1RCSI medical student
Royal College of Surgeons in Ireland Student Medical Journal 2012;5: 75-77.
Attention deficit hyperactivity disorder (ADHD) is the most common behavioural disturbance in children, affecting 3-5% of Irish school-age children.1 The main features of ADHD are inattention, hyperactivity and restlessness. Current standard diagnostic criteria maintain that symptoms should be present before six years of age, persist over time and be assessed in the context of the child’s developmental and cognitive level for his/her age group and IQ.1 There is currently no cure for ADHD. Symptomatic management has been proven to help improve quality of life in many patients as a first-line intervention.2 However, pharmacological treatment is not without its difficulties. Stimulant drugs are ineffective in up to 10% of patients,2 and many patients experience at least some side effects. Furthermore, many parents are wary of giving their hyperactive children stimulant drugs. Therefore, there is a high demand for complementary and alternative treatments for ADHD. These therapies can vary widely and involve any one or a combination of psychological, behavioural, natural and dietary interventions.
The current accepted standard treatment of ADHD in children is pharmacological intervention, specifically the administration of stimulants such as methylphenidate. However, non-stimulant drugs, selective serotonin re-uptake inhibitors and tricyclic antidepressants are also used. Methylphenidate is used as first-line treatment when medication is deemed necessary and is effective in up to 90% of cases in treating ADHD symptoms in children.2 However, many children report distressing side effects, such as transient abdominal pain and anorexia.3 Other adverse effects include palpitations, hypertension and irritability.3 Rare instances of sudden death and cardiovascular disease have been reported while taking methylphenidate.4 These side effects can be severe enough to lead to non-compliance. Non-compliance may be furthered if parents become aware of the possibility that methylphenidate may cause psychological dependence with chronic use.5 Atomoxetine is a relatively new non-stimulant drug prescribed in the treatment of ADHD; however, it has serious adverse side effects, such as suicidality, aggression and liver damage.2 These side effects make atomoxetine an unfavourable treatment option in up to 80% of children with ADHD who experience a second comorbidity, such as oppositional defiant disorder, depression or bipolar affective disorder.1 While pharmacological intervention remains the most effective and widely prescribed treatment for children with ADHD, social and parental attitudes about giving medication to children, along with the significant side-effect profile of the drugs, encourage many to search for alternative and complementary medicines.
The frequency of use of complementary and alternative medicine (CAM) in children with ADHD ranges from 12-64%, depending on the therapy involved.3 There are several CAM therapies currently available to treat ADHD in children, including, but not limited to, chiropractic care, electro-acupuncture and meditation. A lot of patients may feel that the risks, although small, outweigh the benefits of pharmacological intervention, and many people feel it is not safe to prescribe behaviour-modifying medication to young children. On the other hand, many also doubt the effectiveness and safety of the so-called natural remedies that CAM has to offer.6
This debate is not easily resolved, as many CAM modalities do not lend themselves to conventional evaluation. One problem with trying to assess alternative medicines with conventional scientific trials is that many alternative therapies adhere to the dogma that health problems are the result of immeasurable defects. Chinese medicine proposes that ADHD is a result of mind dissatisfaction; acupuncture hypothesises that disease is the result of bad flow of chi – a life force which courses through the human body. As there is no meaningful way of measuring these concepts in a standardised manner, the principles of evidence-based medicine cannot be applied. Moreover, it would be ethically wrong to withhold proven treatment in a trial.
There is a myriad of unconventional treatments available to be used alongside or instead of stimulant drugs. Some of the most popular include chiropractic care and acupuncture. Chiropractic care focuses on the musculoskeletal system with the intent to optimise functioning of the nervous system.3 While the majority of spinal manipulation therapy and chiropractic care focuses on general wellness, treatment of paediatric ADHD remains a common presenting complaint of chiropractic patients. But how does this popular alternative treatment option perform as a treatment for ADHD in children? Since 2008, four case reports and one case series have been published that studied the effect of chiropractic care in children with ADHD.7-11 All these studies reported positive outcomes for the use of chiropractic treatment in children with ADHD. However, the power of these studies was low. For example, one retrospective case series analysis considered just four boys aged nine to 13 years, two of whom were on stimulant medications for ADHD at the start of chiropractic care.8 Their responses were monitored using a previously unpublished 15-item parent/teacher ADHD questionnaire that had not been formally validated. Despite considerable flaws in study design, all authors reported a decrease in patients’ levels of hyperactivity, impulsivity and inattentiveness following their chiropractic care.7-11 Although a large-scale, high-quality study is needed before definite recommendations can be made in this regard, there is currently no evidence that dismisses chiropractic care in the treatment of ADHD in children.
Traditional Chinese medicine originated thousands of years ago, and yet continues to account for 40% of healthcare delivered in China.12 Some commonly prescribed traditional treatments include herbal remedies, acupuncture and massage.12 Traditional Chinese medicine varies greatly from Western medicine in proposing that ADHD represents the connection of congenital constitutional insufficiency and the postnatal loss of nourishment, affect, mind dissatisfaction and trauma. Furthermore, Chinese medicine holds that the origin of ADHD is not in neurological structures but rather in the kidneys, heart, liver and spleen.13 The practice of acupuncture aims to correct internal imbalance via the insertion of fine needles into therapeutic acupoints.12 Electro-acupuncture is a modification of the traditional Chinese medicinal practice of acupuncture where the inserted needles are attached to pulsating electrical currents to better stimulate acupoints.
A study in China recruited 213 preschool children with a diagnosis of ADHD by DSM-IV criteria to assess the effectiveness of electro-acupuncture in treating ADHD in young children.14 The subjects were randomly assigned to experimental and control groups. The experimental group received electro-acupuncture and various methods of non-pharmacological behaviour therapy, while the control group received sham electro-acupuncture and behaviour therapy. The type of behavioural treatment used was planned according to the individual patient’s symptoms and was then reduced through exercise and positive reinforcement, among others.14 The authors reported that core ADHD symptoms were significantly lower in the experimental group than in the control, and thus proposed that electro-acupuncture is a valid and effective treatment option for paediatric ADHD. However, some flaws in the study design existed. There was a considerable drop-out rate of 20%, and it is not known how many children (or their parents) refused this treatment option.14 Moreover, the study was carried out by the National Chinese Medicine Committee, so some conflict of interest may have occurred.
Meditation is a popular method of relaxing and reducing stress. Therapeutic meditation can be divided into concentrative and mindfulness meditation. In concentrative meditation, one focuses attention on an object and sustains attention on the object until the mind achieves stillness.15 On the other hand, mindfulness meditation emphasises awareness of any emerging thoughts of the mind. After much practice, the meditator is thought to develop an increase in attentive capability – that is, the ability to abstain from reacting to their own thoughts and emotions, with a certain emphasis on self-control.15 It has been proposed that meditation lessons could be useful in improving some common ADHD symptoms that many children encounter. One three-month open pilot study tested the use of transcendental meditation in ten students aged 11-14 years with a diagnosis of ADHD. Transcendental meditation involves two components: a suitable sound/mantra specifically chosen to enable the mind to settle, and skilful use of the sound to lead to the experience of quieter aspects of a person’s awareness. After three months of intervention, there was a documented drop in participants’ scores on both the Child Behaviour Checklist and the Achenbach Youth Self-Report ADHD Problems Scale.16 However, this study was of low power, and did not compare the intervention group to a control. Meditation, like all therapeutic modalities, is not without its fair share of adverse effects.17-18 Some reports suggest that meditation can produce unwanted effects, such as temporary depersonalisation17 and psychotic states.18 As such, meditation should not be recommended without the guidance and close supervision of a trained professional.
ADHD is a common disorder of complex pathology with several possible treatment options. The first-line treatment of ADHD is the prescription of stimulant drugs such as methylphenidate or dexamphetamine. However, this pharmacological intervention does not agree with every child. In addition to perceived social stigma, many children also experience distressing side effects from these medications.
Several CAM modalities have gained popularity for the treatment of ADHD in children. The difficulty in assessing the efficacy of such treatments lies in the different definitions of the aetiology of illness, along with the ethical issues that are inherent in such a study. Several studies that consider alternative therapies show potential. However, most of the studies are small-scale and of questionable study design.
More reliable, high-quality research is needed to assess the effectiveness of CAM modalities – such as chiropractic care, electro-acupuncture and meditation – in the treatment of ADHD in children.
- Buckley S, Hillery J, Guerin S, McEvoy J, Dodd P. The prevalence of features of attention deficit hyperactivity disorder in a special school in Ireland. J Intellect Disabil Res. 2008;52(2):156-62.
- Murtagh A. Child health: ADHD challenge. World of Irish Nursing & Midwifery. 2007;15(6)28-9.
- Loscalzo R. An integrated approach to the management of attention deficit hyperactivity disorder (ADHD) in children: the role of dietary and nutritional interventions. Nutritional Perspectives: Journal of the Council on Nutrition. 2004:27(4):33.
- Gould MS, Walsh BT, Munfakh JL, Kleinman M, Olfson M, Greenhill L et al. Sudden death and use of stimulant medications in youths. A J Psych. 2009;166(9):992-1001.
- DynaMed [Internet]. Ipswich (MA): EBSCO Publishing. 1995. Record No. AN 233098, Methylphenidate; [updated October 31, 2011; cited November 4, 2011]; [about 50 screens]. Registration and login required.
- Barkley RA, Cox D. A review of driving risks and impairments associated with attention-deficit/hyperactivity disorder and the effects of stimulant medication on driving performance. J Safety Res. 2007;38(1):113-28.
- Wittman R, Vallone S, William K. Chiropractic management of six-year-old child with attention deficit hyperactivity disorder (ADHD). J Clin Chiroprac Pediatr. 2009;10:612-20.
- Alcantara J, Davis J. The chiropractic care of children with attention-deficit/hyperactivity disorder: a retrospective case series. Explore (NY). 2010;6:173-82.
- Cassista G. Improvement in a child with attention deficit hyperactivity disorder, kyphotic cervical curve and vertebral subluxation undergoing chiropractic care. J Vert Sublux Res. 2009;5:1-11.
- Bedell L. Successful care of a young female with ADDH/ADHD and vertebral subluxation: a case study. J Vert Sublux Res. 2008;7:3-9.
- Stone-McCoy PA, Przybysz L. Chiropractic management of a child with attention deficit hyperactivity disorder & vertebral subluxation: a case study. J Paediatr Matern Fam Health Chiro. 2009;3:1-8.
- Hesketh T, Zhu WX. Health in China. Traditional Chinese medicine: one country, two systems. BMJ. 1997;315(7100):115-7.
- Jiang S, Yang GH. Clinical Research and Application of Acupuncture and Tuina. Beijing; People’s Medical Publishing House, 2008.
- Li S, Yu B, Lin Z et al. Randomised-controlled study of treating attention deficit hyperactivity disorder of preschool children with combined electro-acupuncture and behaviour therapy. Complement Ther Med. 2010;18:175-83.
- Krisanaprakornkit T, Ngamjarus C, Witoonchart C, Pivavhatkul N. Meditation therapies for attention-deficit/hyperactivity disorders (ADHD). Cochrane Database of Systematic Reviews (Online) [serial online] June 16, 2010:(6):CD006507. Available from: MEDLINE, Ipswich, MA. Accessed September 18, 2011.
- Grosswald SJ, Stixrud WR, Travis F, Bateh MA. Use of the transcendental meditation technique to reduce symptoms of attention deficit hyperactivity disorder (ADHD) by reducing stress and anxiety: an exploratory study [online]. Curr Iss Educ. 2008;10:34-40.
- Castillo RJ. Depersonalisation and meditation. Psychiatry. 1990;53(2):158-68.
- Chan-Ob T, Boonyanaruthee V. Meditation in association with psychosis. J Med Assoc Thai. 1999;82(9):925-30.