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)1among school-age children in Western cultures range from 2-8%, with boys being affectedabout 2-10 times more often than girls 2 . The main symptoms of ADHD are poorconcentration, inattentive behavior, easy distraction, difficulty organizing, fidgetiness,excessive running or climbing, and a tendency to quick and impulsive interruption orintrusion. Currently, the most common treatment for children suffering from ADHD is theuse of the stimulatory and mildly addictive drug Ritalin, which works as a central dopamineagonist. However, side effects from long-term use of Ritalin are many, including appetitesuppression with weight loss, irritable mood, insomnia, or even, also rarely, visualhallucinations 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, cerebraldysfunctions, thyroid disorders, environmental influences, such as brain insults, food allergiesor 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, Iremember vividly how a young boy suffering from ADHD was brought in by his worriedparents. The very first question Dr. Feng asked was if he had been playing video gamesexcessively. The child's answer was yes. Hence, Dr. Feng's main advice, besides prescribingan herbal formula, was for him to stop playing video games. Furthermore, Dr. Feng, a lao yisheng (i.e., old [and experienced] doctor) with 40 years of experience in pediatrics, thenpointed out to me that, "Those Western games are disturbing children's brains." This mayonly be a non-representative and anecdotal incident. However, the heightened influence ofWestern values and the subsequent influx of Western foods, music, and games into the Eastand 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. Staticblood may also interfere with the normal engenderment of blood and hence lead toinsufficient spirit nourishment. The manifestations characterizing the different patternsclosely 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 anavoidance of tasks requiring sustained mental effort, commonly suffer from heart bloodinsufficiency secondary to spleen vacuity, i.e., heart-spleen dual vacuity. The hyperactivesubtypes, manifesting with fidgetiness, excessive running and climbing, difficulty waitingturn, 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, yinvacuity may contribute to the inattentive subtype, giving rise to the mixed inattentive-hyperactive subtype. The mixed type may also manifest in children who suffer from avacuous spleen and a replete liver. The pattern of static blood should be considered whenthere has been trauma to the brain, most commonly at birth, or, based on the fact that long-standing diseases enter the network vessels, if the condition has persisted for a prolongedperiod of time and does not respond well to all other treatments. Lastly, if dietaryirregularities with excessive consumption of dampening foods, as is very common in Westernchildren, aggravate the condition and if the child manifests with other manifestations ofphlegm, such as profuse phlegm, nausea, chest and abdominal fullness, slimy tongue fur, anda 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 (seefootnote #2), five different patterns are listed under ADHD: 1) spleen vacuity-liverhyperactivity, 2) heart-spleen dual vacuity, 3) yin vacuity-yang hyperactivity, 4) phlegm heatharassing internally, and 5) static blood obstructing internally. However, in real-life clinicalpractice, it is rare to find children that fit any one of these textbook patterns. Hence, treatmentcommonly must account for a combination of the above patterns.Professor Lai Xin-sheng from the Guanzhou Chinese Medical University has many years ofexperience in the treatment of ADHD with acupuncture. It is his believe that the treatmenteffect of Western drugs as well as Chinese medicinals is limited to the time period the child isactively taking them and that recurrence rates after discontinuing the medications are high.Therefore, Professor Lai does not consider drugs or even Chinese medicinals effectivetherapies. Rather, he has found acupuncture to be the most stable and effective treatment forchildren with ADHD. The following summary of an article which appeared in the January1999 edition of the Zhong Guo Zhen Jiu (Chinese Acupuncture & Moxibustion) introduceshis method of treatment and compares a group of 155 children treated with acupuncture to acontrol 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 ageranged from as little as 5 years to as old as 14 years. Most children were between 7-9 yearsold. The shortest disease duration was half a year and the longest was 8 years. The controlgroup, who was prescribed oral Ritalin, consisted of 58 children, of which 46 were boys and12 were girls. Their age ranged from as young as 7 years to as old as 15 years, with most ofthe children between 7-10 years old. Their disease course had lasted anywhere from 1-9years. 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 theDSM-IV. Cases suffering from other psychological illnesses, such as schizophrenia, andpatients 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 [AlertSpirit 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 cundirectly above the ear apex and 1 cun anterior and posterior to that first point). Additionalpoints: For heart-kidney yin vacuity, manifesting with slack spirit thinking, i.e., inattentivesubtype, Nei Guan (Per 6), Shen Men (Ht 7), Lao Gong (Per 8), Zu San Li (St 36), Fu Liu (Ki7), and Tai Xi (Ki 3) were added. For heart-liver fire effulgence, manifesting with copiousimpulsive 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 wereretained for 30 minutes and twirled every 10 minutes with even supplementation-evendraining. Five treatments per week for two weeks constituted one course of treatment, and sixcourses of treatment were administered. All main points were needled daily (i.e., everytreatment),while the supplemental points were divided into two groups that were alternatedbetween treatments. Treatment effects were analyzed at the end of the six treatment coursesand again one month later.Control group: Children in the control group were started at 5mg of Ritalin in the morningand 2.5mg at lunch. If this was not strong enough, the Ritalin amount was increased to 10mgin the morning and 5mg at lunch. If this still was not strong enough, Ritalin was increased asneeded 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 threemonths after which the treatment effect was observed. One month after having stopped theRitalin therapy, treatment effects were re-evaluated.Treatment effect analysis: Treatment effect criteria: Patients were judged cured if the 18diagnostic symptoms listed in the DSM-IV had basically dispersed. Patients in whom five ormore 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 tohave had some effect. No improvement in disease symptoms was considered no effect.Treatment results:

Group Total Cases Cured MarkedEffect Some Effect No Effect

Acupuncture 155 (100) 19 (12.3) 72 (46.4) 37 (23.9) 27 (17.4)

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 thetwo different treatment protocols did not differ significantly (P>0.05).

Group Total Cases Cured Marked Effect Some Effect No EffectAcupuncture 155 (100) 12 (7.7) 53 (34.2) 63 (40.7) 27 (17.4)

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 1month; Cases (%)Table 2 shows that, after either therapy had been stopped for one month, the treatment effectin the acupuncture group remained at 82.6% whereas the treatment effect in the Ritalin groupdecreased to 32.8%. This difference in treatment effect is significant (P<0.01) and points outthat in the acupuncture group, the treatment effect, even after stopping treatment for onemonth, had remained relatively stable; in the Ritalin treatment group, as can be expected, amajority of cases regressed into the no effect category.

Age Total Cases Cured Marked Effect Some Effect No Effect5-9 yr 65 11 43 8 39-12 yr 56 6 23 20 712 or older 34 2 6 9 17

Table 3: Relationship between age and treatment effect in the acupuncture groupTable 3 shows that acupuncture treatment was significantly more effective in youngerchildren (P<0.001).

ADHDSubtype Total Cases Cured Marked

Effect Some Effect No 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 acupuncturegroup; Cases (%)Table 4 points out that the acupuncture protocol was most effective in the treatment of thehyperactive subtype followed by the mixed subtype. Acupuncture was least effective in thetreatment of the inattentive subtype. The difference in treatment effect between the differentsubtypes is significant (P<0.001).

TreatmentCourse Cured Marked Effect Some Effect No Effect

1 0 24 35 962 0 32 42 813 1 38 45 714 8 48 52 475 11 57 44 436 19 72 37 27

Table 5: Relationship between the number of treatment courses and treatment effect in theacupuncture group.As Table 5 clearly points out, the amount of treatment courses has a direct relationship to thetreatment 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 inChina. However, this stimulant, as highlighted above, causes such side effects as appetitesuppression with weight loss, irritable mood, insomnia, or, rarely, visual hallucinations andtics. Furthermore, even though Ritalin controls the symptoms associated with ADHD in mostkids effectively, it only does so as long as it is actively taken. In other words, it does not curethe diseases but rather stimulates the brain to stay "awake," thereby eliminating the child'sneed to stimulate the brain him or herself through excessive fidgetiness and hence ending thehyperactive 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 side-effects and which has more permanent results is highly desirable.The above described acupuncture treatment, called Jiu San Zhen Liao Fa (Jiu's three needlestreatment method) is based on the many years of experience of Dr. Jiu Rui-jiao. It heavilyemphasizes head points. The Si Shen Zhen points at the top of the head are the transportpoints of the sea of marrow (i.e., brain); the Nao San Zhen points, located on the tai yang'sthoroughfare, are the door and opening to connect to the brain 7. The Nie San Zhen points arelocated in the shao yang area of the head. The shao yang is the hinge of the body's qipathways. 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 thetemporal lobe is closely related to the mental task of studying. Thus this combination ofpoints affects all the qi of the viscera and bowels and channels and network vessels aa well asharmonizes yin and yang. Clinically, the three viscera of the heart, liver, and kidneys areoften involved in the pattern differentiation of ADHD. Hence, many of the additional pointsare located on these three channels. Overall, this treatment approach leads to harmonizationand disinhibition of the blood vessels where essence spirit can dwell and thus achieves itsgood results.The comparison between the treatment results of the Ritalin treatment group and theacupuncture treatment group points out that both treatments are about equally effective. Theadvantage of using acupuncture over Ritalin lies in the fact that acupuncture does not causeany side effects and that its treatment success is not as short lived as Ritalin's. This wasclearly demonstrated in the follow-up evaluation conducted one month after stoppingtreatment in both groups when the acupuncture group's treatment effects had remainedsignificantly more stable.Acupuncture was more effective in younger children than in older patients. The authorexplains this by the fact that the cerebrum in younger children is still developing at a muchhigher rate than in older children and that, therefore, the intervention caused by the insertionof needles on the scalp is more apt to regulate the brain's function. After age 12, the cerebrumhas already reached adult-level shape and form. Hence, the regulatory functions thatacupuncture can exert are more limited. Also, acupuncture seems to be much more effectiveto repress hyperactive behavior than to stimulate inattentive behavior; the treatment of the

hyperactive and mixed subtypes was much more effective than the treatment of theinattentive subtype. The comparison between the number of treatment courses and theimproved treatment effect demonstrates that this acupuncture protocol's regulation of thenervous system is progressively heightened by more treatments, also pointing out that anabbreviated version of this protocol would certainly lead to decidedly reduced treatmentresults.Conclusion:The use of Ritalin for children suffering from ADHD is, because of its side effects andaddictiveness, becoming less and less popular among many health conscious parents. Theseparents then often look for alternative treatments to solve their children's behavioralproblems. Besides the obvious first steps of normalizing a child's social environment,regulating the balance between active exercise/playing and mental stimulation, reducing thegross mental overstimulation from TV, movies, and video games, and adjusting the child'sdiet so as to limit the intake of sugar, dairy, and food preservatives and provide him or herwith a freshly prepared diet, several new "alternative" treatment methods to Ritalin haveemerged. 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 totheir clinical applicability. One is the frequency of treatments; the other is the heavy use ofhead points. Both of these factors, I believe, are of the essence for achieving treatmentsuccess with this protocol. It is both my opinion and experience that an abbreviated version ofthe above protocol needled once or even twice weekly would not be nearly as effective as theprotocol presented above. This means, then, that the parent has to bring the child to theacupuncture clinic five times per week for three months and has, if regular Westernacupuncture rates are charged, to spend a lot of money. Unfortunately, it is also my opinionand experience that few Western parents are willing to do so. Hence, solutions to the aboveproblems need to be found.One possible solution is that schools set up programs where an acupuncturist would come inonce daily and administer the treatment to a pre-selected (and willing) group of ADHDchildren. Payment would be dispersed over all the children's parents (or possibly even theschool) and would, therefore, be lessened to a fraction of the regular cost for any one child'sparents. 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 achance to try one or two scalp needles, many children as well as parents may be pleasantlysurprised that it really does not hurt that much. Acupuncture on the scalp is not at all painfulif the needles are inserted correctly. Also, the children suffering from the hyperactivesubtype, the type most respondent to this treatment protocol, tend not to be excessively scaredof 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 theabove study who, in his concluding statement, points out that:

Acupuncture achieves a relatively good clinical effectivenessin the treatment of ADHD, particularly for the hyperactive andmixed subtypes. [Furthermore,] post-treatment recurrence ratesare low. [Hence,] this is an effective type of treatment for ADHD which deserves to bepopularized.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. 20013 Ibid

4 According to the Xian Dai Er Tong Jing Shen Yi Xue (Modern Pediatric Psychology) by LiXue-rong, Hunan Science & Technology Press, Changsha, 1994, the prevalence rate in Chinais given at 1.5-10%, whereas the prevalence rate for the rest of the world is given at 5-20%. Itmust be noted, however, that such numbers have to be regarded with caution, since differentcountries employ different ADHD definitions. Hence, a cross-country comparison ofprevalence rates is difficult.5 Chai Tie-qu, supervised by Lai Xin-sheng, "Observation of the Treatment Effect ofAcupuncture in the Treatment of 155 Children with Attention Deficit HyperactivityDisorder," Zhong Guo Zhen Jiu (Chinese Acupuncture & Moxibustion), Jan. 1999, p. 5-76 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'sDoor.8 Another promising therapy is EEG biofeedback which bases its treatment success oninfluencing the ADHD child's brain waves. Furthermore, Chinese medicinals can be veryeffective in the treatment of ADHD. For treatment formulas for the different patterns ofADHD or research abstracts on this topic, please see Chinese Medical Psychiatry.