Contents

 

Introduction

 

Part I: Western Biomedicine

1. DSM IV
1. Diagnostic criteria
2. Differential Diagnosis
2. Neurological Information
3. 3 clinical subtypes
4. Ethics Issues in Diagnosis and Treatment
5. Meyers Brigg Temperment Indicator Types for ADHD
6. Gifted and Talented Children Misdiagnosed
7. Medications
8. Western Herbs
9. Diet

 

Part II: Chinese Medicine

1. ADHD and TCM
2. Frequency of ADHD Patterns
3. ADHD Patterns, Symptoms and Treatment Principles
4. Etiologies
5. Treatment with Acupuncture
6. Herbal Treatments and Diet
7. Treatment Plan and Prognosis

 

Conclusion

 

Biography

 

Sources

 

            Chinese Medicine can treat ADHD in much the way it treats all diseases; diagnosis involves pattern-differentiation, and treatment follows from correct identification of the pattern(s) involved.  There is also a growing body of specific information about the treatment and pathomechanisms of ADHD gathered from the clinical experience of TCM practitioners.

 

 

 

 

 

 

 

Part I:

Western Biomedicine

 

DSM IV Diagnostic Criteria

 

The DSM IV (1994) criteria are much more exact than the DSM III criteria. 

 

A.  Either 1 or 2

        1.Six or more of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with

          developmental level:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
• Often has difficulty sustaining attention in tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as school work or homework)
• Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities

 

        2.Six or more of the following symptoms of hyperactivity/impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level

 

          Hyperactivity

• Often fidgets with hands or feet or squirms in seat
• Often leaves seat in classroom or in other situations in which remaining seated is expected
• Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
• Often has difficulty playing or engaging in leisure activities quietly
• Is often "on the go" or often acts as if "driven by a motor"
• Often talks excessively

 

Impulsivity

• Often blurts out answers before questions have been completed
• Often has difficulty awaiting turn
• Often interrupts or intrudes on others (e.g. butts into conversations or games)

 

   B.Some hyperactive, impulsive or inattentive symptoms that caused impairment were present before 7 years of age

 

  C.Some impairment from the symptoms is present in two or more settings (e.g., at school or work and at home)

 

  D.There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning

 

   E.The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder, and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder.)

 

 

Clinical Subtypes

1. ADHD combined type: qualifies for both the inattentive and the hyperactive/impulsive portions of the DSM IV criteria
2. ADHD, predominantly Inattentive type
3. ADHD, predominantly Hyperactive-Impulsive type

Differential Diagnosis

 

Be sure the symptoms are not actually more due to:

 

• Mood disorder
• Anxiety disorder
• Dissociative disorder
• Personality disorder
• Oppositional behavior
• Psychotic disorder
• Age-appropriate behaviors in active children
• Mental Retardation with attentiveness and behavior appropriate to child's mental age

• Allergies
• Hypoglycemia
• Abusive/stressful home situation
• Malnutrition
• Chronic middle ear infection
• Sinusitis
• Visual/hearing problems
• Dyslexia
• Other neurological problems (e.g. CFIDS)
• Intelligent/Gifted but in an understimulating environment

Neurological Information

 

Anatomic Studies

 

• Symmetry of the frontal lobes instead of the normal right greater than left pattern
• Smaller left caudate and globus pallidus

 

Positron Emission Scanning

 

• Glucose metabolism in the adults with residual type AD/HD has been measured by PET scan and was found to be globally decreased.

 

Blood Flow Analysis

 

• Alterations in blood flow to the frontal and basal ganglia regions have been reported in patients with AD/HD. These abnormalities of flow are reversed by treatment with methylphenidate.

 

Clinical Correlation

 

• The right hemisphere may be dominant for mediating attention.
• Left hemisphere lesions are associated with no effect on attention.
• However, lesions of the right hemisphere will induce severe inattention and an inability to sustain simple motor acts.
• Lesions of the medial and dorsolateral frontal lobes are associated with inattention, impaired response inhibition and motor impersistence.
• The right frontal lobe and right striatum appear to be particularly important for inhibiting unwanted action in response to stimuli.
• The neurons of the prefrontal cortex respond to sensory stimuli and are thought to integrate motivational events with complex sensory stimuli. They are also involved in inhibiting or delaying motor response to stimuli. The right frontal lobe has been implicated as one potential site of pathologic neurotransmission in AD/HD.
• Prefrontal damage is known to cause disturbance in drive and executive control. This lack of executive control results in impulsive actions do to an inability to think ahead to the consequences of an action.
• Circuits connecting the basal ganglia with the prefrontal cortex may also be important in cognition. Abnormalities of blood flow to these regions are noted in patients with AD/HD.
• One fx of the LC (locus ceruleus)/noradrenergic system is modulation of behavioral state.  It can enhance the processing of relevant stimuli and increase the SNR (signal to noise ratio).  In primates, the PFC (prefrontal cortex) is the major region that inhibits the processing of irrelevant stimuli... LC dysfx can also cause decreased levels of PFC dopamine. LC hypofx could therefore produce ADD because an individual's ability to decide what is salient when exposed to sensory input would be impaired-  norepinephrine xu -> low SNR  (Goldstein, p59)
• the Locus Ceruleus is important is arousal and vigilance. Vigilance is a state of increased arousal. Vigilance is necessary for focus or directed attention but not suffecient. Focused attention requires that incoming sensory information be given a priorty according to importance. The process of habituation occurs if stimuli is not reinforced. A lack of directed attention can appear as impaired concentration.

 

Neuroanatomy of AD/HD

 

The frontal lobe, right cerebral hemisphere, globus pallidus, hippocampus, nucleus acumbens, locus ceruleus, and thalamus have been implicated in the etiology of AD/HD

 

Putting It All Together: A Neuroanatomical/Neurochemical Model for ADHD

 

Several anatomic locations in the brain contain pathways which modulate cortical motor and cognitive output. At each anatomic location a different neurotransmitter is used primarily.

 

1. Dopaminergic pathways exist at the cortical and subcortical level (with in the right cerebral hemisphere, prefrontal cortex, hippocampus and nucleus accumbens) which when impaired prevent appropriate sensory filtering and cognitive processing. Deficiencies in these Dopaminergic pathways are most closely related to the inattentive form of AD/HD.
2. Arousal level is mediated in the brain stem by the reticular formation and locus coeruleus. The primary neurotransmitter is norepinephrine.  Disorders in this pathway result in the hyper-aroused AD/HD.
3. The prefrontal cortex modulates behavior inhibition and serotonin is the predominant central inhibiting neurotransmitter. Defects in this pathway lead to AD/HD-like behaviors secondary to impulsivity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Here is a graphic representation of this model:

 

All three types meet DSM IV criteria for AD/HD but represent different neurochemical pathologies which may respond differentially to specific pharmacotherapies.

 

These concepts remains to be evaluated in a controlled fashion. However, such a model may ultimately prove useful in choosing the best therapeutic agent for a given child, predicting comorbid disorders, aid in defining prognosis and in designing better case specific behavioral interventions.

 

Ethical Issues in Diagnosis and Treatment

 

• Gifted children exhibit significantly more "overexcitabilities" than average children, including physical, emotional, intellectual, sensual and imaginational overexcitabilities
• Lists of creative behaviors are strikingly similar to the ADD diagnostic criteria (see inset above)
• Children diagnosed with ADD score higher on tests of creativity.  In one study, more than a quarter of the children previously diagnosed as ADHD scored high enough to qualify for a Creative Scholars program in Louisiana
• Most people diagnosed with ADD can focus extremely well on something they find interesting - even better than the average person;
• A 1999 survey of two Virginia school districts (30,000 children) found that 20% of the 5th-grade white boys were taking ADD medications; in another study between 1 and 1.5 percent of preschoolers were found to be taking psychotropic medications in 1995, often two or three medications simultaneously (usage is probably much higher now) - compare 20% to the DSMIV's stated 3-5% prevalence.
• Temperament experts believe ADD behaviors are within the realm of "normal" behavior for certain MBTI temperament types
• Professionals espousing a positive view of ADD are usually ADD themselves (Hallowell, Hartmann, Weiss) while professionals sticking to a strictly negative view are not ADD (Barkley) or are associated with the pharmaceutical industry (CHADD).
• A Purdue University study found that kids deficient in omega-3 fatty acids are more likely to have ADD, learning disorders, behavior problems, depression and dyslexia
• Some researchers argue that ADD traits such as impulsivity and restlessness are adaptive behaviors that once helped humans to survive in harsh, unstable environments
• The Center for Science in the Public Interest recently reviewed 25 years of scientific studies and determined that food additives and certain foods DO cause behavior problems in a significant number of people and that public policy should be changed accordingly. Groups such as CHADD (funded by the makers of Ritalin) adamantly tell parents not to waste their time checking for food sensitivities
• Top psychiatrists are increasingly beginning to speak out against their peers for over-medicating America's children, especially preschool children. Dr. Joseph T Coyle, chair of the psychiatry department at Harvard Medical School said "these drugs are being used at ages for which there is abolutely no justification." Dr. Coyle polled the editorial board of the Journal of Child and Adolescent Psychopharmacology (48 physicians) and found "most of the experts said they have not or very rarely use these drugs" on young children.  He says this raises the question: If the experts feel that this is inappropriate, then who's prescribing these drugs?

Meyers Brigg Temperament Indicator

The MBTI is a system of personality differentiation.  There are 16 types, which come from 4 either/or attributes; Extrovert/Introvert, Sensing/iNtuituing, Thinking/Feeling, Judging/Perceiving.  For example, Someone who has preferences for Extraversion, iNtuition, Thinking and Perceiving is said to be an "ENTP" type.

Brief Descriptions of the 4 Most Common Temperaments To Visit Borntoexplore.org (a website devoted to alternative views on ADHD):

Quotes are from the book "The Pathfinder" by Nicholas Lore.

INFP "The Healer" (By far the mostly likely type to identify themselves as ADD, considering they are only 1% of the population): "Idealistic, warm, caring, creative, imaginative, original, artistic, perceptive, supportive, empathetic, cooperative, facilitative, compassionate, responsive, sensitive, gentle, tenderhearted, devoted, loyal, virtuous, self-critical, perfectionist, self-sacrificing, deep, multifaceted, daydreamer, persistent, determined, hard-working, improviser, initiator of new projects and possibilities, agents of change. Drawn to possibilities, 'what could be' rather than 'what is.' Values-oriented with high level of personal integrity.  Their focus is on understanding themselves, personal growth, and contributing to society in a meaningful way.  If their career does not express their idealism and drive for improvement, they usually become bored and restless. Dislike conflict, dealing with trivialities, and engaging in meaningless social chatter.  Needs a private work space, autonomy, and a minimum of bureaucratic rules." Some of the best novelists are INFPs. Suggested careers: Counselor, artist, and journalist.  INFPs are prone to depression when they cannot meet their own sense of perfection or the expectations of others. The very often accept blame, even when it's not deserved, and really dwell on how bad they think they are, but they are not likely to let people know that.  They also tend to write me the nicest letters. 

ENFP "The Advocate": "Enthusiastic, expressive, emotional, warm, evocative, imaginative, original, artistic, improviser, perceptive, affirming, supportive, cooperative, positive, open responsive, sensitive, playful, fun-loving, multifaceted, gregarious, zestful, spontaneous, idealistic, initiators of new projects and possibilities, agents of change.   Their focus is on self-expression and possibilities, "what could be' rather than 'what is.' Life is a celebration and a creative adventure.  Enthusiastic initiators of new projects, relationships, and paradigms.  Masters of the start-up phase. Lose interest when the project or relationship gets routine or when the primary goal is well on the way to accomplishment.  Often eloquent in expressing their vision of a world where ideals are actualized. Frequently have a positive attitude in situations others would consider to be negative.  Work in bursts of enthusiasm mixed with times when little gets done. Need careers that are personally meaningful, creative, and allow for full self-expression and that contribute to other people in some way.  Extremely versatile.  They may have friends from many walks of life, a wide range of interests and hobbies, and they gain a professional level of mastery without formal training." Suggested careers: Public relations, actor, teacher.

ENTP "The Inventor":  "Enthusiastic, puzzle master, objective, inventive, independent, conceptual thinker, creative problem solver, entrepreneurial risk taker, improviser, competitive, questioning, rebellious, rule breaker, gregarious, witty, involved, strategic, versatile, clever, adaptable, energetic action-oriented agents of change.  Improves systems, processes, and organizations. Relentlessly tests and challenges the status quo with new, well-thought-out ideas, and argues vehemently in favor of possibilities and opportunities others have not noticed ["Born To Explore" is a prime example of an ENTP doing this!].  Can wear out their colleagues with their drive and challenging nature.  See the big picture and how the details fit together.   The most naturally entrepreneurial of all types. Usually not motivated by security.   Their lives are often punctuated with extreme ups and downs as they energetically pursue new ideas.  They have only one direction: ahead at full speed, leaving a trail of incomplete projects, tools, and plans in their wake.  Their idea of fun and best creative self-expression involves devising new conceptual modeling and dreaming up imaginative and exciting ventures.  Need lots of room to maneuver.  When forced to dwell on details and routine operating procedures, they become bored and restless.   Respect competence, not authority.  Seek work that allows them to solve complex problems and develop real-world solutions. Often surrounded with the latest technology."  Suggested careers: High tech engineer, marketer, entrepreneur. This type is the most likely to switch careers.

INTP "The Architect": "Logical, original, speculative quick thinkers, ingenious, inventive, cerebral, deep, ruminative, critical, skeptical, questioning, reflective problem solver, flaw finder, architect and builder of systems, lifelong learner, precise, reserved, detached, absent-minded professor.  Seeker of logical purity. They love to analyze, critique, and develop new ideas rather than get involved in the implementation phase. Continually engage in mental challenges that involve building complex conceptual models leading to logically flawless solutions.  Because they are open-ended and possibility-oriented, an endless stream of new data pours in, making it difficult for them to finish developing whatever idea they are working on.  Everything is open to revision.   Consequently, they are at their best as architects of new ideas where there are endless hypothetical possibilities to be explored, and no need for one final concrete answer.  Their holy grail is conceptual perfection.  May consider the project complete and lose interest when they have it figured out.  To them, reality consists of thought processes, not the physical universe.  Often seem lost in the complex tunnels of their own inner process.  Seek work that allows them to develop intellectual mastery, provides a continual flow of new challenges, offers privacy, a quiet environment, and independence.  Thrive in organizations where their self-reliance is valued and colleagues meet their high standards for competency."  Suggested careers: Chemist, lawyer, mathematician.  INTPs are prone to depression when they dwell on their inability to meet their extremely high expectations of themselves.

Gifted and Talented Children Misdiagnosed

Many people diagnosed as ADD are "gifted."    The definition of giftedness is somewhat arbitrary, and there are probably many kids out there who are not quite gifted but still smarter than most of their peers.   "Bright" kids may display the same behavioral traits as gifted kids, which are strikingly similar to ADD traits (see below).

 

There are various definitions of giftedness out there, but in general a person is considered gifted by meeting one of the following characteristics:

1. An IQ of 130 or over.
2. Aptitude or achievement in a particular subject, such as math (generally being in the 97th percentile).
3. Creative and productive thinking.  ADDers are more likely to be gifted in this area than others.  Characteristics include openness to experience, setting personal standards for evaluation, ability to play with ideas, willingness to take risks, preference for complexity, tolerance for ambiguity, positive self-image, and the ability to become submerged in a task.  Students may be identified through tests like the Torrance Test of Creative Thinking or through demonstrated creative performance.
4. Leadership ability. 
5. Visual and performing arts.   ADDers may be over-represented in this category.
6. Psychomotor ability (seldom used).

The link between ADD traits and IQ might be explained by the presence of Over-Excitabilities (OEs). Dabrowski's Theory of Positive Disintegration suggested that people with OEs have a higher level of potential development than others. Later research verified that OEs are related to intelligence. Over-excitabilities include physical, imaginational, and cognitive excitabilities, all of which would lead someone down the path to an ADD diagnosis.

Many proponents of the Gifted will say that a child with an IQ of 130 is not ADD, rather, they are Gifted.  However, the DSM IV diagnostic criteria for ADD do not exclude people who meet the criteria due to giftedness, and gifted ADDers can experience the same problems as non-gifted ADDers.  For example, they are often underachievers and have social difficulties. 

 

Medications

 

Choosing a Medication

Methylphenidate and Dextroamphetamine have been used for first line therapy for many years. Clonidine is being used with increasing frequency by the primary care provider particularly for patients with aggressive/hyperaroused behaviors or comorbid tic disorders. The mechanisms by which these drugs modulate their effects are not fully understood. It is presumably through their effects on multiple catecholamine neurotransmitters.  With this approach 60-90% of children respond to therapy.

 

No clinical data clearly predict the medicine to which a particular child is most likely to respond. The presence of a comorbid diagnosis and parental

preference best dictate the choice of medication. The advantages and disadvantages of each medication are detailed in each medication summary.

 

Pemoline a central nervous system stimulant structurally dissimilar to dextroamphetamine and methylphenidate, was being used with increasing frequency in the primary care setting. However, because of reports of life threatening liver failure, pemoline is no longer felt to be a first line treatment agent. Other medications (e.g. tricyclic antidepressants, carbamazepine) are used primarily in patients with complicating factors (e.g., comorbid psychiatric conditions, contraindications to first line agents) or if symptoms are resistant to first line agents. These medications are used infrequently in the primary care setting and are not discussed in this review.

 

METHYLPHENIDATE  (e.g. Ritalin)

     Advantages/Disadvantages:

          Long track record

          May unmask/exacerbate a tic disorder

     Availability:

          5mg,10mg(scored), 20mg (scored)

          20mg SR

     Starting Dose:

          preschool aged: 2.5 mg q am (w/ breakfast)

          school aged: 5 mg q am (w/ breakfast)

     Onset of Action:

          15-30 minutes

     Duration of Action:

          2-4 hrs

     Dosage Adjustment:

          Increase 5 mg every 3-5 days until effect observed.

          When a therapeutic effect achieved, a second dose of the same amount can be given at lunch to control afternoon symptoms.

          An occasional child with severe symptoms may need a 4:00pm dose to control evening symptoms.

          Once the regimen has been adjusted the child can be switched to the long acting form. The total daily dose of long acting preparation often needs to be

          slightly higher than the total daily dose of short acting preparation. Long acting preparations may not be effective for some patients.

     Maximum Dose:

          0.8-1 mg/kg/dose (Doses higher than 1mg/kg have been shown to impair cognitive abilities in some patients.)

 

DEXTROAMPHETAMINE (e.g. Dexadrine/Adderall)

     Advantages/Disadvantages:

          Long track record

          Longer half life -- less likely to need afternoon dose.

          Adderall is a mixture of dextro and levo amphetamine and has a slightly longer half-life (8-12 hours) potentially allowing less frequent dosing. These

          isomers have been shown to have equal effects on noradrenergic function but differential effects on dopaminergic function and clinical symptoms of

          inattention. The levo isomer is not as active as the dextro. These differences may have implications regarding the mixtures efficacy.

          May unmask/exacerbate a tic disorder

     Availability:

          5,10 mg

          5,10,15 mg SR

          Adderall: 10, 20, 30 mg (double scored tabs).

     Starting Dose:

          preschool aged: 2.5 mg q am (w/ breakfast)

          school aged: 5 mg q am (w/ breakfast)

     Onset of Action:

          15-30 minutes

     Duration of Action:

          2-6 hrs

     Dosage Adjustment:

          Increase 2.5-5 mg every 3-5 days until effect observed.

          When a therapeutic effect achieved, a second dose of the same amount can be given at lunch to control afternoon symptoms -- usually slightly less than

          the am dose.

          An occasional child with severe symptoms may need a 4:00pm dose to control evening symptoms.

          Once the regimen has been adjusted the child can be switched to the long acting form. The total daily dose of long acting preparation often needs to be

          slightly higher than the total daily dose of short acting preparation. Long acting preparations may not be effective for some patients.

     Maximum Dose:

          1.5 mg/kg/day (rarely need to exceed 40mg/day)

 

CLONIDINE (e.g. Catapress)

     Advantages/Disadvantages:

          May suppress tics

          May be preferred agent to treat aggressive or hyperaroused behaviors

               More effective in controlling aggressive/hyperaroused symptoms than other agents

               Improves inattentive symptoms to a lesser extent than other agents

          Somnolence may limit use but often resolves with time

          Rebound HTN if stopped rapidly

          May be contraindicated for patients with cardiac pathologies

     Availability:

          0.1, 0.2, 0.3 mg

          Transdermal Patch 0.1, 0.2, 0.3 mg/day (Lasts 7 days)

     Starting Dose:

          0.025-0.05 mg qhs

     Onset of Action:

          1-2 weeks for maximal effect

     Duration of Action:

          N/A

     Dosage Adjustment:

          Increase to BID after 5-7 days, then to TID after another 5-7 days. Then increase by 0.025-0.05 mg/day every 5-7 days till therapeutic effect

          achieved. (Titrate up very slowly to minimize somnolence --- one of the most common reasons parents dislike/discontinue this medication.)

          Monitor blood pressure and heart rate with each increase in dose

          To discontinue, wean over one week.

 

Medication Side Effects

     Anorexia, abdominal discomfort, insomnia and weight loss are side effects that are common to these medications but appear to resolve in most patients with continued therapy.

     Potential growth suppression has been a concern. Patients may show a temporary decrease in linear growth and weight gain however there is no evidence that these medications affect ultimate adult stature or weight.

     Stimulant medications are now considered safe in children with seizure disorders if the child's seizures are well controlled on a single anticonvulsant.

     Cardiovascular Effects: Dextroamphetamine and methylphenidate have sympathicomimetic effects and may elevate blood pressure and heart rate. Clonidine may lower blood pressure or cause rebound hypertension if stopped rapidly.

     The risk of unmasking or exacerbating a tic disorder with methylphenidate, dextroamphetamine and pemoline is only 1.3%. This risk could be higher if there is a family history of a tic disorder. Clonidine is the preferred initial medication for children with tics because it suppresses tic disorders. The presence of or family history of a tic disorder is not an absolute contraindication to the stimulants but the patient should be monitored closely for exacerbation of tics.

     This effect is reversible with discontinuation of the drug.

 

Western Herbs

 

For alleviating depression. St. John's wort extract; 300(milligrams) mg., three times daily. It is a mild antidepressant and increases norepinephrine levels in the brain.   It appears to increase dopamine activity in the brain with almost no side effects.  Dopamine is the "feel-good" neurotransmitter responsible for concentration. All the major ADD medications are said to work on dopamine.  St. John's Wort is not a stimulant however, and you are not likely to feel like you're "on something".  To get a significant effect you may have to take two to three times the normally recommended dosage and it takes up to six weeks for it to really start working.  You must also be sure to purchase high-quality product because there is a lot of St. John's Wort on the market that doesn't contain what is claimed on the package.  Kira is the brand that was used in studies showing effectiveness in treating depression. St. John's Wort is probably the most studied of all the herbs and it is actually prescribed quite a bit in Germany for mild depression.  It has not been tested for use in treating ADD

 

For increased memory and mental acuity. Ginkgo biloba; 240 mg. in pill or powder form, divided into two or three doses per day. This herb increases blood flow to the brain.  For difficulties with concentration and memory due to blood circulation problems, especially associated with aging.  It's a popular herb and a lot of people try it out for ADD.  It's a blood thinning or anti-clotting agent, so there are potential sides effects such as bleeding under the skin or into the eye, and there are possible interactions with other medicines that also thing blood such as aspirin or heart medications.

 

For energy and endurance. Siberian ginseng (Eleutherococcus senticosus); 300 mg. to 400 mg. in two or three daily doses. (In tincture, 8 milliliters (ml.) to 10 ml. in two to three divided doses). Use for four to six weeks, stop for one to two weeks, then, resume.

 

Pine bark extract (or Pycnogenol) and grape seed extract contain proanthocyanidin,a bioflavonoid which has reportedly demonstrated anti-oxidant properties and may be closer to a nutritional supplement than a medication.  Very popular for treating ADD, with some scientific backing.

 

Primrose oil, flax oil, fish oil and Effalex are nutritional supplements rather than medicinal herbal supplements because they contain essential fatty acids, something the body must have.

 

For liver cleansing. Milk thistle is useful in counteracting the effect of drugs, yeast infections and toxic byproducts resulting from food allergies: Milk thistle extract of 420 mg. Is recommended, divided into three doses. Milk thistle is particularly valuable for protecting the liver when taking prescription antidepressants, which is sometimes part of the ADHD treatment plan.

 

For insomnia. Valerian root extract; 300 mg. to 500 mg., one hour before bedtime. Combine with passionflower, lemon balm and skullcap. Consult with an herbalist to determine the right amount of each. Valerian is a mild central nervous system sedative that helps children get to sleep faster and enjoy deeper sleep.

 

For calming. Chamomile extract; two to three ml. Of liquid extract in warm water before bed. Or, if the child is allergic to ragweed (related to chamomile, botanically), use other mild herbal sedatives such as skullcap and passionflower.

 

Coenzyme Q₁₀ in high doses reportedly stimulates dopamine activity in nerve cells.  Dopamine is the neurotransmittor implicated in ADD.  The National Institute of Health has launched new studies of coQ₁₀ as a treatment for Parkinson's and Huntington's diseases.  

 

 

 

 

 

Diet

 

All children need healthful diets to learn and feel their best. It is important that children with AD/HD eat a well-balanced diet. However, because of behaviors and medications, it may be difficult for them to eat right.

Children with AD/HD don't always pay attention to their own body signals for hunger, rest, or need to use the toilet. Even when they do, they often don't sit still long

enough to finish the job! They may eat just enough to "take the edge off" before they are off to do something else. Because of their high activity level and need for

calories they may crave sweets to meet their energy needs. Medication often decreases the appetite during the daytime.

 

What can you do to help?  Advice for Parents:

·        Give your child 3 regular meals.

o       He/she should be seated at a table with the family rather than in front of the TV or wandering around the house.

·        Offer a variety of health foods.

o       Let him/her choose what and how much to eat.

o       Give milk to drink and fruit for dessert.

·        Make healthful snacks part of your diet plan.

o       Midmorning and afternoon snacks of fresh or dried fruit, graham crackers, popcorn of juice will supply calories and vitamins.

·        An evening or bedtime snack may be really important since medication effects will usually have worn off by then.

o       A protein snack such as peanut butter or meat sandwich, yogurt, cheese, nuts, milk and cereal or a milkshake are some good choices.

·        Increase your child's interest in meals.

o       Include him/her in the planning or preparation.

·        Save sweets and other "junk foods" for occasional use.

o       It is best not to have them in the house on a regular basis.

·        Give stimulant medication with milk or after meals.

·        If your child continues to be a very picky eater, check with your nurse, doctor, or dietitian about the need for multivitamins or other supplements.

 

 

What about sugar, food additives and food allergies?

If you feel your child is more active or behavior is worse after eating certain foods, simply eliminate those foods for at least two weeks to see if it makes a difference.

If your child has allergic symptoms such as hayfever or asthma, it may be helpful to talk with your nurse or doctor about foods that might be making these symptoms

worse.

Again, we know that good nutrition does make a difference in learning and behavior. Your energy and money is best spent in providing a varied and healthful diet. If you need more information on healthy diets for children, ask your nurse, doctor, or dietitian.

 

 

 

 

 

 

 

Part II:

Chinese Medicine

 

ADHD and TCM

 

 

Memory problems

Alex Tiberi makes a simple differentiation in types of memory and the pathological organ involved in each:

• intellectual material and learning, memory- Sp
• alzheimer's memory loss - K
• distraction, absent-minded, lack of focus, lost something they just had - H  (Sp not producing xue, H not nourished)

 

 

Characteristics and symptoms of various ADHD organ involvements:

The Heart type is withdrawn, doesn't want relationships, and lacks emotional warmth.

The Liver type provokes others, is argumentative and combative.  From birth, the liver is very big proportionally (kids grow into their liver).  It acts as a sensitive emotional antenna.  Because of this the practitioner must give them attention, stay focused, and communicate in their behavior that the child can't manipulate the practitioner.  Children need limits placed on them so that liver doesn't run wild or stagnate.  Otherwise, the liver expands but nothing contains it. The child tries to figure it out and his liver gets stagnated.  Parental, classroom, and societal limits and guidance constrain the liver for them.  What is needed is consistent reasonable discipline.  Inconsistent or excessive discipline leads to liver heat.  This kind of ADHD is worse in a hot classroom.

If the child has no nourishing connection to caregivers, they develop a Lung xu.

The nurturing aspect of relationships goes to the Spleen.  If the parents only play with kids then they get L qi but not Sp qi.  Excessive nurturing causes dampness (trying to do everything for them).

poor self-esteem/concept; hypercritical parents, situations where failure is inevitable, liv xue xu, K yang xu- liv qi yu from parental overcontrol; adult behaviors that destroy liver - are they destroying their fathering influence?  tonify K by put self in challenging situations that you can overcome, succeed - slower kids and gifted kids in classroom check out, boredom- poor coordination, clumsy H not focused or L 'po' connection of mind to body L xu lack of fine motor skills - yang shi Liver or Liv yin xu injure selves

 

inconsistency- environmental triggers to ADHD-

persistent obsessive thinking- OCD diff diagnosis- Sp worry overthinking, Liv qi or xue yu (especially eating disorders)

 

 

 

 

 

 

 

Frequency of ADHD Patterns

 

 

Dr. Zhang surveyed 326 cases and found three major patterns:

 

Pattern	Frequency of occurence
Liv/K yin xu	94.1%
H/Sp qi xu	3.4%
Internal Disturbance of Phlegm Heat	2.5%

 

 

Of course, Dr. Song found a completely different set of predominances:

 

 

Pattern	Frequency of occurence
Yang qi xu	50.7%
Yin xu	26.1%
Phlegm Heat	23.2%

 

 

It's clear that more work needs to be done to determine the true predominance of different patterns in the ADHD population.  Another problem here could be in the definition of ADHD.  The source for these statistics did not go into detail about each doctor's own definition.

 

ADHD Patterns, Symptoms, and Treatment Principles

 

Here is a table for treatment of the various diagnoses that either:

1. As elements may combine in the complete presentation of the patient, or
2. represent the major pattern or pattern combination causing the patient's symptoms

 

Syndrome	Symptoms	Treatment Principles	Source
Liver heat	provokes others, argumentative, combative, fighting, biting	clear heat from and soothe liver, calm spirit	tiberi
Kidney xu	easily startled, slow development (especially mental)	ton k yin, yin qiao, reg nervous system, bring energy up	tiberi
Spleen xu	attention deficit; spaced out, not remembering material studied in class	tonify spleen	tiberi
dampness	slow mental response, overwhelmed, sp xu symptoms	drain or transform dampness, tonify the spleen	tiberi
Liv/K yin xu	scattering mind, daydreaming, hyperactivity, polyphrasia, decreased sleep with many dreams, restless heat of 5 centers, frequent changes of interest, boisterous activity, clumsiness, dryness of lips, dry red T, thready rapid P	moisten K and soften Liver, benefit Yin and subdue Yang	dr zhang
H and Liv Fire Shi	violent rage, hyperactivity, ruthlessness, talkativeness, impulsiveness, thirst desiring fluid, dry stools, dark urine, red T with yellow fur, bowstring rapid P	cool Liver and purge Fire, clear Heart and pacify Spirit	dr. zhang
H/Sp qi xu	lusterless complexion, poor memory, distractibility, feebleness of mind and body, easy fright and fatigue, poor sleep, pale T with scanty fur, thread weak P	sedate fright, pacify spirit, open yang and arrest perspiration	dr zhang
phlegm heat	persistent agitation, capriciousness, chest oppression, epigastric spleen obstruction, mental dullness, poor appetite, bubbling phlegm sound in throat, yellow turbid urine, red T with yellow stick greasy fur, bowstring slippery rapid P	clear heat and dissolve phlegm, pacify spirit and sedate emotion	dr zhang
K yin xu			dr hou
Sp xu with phlegm turbidity			dr hou
Phlegm heat agitating wind	hyperactivity, extreme naughtiness, lack of fatigue, impetuosity, poor self-control, irascibility, involuntary muscle contraction, blinking, distortion of mouth exposing teeth, oral muscular tremor, stooping head heaving shoulder, hyperactivity, restlessness, lack of concentration, red tongue with thin yellow fur, bowstring slippery or slippery rapid pulse	1.                  Expel Phlegm, sedate fright and extinguish wind 2.                  Nurture Heart, pacify Spirit, benefit Stomach and relax Center 3.                  Moisten Yin, clear Heat, tonify heart and pacify Spirit	master li shao
H Sp xu with reckless floating yang		1.                  nurture heart and pacify spirit 2.                  fortify spleen and relax center	Dr. Wang
Confined entanglement of wet heat with flaming of phlegm fire		1.                  drain wet fire and purge fire 2.                  dissolve phlegm and open orifices	Dr. Wang
Flaming Liver Fire disturbing Spiritual Brightness	stagnated stare, congested eyes, insomnia, memory xu, low school grades, red T with thin white fur, bowstring rapid pulse	calm mind, clear heat, descend fire, relieve restlessness	Dr. Ma
Qi yu with congested entanglement, internal Flaming of H fire, perturbation of spiritual brightness	anger, noisiness, distractibility, shouting and wailing, manic agitation, attacking people, abusiveness, deep red T without fur, bowstring rapid or flooding rapid P	move qi, relieve congestion, descend and clear H fire, restore spirit	Dr. Ma

Etiologies

 

Syndrome	Etiology	Source
Phlegm Heat agitating Wind	Children have constitutional xu of Sp and H, damaged by emotional instability, prolonged accum of anxiety, H and Sp damage leads to qi yu, fluid xu and internal entanglement of phlegm tubidity.  Prolonged congestion of phlegm turbidity may transform into heat, involve the liver, agitate wind and invade spiritual brightness	Master Li Shao
Qi yu with congested entanglement, internal Flaming of H fire, perturbation of spiritual brightness	Harsh and stern family education, more work than play	Dr. Ma

 

 

Excessive activity and inability to pay attention have a common root in TCM- insufficient yin.  Yin deficit frequently affects the kidneys and liver.  The task of yin-building is not far different from that in adults.

One reason children may exhibit yin deficit is heredity, if not enough was available from the parents.  Studies have shown that parents who are themselves subject to depression, attention deficit, hyperactivity, and other developmental imbalances have a greater likelihood of bearing children with ADHD.  since children are in a yang growth phase of their life, which needs the support of their yin resources, they easily become at least somewhat deficient in yin.  Because yin and its supporting nutrients are depleted by refined foods, synthetic chemicals, pesticides, radiation from computers and TV's, highly spiced foods, fluorescent lights, smog, and numerous other toxic elements of modern life, it is advisable for children with yin xu to have as natural a diet and lifestyle as possible.

 

 

Hyperactivity before birth- restless fetus

The child may actually have been restlessness (hyperactive) in the womb!  A mother's liv xue xu, among other causes, can lead to a restless fetus and breech presentation.  To treat, tonify liv xue and k yin (jing and essence of child) during pregnancy.  Another example etiology is emotional shock to the mother during pregnancy (in fear the qi goes from the kidney to the heart, up rather than down, not to baby, so k yin doesn't get to the baby).

Restless fetus can be treated herbally through the mother:

·        shou tai wan (fetus longevity pill) for threatened miscarriages- stabilizes the K and calms the fetus- for K xu

·        jiao ai tang (ass-hide gelatin and mugwort) chong and ren vessels injured and xu- uterine bleeding

·        gui zhi fu ling wan - blood stasis in the womb

·        tai shan pan shi wan - qi xu, xue xu, threatened miscarriage

·        bai zhen yi mu wan - qi and xue xu with xue yu

·        dang gui san - xue xu, sp xu, heat- thin women with long-standing xue and yin xu

·        si wu tang + ai ye + e jiao - Liv xue xu, continuous vaginal bleeding

jia jian bu zhong yi qi tang - sinking qi xu, constitutional weakness, formula is good for 4^th and 5^th month of pregnancy
Treatment with Acupuncture

 

Dr Zhang Jia Wei

• P6: confluent point of the yin wei, pacifies Heart and calms Spirit, regulates Qi and expands the chest
• Liv3: Liver source point, pacifies Liver and subdues Yang, restrains the reckless agitation of Liver Yang
• Du14: meeting point of all yang channels, strengthens Brain, pacifies Spirit, regulates Qi and lowers reflux
• LI11: as a he-sea point, it purges and lowers reflux Qi
• lack of concentration: Du20, Sishencong, P7
• hyperactivity: ding shen, an mian, B15
• emotional instability, restlessness: Du24, Ren17, K6
• As it is difficult to needle children, use only the very effective points, perhaps only 4.  Treat once every day or every other day.  10 times is one therapeutic course.

 

Alex Tiberi:

• Liver- heat
• calm shen H3,7,8 (maybe not acu on last- cutaneous estim) focus H, ton H yin, calm H fire, moxa H9 tonifies H qi concentration and focus
• control Liv heat with Liv2,3,B18,GB20,21
• K xu
• k3,6,b23,gb25,b10,du16,20
• Sp xu
• sp3,8 (sweet craving), b20
• Damp
• sifeng, st40, sp5, b20, s8, du20

 

Needling ideas from Alex Tiberi:

Use the sifeng points for dampness (save them and other uncomfortable points until the end of the treatment).  Start with sho ni shin tapping, then moving to using a needle in the insertion tube.  The Heart type is easily startled, so just tap needle within insertion tube; that way they won't see the needle and get freaked out.  For the Liver type, tap the needle in pull away tube let them see.  They tend to find it fascinating.

Needle all 4 sifeng pts (for dampness); left hand on boys, right hand on girls.

 

George Soulie de Morant:

·        malcontent who speaks a lot: sedate K7

·        anterior frontal lobes (the prefrontal cortex being a major area related to attention deficit problems):

o       xu (lack of foresight): tonify Sp2,3, H9, Du23,24, ST40, P4

o       shi (agitated, anxious, psychotic): sedate Sp5,3, Du23,24

·        acute emotional agitation in children: LI4; but if from H xu: H9

·        Lung points for ADHD-related mental symptoms:

o       nervous tremors, emotiveness, crisis of hopelessness, laughs too easily, hallucination: L7

o       counterflow energy (nervous crisis anger), hyperexcited speech, vicious speech, insomnia from internal agitation: L8

·        Large Intestine points:

o       hyperexcited speech, gripped by emotions: LI5

o       hyperexcited speech, hyperexcitiation, insanity: LI6

o       depression, fear, forgetfulness: LI11

o       violent anger, epilepsy from fear: LI16

·        Stomach points:

o       insomnia from nervousness- hypexcitation or anxiety, tonify ST12

o       laziness, indolence, lassitude, attacks of hyperexcitation, sings, gets up on tables, takes clothes off: sedate ST40

o       easily frightened, continually excited, sings, climbs on tables, marches around aimlessly: ST42

o       detests human noises (could be related to low SNR), looks for silence, sedate ST44

·        Spleen points:

o       lack of inner discipline or emotional control, obstinate, cannot concentrate too long, mind does not compare facts with previous knowledge, lack of foresight: tonify Sp2; if very worried, insomnia, anguish, agitation and anxious depression, sedate Sp2

·        Heart points:

o       illnesses of personality, heart psych;

§         excess: sorrow, sobbing, frenetic laughing and sighing, mad anger, absurd false ideas, violent hallucinations, insomnia from hyperexcitation, sad at heart: sedate H7

§         deficient: little energy, numerous sighs, stubborn forgetfulness, forgetting names, fear, stupidity of nature and spirit, anguish, depression: tonify H7

·        Kidney points:

o       timidity, eayy sadness, easily upset, confused memory, forgets easily, does not want to speak, wants to stand up as soon as they sit down: K1

o       prevention of ADHD- while mother is pregnant, tonify K9 for prevention of faulty heredity or ancestral defects.  Once is enough, but can be done once at 3 months and once at 6 months.

·        Pericardium points:

o       loss of memory for words, loss of decision-will, anxiety, emptiness, laziness: P6

o       fatigue, physical exhaustion, timid, withdrawn, restless, anxious, easily discontented or cannot stop laughing (sounds like H/Sp xu): P8

·        Gall Bladder points:

o       delusions, joyless, escapades (blindly without direction), stupidity, insomnia after 3am from cerebreal hyperactivity, eats and drinks quickly: GB2

·        Du points:

o       always in a hurry, irrational impulses: Du5

o       from birth: arrogance, loose moral sense, childish mind, cries easily, distracted, lack of attention, sad, dispirited, mental instability, agitation: Du14

o       escapades (blindly without direction): Du16

o       like St40. cerebral and psychological hyperexcitation, excessive sadness, sobbing, pulls out hair, cannot sleep, apprehension, anxiety, jumps up on tables, sings, takes off clothes, depression: Du24

 

Denis Lawson-Wood

·        preoccupation: L9

·        mental confusion and obsessions: LI4

·        mental confusion and depression: LI11

·        anguish, cerebral fatigue, cries of agitation, insomnia, melancholy: Sp2

 

Michael Smith, MD, mentions a treatment in connection with hyperactivity and schizophrenia.  He suggests the use of a gold/magnetic ear seed on the back of the ear behind shen men.  Evidently this is very effective.

 

Alex Tiberi suggests that the Chinese folk remedy was to have the kid touch a dead body, since ADHD is excess yang and there's nothing more yin than dead body.  No comment from me!
Herbal Treatments and Diet

 

The child is more likely to take a patent medicine than any other kind. 

 

Syndrome	Herbal Formula	Source
Liver heat	Bupleurum dragonbone oystershell	tiberi
Kidney xu	Emperor's tea tian wang bu xin dan connect h k Zhi bai di huang wan; pull down empty heat Ju di huang wan (chyst rheum liv and k ju hua)	tiberi
Spleen xu	Xiao jian zhong tang - minor reconstruct the middle (cinn and peony)	tiberi
dampness	more xu: shen ling bai du san §         more shi: ban xia huo po tang pinellia magnolia plumpit qi one	tiberi
Liv/K yin xu	jing ling dan (tranquilizing pills) OR zuo gui wan and zhi bai di huang wan	dr zhang
H and Liver Fire in Excess	Long Dan Xie Gan Tang, Dao Chi San, Zhu Sha An Shen Wan	dr. zhang
H/Sp qi xu	modified gui zhi gan cao long gu mu li tang (rm cinnamomi, rx glycyrrhizae, os draconis, concha ostrae decoction) with liu shen san (six immortal powder) zhi huang qi, dang shen, gui zhi, long gu, mu li, fu ling, chao bian dou, zhi gan cao	dr zhang
phlegm heat	modified huang lian wen dang tang (rz coptidis warm gb decoction) and zhi zi chi tang (fr gardeniae fermented glycine decoction); huang lian, chao zhi zi, ban xia, dan nan xing, yu jin, shi chang pu, yuan zhi, fu ling, huo xiang ye, pei lan ye	dr zhang
K yin xu	bu nao yi shen tang jiang	dr hou
Sp xu with phlegm turbidity	jian pi yi zhi tang jiang	dr hou
Phlegm heat agitating wind	hyperactivity, extreme naughtiness, lack of fatigue, impetuosity, poor self-control, irascibility, red tongue with thin yellow fur, bowstring slippery or slippery rapid pulse	master li shao
Flaming Liver Fire disturbing Spiritual Brightness	Zhen Zhu Bai He Tang: zhen zhu mu 30 g bie jia 30 sheng bai he 15 gou teng 15 ye jiao teng 15 sheng di huang 15 chao zao ren 15 sheng bai shao 10 bai zi ren 10 yu zhu 5 chao bai zhu 6 dang gui 6	Dr. Ma
H/Sp xu with reckless floating yang	Modified gui pi tang and gan mai da zao tang	Dr. Wang
confined entanglement of wet heat with flaming of phlegm fire	modified huang lian wen dan tang	Dr. Wang

 

 

The most commonly used herbs for ADHD:

1. yuan zhi
2. shi chang pu
3. gui bqan
4. fu ling, fu shen
5. deer horn
6. shu di huang
7. shan yao
8. wu wei zi - balances excitation and inhabitation of cerebral cx
9. fu zi
10. long dan cao according to divine farmer's can benefit intell, improve memory, lighten body, prolong longevity, sedate epilepsy

 

 

Specific nutritional remedies that frequently help especially over the long-term are: sea vegetables, kelp tablets, spirulina, tempeh, butter and ghee, almonds, omega-3 and GLA oils (flax, borage) (for liver yin), garlic for parasites (but aloe vera gel and collodal silver are better).  windy ADHD is made worse by eggs, crab meat, and buckwheat.
Treatment Plan and Prognosis

 

The practitioner should see results within 3-4 wks from treatment.  Otherwise, the diagnosis may be incorrect.  You can then diagnose by treatment; try treating another pattern that causes ADHD symptoms.  If you get a good result, then you are closer or right on target.

I would suggest that the child at first get acupuncture frequently.  Twice a week would be good.  Once the practitioner is confident in their diagnosis, getting results, and the child is improving, office visits can be less frequent (perhaps every two weeks).

Also, once the correct diagnosis is obtained, the practitioner can send the child home with an herbal patent medicine.  Or they may choose to diagnose by treatment with herbs once they feel they are close to a good diagnosis.

Another thing which will improve the speed and likelihood of good results would be to teach the parents to apply ear seeds or magnets to the children.  If they use ear seeds, having the parent remind the child to press on them will help.

Conclusion

 

            ADHD diagnosis and treatment is a serious issue.  The diagnosis made by western practitioners must be checked because inappropriate administration of the indicated pharmaceuticals can cause even more problems in the long-term.  Interventions can be effective if the real problems are identified.  Parents, teachers, and practitioners have many tools at their disposal if they are willing to apply the right ones.  Someone must take responsibility for the child in every situation: classroom, home, and treatment office.  Communication among the various responsible people is paramount.  A number of combinations of modalities are possible.  Even if the child takes a pharmaceutical, TCM can aid in preventing the long-term damage of pharmaceutical side-effects.  The TCM practitioner must educate, raise awareness with the parents, children and perhaps even the child's teacher.  TCM practitioners must remain flexible, aware, and clear in their diagnosis and treatment efforts.

 

Biography

 

At the time of this writing, Brian Carter is a student at the Pacific College of Oriental Medicine.  He created and maintains a Chinese Medicine informational website, The Pulse of Oriental Medicine, and is in the midst of writing of several books for a public audience.  Brian is also a massage therapist, web designer, musician, and co-owner/co-founder of Healthprints, an internet company currently in the development phase.  Brian has received the Competent ToastMaster award at his club, Toastmasters of La Jolla.  He resides in San Diego, California, and can be reached by email at bbcarter@pulsemed.org.
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