Chiropractic Care of Children with Attention Deficit Hyperactivity Disorder and Developmental Delays: A Case Report
Objective: To evaluate and discuss the long-term effect of chiropractic care on a 3-year-old male patient with attention deficit hyperactivity disorder, developmental delays, and behavioral disturbances.
Clinical Features: The patient came to the clinic as a 3-year-old male who suffers with ADHD, behavioral disturbances and cognitive developmental delays. The patient experienced difficulty paying attention, daily tantrums, and long-lasting obsessive-compulsive episodes. The patient had a hard time following directions due to his hyper-behavior. The patient also has signs of fatigue, forgetfulness, and depression. Further evaluation of the patient’s history revealed that he had asthma and episodes of shortness of breath. The parents sought chiropractic care at age three when they realized difficulty reaching developmental milestones.
Intervention & Outcomes: After performing a case history, physical examination and chiropractic evaluation, it was determined that the patient had subluxations at multiple spinal regions. Also, a pelvic imbalance is noted with a right un-inhibited tensor fascia lata. The patient received chiropractic adjustments utilizing the Applied Kinesiology technique. The patient started care in the year 2000, and has been under care for the 13 years. The patient is checked for vertebral subluxations/misalignments every visit and is adjusted as needed. There was improvement of all symptoms including an increase in the child’s performance under initial and long-term care. Additionally, there were improvements in the patient’s behavioral disorders and cognitive development.
Conclusion: The findings presented in this case study suggest that chiropractic adjustments may induce benefits to patients who are suffering from behavioral disturbances and developmental delays.
Key Words: Applied Kinesiology, Chiropractic, ADHD, Subluxation, Neurodevelopmental, and Pediatric.
Introduction:
According to the Merck Manual, learning disabilities such as attention deficit hyperactivity disorder are conditions that cause a discrepancy between potential and actual levels of academic performance as predicted by the patient’s intellectual abilities. The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition states that ADHD criteria include, but are not limited to inattention to tasks, disorderly behavior, fidgeting, leaving seats frequently, inability to follow directions, etc. These actions need to be met in a certain quantity and need to be expressed for six months or more. If a child displays these behaviors and it is apparent that it is affecting their lives they are diagnosed with ADHD.
According to Rohde and Halpern attention deficit disorder, also known as ADHD has been around since the 19thcentury. In 1902, Still described 43 children with characteristics of aggression, defiance, emotionality, disinhibition, inattention, and deficient rule governing behavior. Still had hypothesized that the central feature of the disorder was “a defect in moral control” and could affect individuals with our without a cognitive disorder and with or without a neurological disorder. Fast forward a few hundred years and the prevalence of this disorder drastically increased with no genetic predisposition. In 2003-2004 one in five white males had received ADHD medication. There are now growing concerns with the safety of the medications given, its long-term use, and effectiveness in treating this condition. This has brought a growing demand for alternative forms of healthcare.
Currently, Shum et al found ADHD is one of the most common behavioral disorders in childhood, which affects 3%-9% of children, which are mostly male. Behavioral and electrophysiological studies divulge abnormalities in brain regions concerning sensory integration. The prefrontal cortex is involved in executive functioning, however, other areas that are imperative for sensorimotor control which include the basal ganglia and cerebellum. These factors can explain suboptimal performance in some children who experience ADHD. Shum et al proposed, “Balance control is an important sensorimotor function that may be compromised in ADHD population because it requires the ability to integrate inputs from various sensory systems (ie, somatosensory, visual, vestibular) and to utilize the integrated sensory signals in generating coordinated motor actions to maintain body equilibrium.”
The complexity of this condition and an unknown etiology leaves no set template when dealing with a child with ADHD. The medical approach has always been a one-trick pony with ADHD by prescribing drugs. 30% who use medication for their ADHD do not experience clinically significant outcomes. With a lot of families questions that have gone unanswered with the medical approach, they decided to try complementary alternative medicine therapies also known as CAM. There has been a 68% surge in CAM based practitioners ranging from speech therapy, nutritionists, supplement companies and especially chiropractors. This evidence emulates the need for further research involving chiropractic and ADHD.
At this time developmental delay syndromes such as ADHD have an inconclusive etiology. While many consider developmental delay disorders are primarily genetic in nature there are many that are trying to dig deeper to find a cause but a plethora of people working together in a multimodal approach for the purpose of making those lives who suffer less dismal.
Case Report:
Patient History:
A three-year-old male patient entered the chiropractic clinic due to issues sleeping, problems focusing, chronic allergies, sinusitis, obsessive-compulsive disorder, and attention deficit disorder. The parents primarily brought the child in because he was not meeting his developmental milestones observed by his pediatric physician. His obsessive behavior and difficulty holding attention made it very hard for the family to have a normal life. His parents felt that their child was too young to start on a strict regiment of pharmaceuticals that have a wide range of negative side effects, instead wanted to seek an alternative approach.
Examination:
During the physical examination, it was noted the patient exhibited a right head tilt, a right low shoulder due to a left inhibited left upper trapezius muscle innervated by the spinal accessory nerve. Also affected were the patient’s eyes, ears, nose, and throat as standard asthmatic symptomology. The patient also presented with anterior head carriage measuring 3cm, which doubled the weight of the cervical column in this instance. Upon range of motion evaluation, the patient also presented with a low left hip a left posterior inferior ilium. Inhibition of the right psoas and right sternocleidomastoid were muscle graded at +2/5 that is considered a weak contraction of the muscle. The patient presented with a normal oral PH, and normal vitamin C. The patient’s cervical range of motion was restricted in all directions. The patient restricted right thoracic rotation resulted in a hyperactive and hypertonic diaphragm. Most importantly the patient had upper cervical fixations at the first cervical vertebrae (also known as the atlas) and occiput. The patient also presented with thoracic and pelvic fixation. During the exam the patient had difficulty taking directions, paying attention, and completing tasks on his own. The chiropractor also observed a left short leg while checking for leg length inequality in the prone position. Analysis of leg length inequality is a commonly used criterion among chiropractors for the detection of vertebral subluxation. Also shown to have good inter-examiner reliability is the use of prone leg length analysis. Applied Kinesiology chiropractic deals with the modification of the motor system in assessing, treating as well as understanding one of the causes of musculoskeletal dysfunctions. Applied kinesiology (AK) locates lesions in the nervous system called subluxations by the manual testing muscles. According to Cuthbert and Goodheart “Manual muscle tests evaluate the ability of the nervous system to adapt the muscle to meet the changing pressure of the examiner’s test. This requires that the examiner be trained in the anatomy, physiology, and neurology of muscle function. Combined with other standard methods of chiropractic diagnosis. The treatments are a variety of conservative, non-invasive treatments, which involve joint manipulations, mobilizations, myofascial therapies, cranial techniques, and nutrition.
Intervention:
Treatment
After a full evaluation of the patient, a care management plan was created by the chiropractic physician. The patient started receiving adjustments one time a week for three months, then once the patient began to improve he visited the office twice a month for the next 6 months. Since then the patient has been under maintenance care for the past thirteen years averaging six office visits per year. During the entire care plan, the patient was adjusted using Applied kinesiology.
Subluxations upon examination were found in the cervical, thoracic, and pelvic imbalance was noted due to an un-inhibited tensor fascia lata on the right. The patient had subluxations that were confirmed with motion palpation, and manual muscle testing to assess the malposition of each vertebra. The doctor would find a strong muscle by isolating it with a muscle test. Then this muscle is used as an indicator when certain vectors to the body make the muscle fail. The doctor would use leg length analysis, along with motion palpation to get a general idea of where the subluxations are located. Then the doctor goes up the spinal vertebral levels in vectors that would make the patient either strong or weak. When the doctor finds a possible subluxation, the strong muscle being tested would fail. The corrections are then made in the direction where the challenged muscle holds strong. At the first cervical vertebrae also known as C1, the patient’s lateral mass was protruding to the right upon palpation. The doctor found that the child’s deltoid muscle was stable and strong and used it as a reference when muscle testing this specific vertebra. When pushing on the left transverse (which exaggerates the malposition) process of the atlas, the patient was not able to hold his arm up and when the doctor pushes on the right transverse process of the atlas, it was recorded that he was able to hold strong. These indications with a short right prone leg length of the patient supported the doctor’s findings to adjust the right atlas. The doctor made a sustained contact with the tip of his second digit on the patient’s right transverse process of atlas in a lateral to medial vector. For approximately 20 seconds the doctor held the contact and then re-evaluated the previous muscle tests, to make sure the patient could hold his arm up against all vectors of stress in an active muscle test. The doctor would not proceed unless the patient was able to hold strong and on some visits, he had to repeat the procedure one more time until the patient held strong in all vectors of stress. The patient also had subluxations in the thoracic spine at the levels of T7, T8, and T12 with a posterior and left rotation malposition. The doctor used the hamstrings as a strong muscle to muscle to test the patient. Upon isolating the thoracic vertebra mentioned above the muscle tested weak. Then the doctor put a posterior to anterior sustained force and the muscle held strong indicating a posteriority of the thoracic spine. Also, the doctor contacted the spinous and pushed it from right to left and the muscle test failed. Then the doctor pushed the spinous from left to right making the patient hold strong, which indicates a left rotation malposition of the spinous. The adjustments were given with a single hand pisiform contact with the other hand stabilizing. The line of drive was superior to inferior, posterior to anterior, and left to right. The thrusts were a high amplitude, short lever, and low force adjustment at the levels of T7, T8, and T12. The pelvic imbalance was found due to an un-inhibited tensor fascia lata which was found weak on a muscle test rated at +2/5. The doctor manually held trigger points at the Golgi tendon organ of the muscle while applying circular pressure for 20-40 seconds to inhibit the muscle.
Outcomes:
The outcomes were measured with reassessments including parent questionnaires, spinal ranges of motion, posture assessment, and muscle testing. The patient had restored ranges of motion in all directions, normal posture, even muscle tone, and normal reflexes.
The patient has been under chiropractic care since age three and is now sixteen. This coming fall of 2013 he will be entering a public high school for the first time. He has taken up standup comedy as a hobby and performs successfully in front of large audiences.
Discussion:
Chiropractic approach of ADHD
The purpose of this case study is to discuss the relationship between Chiropractic care and an improvement in behavioral disturbances and cognitive developmental delay with those who suffer from ADHD. Most approaches to this disorder are multimodal consisting of pharmaceuticals and cognitive behavioral therapy. According to Cuthbert, in an article called, Developmental delay syndromes: psychometric testing before and after chiropractic treatment of 157 children the main ingredient in ADHD medication is methylphenidate, which has an increase of use by 700% since 1990. However, due to side effects and other complications with pharmaceuticals, many parents have been exploring new territory. According to a case report by Mcreynolds. the common side effects of methylphenidate include nervousness, agitation, anxiety, insomnia, loss of appetite, nausea, vomiting, dizziness, palpitations, headache, increased heart rate, increased blood pressure, and psychosis.
Chiropractic approach:
In a case study called, Chiropractic Management of a Patient with Symptoms of Attention-Deficit Hyperactivity Disorder, we have a 5-year-old boy diagnosed with ADHD. Just like our patient this child suffered from breathing difficulties such as asthma that would wake him at night and would cause him to act out. The patient also presented with similar hypertonicities of spinal postural muscles, which indicates a nervous system that is not functioning the way is should. Treatment began three times a week and eventually progressed 2 to times a week over the course of 12 weeks. After one year the patient’s symptoms improved where he was able to follow instructions, his performance in school went up, and his general home life had improved drastically, namely by the parent’s report.
Chiropractic care for non-musculoskeletal issues seems like an outside the box idea, but few recognize the brain is connected to everything in the body through nerves that are transmitted through the whole spine. It is not surprising to many that chiropractic can help those who suffer from ADHD. According to a case study by Shum called, compares standing balance performance and sensory organization balance in children with ADHD. 43 children with ADHD were evaluated in their abilities to balance with a Sensory Organization Test and the conclusion was that children with ADHD had statistically lower values and in this case proved a decreased performance level in the visual system controlling balance.
In one qualitative study by Hermansen, and Miller concerning mothers with children who have ADHD, chiropractors coupled the use of adjusting and the use of interactive metronome exercises. The study highlights the point of view of the parent to help better understand this disorder and to also show the benefits and the safe option of chiropractic. Five mothers with six children participated in the study and were under care for two months; the drop out rate was zero. The analysis included interviews from the mothers before and aftercare. From the data collected the researchers found that all mothers found an improvement in their children’s performance and behavior. The study revealed the need to expand research by applying a biopsychosocial model into our current health care model.
It is important to assess that the Evidence-based practice should be utilized to treat the nature of this condition. However, there are challenges in the pediatric chiropractic field that are not being had by the medical field. The chiropractic research community has a hard time performing substantial-quality randomized, triple-blind, and placebo based trials due to a disconnect between doctors and practice, and doctors who are in research. Funding also comes into account, as chiropractic is considered an alternative measure and does not get as many opportunities as Medical research does. There needs to be larger randomized control trials to be able to apply the scientific data to a set population. According to Alcantara, Ohm J, and Kunz the terms of safety of pediatric chiropractic treatment the International Chiropractic Pediatric Association (ICPA) described how 264 chiropractors reported on 512 children and the prevalence of an adverse event was 0.67%. These adverse effects are much lower than the risk of taking pharmaceuticals. Due to such low adverse effects and a growing demand for chiropractic for children it would only make sense to continue research. Chiropractic care of children offers a conservative option to higher the risk of medical options.
In an article by Blum and Cuthbert16called, Developmental Delay Syndromes and Chiropractic: A Case Report we look at one fraternal twin diagnosed with ADHD and developmental delays and their outcomes from chiropractic treatment. The article discusses a 2-year-old girl with evident head tilt and obvious plagiocephaly. The child would experience frequent temper tantrums and nightmares that would cause her to wake up screaming. The child was not able to perform at preschool or at home. She was noted to be slower emotionally and intellectually compared to her brother. The doctor saw the patient five times and gave her a supplemental mineral to help soothe the nervous system. The patient’s cranial bones that were adjusted were occiput, maxilla, and left temporal bone. After the first visit, the patient noticed improved posture and a resolution of her pelvic imbalance. After the fifth visit, the patient was stable within her family and school. She was followed up for five years and when she turned seven it was noted that she is equal to her twin brother and was performing well in school. However, more information must be collected and more research must be conducted to determine an evidence relationship with chiropractic care and the improvement of ADHD and developmental disorders.
In an article by Young called, Chiropractic management of a child with ADD/ADHD we examine a four-year-old boy who suffers from ADHD and developmental disorders. The patient came into the clinic with frequent temper tantrums, obsessive-compulsive tendencies, aggression towards other children, and spoke very rarely. He also was unable to go to the bathroom by himself and was having frequent accidents. The child received ten chiropractic adjustments over a two-year period. Four treatments were done over a period of one month and then once every four months. An activator was used to adjust the patient’s atlas and was given single leg balancing proprioceptive exercises. The patient was also put on a multivitamin and zinc supplement. The parents and teachers reported that after the first phase of care the patient had improved in all areas of deficit. He was behaving and engaging in activities as well as talking a lot more. This is definitely a successful outcome of chiropractic but some might question the role of the supplementation. The study could have been more specifically geared towards the effects of the adjustment if the multivitamin was left out. Many children display other issues along with ADHD that seem to be addressed in many case studies supporting chiropractic treatments. However, more randomized control trials need to be published to support chiropractic care in this avenue.
ADHD and Vertebral Subluxation
According to McReynolds, due to the chronicity of some of these symptoms, it is important to have the child under long term care so we can monitor the adjustments over time.18 Some children have resolution of their behavioral issues while others still have to manage their condition throughout their lives. However, according Kent’s19article it is important to continue to analyze and adjust especially if symptoms do not resolve because the motion of spinal segments are endowed by nociceptive and mechanoreceptive structures. This is important because biomechanical dysfunction can affect normal nociception, mechanoreception or both. Aberrant neurological input to the CNS may lead to dysponesis and altered states of homeostasis. To use the contemporary jargon of the computer industry, “garbage in—garbage out.” Therefore unless the vertebral subluxations are corrected the children with ADHD are going to continue to have altered perception due to interference on the nervous system into and throughout adulthood. According to Cuthbert and Barras a vertebral challenge is manually muscle tested and used a diagnostic tool to determine inhibition. The manual muscle test is a theory that tests a patient’s ability to handle external forces. An inability to withstand external forces in a manual muscle test would indicate that the sensory information is not getting to the brain and back efficiently enough to elicit a proper response. These three forces are according to Stephonson21 can be mental chemical or physical. Stephenson said, “a subluxation is the condition of a vertebra that has lost its proper juxtaposition with the one above or the one below or both; to an extent less than a luxation; which impinges nerves and interferes with the transmission of mental impulses.” The interference that Stephenson mentions supports the garbage in and garbage out theory proposed in Kent’s article. It is this same interference that causes the muscle tests to fail and once the doctor finds a weak muscle, he then finds the correction, which is specific to each adjustment. Once the correction is made to a subluxation, the doctor re-checks the involved structure or structures to make sure the body can handle a stimulus. The direct information from holding strong after an adjustment gives positive feedback to that practitioner.
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Conclusion:
This case report outlines long term (10 years of) chiropractic care of a 3-year-old boy who suffers from ADHD, behavioral disturbances and cognitive developmental delays. After chiropractic care consisting of specific vertebral subluxation-based adjustments, the patient is now free of his pre-existing disabilities. He had remarkable improvements with his behavioral problems and cognitive abilities. This case is one example of how chiropractic is helpful in bringing balance back to a child’s life. Though this is only one example, it adds to the studies that show chiropractic care has shown to be effective for helping to control ADHD in children and other non-musculoskeletal conditions. More research in this area should be explored to better inform the public and other healthcare practitioners as to the results of chiropractic care.
If you have any comments or questions please email me: Dr.RyanBland@gmail.com
– Dr. Bland
Dr. Ryan Bland is a second-generation Chiropractor and Applied Kinesiologist practicing in Tacoma / Seattle WA. Dr. Bland treats chronically ill patients with fatigue, intestinal issues, depression, autoimmune conditions, etc. The patients he has seen most often seen many other doctors beforehand and can be helped using a unique protocol developed by Michael Lebowitz DC. He also works with professional athletes, actors, dancers, and people from all over the world, working to optimize overall health.
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To whom it may concern,
I Ryan Scott Bland state that this current paper is my original work and has not been published previously nor is it in consideration by a publication.
Signed,
Ryan Scott Bland
