by Joel Alcantara, D.C.
Although there are several medical approaches to the treatment of patients with ADHD (i.e., behavioral modification, alternative therapies, etc.), methylphenidate (Ritalin) is the medication that is almost universally prescribed for children with ADHD, while selective serotnin reuptake inhibitors (SSRIs) is gaining widespread popularity. Ritalin is a central nervous system stimulant that affects the core behavioral features of ADHD; namely, age-inappropriate levels of inattention, impulsivity and hyperactivity. It has effects similar to both amphetamines and cocaine.
Ritalin is a schedule II controlled substance, and both its production and distribution are tightly controlled. Concerns about possible over-diagnosis and over-treatment of children with ADHD have been prominent in media reports, as have various competing claims about the safety and efficacy of the various treatments.
A study by Zito et.al. (10) published in the Journal of the American Association indicated that psychotropic medication increased dramatically between 1991-1995, with a great number of the medications being "off-label." "Off-label" is a term used to describe a medical doctor's drug prescription for a condition wherein the drug is not specifically approved for it. Children are most likely to be treated with "off label" medication. Ironically, the warning label on Ritalin states, "Ritalin should not be used in children under six years, since safety and efficacy in this age group have not been established." Last year, doctors estimated that 70 percent to 80 percent of drugs used on children had not been tested in children.
In 1999, 9.9 million U.S. prescriptions were written for Ritalin. Non-medical illicit use resulted in 1,478 hospital emergencies during the year. White and Yadao (11) investigated the frequency, risk, symptoms and outcome in the use of Ritalin reported to a regional poison control center. Of 289 patients, methylphenidate exposure was associated with symptom development is 31% of the cases, particularly in the 6-11 year old age group. Common symptoms reported were tachycardia, agitation, lethargy or a combination thereof.
Signs of Ritalin (12) overdose include the following:
- "severe confusion"
- "convulsions or seizures"
- "dryness of mouth or mucous membranes"
- "false sense of well-being"
- "fast, pounding, or irregular heartbeat"
- "severe headaches"
- "increased blood pressure"
- "increased sweating"
- "large pupils"
- "muscle twitching"
- "overactive relaxes"
- "seeing, hearing, or feeling things that are not there"
- "trembling or tremors"
In a very recent publication, Rappley et.al. (13) identified patterns of diagnosis and treatment of ADHD in 223 very young children enrolled in the Michigan Medicaid program. What they found was alarming to say the least. In children 3 years or younger with diagnosed ADHD, psychotropic medication use was markedly variable based on little or no clinical guidelines. Twenty two different psychotropic medications were used. In addition, these children had comorbidities (i.e., other health conditions and injuries) and based on the study authors' comments, "attest to these children's vulnerability."
A meta-analysis by Schachter et.al. (14) examined the efficacy and safety of short acting methylphenidate in children and adolescents with ADHD. Of the 62 randomized trials examined, the following interpretations were made. One, there was substantial publication bias such that the studies demonstrating no effect of methylphenidate or when it fared less well than placebo, "may not have been published." Second, adverse events to the medication were underreported. Third, the effects of methylphenidate beyond 4 weeks was found questionable, particularly with the lack of long term studies. As the study authors noted, "Collectively, these observations reflect a less-than-ideal state of affairs given the long history of extensive, and ever increasing, use of methylphenidate for ADD, particularly in North America for groups that now include preschoolers and adults."
Concern about Ritalin use in the school systems throughout the country is such that the Texas Board of Education adopted a resolution that schools consider non-medical solutions to behavior problems. The Colorado School Board has approved a similar resolution. In Connecticut, the Legislature approved unanimously (and signed by Gov. John G. Rowlands) to prohibit teachers, counselors and other school officials from recommending psychiatric drugs for any child. Other states are following suit.(15)
Within the last decade, complementary and alternative medicine ( CAM) have been a focus of interest and discussion in the popular media (including the internet) and in funded research in the scientific community. Parents of children with ADHD actively seek out "alternative" treatments due to concerns of the risks of their children being given powerful psychoctive medications over an indeterminable and prolonged period of time.
A recent review paper by Chan (16) examined the epidemiology of CAM use for ADHD. Using the CAM conceptual model of a therapeutic wheel by Kemper (See Figure 2), Chan examines the various alternative approaches to the care of the child with a diagnosis of ADHD.
Biochemical therapies include herbal remedies, vitamins and nutritional supplements. Lifestyle/Mind-Body therapies include exercise, nutrition, environmental changes and mind body techniques such as hypnosis, psychotherapy and biofeedback.
Include acupuncture, therapeutic touch, prayer and homeopathy. These therapies are based on the notion that they restore harmonious balance of an invisible energy or spirit that surrounds and flows through the body.
Include surgery, massage and "spinal manipulation" (including chiropractic)." According to Chan, very few studies of children in ADHD exists. And she's right. Furthermore, Chan admonishes the aggressive and widespread alternative therapies advertised as "miracle cures" for ADHD in the lay press and Internet. For your interest, I have provided in the newsletter reference section (see below), articles and websites that Dr. Chan has listed as resources for CAM and ADHD. To empower you with addressing questions from parents and medical doctors alike, you should be aware of these websites and be able to address the issues involved.
The Chiropractic Perspective
Recent research efforts are now bringing into fruition supporting evidence upon the chiropractic principle of the supremacy of the nervous system. ADHD is a central nervous system disorder Attempts at understanding the underlying neurobiology of ADHD remains a challenge.
In chiropractic, to the best of my knowledge, the first and only documentation in the scientific literature addressing the effects of chiropractic care in children with hyperactivity was performed by Giesen et.al. (17). The principle aim of their study was to determine the effectiveness of chiropractic manipulative therapy in the treatment of children with hyperactivity. Using blinds between investigators and a single subject research design, the investigators evaluated the effectiveness of the treatment for reducing activity levels of hyperactive children. Data collection included independent evaluations of behavior using a unique wrist-watch type device to mechanically measure activity while the children completed tasks simulating school-work. Further evaluations included electrodermal tests to measure autonomic nervous system activity. Chiropractic clinical evaluations to measure improvement in spinal biomechanics were also completed. Placebo care was given prior to chiropractic intervention. Data were analyzed visually and using nonparametric statistical methods. Five of seven children showed improvement in mean behavioral scores from placebo care to treatment. Four of seven showed improvement in arousal levels, and the improvement in the group as a whole was highly significant. Agreement between tests was also high in this study. For all seven children, three of the four principal tests used to detect improvement were in agreement either positively or negatively (parent ratings of activity, motion recorder scores, electrodermal measures, and X-rays of spinal distortions). While the behavioral improvement taken alone can only be considered suggestive, the strong interest agreement can be taken as more impressive evidence that the majority of the children in this study did, in fact, improve under specific chiropractic care. The results of this study, then, are not conclusive. However, they do suggest that chiropractic care has the potential to become an important non-drug intervention for children with hyperactivity. Further investigation in this area is certainly warranted.
Considering that all of the alternative therapies as described by above are incorporated in a number of chiropractic practices or at least networked into by most, it is my contention that chiropractic provides the best "alternative" for children with a diagnosis of ADHD.
This article appears by kind permission of Dr. Alcantara and the International Chiropractic Pediatric Association.
© Dr. Joel Alcantara
ABOUT THE AUTHOR
Dr. Joel Alcantara serves as the Research director for the International Chiropractic Pediatric Association. Their mission is to provide parents with the information to make informed health care choices. Their site may be accessed at: www.icpa4kids.org