A Ritalin Alternative: Acupuncture in the Treatment of ADHD

A Ritalin Alternative: Acupuncture in the Treatment of ADHD by Simon A. Becker, Dipl. Ac. & C.H. Conservative prevalence estimates of attention deficit hyperactivity disorder (ADHD)1 among school-age children in Western cultures range from 2-8%, with boys being affected about 2-10 times more often than girls 2. The main symptoms of ADHD are poor concentration, inattentive behavior, easy distraction, difficulty organizing, fidgetiness, excessive running or climbing, and a tendency to quick and impulsive interruption or intrusion. Currently, the most common treatment for children suffering from ADHD is the use of the stimulatory and mildly addictive drug Ritalin, which works as a central dopamine agonist. However, side effects from long-term use of Ritalin are many, including appetite suppression with weight loss, irritable mood, insomnia, or even, also rarely, visual hallucinations and tics. The cause of ADHD has not been limited to one single factor. Rather, current theories consider ADHD to be a mix of the following factors: genetics, cerebral dysfunctions, thyroid disorders, environmental influences, such as brain insults, food allergies or a higher requirement for vitamins, or psychosocial factors 3. In China, the rate of ADHD is slightly lower than in the West 4. While studying under Dr. Feng in the pediatric department of the Heilongjiang Chinese Medicine University Hospital, I remember vividly how a young boy suffering from ADHD was brought in by his worried parents. The very first question Dr. Feng asked was if he had been playing video games excessively. The child's answer was yes. Hence, Dr. Feng's main advice, besides prescribing an herbal formula, was for him to stop playing video games. Furthermore, Dr. Feng, a lao yi sheng (i.e., old [and experienced] doctor) with 40 years of experience in pediatrics, then pointed out to me that, "Those Western games are disturbing children's brains." This may only be a non-representative and anecdotal incident. However, the heightened influence of Western values and the subsequent influx of Western foods, music, and games into the East and the increasing rate of ADHD may be, at least in part, related. According to Chinese medicine, ADHD is either due to insufficient nourishment of the spirit, spirit agitation by some type of heat, or orifice obstruction by static blood or phlegm. Static blood may also interfere with the normal engenderment of blood and hence lead to insufficient spirit nourishment. The manifestations characterizing the different patterns closely parallel the three most common types of Western medical classification of ADHD: 1) inattentive subtype, 2) hyperactive subtype, and 3) a mixed inattentive-hyperactive subtype. Inattentive subtypes, manifesting with difficulty concentrating, easy distraction, and an avoidance of tasks requiring sustained mental effort, commonly suffer from heart blood insufficiency secondary to spleen vacuity, i.e., heart-spleen dual vacuity. The hyperactive subtypes, manifesting with fidgetiness, excessive running and climbing, difficulty waiting turn, and interruptive and impulsive behavior, commonly suffer from heat agitating the spirit. This heat may be replete liver heat or heat secondary to yin vacuity. In the latter case, yin vacuity may contribute to the inattentive subtype, giving rise to the mixed inattentivehyperactive subtype. The mixed type may also manifest in children who suffer from a vacuous spleen and a replete liver. The pattern of static blood should be considered when there has been trauma to the brain, most commonly at birth, or, based on the fact that longstanding diseases enter the network vessels, if the condition has persisted for a prolonged period of time and does not respond well to all other treatments. Lastly, if dietary irregularities with excessive consumption of dampening foods, as is very common in Western children, aggravate the condition and if the child manifests with other manifestations of phlegm, such as profuse phlegm, nausea, chest and abdominal fullness, slimy tongue fur, and a slippery pulse, then treatment must also focus on the transformation of phlegm and the

elimination of dampness. In Flaws and Lakes' book, Chinese Medical Psychiatry (see footnote #2), five different patterns are listed under ADHD: 1) spleen vacuity-liver hyperactivity, 2) heart-spleen dual vacuity, 3) yin vacuity-yang hyperactivity, 4) phlegm heat harassing internally, and 5) static blood obstructing internally. However, in real-life clinical practice, it is rare to find children that fit any one of these textbook patterns. Hence, treatment commonly must account for a combination of the above patterns. Professor Lai Xin-sheng from the Guanzhou Chinese Medical University has many years of experience in the treatment of ADHD with acupuncture. It is his believe that the treatment effect of Western drugs as well as Chinese medicinals is limited to the time period the child is actively taking them and that recurrence rates after discontinuing the medications are high. Therefore, Professor Lai does not consider drugs or even Chinese medicinals effective therapies. Rather, he has found acupuncture to be the most stable and effective treatment for children with ADHD. The following summary of an article which appeared in the January 1999 edition of the Zhong Guo Zhen Jiu (Chinese Acupuncture & Moxibustion) introduces his method of treatment and compares a group of 155 children treated with acupuncture to a control group of 58 children who were treated with Ritalin 5. Clinical data: Of the 155 children in the acupuncture group, 116 were boys and 39 were girls. Their age ranged from as little as 5 years to as old as 14 years. Most children were between 7-9 years old. The shortest disease duration was half a year and the longest was 8 years. The control group, who was prescribed oral Ritalin, consisted of 58 children, of which 46 were boys and 12 were girls. Their age ranged from as young as 7 years to as old as 15 years, with most of the children between 7-10 years old. Their disease course had lasted anywhere from 1-9 years. The male to female ratio of the two groups combined was 3.2 : 1. Diagnostic criteria: Patients were selected according to the diagnostic standards for ADHD as set forth in the DSM-IV. Cases suffering from other psychological illnesses, such as schizophrenia, and patients demonstrating intellectual disturbances were removed from the study. Treatment method: Treatment group: Main points: Si Shen Zhen (Four Spirit Needles, a.k.a., Si Shen Cong [Alert Spirit Quartet]), Nao San Zhen (Three Brain Needles, i.e., Nao Hu [GV 17] and Nao Kong [GB 19]), Nie San Zhen (Three Temple Needles, i.e., a group of three points located 2 cun directly above the ear apex and 1 cun anterior and posterior to that first point). Additional points: For heart-kidney yin vacuity, manifesting with slack spirit thinking, i.e., inattentive subtype, Nei Guan (Per 6), Shen Men (Ht 7), Lao Gong (Per 8), Zu San Li (St 36), Fu Liu (Ki 7), and Tai Xi (Ki 3) were added. For heart-liver fire effulgence, manifesting with copious impulsive stirring, i.e., hyperactive subtype, Hou Xi (SI 3), Lie Que (Lu 7), Zhi Gou (TB 6), Tai Chong (Liv 3), Chong Yang (St 42), and Fei Yang (Bl 58) were added. Needling method: On the scalp, the needles were inserted horizontally to about one inch depth. On the body, they were inserted perpendicularly to the normal depth. After obtaining qi, the needles were retained for 30 minutes and twirled every 10 minutes with even supplementation-even draining. Five treatments per week for two weeks constituted one course of treatment, and six courses of treatment were administered. All main points were needled daily (i.e., every treatment),while the supplemental points were divided into two groups that were alternated between treatments. Treatment effects were analyzed at the end of the six treatment courses and again one month later. Control group: Children in the control group were started at 5mg of Ritalin in the morning and 2.5mg at lunch. If this was not strong enough, the Ritalin amount was increased to 10mg in the morning and 5mg at lunch. If this still was not strong enough, Ritalin was increased as needed but did not exceed a daily dose of 30mg. Furthermore, Ritalin was only taken for five

days per week so as to reduce the side effects. This type of therapy was continued for three months after which the treatment effect was observed. One month after having stopped the Ritalin therapy, treatment effects were re-evaluated. Treatment effect analysis: Treatment effect criteria: Patients were judged cured if the 18 diagnostic symptoms listed in the DSM-IV had basically dispersed. Patients in whom five or more of the 18 symptoms were relieved were considered as demonstrating a marked effect. Patients in whom two or more (up to five) symptoms had been resolved were considered to have had some effect. No improvement in disease symptoms was considered no effect. Treatment results: Marked Group Total Cases Cured Some Effect No Effect Effect Acupunctur 155 (100) 19 (12.3) 72 (46.4) 37 (23.9) 27 (17.4) e Ritalin 58 (100) 21 (24.1) 21 (36.2) 16 (27.6) 7 (12.1) Table 1: Acupuncture and Ritalin group treatment results; Cases (%) From the above, it can be seen that the treatment effect in the acupuncture group was 82.58% and the treatment effect in the Ritalin group was 87.9%. Thus, the treatment efficacy from the two different treatment protocols did not differ significantly (P>0.05). Group Total Cases Cured Marked Effect Some Effect No Effect Acupunctur 155 (100) 12 (7.7) 53 (34.2) 63 (40.7) 27 (17.4) e Ritalin 58 (100) 2 (3.5) 5 (8.6) 12 (20.7) 39 (67.2) Table 2: Treatment effect after having stopped therapy, either Ritalin or acupuncture, for 1 month; Cases (%) Table 2 shows that, after either therapy had been stopped for one month, the treatment effect in the acupuncture group remained at 82.6% whereas the treatment effect in the Ritalin group decreased to 32.8%. This difference in treatment effect is significant (P<0.01) and points out that in the acupuncture group, the treatment effect, even after stopping treatment for one month, had remained relatively stable; in the Ritalin treatment group, as can be expected, a majority of cases regressed into the no effect category. Age Total Cases Cured Marked Effect Some Effect No Effect 5-9 yr 65 11 43 8 3 9-12 yr 56 6 23 20 7 12 or older 34 2 6 9 17 Table 3: Relationship between age and treatment effect in the acupuncture group Table 3 shows that acupuncture treatment was significantly more effective in younger children (P<0.001). ADHD Marked Total Cases Cured Some Effect No Effect Subtype Effect Mixed 69 (100) 4 (5.8) 43 (62.3) 12 (17.4) 10 (14.5) Hyperactive 49 (100) 12 (24.5) 18 (36.7) 15 (30.6) 4 (8.2) Inattentive 37 (100) 3 (8.1) 11 (29.7) 10 (27.0) 13 (35.2) Table 4: Relationship between ADHD subtypes and treatment effect in the acupuncture group; Cases (%) Table 4 points out that the acupuncture protocol was most effective in the treatment of the hyperactive subtype followed by the mixed subtype. Acupuncture was least effective in the treatment of the inattentive subtype. The difference in treatment effect between the different subtypes is significant (P<0.001). Treatment Course Cured Marked Effect Some Effect No Effect

1 0 24 35 96 2 0 32 42 81 3 1 38 45 71 4 8 48 52 47 5 11 57 44 43 6 19 72 37 27 Table 5: Relationship between the number of treatment courses and treatment effect in the acupuncture group. As Table 5 clearly points out, the amount of treatment courses has a direct relationship to the treatment efficacy: the more treatments, the higher the treatment success (P<0.001). Chinese author's discussion: Ritalin is the most common drug used in the treatment of ADHD in the US as well as in China. However, this stimulant, as highlighted above, causes such side effects as appetite suppression with weight loss, irritable mood, insomnia, or, rarely, visual hallucinations and tics. Furthermore, even though Ritalin controls the symptoms associated with ADHD in most kids effectively, it only does so as long as it is actively taken. In other words, it does not cure the diseases but rather stimulates the brain to stay "awake," thereby eliminating the child's need to stimulate the brain him or herself through excessive fidgetiness and hence ending the hyperactive behavior. However, Ritalin's stimulatory effect only lasts for about 4 hours; thereafter, a new dose must be taken 6. Hence, a treatment method which does not cause sideeffects and which has more permanent results is highly desirable. The above described acupuncture treatment, called Jiu San Zhen Liao Fa (Jiu's three needles treatment method) is based on the many years of experience of Dr. Jiu Rui-jiao. It heavily emphasizes head points. The Si Shen Zhen points at the top of the head are the transport points of the sea of marrow (i.e., brain); the Nao San Zhen points, located on the tai yang's thoroughfare, are the door and opening to connect to the brain 7. The Nie San Zhen points are located in the shao yang area of the head. The shao yang is the hinge of the body's qi pathways. If it is in harmony, then the constructive and defensive can enter and exit normally. It is interesting to compare this to the findings of modern medicine which believes that the temporal lobe is closely related to the mental task of studying. Thus this combination of points affects all the qi of the viscera and bowels and channels and network vessels aa well as harmonizes yin and yang. Clinically, the three viscera of the heart, liver, and kidneys are often involved in the pattern differentiation of ADHD. Hence, many of the additional points are located on these three channels. Overall, this treatment approach leads to harmonization and disinhibition of the blood vessels where essence spirit can dwell and thus achieves its good results. The comparison between the treatment results of the Ritalin treatment group and the acupuncture treatment group points out that both treatments are about equally effective. The advantage of using acupuncture over Ritalin lies in the fact that acupuncture does not cause any side effects and that its treatment success is not as short lived as Ritalin's. This was clearly demonstrated in the follow-up evaluation conducted one month after stopping treatment in both groups when the acupuncture group's treatment effects had remained significantly more stable. Acupuncture was more effective in younger children than in older patients. The author explains this by the fact that the cerebrum in younger children is still developing at a much higher rate than in older children and that, therefore, the intervention caused by the insertion of needles on the scalp is more apt to regulate the brain's function. After age 12, the cerebrum has already reached adult-level shape and form. Hence, the regulatory functions that acupuncture can exert are more limited. Also, acupuncture seems to be much more effective to repress hyperactive behavior than to stimulate inattentive behavior; the treatment of the

hyperactive and mixed subtypes was much more effective than the treatment of the inattentive subtype. The comparison between the number of treatment courses and the improved treatment effect demonstrates that this acupuncture protocol's regulation of the nervous system is progressively heightened by more treatments, also pointing out that an abbreviated version of this protocol would certainly lead to decidedly reduced treatment results. Conclusion: The use of Ritalin for children suffering from ADHD is, because of its side effects and addictiveness, becoming less and less popular among many health conscious parents. These parents then often look for alternative treatments to solve their children's behavioral problems. Besides the obvious first steps of normalizing a child's social environment, regulating the balance between active exercise/playing and mental stimulation, reducing the gross mental overstimulation from TV, movies, and video games, and adjusting the child's diet so as to limit the intake of sugar, dairy, and food preservatives and provide him or her with a freshly prepared diet, several new "alternative" treatment methods to Ritalin have emerged. As the above study clearly demonstrates, acupuncture is one of them 8. However, there are two points about Dr. Jiu's three needles treatment that deserve more thought as to their clinical applicability. One is the frequency of treatments; the other is the heavy use of head points. Both of these factors, I believe, are of the essence for achieving treatment success with this protocol. It is both my opinion and experience that an abbreviated version of the above protocol needled once or even twice weekly would not be nearly as effective as the protocol presented above. This means, then, that the parent has to bring the child to the acupuncture clinic five times per week for three months and has, if regular Western acupuncture rates are charged, to spend a lot of money. Unfortunately, it is also my opinion and experience that few Western parents are willing to do so. Hence, solutions to the above problems need to be found. One possible solution is that schools set up programs where an acupuncturist would come in once daily and administer the treatment to a pre-selected (and willing) group of ADHD children. Payment would be dispersed over all the children's parents (or possibly even the school) and would, therefore, be lessened to a fraction of the regular cost for any one child's parents. The second problem, the heavy use of head points, is somewhat more challenging. However, if the procedure is clearly explained to the child and if he or she is then given a chance to try one or two scalp needles, many children as well as parents may be pleasantly surprised that it really does not hurt that much. Acupuncture on the scalp is not at all painful if the needles are inserted correctly. Also, the children suffering from the hyperactive subtype, the type most respondent to this treatment protocol, tend not to be excessively scared of needles and, therefore, more willing to at least give it a try. To conclude this article, I would like to quote Lai Xin-sheng, the supervising author of the above study who, in his concluding statement, points out that: Acupuncture achieves a relatively good clinical effectiveness in the treatment of ADHD, particularly for the hyperactive and mixed subtypes. [Furthermore,] post-treatment recurrence rates are low. [Hence,] this is an effective type of treatment for ADHD which deserves to be popularized. Hopefully, the publication of this article will help to serve this last purpose. 1 Note that ADHD as defined in the DSM-IV includes Attention Deficit Disorder (ADD) 2 Flaws, Bob & Lake, James, Chinese Medical Psychiatry: A Textbook & Clinical Manual, Blue Poppy Press, Boulder, CO, Jan. 2001 3 Ibid

4 According to the Xian Dai Er Tong Jing Shen Yi Xue (Modern Pediatric Psychology) by Li Xue-rong, Hunan Science & Technology Press, Changsha, 1994, the prevalence rate in China is given at 1.5-10%, whereas the prevalence rate for the rest of the world is given at 5-20%. It must be noted, however, that such numbers have to be regarded with caution, since different countries employ different ADHD definitions. Hence, a cross-country comparison of prevalence rates is difficult. 5 Chai Tie-qu, supervised by Lai Xin-sheng, "Observation of the Treatment Effect of Acupuncture in the Treatment of 155 Children with Attention Deficit Hyperactivity Disorder," Zhong Guo Zhen Jiu (Chinese Acupuncture & Moxibustion), Jan. 1999, p. 5-7 6 Slow-release types of Ritalin, such as Metadate ER and others, are now available. 7 Note that the name for one of the three points, GV 17, is Nao Hu which translates as Brain's Door. 8 Another promising therapy is EEG biofeedback which bases its treatment success on influencing the ADHD child's brain waves. Furthermore, Chinese medicinals can be very effective in the treatment of ADHD. For treatment formulas for the different patterns of ADHD or research abstracts on this topic, please see Chinese Medical Psychiatry.