Medical & Alternative Approaches to ADHD
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:
- "Agitation"
- "severe confusion"
- "convulsions or seizures"
- "dryness of mouth or mucous membranes"
- "false sense of well-being"
- "fast, pounding, or irregular heartbeat"
- "fever"
- "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"
- "vomiting"
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)
Alternative Therapies
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
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.
Bioenergetic therapies
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.
Biomechanical therapies
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. References for this article and additional
resources are available on-line at: http://www.icpa4kids.com/chiropractic_newsletter_references.htm.
The ICPA offers free e-news updates on this topic and more. To sign up
visit:: http://www.icpa4kids.com/ped_ex_chiropractic_pediatrics_email_updates.htm
© 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
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