality of life, and physical health.
Therefore, there is insufficient evidence to support yoga over other forms of
exercise or vice versa. It was not clear whether the participants were also being
treated with conventional antipsychotic medications at the time, and the qualityof the studies was low. However, there were no reported adverse events.

Meditation
Meditation is used in both religious and secular settings and may help
achieve relaxation and an altered state of consciousness. The latter potentially has
cognitive-behavioural benefits (Krisanaprakornkit et al, 2010b). Meditation canbe divided into two types: concentrative, where attention is focused on an object
and aims to achieve sustained attention and stillness of the mind, and mindfulness,where there is an open awareness to any thoughts and the practitioner aims todevelop a sustained attentiveness without reacting to their thoughts or emotions(Krisanaprakornkit et al, 2010a).

Anxiety and Depression
Two RCTs of meditation as a treatment for anxiety in adults reported only
slightly supportive evidence for its efficacy, similar to that of relaxation therapy(Krisanaprakornkit et al, 2010b). Both studies were conducted in the US
and the reviewers were not able to identify any studies from India, China or
Thailand which met their inclusion criteria. This is a potential bias as meditation
techniques originated in the East and may be practised more purely in thosecountries. Another systematic review (Goyal et al, 2014) found that mindfulness
produced small improvements in anxiety and depression, but not mantra
meditation, when compared to active controls. However, neither mindfulness
nor mantra meditation were more effective than active control interventions
such as cognitive behavioural group therapy, exercise or progressive muscle
relaxation. Goyal et al (2014) also reported that few trials investigated adverse
effects. Meditation may be a useful adjunct to conventional treatments but larger
trials of better quality are required to show its effectiveness (Krisanaprakornkit etal, 2010b). In summary, there is no evidence to show that meditation is superior
to medication or other psychotherapies.

Attention Deficit Hyperactivity Disorder (ADHD)
A review assessed four RCTs in children but found the quality of the studies tobe poor and there was insufficient evidence to recommend meditation in treating
ADHD (Krisanaprakornkit et al, 2010a). A Dutch pre-post trial of an eightweek mindfulness program for children aged 8-12 years with ADHD and theirparents reported significant reductions in ADHD behaviour rated by the parents(inattention, hyperactivity/impulsivity) but not when rated by the teachers(except for inattentive behaviour) (van der Oord et al, 2012). The children were

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IACAPAP Textbook of Child and Adolescent Mental Healthstill following their medication regimens. The program was intensive and its
cost-effectiveness is not yet known, nor its potential effectiveness in low andmiddle income countries.

QigongQigong is a traditional Chinese practice of mind, body, and breathing
regulation that seeks to restore the flow of “Qi” (life energy) via gentle focused
exercises for the mind and body (Hartley et al, 2015). Qigong Sensory Training—
also called Kai Qiao Tuina (Silva et al 2011a)—is a manual-based therapy thathas been used to treat children with autism (Silva et al, 2011b). Qigong Sensory
Training comprises a protocol that applies 12 patting, shaking, and pressing
movements to 12 body areas and can be delivered by occupational therapists orparents.
Randomised controlled trials suggest that Qigong Sensory Training may
improve behavioural, social, and language measures in children with autism, as
well as their sensory impairment and self-regulation (Silva et al, 2011a; 2011b).
However, the therapy is resource-intensive. Training and supporting parents todeliver it is a feasible alternative.

Tai Chi
A traditional Chinese mind and body exercise, Tai Chi has been trialled forthe physical and psychological wellbeing of tertiary students in China (Zheng etal, 2015). However, the RCT recruited students from the community and notfrom a clinical setting. Participants in the Tai Chi group improved their physicalflexibility and balance following 12 weeks of intervention but they did not differ
from the control group in their mood, quality of life, or sleep quality. Having
depression or a mental disorder at baseline was not a recruitment criterion andso it is unclear whether Tai Chi would benefit patients from a clinical setting.

Adverse effects and compliance issues
There is generally a dearth of information regarding adverse effects ofmeditation in children. Effectiveness and potential adverse effects aside,
meditation as an exercise or treatment requires considerable motivation anddiscipline in the same manner that physical exercise routines do, which may beproblematic in young people with anxiety or depression. Compliance concerns
were highlighted by the high drop-out rates in the two studies of meditation
and anxiety (Krisanaprakornkit et al, 2010b). However, for patients from some
cultural backgrounds, meditation may already be a routine part of their lives,
including in young people, such as in Thailand. In these settings, meditation isan accepted method of improving attention, temperament, discipline, character,morals and school performance, and is also used for religious reasons. In suchenvironments, a psychiatrist can expect the patient to have already undertaken
meditation before presenting for assessment and treatment. Interestingly, Kapur(1979) claims that in Ayurveda, the “mentally disturbed” (author’s term) areforbidden to practice Yoga, although Yoga is recommended to promote mental
growth in the healthy person.
Though uncommon, acupuncture can have adverse effects, such as headaches,
palpitations, sleep disturbance, tiredness and dryness of mouth (Smith &Traditional and alternative medicine J.2

Adulteration of
African herbal
medicinewith western
pharmaceuticals
Synman et al (2005)
presented two cases where
African herbal medicine
had been adulterated with
Western pharmaceuticals:a five year old child wasadmitted to intensive
care with seizures after
consuming a traditional
herbal infusion to treat
seizures; and a 30 year
old woman was admittedwith a ruptured uterus
following consumptionof a herbal medicine toinduce abortion. Analysesof the infusions showed
trimethadione (a drug used
to treat petit mal seizures),in the one taken by the five
year old, and propofol (ananaesthetic) and diclofenac(a non-steroidal antiinflammatory) in the herbal
medicine consumed by
the 30 year old. The herbs
used in the infusions were
unknown.
Numerous cases ofadulteration of Chinese
herbal medicines withorthodox pharmaceuticals
have been previously
reported and both Chineseand Ayurvedic herbal
medicines have been
subject to contamination
with heavy metals (Feucht& Patel, 2011), but this is
the first published reportof adulteration of African
herbal medicine withorthodox medications.

12IACAPAP Textbook of Child and Adolescent Mental Health

Incorporating traditional beliefs in a psychiatric treatment plan
Suryani and Jensen (1992) reported a case in Bali
where school children were experiencing trance en masse,causing much community disruption. Attacks were occurringfrom once to 30 times a day and continued for seven months,
with each episode spanning about 40 minutes.
Prior to Suryani’s intervention, a traditional healer,a balian, had provided treatment with ceremonies andofferings to appease gods and spirits and to compensate
for an inadvertently desecrated old and buried temple. One
village individual was blamed for the afflictions and expelledfrom the community while some of the afflicted children
were transferred to another school. These treatments did
not yield improvements, with children at the new schools
also experiencing attacks. There was an appearance ofcontagion and non-affected community members wereafraid that they would have an episode.
In her treatment strategy, Suryani settled on adiagnosis of kesurupan, meaning possession, which wasunderstood by the Balinese, accepted as a normal part of life
and also did not carry stigma. Community leaders, health,education and religious officials as well as psychiatrists
were involved. A high priest acted as primary traditional
healer, since the people believed the condition was due
to supernatural forces, as opposed to a disease. Anotherreason for selecting a traditional healer was because oflogistical problems and inadequate psychiatric resources. A
new temple in the correct orientation would be constructed(to replace a temple in the school grounds which was notcorrectly oriented according to the Hindu religion), school
teachers were to teach traditional Hindu stories about
benevolent spirits to reduce the children’s anxiety, thevillage was closed to outsiders to reduce stress and fear
from visitors (visitors and media were disturbing the normallyisolated community and expected to witness episodes), andthere was a back-up plan of individual psychotherapy. Withina month, trance episodes ceased and did not reoccur in thethree years of follow-up.

Hay, 2004). Apart from adverse effects, conducting acupuncture in children iscomplicated by children’s acceptance. Children often have a fear of needles anddo not retain needles for as long as adults, reducing treatment duration (Jindal etal, 2008). For children under 6 years of age, shorter needles are often substituted
for the conventional longer ones.
No adverse events were reported for Tai Chi (Zheng et al 2015) and it canbe expected that patients, including children, with a Chinese background may
have experienced or undertaken Tai Chi as a traditional form of exercise. Adverse
events were not reported on for Qi Gong (Silva et al 2011b).

Conclusion
There is inconsistent evidence as to the benefits of CAM procedural therapies
as primary treatment in mental conditions, particularly in the paediatricpopulation.

PRACTICES, BELIEFS AND PHENOMENA RELATEDTO MENTAL HEALTHThis section provides context and awareness for psychiatrists of a range of
traditional beliefs, practices and phenomena with regard to mental health andsome of the challenges they may encounter when managing patients for specificbackgrounds. While most of the material presented here relates to experienceswith adult patients, it is likely that children from these backgrounds may havereceived or been exposed to such practices and beliefs prior to coming to a
psychiatrist’s attention.

Religious Healing and Sorcery
Indian Subcontinent
Religious treatment in India may be conducted alone or with a guru and may
take the form of religious lectures, praying, bathing, fasting and religious rituals

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IACAPAP Textbook of Child and Adolescent Mental Health(Bagadia et al, 1979). Thus, various shrines and religious centres have evolved
therapeutic programs (rituals and lifestyles) where patients (or pilgrims) seek
religious help for their maladies. When a mental illness is deemed to be due tothe planets, an astrologer will recommend rituals as treatment (Bagadia et al,1979)). Indian Ayurvedic medicine, practiced by Vaids (a class of priests), notonly involves herbs but also spans spiritual or supernatural causes and treatments
for mental illness. An old observational study described unmada (mental illness)
as being caused by heightened activity of any of the three humors or by noxious
foods, and the resulting imbalance of heat and cold, or sexual overindulgence(Kapur, 1979). Mental illness may also be caused by evil spirits (pischachis)possessing the patient. Traditional healers (Mantarwadis and Patris), treat mental
illness on the basis that the ailment is a divine punishment for the patient’s
misdeeds, either in the present or a past life. Treatment may involve penance, apilgrimage to a shrine, talismans and a monetary fee. A Patri acts as a medium
for spirits and demons and treats a patient by going into a trance and being
possessed by a master demon. In this situation, treatment involves the Patri’s
demon either exorcising the patient’s demon, or asking the patient’s demon
what it requires to leave the patient. The latter may be a ritual feast, an animal
sacrifice, or a dwelling for the demon’s use (Kapur, 1979). Kapur reported thatthe villagers he observed patronised both Western-trained doctors and traditional
healers simultaneously.
In Sri Lanka, aduras (devil-dancers) were a popular choice of healer for mental
illnesses in some rural areas (Wolffers, 1988), with orthodox medical treatment
and Ayurveda being patronised much less frequently. Aduras use a number oftreatments, including ceremonies and fastening strings around the patient’s armor neck, and if this does not yield results, a publicly conducted exorcism may
follow. Western-style treatment would then be used if treatment by an adura
fails.

Click on the picture to watch
a lecture on Ayurveda (1hour 28 minutes) by Sudah
Prathikani MD, explaining thephilosophy behind Ayurveda
and some of the modern
research into its efficacy.

Fast East
In the Far East, the combination of religion, shamanism and the supernaturalis accepted and an individual or a community will not necessarily adhere to one
dogma over another in their concepts of mental illness. Li and Phillips (1990)
reported on witch doctors (shamans) and mental illness in mainland China,
particularly among the rural peasant population. Their methods for treating
illnesses were shamanistic and ritualistic, with a blend of Taoism, Buddhism,
and animistic beliefs. The case studies presented showed treatment rituals similar
to those described by Harrell in Taiwan. Li and Phillips reported that 70% of
patients in their psychiatric hospital surveyed admitted to consulting witch
doctors before presenting to their outpatient clinic. Li and Phillips also notedthat some rural patients never present for Western psychiatric treatment andonly used traditional folk healers (witch doctors).
Harrell (1991) reported the case of a 16-year-old female patient who
presented with psychoses in rural Taiwan in the 1970s, where he detailed a large
mixture of folk or traditional treatments as well as explanations for the girl’s
illness. Diagnoses were made by spirit mediums or Taoist fortune tellers andincluded the patient having lost her soul, being attacked by ghosts, living in ahaunted dwelling, her grandfather’s failure to produce a direct male descendant,
something being wrong with her spirit or character, and bad luck. Treatments

Traditional and alternative medicine J.2

Amulets or talismans
are objects believed topossess supernatural or
magical powers. They areintended to bring good luck,
protection or health to theirowner.

14

IACAPAP Textbook of Child and Adolescent Mental Healthincluded writing of charms on spirit money or paper whichwere then eaten, used to make infusions for drinking orbathing in, or hung in various parts of the girl’s dwelling,placating ghosts and ancestral spirits with ritualistic foodofferings and burning of spirit money and incense. In
this case, orthodox medicine was only used to provide asedative. Harrell observed that the community this patient
lived in did not consider that there was only one cause
or diagnosis for her condition and accepted all offeredexplanations, including retrospective ones, whereupon
the cause of the illness was decided on the basis of which
treatment (temporarily) succeeded.
In traditional Tibetan medicine, mental illness isoften described as an imbalance or disturbance of thewind humour or as a wind humour illness, with particularreference to the life-bearing wind. The term srogrlung may
describe depressive or anxiety symptoms and may also
include episodes of panic and psychosis (Jacobson, 2007;
Millard, 2007). Thus, an individual may report having
high wind, meaning greater stress, exhaustion, hardship or
Example of an amulet which is supposed to protect
irritability. There is also stigma attached to srogrlung, andagainst the evil eye.
some patients will therefore deny having the condition.
Mental illnesses may also be attributed to harmful spirits or
gnod pa (Millard, 2007), in which case the emphasis is on supernatural origins
and reflects Tibetan religious beliefs. Herbal medicines were prescribed to treat
srogrlung while gnod pa illnesses would be confirmed by divination and treatedby lamas or local healers (jhānkri). Millard reported such treatments included
rituals and prayers to appease the spirits and fastening blessed cords (cords
blessed by lamas) about a patient’s fingers to seal a spirit inside the patient inorder to communicate with it and thus discover the reasons for it attacking thepatient.

African Continent and the Middle-East
A study in Liberia described that mental illness was traditionally believed
to be caused by breaking taboos, offending ancestral spirits and deities, being
possessed by spirits, being bewitched or having a curse applied by a witch doctor(zoe), or was inherited through the family (Hales, 1996). Some of the beliefs in
Arab societies, where illness is due to devils, sorcery, jinn (demons), the evil eye
or ill-wishing from others, also apply to South Saharan Africa (Hales, 1996)
and to the Indian subcontinent (Littlewood & Dein, 2013). Treatments include
confession to doing wrong (e.g., breaking taboos), animal sacrifices to deities
and spirits, and paying fees and exorcism, usually through physically beating thepatient. Some inherited mental illnesses are deemed incurable and patients may
be restrained or left to die (Hales, 1996). Jamaican health concepts also haveroots in African religious and supernatural beliefs, including Obeah, a conceptthat spans traditional health and medicine (James et al, 2014). Illnesses thatare considered “unnatural” would be treated by an Obeah practitioner while
illnesses considered natural (ie with physical symptoms) would be treated by theorthodox medical system. However, in Jamaica Obeah practice is illegal, unlike

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IACAPAP Textbook of Child and Adolescent Mental Healthin some African countries (James et al, 2014). These strong cultural beliefs canmake it difficult to convince patients that the supernatural does not cause theirmental illness.
Adjido (1997) discussed the association between psychosomatic medicine
and sorcery in Africa, describing sorcery as “one of the central mysteries ofAfrican life” (p266). It is difficult for outsiders to grasp and define sorcery due tothe secrecy encapsulating sorcerers’ societies, and the social and cultural barriers
surrounding sorcery enforced by the rest of African society. While not specificallyfocusing on psychiatric illnesses, Adjido noted sorcery’s role in African society,the way it permeates African cultures and that sorcerers prefer children andadolescents with “psychosomatic personalities” as “victims” (the author’s terms).
In doing so, sorcerers are able to utilize the targets’ suggestibility. Illness, throughthe lens of belief in witchcraft or sorcery, therefore results from an enemy’s orspirit’s attack, and cure is through exorcism. Adjido provided a case study of a
12-year-old boy with psychosomatic symptoms who was successfully treated withpsychotherapy and possibly magical rituals. The social history of this patient also
revealed complex family issues preceding the psychosomatic symptoms and thatritual sacrifices had been conducted for his and his mother’s protection before
the patient presented for psychiatric treatment. Adjido describes “psychosomatictransfer” being used to destroy victims by exhausting them through “a microenvironment of suggestion-induced insecurity, source of a lethal anguish” (p277),
leading to chronic illness or death. In Kenya, Gona et al (2016) reported thatsome parents believe their child’s autism is a result of “God’s wish”. There was abelief in prayer and divine intervention as a means of healing and, in some cases,
parents opted for prayers as a means of healing instead of a traditional healer(Gona et al, 2016). Ahyi (1997) investigated the traditional models of mental
illness in Benin, a West African country where the Vodun (Voodoo) religion has
its roots: these models are considered applicable to a reasonably large proportionof Africa’s population.
In the Arab world, there is common belief in Jinn possession, sorcery,
witchcraft and the evil eye as causes of mental illness. Treatment by traditional
healers, the Motawwa, is often sought first, with patients seeking psychiatrist’s
help after traditional treatments prove unsuccessful (Kronfol et al, 2013).
Traditional Arabs may seek out traditional healers to exorcise jinn (Fakhr ElIslam, 2008). Other treatments include purification ceremonies and herbal
treatments. Charms and markings are also used as prophylactics. Traditional
healers include: Dervish healers, who treat mental illnesses with religious andcultural rituals, including exorcism; amulet writers, who produce amulets
to ward off evil spirits; fortune tellers, who predict the future or diagnose byreading the dregs in patients’ coffee cups; and Koranic healers, men who treat
patients who have been attacked by evil spirits by using religious principles basedon the Koran (al-Krenawi & Graham, 1999). The Dervishes may themselves have
had psychiatric illnesses, in that a previous mental breakdown is viewed as a“blessing gift from God” (p224). There are some gender and social differences in
how patients perceive the cause of their illnesses with women citing sorcery andspirits as the cause, educated men citing divine will and punishment (religious)
causes and less educated men citing spirits. The evil eye (being the subject ofanother person’s envy) is also reported as a cause of mental health problems
in many cultures. Further, as a result of the social environment they inhabit,
women use sorcery as their means of coping with psychiatric problems.
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IACAPAP Textbook of Child and Adolescent Mental Health

Applying the Concept of Sorcery in Orthodox Treatment
Ahyi (1997), a psychiatrist, described clinical cases where he had “exorcised
sorcerers” with medication and where he successfully treated cases of witchcraft
which he called “fake witchcraft”. In effect, Ahyi explained the conventional
medical treatment within the patients’ cultural reference points. However,he acknowledged that to use such a construct is to concede there is genuine
witchcraft, which he had yet to encounter. Furthermore, some patients cometo see a Western trained psychiatrist because they relapse after consulting
traditional healers. Ahyi also highlighted the importance of social support
and the social network in such societies, which are important for the patient,beyond what medication alone can provide. This also highlights the importanceof communication with the patient. Braathen et al (2013), in their qualitative
study in rural South Africa, presented a case report that demonstrated poor
communication in orthodox treatment for a mental health problem, where thepatient and family were not told what the problem was, nor what the medication
was provided for. The situation was further exacerbated by severe shortages ofhealth professionals in general, including mental health professionals, in the area.
The patient and family were subsequently referred by a clinic nurse to traditional
healers (Braathen et al 2013).
Adjido (1997) and Ahyi (1997) show how mental illnesses are interpreted
in African societies and suggest how psychiatrists working with patients withthese cultural backgrounds may need to frame their discussions to engage thesepatients and thus provide culturally acceptable care. The traditional religious andsupernatural beliefs in South Saharan Africa lead to a common sequence of helpseeking for mental disorders: traditional healer, then a church for prayers or faithhealing, and then, if the symptoms become worse, to a hospital (Odejide et al,1989). Association with traditional and religious care systems may continue after
effective hospital treatment. Thus, for psychiatrists working with patients fromthese communities, it is likely the patients will already have sought treatment
from traditional healers and religious bodies before presenting, and will continue
to do so after receiving orthodox psychiatric care. Odejide and co-workers advise
there are cultural and social limitations to Western-style psychotherapy in Africa
due to common beliefs in the supernatural and a tendency to attribute mental
illnesses to an external cause (as inferred by Ahyi above). This parallels theattitudes of some traditional Arab patients, where patients expect psychiatrists
to cure them, as opposed to taking an active role themselves, as cognitive andbehavioural therapies require (Fakhr El-Islam, 2008).
Explaining orthodox psychiatric treatment within a patient’s culturalreference points—as Ahyi has by treating “fake witchcraft” and “exorcising
sorcery” with medication—may improve patients’ compliance with treatment
and help retain their carers’ support. Further, it may be of little practical benefit
to openly challenge patients’ beliefs regarding sorcery and the supernatural when
their family and the community they live in share the same beliefs.

DervishDervishes are individuals
who follow a Sufi Muslim
ascetic path or tariqah andare known for their extreme
poverty and austerity,
similar to the Christianmendicant friars or Hindu
sadhus.

Click on the image to hear
about the false dichotomy
between alternative andtraditional medicine, or
between Eastern andWestern medicine (6:40).

Relevance of Religious Healing and Challenges for Scientific
Medicine
The above scenarios illustrate not only the traditional treatments patients andtheir families or communities may seek for mental illness, but also how people

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IACAPAP Textbook of Child and Adolescent Mental Healthview, describe or interpret a mental illness through their cultural lens. As in thecase of sorcery, being able to engage patients and families within their culturalreference points is important for psychiatrists working with patients from thesebackgrounds. Clinicians require an understanding of the importance of spiritualbeliefs, but not necessarily to hold these beliefs personally, to allow them toaccurately access patients make suitable referrals (van Rensburg et al, 2013).
Ahyi (1997) highlighted the challenges reconciling Western and traditional
African models of mental illness. This contrasts with Suryani and Jensen’s (1992)
experiences in Bali, where both traditional and Western models and treatments
were successfully integrated in treatment. Ahyi states that in the African healing
system it is understood that some facts should not be mentioned. Further,
attributing the behaviours associated with mental illness (e.g., suicide attempts)
to another person or spirit removes guilt from patients and their families. There
are parallels to this in traditional Bedouin-Arab beliefs, where mental illness
is attributed to external, supernatural causes and patients are less likely tobelieve the illness is their own fault (al-Krenawi & Graham, 1999). Al-Krenawi
and Graham noted the difficulties Western-trained psychiatrists may face inaccurately diagnosing patients from Arabic backgrounds because patients use
proverbs, similes, and metaphors to describe their symptoms and emotions.
These descriptions are understood by traditional healers, who have the same
cultural experience and language, but can be very difficult for clinicians fromother backgrounds to interpret. For example, Al-Krenawi and Graham quotefemale patients describing despair and hopelessness as “my eyes are blind andmy hand is shorter” (p232). This has also been commented upon in Jamaicanpatients who may describe their illnesses using folk medicine terms such as “eyesdark”, “bad feeling”, and “take it on the brain” (James et al, 2014).
Clinicians treating patients from these backgrounds should ask what thepatient and their family believe is causing their problem and what they havealready tried as treatment. For example, patients and carers who believe thecondition is caused by sorcery, may have tried sorcery as a treatment, or plan
to continue with sorcery and related rituals; a clinician should note if any of

By clicking on the title,
interested persons may readthe WHO’s report:
Legal Status ofTraditional Medicine
and Complementary/
Alternative Medicine: A
Worldwide Review.

Table J.2.3. Managing young patients and their families using or planning to use
traditional medicines•

When taking a medical history, ask and record current and past use of traditional treatments.

•

Note what the patient and family believe is causing the child’s illness. This may provide information on the patient’s andfamily’s cultural reference points when psychiatric treatment is explained and administered.

•Ask if the family intends for the child to continue taking traditional treatments or whether they plan to commence using
traditional treatments.

•

Do not dismiss the use of traditional medicines lightly. Allowing patients to continue their traditional treatments (ifharmless) encourage compliance. Also, because of the belief systems associated with some traditional treatments, theuse of traditional therapies can lessen the stigma of the illness and allow patients and families to continue functioning intheir community.

•

Balance the above openness to consider traditional treatment with concerns about the interactions of herbal medicineswith prescription medications, their safety, efficacy and potential burdens (including financial and time-related).

•

Safety concerns are not exclusive to herbal medicines but extend to non-biological physical therapies as well. The
importance of using properly sterilized needles in acupuncture, and potential injury by the more physically demanding
types of meditation, are examples.

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IACAPAP Textbook of Child and Adolescent Mental Health

Severe, life-threatening or fatal events due to complementary
and alternative medicine use in children
In Lim et al’s (2011) Australian survey of paediatricians, 29 CAM-associated adverse
events were reported in a 36 month period (2001-3). Four resulted in death due to CAM
treatments being used in place of orthodox medicine: one case of pulmonary embolism(anticoagulants should have been used); two cases of malnutrition leading to sepsis and death
due to dietary restrictions and homeopathy; and seizures and death because anticonvulsantswere not used. Other serious adverse events from substituting orthodox treatments with CAM
included delayed management of severe cerebral palsy, undiagnosed urinary tract infections,and hyperglycaemia because the insulin dose had been reduced and diabetes was treatedwith naturopathy.
Adverse effects directly due to the use of CAM in children included argyria fromadministering colloidal silver, acute hepatitis and liver failure from multiple herbal treatments
and minerals which subsequently required a liver transplant, mouth ulcers from homeopathic
medicines, hypercalcaemia from oral and intravenous calcium, acidosis from crushed pearls
and bleeding due to gingko and ginseng.

the practices are likely to be detrimental to the patient. This is not merely interms of physical or medical harm but also includes potential financial burden.
Permitting sorcerous or other culturally sanctioned rituals to continue if they are
not harmful, while continuing to monitor the patient, may help to build trust
and rapport.

SOCIALLY SANCTIONED DISORDERS AND
TREATMENT
TranceWhat is deemed a mental disorder in one culture may not be so in another.
Cultural sanction of a mental illness influences how treatment is delivered, if
required. This section looks at trance as a social phenomenon, as an illness, andas a treatment.

Trance in its Social Context and as a Disorder
Trance may be socially acceptable or have a socially acceptable explanation insome cultures. This is partly reflected in a case reported by Suryani and Jensen(1992) in Bali, Indonesia, where 45 out of 215 school children experienced
dissociative disorder en masse. According to Suryani and Jensen, trance is anormal part of the Balinese Hindu faith in the sense that it is expected to occur
in association with ceremonies and dances. What was different in this case wasthat the children were going into trance outside of culturally acceptable scenarios
and, in turn, this led to significant disruption of the school’s functioning (seeBox).
Suryani and Jensen elegantly state: “The psychiatrist can help patients recoverfrom symptoms of mental disorder as defined by Western psychiatry but cannot
provide patients with necessary direct treatment for problems or illness caused
by cultural beliefs or the supernatural. The latter are best treated by those persons
responsible for them.” (p312, our italics).
In this Balinese case, the people responsible were traditional healers andpriests. Incorporating patients’ cultural language and reference points when

Traditional and alternative medicine J.2

TranceTrance has a multitude ofmeanings, from stupor anddaze to a sleep-like state
usually characterized bypartly suspended animation
with diminished or absent
sensory and motor activity.
Trance is often described
as a half-conscious state,
between sleeping andwaking, in which the ability
to function voluntarily
may be suspended and isassociated with meditation,
hypnosis, magic, andprayer. In spiritualism,trance is a temporary
state in which a medium,with suspension of
personal consciousness, iscontrolled by an intelligencefrom without and used as ameans of communication,such as with the dead.

19

IACAPAP Textbook of Child and Adolescent Mental Healthexplaining and administering psychiatric treatment was also highlighted by Ahyi
(1997) in Africa, describing treatment as “exorcising sorcery” with medication(see section on sorcery).

Trance as Treatment
Trance can be a direct means of treatment. Skultans (1991) conducted
fieldwork at a Mahanubhav healing temple in India in the 1980s. The female
patients with mental illness who went to this temple as supplicants were usually
recorded by the temple as either having pida (spiritual affliction) resulting fromspirit possession, or ved (madness). Trance was associated with having pida but
trancing also offered symptomatic relief to the patients. Also, female family
members and caregivers of male patients at the temple would go into trance as ameans of taking on the burden of the male patients’ afflictions. In this scenario,
trance is a means of redistributing the intensity of the illness. Skultans noted thatno men were recorded as going into trance.
In India’s Balaji temple, which is popular for treatment for psychologicalproblems, ritualised trance (peshi) and religious prescriptions are used (Sood,2016). Mental disorders are interpreted as spirit afflictions. Some of thetreatment practices include sleep deprivation, consuming bitter or tastelessfoods, hard physical labour, hitting the body against walls, inducing dissociative
states by moving the head repeatedly in circular motions for extended periods
and restricting the body’s movements with chains. Sood (2016) observed thatsome of these practices no longer occur due to India’s mental health policy andadoption of the Global Mental Health agenda and that the temple is positioning
itself to appeal to a wider Hindu audience, beyond those who seek healing.

Socially Sanctioned Attribution of Mental Illness to
Spiritual Causes
Society’s concealment allows protection for the guilty parties while theycorrect their behaviour. Also, if behaviours such as violence are attributed toa spirit, individuals may be seen as a vessel or medium through which spirits
communicate instead of being viewed as criminals; that is, the individual is still
accepted in society. Ahyi (1997) illustrated this with a Ghanaian cult, Tigari,
where a “hysterical crisis” was interpreted as a visitation from the spirit world.
Such a person is thus not viewed as having an episode of a mental illness or
as a sick person, but instead as a spokesperson for a spirit or deity and is thus
accepted in society. This in turn allows patients time to develop a new life forthemselves. In a similar situation, Li and Phillips (1990) reported a case in rural
China where a female patient with a tentative diagnosis of schizophrenia wasbelieved by others in the community to be in communication with spirits. As aresult, community members began to ask the patient to see their sick relatives,
who they believed were affected by evil spirits.
LIttlewood and Dein (2013) reported on Bangladeshi psychiatric patientsliving in the UK and how they and their families described mental illness as
spiritual illnesses (“mullah illness”) or attributed the cause to spirits such as jinn
and bhut peroth, their influence, or sorcery. The authors noted that some ofthe study participants described having religious visions and these were to some

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20

IACAPAP Textbook of Child and Adolescent Mental Healthdegree normalised or sanctioned by family members or the clergy. These “visions”
may have been psychotic episodes. Social sanctioning of mental illnesses mayhinder patients from seeking treatment, as neither patients nor their families orcommunity see that there is a problem.

STIGMA OF MENTAL ILLNESS AS A DRIVING FORCE
FOR CAM USE
The stigma of mental illness may be a driving force behind attributing theillness to spiritual causes and the use of CAM to treat it. For example, Gona
et al (2016) noted that in Kenya, attributing autism to “God’s wish” appeared
to be a coping strategy for the parents, including when coping with the stigma
associated with autism. There is less stigma associated with accessing traditional
medicine for a mental health problem (Stuttaford et al, 2014) and Liu et al(2016) believes that the stigma of depression may turn patients to traditional
Chinese medicine as the diagnostic terms used in traditional Chinese medicine
are more vague and more socially acceptable.

ACCESS, EQUITY, LEGAL STATUS AND REGULATORYISSUES
CAM may be preferred because it is in keeping with patients’ culture, faith or
beliefs (Onyiapat et al, 2011). The United Nations defines “the right to health in
all its forms” to include health facilities, products and services being culturally
appropriate and acceptable as well as scientifically and medically appropriate.
Health services should also take into account “traditional preventive care, healing
practices and medicines”, particularly in relation to indigenous peoples. However,
the Committee also highlighted the need to protect children, expectant and new
mothers from harmful traditional health practices (Committee on Economic,
Social and Cultural Rights, 2000).
The regulation and legal status of traditional and complementary medicine
varies widely from country to country. Even in countries where herbal medicines
are regulated, the standards to which they are held are lower than conventionalor orthodox medicines. Thus, regulation does not automatically imply efficacy
and safety (Rey et al, 2011). Where regulations and laws exist, these can also varyfrom region to region within one country (World Health Organization, 2001).
Regulation of traditional medicines, or the lack of it, also means that access canbe much easier than for orthodox medicines. For example, in Germany, herbal
medicines have the same legal status as all other medicines while in the US,
herbal medicines were mainly regulated as foods and, more recently (as of 1994),
as dietary supplements (World Health Organization, 1998). In other countries,
traditional medicines may be completely unregulated in terms of source,
manufacturing, quality control, dispensation and who is permitted to administer
treatments, including procedural treatments such as acupuncture. Stuttaford etal (2014) compared South Africa, where traditional healing is legally regulated,
to Kenya where only biomedicine (that is, orthodox medicine) is regulated. As
another example, in Australia, minors have been able to purchase St John’s wort
over the counter (Walter & Rey, 1999), implying they may even self-administerherbal medicines without their carers’ knowledge.
Equity issues and equitable access to orthodox medicine and CAM have been

Traditional and alternative medicine J.2

Click on the image to hear
about the possible dangers
of alternative medicines forchildren (4:59)

21

IACAPAP Textbook of Child and Adolescent Mental Healthraised. In developing countries, traditional and CAM practitioners and therapies
are more affordable and available than orthodox health professionals, hospitals,
and treatments, and thus tend to be accessed by those of lower socioeconomic
status (Stuttaford et al, 2014; Onyiapat et al, 2011). For example, Ayurvedic
treatments are cheaper and therefore more accessible to poor people thanchlorpromazine, let alone the more recent atypical antipsychotics (Agarwal etal, 2010). Accessibility is not only in terms of cost, but also the availabilityof orthodox mental health professionals, which may make CAM practitioners
more appealing or even encouraged by general orthodox health professionals(Braathen et al, 2013).
In contrast, in a developed country such as the UK, CAM is more accessible
and in greater demand by patients with higher socioeconomic status (Jarvis et al,2015). However, Sood (2016) also reported that in India the clients of the Balaji
temple were urban, middle-class and educated, and sought the temple’s healing
because orthodox treatment or other treatments had been unsuccessful.
There is an additional ethical issue when children receive CAM therapies, as
children usually do not make the decisions about their treatment (Gilmour etal, 2011). Parents are typically viewed as the most appropriate agents to decideon treatment for their children, that their wishes should be accepted unless thepotential harm is of a level that requires referral to other services.

RESOURCES
Click on the picture toaccess MedlinePlus: Drugs,
Supplements and Herbal
Information (also available in
Spanish).

CONCLUSION
There is a vast range of traditional treatments available and this chapter covers
only a selected few. Currently, there is insufficient empirical evidence to support
the efficacy of almost all traditional treatments as a sole therapy for mental
illnesses. Few, if any, traditional medicines or therapies, can be confidently
endorsed by mental health professionals as stand-alone treatments for children
and young people. However, many patients and their families may have alreadyused various traditional remedies before presenting for assessment and may intend
to continue using them. Health professionals need to be alert to, and observantof any traditional treatments a patient may use. A mental health professional
working with such patients will need to balance the potential risks of traditional
treatments (including interactions with orthodox medications, physical injury
from some procedures, and financial costs) with sensitivity to cultural beliefs,
patients’ and their family’s social standing and reputation, and their beliefs about
the patient’s illness. Clinicians should also be aware that allowing a patient tocontinue with a traditional treatment which does not interfere with prescribedorthodox therapies, together with regular and close monitoring, may enhancecompliance to therapy overall.

Traditional and alternative medicine J.2

Click on the picture toaccess the World HealthOrganization website andpublications on traditional,
complementary and herbal
medicine.

22IACAPAP Textbook of Child and Adolescent Mental Health

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