CHINESE HERBAL TREATMENT FOR ATTENTION DEFICIT DISORDER
Attention Deficit Disorder (ADD) is a broad syndrome that may include hyperkinetic syndrome, hyperactivity, and Attention Deficit Hyperactivity Disorder (ADHD). Although hyperactivity is commonly observed, it is not necessarily a component of ADD. There is likely to be a group of related problems, with some different etiologies, encompassed by the term ADD. In some instances, ADD might be a misdiagnosis for behavioral problems that are related to home and social situations without an underlying physiological dysfunction.
The most common manifestation of ADD is a combination of inability to remain at rest while awake, less total sleep time, and difficulty concentrating on a particular activity. The disorder may be somewhat apparent at birth (or even in utero) with excessive movement of the arms, legs, and head, but is usually not diagnosed until lack of concentration at school is deemed a problem, typically in the first or second grades (ages 7 to 8). As much as 10% of the U.S. population is believed to be affected; if that is the case, then ADD is one of America's most prevalent mental disorders. Males are at least four or five times as likely as females to have the disorder. This differential is probably partly genetic in nature, though hormones clearly play a role. The hormonal component of the expression of ADD is revealed in the fact that puberty may alter the course of the symptoms. Furthermore, thyroid hormone disorders are frequently found in persons with ADD.
A genetic basis for the disease is suggested by the fact that children with ADD are more likely to have fathers who suffered from the disorder. But, there are probably preventable environmental factors that lead to developing ADD, a disorder which seems to be occurring in much greater frequency now than just a few decades ago. It is possible that some cases of ADD arise from exposure in utero to harmful chemicals, such as from smoking, alcohol consumption, prescription and illicit drugs, and environmental pollutants, all of which have become wide-spread problems for women during the past four decades. Nutritional deficiencies might also contribute to the development of ADD. It appears that ADD arises from a neurological defect, with abnormalities in the brain tissue or neuron biochemical functions. ADD is found more often in children who have other brain defects, such as those leading to mental retardation, cerebral palsy, or temporal lobe epilepsy.
While for many children affected by ADD there is some reduction in the symptoms as the child enters puberty, the disorder will often continue for the rest of the individual's life, and the impact of the disorder on early childhood behavior, which often includes impulsiveness, recklessness, irritability, aggression, and poor emotional development, in itself produces effects felt throughout life even if the ADD is in remission. Sometimes, puberty brings about a switch from hyperactivity to persistent sluggishness, depression, and moodiness, which is liable to be equally disruptive. Children who suffer from ADD are much more likely, as adults, to be involved in crime, have unsuccessful marriages, and difficulty keeping a steady job, than those who do not experience this disorder. The primary treatment for ADD is the administration of stimulant drugs. This strategy may seem paradoxical in the context of a hyperactivity disorder. However, it is postulated that the controlling action of certain mid-brain activities may be deficient in these individuals and therefore a stimulant is able to bring about the desired control. The stimulation of brain function may enhance alertness and concentration. The primary drug used for this disorder is methylphenidate (Ritalin), a relatively mild derivative of amphetamine. Ritalin is also used in the treatment of mild to moderate depression, emotional withdrawal in the elderly, and narcolepsy. This drug can have side effects, mainly the problems seen with amphetamine use: nervousness and insomnia. It may also encourage epileptic seizures in those with latent epilepsy, and can reduce red blood cell and platelet counts. Many parents of children with ADD appreciate the effects of Ritalin but worry about the potential harm of continued administration of a drug; some note obvious adverse effects and seek alternatives. Ritalin is ineffective in about 30% of cases diagnosed as ADD.
In China, the same attention deficit problem has been noted, and Ritalin has been used as a therapy. From the traditional Chinese medical viewpoint, ADD is caused by a kidney essence deficiency that affects brain development. Further, the yin aspect of the kidney is most deficient, leading to excessive expression of yang: this is manifest as the hyperactivity and wandering of the mind. Accordingly, it is to be treated by nourishing the kidney yin, opening the heart orifices (which are the passages that affect the brain function), and settling the agitated yang. There have been numerous studies of the effects of Chinese herbs on ADD, with a remarkable degree of consistency in the selection of herbs used to treat this condition. Some Chinese physicians rely on differential diagnosis, with selection of somewhat different formulas for each syndrome classification, while others use a standard preparation with few or no modifications.
From the traditional perspective, the marrow and essence is the foundation of the brain, and the early problems with mental development indicate deficiency of the vital essence. The main herbs used for nourishing the kidney in children with this syndrome are rehmannia, tortoise shell, deer antler gelatin, lycium, and cornus. These are ingredients of the traditional Zuo Gui Wan (Left Restoring Pill) used to treat kidney yin deficiency when there are deficiencies of "marrow and essence."
Phlegm obstruction of the heart orifices usually leads to confusion, inability to concentrate, and poor memory. It occurs for a variety of reasons, but often because of weak digestion and/or poor diet, coupled with emotional disorders, especially agitation. The main herbs for clearing the heart orifices and enhancing the mental function are acorus, polygala, curcuma, and alpinia. Acorus is said to "open the orifices, vaporize phlegm, and quiet the spirit." Polygala is said to "expel phlegm and clear the orifices, calm the spirit and quiet the heart." Curcuma, which promotes movement of qi and invigorates the blood, is used to "treat hot phlegm that obstructs the heart orifices when there are symptoms of anxiety, agitation, or mental derangement." The Chinese name for alpinia, yizhiren, means "the seed that benefits intelligence." It aids digestion (preventing phlegm accumulation), astringes the kidney to restrain the essence, and prevents the development of heat from deficiency of kidney; the deficiency heat can cause phlegm to become a "mist that obstructs the heart orifices."
To settle the agitated yang energy (which may manifest as hyperactivity and insomnia) the so-called "heavy sedating agents" are used. The traditional concept is that these mineral-rich substances bear down on the rising and disordered yang. The main substances given for ADD by Chinese doctors are dragon bone or dragon teeth, oyster shell or mother of pearl, succinum, and cinnabar. In some cases, herbs to purge deficiency fire that accompanies yin deficiency syndrome might be employed. Phellodendron and anemarrhena are the most commonly used items for this purpose.
As an example of applying these methods, 30 children with ADD were treated with a syrup, along with a powder, for two to four months, with the result that 22 of them (73%) showed improvements. The syrup was made with alpinia, ho-shou-wu, lycium, dragon bone, oyster shell, acorus, curcuma, and salvia, boiled down to a thick liquid and preserved with benzoic acid. Three times per day, the children would take 25 ml of the liquid and 2 grams of deer antler powder. A similar method was used in a study of 50 children with ADD who consumed a decoction of acorus, polygala, dragon bone, and oyster shell, modified by adding three to six herbs according to symptoms, and who also consumed a powder of succinum. The duration of therapy was not specified but 38 of the children (76%) showed improvements.
Excellent results were claimed in a small study of 15 children treated with a decoction of ligustrum, peony, lycium, mother-of-pearl, and polygonum stem (each ingredient 10-15 grams), modified with addition of some herbs for specific symptoms of blood deficiency (add rehmannia and gelatin), spleen deficiency (add hoelen and atractylodes), or restless sleep (add zizyphus). The total daily dose was about 60 grams of herbs, the decoction taken in three divided doses. All 15 children were apparently cured with treatment times of 15 to 60 days, and no recurrence within six months. Another high dosage decoction, based on the traditional Sanjia Fumai Tang, containing raw rehmannia, ophiopogon, tortoise shell, peony, pseudostellaria, gelatin, baked licorice, curcuma, polygala, cnidium, oyster shell, acorus, and dragon bone, each ingredient 6-12 grams (except 20 grams oyster shell), was given to 68 children with ADD. This combination, with over 120 grams of crude herbs per day, taken as a single dose, was said to improve the condition of 64 of 68 children treated (with 61 declared "cured"). In a large scale study of 326 cases of ADD (267 boys and 59 girls), three different formulas were used; two were decoctions and the third a large honey bolus (six grams per pill). The overall effective rate was 93%, with 103 claimed to be cured. One formula, as decoction, was basically a qi tonic prescription, with astragalus, codonopsis, atractylodes, dolichos, licorice, cinnamon, oyster shell, and dragon bone. The other decoction was a formula for resolving phlegm-dampness, with pinellia, arisaema, agastache, acorus, polygala, eupatorium, soja, hoelen, coptis, and gardenia. The pill was a kidney tonic, with rehmannia, tortoise shell, dioscorea, cornus, hoelen, phellodendron, anemarrhena, polygala, acorus, and dragon teeth.
The large honey pills and bitter and acrid decoctions, as well as the syrups and powders, would not be acceptable in the West, but it is instructive to see that these methods can be used in China with good results: 70-100% of cases treated were said to be improved or cured.
An example of a potentially more practical approach is manufacture of a sugar paste. Two formulas were made in this form, Zhili Tangjiang, comprised mainly of acorus and polygala, and Kangyi Tangjiang, which contains those two herbs plus tortoise shell, hoelen, dragon bone, alpinia, dioscorea, and lotus seeds. The dose of these pastes was 10-15 ml each time, and they were taken two to three times per day. Of 170 cases (two studies), 132 (77%) were improved. Treatment time was about one month. It was pointed out that the paste could be encapsulated for purposes of easier administration.
Since the herbs recommended for ADD are non-toxic and readily available in the West, the main problem with adopting these methods is managing the dosage and administration. The high dosage decoctions may serve in China as a source of mineral substances (e.g., calcium and magnesium) which are more readily administered in the West through nutritional supplements and/or by direct ingestion of natural substances rich in those minerals given in capsules or tablets. Careful selection of ingredients in an herb formula can help to minimize the total amount to be ingested. Children in Western countries may be willing to take small tablets or capsules, tinctures, or syrups, especially if the number of daily doses and the amount taken at each dose is small.
Early in 1993, ITM prepared an experimental small tablet (Acorus Tablets, 300 mg) based on the work done in China for treatment of ADD. The formula contains acorus, polygala, fu-shen, alpinia, curcuma, raw rehmannia, dragon bone, dragon teeth, oyster shell, bamboo sap, tortoise shell, and succinum. In contrast to Ritalin, the formula contains no stimulants. Several reports of its use have been favorable, though much more study needs to be done to determine the extent of response. As a general rule, herb powders are taken in a dose of 1/10 to 1/5 that of decoctions. Since 60 grams (or more) is typical for ADD decoctions in China-mainly given to children 7-13 years old-a daily dose of about 6 grams of the tablets (20 tablets) would be a reasonable minimum for this age range. The dosage method developed at ITM is to give one tablet per year of age (up to a maximum of 7-8 tablets) each time, three times per day. For older children and adults, larger size tablets (700 mg) have been prepared, with a recommended dosage of 3-6 tablets each time, three times daily. Seven of the small tablets contain the same amount of herbal material as three of the large tablets. It is important to note that one formula, even if well designed, will not be ideal for all children. Following the traditional differential diagnosis, phlegm-resolving, fire purging, qi-tonifying, or other combinations may be necessary as adjuncts or substitutes for a basic ADD formulation.
Treatment times reported in the Chinese literature are generally two weeks to two months. When using a low dosage form, one would expect to undertake a longer term of treatment, perhaps four months. Fortunately, some degree of improvement is said to be observed in a relatively short time, so a decision to continue such therapy might be made after just one month (as is the cases with Ritalin). Among reports received by ITM regarding effects of Acorus Tablets or similar herbal preparations, the beneficial effects are noted during the first month of therapy.
Significant adverse effects have not been reported with use of Acorus Tablets. A small number of individuals have reported tiredness after using them. However, it is not clear whether this is an adverse effect of the herbs or a withdrawal symptom from Ritalin or the result of feeling an underlying tiredness from lack of adequate sleep that might not have been brought to awareness with the hyperactivity.
NOTE: The clinical trials mentioned in this paper were described in Chinese language literature. Rough translations of the information were prepared by Heiner Fruehauf, Ph.D., L.Ac., at the Institute for Traditional Medicine.