This syndrome is most commonly seen in children between the ages of 5
and 15 and is characterized by distractibility, short attention span, impulsive
behavior, hyperactivity, and learning and behavior disabilities. In biomedicine,
improper functioning of neurotransmitter systems has been proposed
as a possible cause. Pharmaceutical treatment most commonly involves
central nervous system stimulants such as amphetamine, dextroamphetamine,
and methamphetamine, or similar drugs such as methylphenidate
(Ritalin). These tend to allow the child to focus while also, paradoxically,
calming hyperactivity. Most children, however, are not cured by pharmaceutical
treatment.
APPLIED CHANNELS IN CHINESE MEDICINE
The perspective of Chinese medicine
Chinese medicine views the pattern to be rooted in a generalized imbalance
in the inter-regulation of the organs. Although the pattern might
be broken down into ascendant liver yang, liver-kidney yin deficiency, and
spleen qi deficiency types, there will likely be fairly rapid changes from one
to another symptom pattern during the course of treatment. The internal
organs of children are delicate and thus easily disturbed by irregularities in
diet, environment, or emotional situation. Therefore, this pattern in children
is not the same as it might be in adults, where a particular pathodynamic
(e.g., spleen qi deficiency) may be fairly stable throughout the course of
treatment. In children, because the cause is fundamentally one of imbalance
and not a case of pure deficiency, manifestations are changeable.
In all of its forms, the condition is ultimately rooted in a deficiency of
pre-natal qi and is generally not caused by any of the six externally-contracted
excesses (wind, cold, summer heat, dampness, dryness, and fire).
Etiology
Children with congenital deficiencies of pre-natal qi do not necessarily
develop this pattern. Children with prenatal qi deficiency who go on to develop
this pattern generally also experience one of the following:
• Emotional stressors such as increased pressure in school or socially.
This also includes emotional issues related to family life.
• Severe fear or traumatic experiences.
• Irregular diet, especially one where the child eats only certain foods
without sufficient variety (especially an excess of sweets).
Symptomatology
There are five basic symptom categories. A child experiencing this pattern
may not necessarily have all of the symptoms below:
1. Difficulty concentrating
The child is easily distracted, has problems in school, wants to move
about, tries to do too many things at once and/ or has difficulties with
memory.
2. Emotional problems
Affected children are often irritable and difficult to control. They are
often unconcerned about the results of their actions or their effects on
others. They may also be easily angered.
Appendix 5 The Liver and Attention Deficit Hyperactivity Disorder (ADHD)
3. Sleep disorders
Symptoms may include waking easily, sleepwalking, or talking during
sleep.
4. Muscular changes
These may include twitching or tightness of the muscles, usually in the
neck or face.
5. Difficulties with balance
The child may be clumsier than others and may fall often or have an
unusual gait.
Channel diagnosis
The pattern most often includes palpable changes on the jue yin liver
channel, jue yin pericardium channel, tai yin spleen channel, or tai yin lung
channel. There may also be changes along the shao yin channel or the du
vessel. Palpation of these channels is helpful in the differential diagnosis.
Differentiation
In most cases, patterns will involve an intermingling of yin deficiency,
phlegm, and fire.
Exuberant liver fire/liver fire harassing and stirring (Jff X tftll giin hu6 rao
dong)
In this pattern, irritability and constant movement will be most obvious.
The child may talk excessively and will have difficulty getting to sleep
(yin deficiency). Palpation may reveal small nodules along the jue yin pericardium
channel, especially in the area between PC-3 (qu ze) and PC-4 (xi
men).
The treatment principle, in this case, is to clear heat, transform phlegm
stasis, calm the liver and extinguish wind.
Acupuncture
A helpful point pair for this pattern is PC-7 (da ling) and LR-2 (xingjiiin),
which clears and transforms heat from the jue yin channel. KI-7 (fit liu) may
also be added to benefit the yin (mother point of the kidney channel).
Herbs
Gastrodia and Uncaria Drink (tiiin ma gou teng yin), with modifications
Gastrodiae Rhizoma (tiiin ma)
Uncariae Ramulus cum Uncis (gou teng)
APPLIED CHANNELS IN CHINESE MEDICINE
Paeoniae Radix alba (bai shao)- with a higher dose of up to 30g
Perillae Folium (zi su ye)
Lonicerae Flos (jin yin hua)
Ziziphi spinosae Semen (suan zao ren)
Anemarrhenae Rhizoma (zhi mu)
Angelicae sinensis Radix (dang gui)
Rehmanniae Radix (sheng di huang)
Fossilia Dentis Mastodi (long chi) - if sleep problems are pronounced
Puerariae Radix (ge gen) - if neck stiffness is pronounced
Elements of Warm the Gallbladder Decoction (wen dan tang) maybe
added as well to transform phlegm and open the collaterals.
Liver and kidney yin deficiency Attention problems are often most pronounced
is this pattern. The child may also have dry eyes, warm palms and/ or abdomen
(five-center heat), a red tongue, and a thin, rapid, or frail pulse. The child will
often wake easily during the night. Palpation may reveal changes along the
shiw yin channel, especially the area around HT-5 (tong li) to HT-7 (shen
men) and KI-6 (zhiw hili). Palpable channel changes in children are often
very small, and differentiation is a skill that will only be gained with practice
over time. In this type of case, the changes may feel like very small, crunchy
thickening along the shiw yin channel.
The treatment principle is to benefit the kidney and liver yin.
Acupuncture
The point pair HT-6 (yin xi) and KI-7 (fit liu) is most often used in combination
with LR-3 (tai chong). This pair benefits the kidney yin, as HT-6
(yin xi), the cleft point of the heart channel provides qi from the heart to
facilitate the yin-strengthening action of KI-7 (fit liu). This is an instance
of regulating the shao yin qi transformation to facilitate communication
between the heart and kidney. LR-3 (tai chong), the source point of the liver
channel, benefits the liver yin.
Herbs
Six-Ingredient Pill with Rehmannia (liu wei di huang wan), with modifications
Consider adding Anemarrhenae Rhizoma (zhi mu), Nelumbinis Semen
(lian zi), Platycladi Semen (bai zi ren), and/or Testudinis Plastrum (gui
ban).
Heart and spleen deficiency A child with this pattern will likely present as
more generally deficient, as there is a coexisting deficiency of both heart and
The Liver and Attention Deficit Hyperactivity Disorder (ADHD)
spleen qi. In the case of the spleen, however, the pattern will also include what
may be termed spleen yin deficiency. This can be understood as yang ming
yin deficiency affecting the spleen, thus leading to the common complaint of
constipation. The child will also often be tired, have a low appetite, have excessive
dreams, and will be easily scared. The pulse will often be slow, and the tongue
pale with a dry coating. Palpation often reveals soft nodules or a decrease in
muscle tone along both the lung and spleen tai yin channels, and occasionally
on the shao yin channels as well.
The treatment principle is to benefit the qi.
Acupuncture
The point pair LU-9 (tai yuan) and SP-3 (tai bai) is most commonly used
together with the pair CV-11 (jian U) and ST-36 (zu siin li). Both pairs are
used to benefit the qi throughout the body. Source points on the tai yin
channel stimulate the production of post-natal qi. The CV-11 (jian U) and
ST-36 (zu siin li) pair fortifies the spleen-stomach, primarily by stimulating
yang movement.
Herbs
Emperor of Heaven's Special Pill to Tonify the Heart (tiiin wang bu xin
diin), with modifications
Ziziphi spinosae Semen (suiin zao ren) - higher dose
Platycladi Semen (bai zi ren) - higher dose
Asparagi Radix (tiiin men dong)
Ophiopogonis Radix (mai men dong)
Rehmanniae Radix (sheng di huang)
Polygalae Radix (yuan zhi)
with the addition of Four-Gentleman Decoction (si jun zi tang)
to support the spleen
Conclusion
In all ADD/ ADHD patients, it should be remembered that wind, phlegm,
fire, and qi stasis may always be part of the presentation. Because the pattern
may change fairly quickly during a course of treatment, the diagnosis
should often be re-evaluated. The operative concept for these patients is a
general loss of inter-regulation among the organs.
Other acupuncture points that may be considered include GB-20 (Jeng
chi), TB-18 ( qi mai), and BL-10 ( tiiin zhit) if neck complaints are present.
Also du vessel points such as GV-21 (hou ding) and GV-24 (shen ting) can
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APPLIED CHANNELS IN CHINESE MEDICINE
be used to bring clear qi up to the head/brain. Finally, the spleen, liver, and
heart back transporting points (BL-20, BL-18, and BL-15) as well as the
point pair CV-12 (zhang wan) and ST-40 (Jeng long) can also be used to
facilitate phlegm transformation.
Because of the tendency of these patients to also present with phlegm
(sometimes 'formless' or unseen phlegm), formulas should often include
variations of Warm the Gallbladder Decoction (wen dlm tang) and TwoCured
Decoction (er chen tang). These formulas can open shiw yang! jue
yin, transform phlegm, and unblock the collaterals of the brain.
If the patient is older and the condition more long-standing, it may be
advisable to consider herbs that more strongly calm wind and transform
phlegm, such as Bombyx batryticatus (bdi jiang can) and Scolopendra (wu
gong); or herbs that strongly move blood, such as Carthami Flos (hong
hua).
In general, the Liver is an important part of most ADHD patterns in
the sense that inter-regulation is compromised. Many of the treatment
principles outlined above involve clearing and regulating to facilitate jue
yin function (via not only the jue yin channel, but also by using tai yin and
shao yin to clear and stimulate). Only in the case of a more 'pure' deficiency
of post-natal qi does the liver play a less important role in treatment. In the
most commonly seen patterns, the liver function of dredging and draining
the pathways of qi is at the center of this syndrome
Wang Ju-Yi
Jason D. Robertson