Attention deficit hyperactivity disorder (ADHD) is a prevalent neurobehavioral disorder of childhood period, which is characterized by chronic symptoms of children’s developmentally age-inappropriate, undesirable features and can be accompanied by academic and behavioral problems [1]. The overall incidence rate in children aged from 4 to 17 years in the U.S. was approximately 10.2% in 2015–2016, and the prevalence of diagnosed ADHD children in the U.S. has a continued significant increase in the past twenty years [2]. Children diagnosed with ADHD usually suffer from negative social and academic problems [3, 4], and more than half of them have ADHD comorbidities (e.g. anxiety, depression) [5, 6]. Moreover, as a chronic medical condition, ADHD symptoms may persist into adulthood [7–9].
Medication therapy and behavior therapy are recommended by the American Academy of Pediatrics (AAP) for ADHD [10]. Medication has a beneficial and rapid effect on ADHD core symptoms, but the effect does not maintain if the treatment discontinues. Besides, medication treatment, both stimulants, and non-stimulants may lead to potential adverse side effects [10–12]. Medication has a beneficial and rapid effect on ADHD core symptoms, but the effect does not maintain if the treatment discontinues. Besides, medication treatment, both stimulants, and non-stimulants may lead to potential adverse side effects [10]. Evidence-based behavioral treatments are strongly recommended for ADHD children of all ages. It provides parents with more chances to interact with their children. However, some factors limit the popularization of this therapy, such as the high cost, high family involvement, parents’ learning abilities, and the lack of standardized training patterns [10, 13]. Complementary therapies are also commonly used by children and adolescents with ADHD symptoms [14], and pediatric tuina is one of the complementary therapies.
Pediatric tuina, which is also called traditional Chinese medicine (TCM) pediatric massage or pediatric anmo, is a special modality of TCM therapies. It is a manual intervention for preventing and treating medical conditions in children based on TCM theories and previous experience. Different from other massage types, the body part to be treated by pediatric tuina could be a point, a line, a circle, or an area, thus the corresponding manipulations are more complex. Commonly used tuina techniques include pushing, circular rubbing, nipping, kneading, pushing, arc-pushing, twisting, rotating, and so forth. Pediatric tuina is usually used for asthma, respiratory infection, congenital muscular torticollis (CMT), diarrhea, constipation, anorexia, atopic eczema, and other medical conditions in infants and children [15–21]. In the perspective of TCM, ADHD symptoms are associated with the disharmonious situation between yin and yang of a body. An ancient TCM literature – “Ling Shu· The Application of the Needles” - recorded relevant symptoms as follows: “Double yang persons, their spirit is easily excited, and their qi proceed easily, they are fervid and lofty, speak well and fast. When walking they raise their feet high". Most researchers believe that the pathogenesis of ADHD is the abnormal exuberance of yang, which can be relieved by specific approaches of massage [22, 23], and the corresponding principle is to adjust the excess, deficiency, and inter-impairment of yin and yang to return to the balanced state. Yin and yang are mutual rooting and may induct, contain, transform to each other, which explains why yang syndrome could comprise some comorbidities like anxiety disorders, oppositional defiant disorder, psychomotor inhibition, and intermittent explosive disorder (Fig. 1).
Parent-administered interventions attempt to enhance a parent's understanding of child behavior management and the quality of the parent-child interactions, with the ultimate goal of optimizing the child's developmental course [24]. A systematic review and meta-analysis of non-pharmacological interventions for ADHD found that psychological treatments administered by parents showed the largest effects among 54 randomized controlled trials (RCTs) for preschool children in terms of ADHD symptoms improvements [25]. A recent RCT of a dual-parent and trainer-delivered qigong massage intervention for young children with autism indicated that the parent-delivered massage provided effective early intervention for autism that was feasible for delivery at home [26]. Hence, the combination of parent-administered intervention mode and pediatric tuina might be a cost-effective and feasible way of treating ADHD symptoms.
Studies have been done to examine the effects and safety of pediatric tuina for ADHD. Chen and colleagues carried out an RCT on using TCM acupressure therapy for treating ADHD in children, leading to a conclusion that TCM acupressure therapy had better effects than Ritalin on ADHD symptoms with higher acceptability [27]. Recently, Chen and colleagues performed a systematic review of using massage therapy for ADHD in children and adolescents, suggesting that massage seemingly has beneficial effects for improving ADHD symptoms. However, the methodological quality of the included clinical trials was generally poor. Limitations include unclear randomization and allocation concealment methods, incomplete reporting of outcome data, a lack of validated outcome measures, as well as a high risk of biases correlated to a failure to blind participants and outcome assessors [28]. Further rigorously-designed clinical trials are warranted to assess the effects of pediatric tuina on ADHD. Furthermore, there is no RCT conducted to test the feasibility and effects of parent-administered pediatric tuina for ADHD. Our team has demonstrated that it is feasible to train patients to perform self-administered acupressure for insomnia [29], knee pain [30], and stress [31] by a short training program. This pilot study will test the feasibility of training parents to conduct tuina on their children. Therefore, we designed this pilot study to explore the effects and feasibility of parent-administered pediatric tuina for ADHD in preschoolers.