JACM

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 26, Number 6, 2020, pp. 473–481
ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2020.0009

The Effects of a Traditional Chinese Medication

on Children with Attention-Deficit/Hyperactivity Disorder
Zhijian Wilfred Liang, BSc,1,2 Say How Ong, MBBS,1 Yu Huan Xie, MBBS, MSc,1,3
Choon Guan Lim, MBBS,1 and Daniel Fung, MBBS1

Abstract
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Objective: This feasibility study examined the effects of a particular Traditional Chinese Medicine (TCM)
herbal formula on attention-deficit/hyperactivity disorder (ADHD) and related problem behaviors.
Design: A total of 79 participants aging 6–12 years consumed a granulated TCM herbal formula twice daily
over a period of 3 months and underwent assessments at months 0, 3, and 6. Changes in ADHD symptoms and
related behaviors were measured using the ADHD rating scale-IV (ADHD-RS-IV), child behavior checklist
(CBCL), children’s global sssessment scale (CGAS), as well as the clinical global impressions-severity (CGI-S)
and improvement (CGI-I) scales.
Results: Repeated measures mixed model analyses revealed significant differences in scores across time on
all ADHD-RS-IV and CBCL subscales as well as on the CGAS, CGI-S, and CGI-I scales. Pairwise comparisons
between months 0 and 3 as well as months 0 and 6 indicated significant improvements in scores. Scores also did
not differ significantly between months 3 and 6. The results may suggest that this particular TCM formula
possesses potential therapeutic qualities in the treatment of ADHD. Furthermore, changes in ADHD symptoms
generally appear to be stable 3 months after discontinuation. However, these findings could also be attributed to
placebo effects as well as reporting biases.
Conclusion: This particular TCM formula may prove to be a useful adjunctive treatment for children with
ADHD, and randomized controlled trials need to be conducted to evaluate its efficacy.

Keywords: attention-deficit/hyperactivity disorder, Traditional Chinese Medicine, complementary and alternative

medicine

Introduction rigorously reviewed to be efficacious,3–5 promoting fa-

vorable long-term outcomes and behavior.6–8

A ttention-deficit/hyperactivity disorder (ADHD)

is one of the most diagnosed and researched illnesses
among children and adolescents, interfering with many
aspects of daily functioning, which include learning,
productivity, and social relationships.1 A chronic condi-
tion affecting millions worldwide, ADHD often requires
treatment to enable affected individuals to cope and
manage their symptoms.2 Western medications, particu-
larly methylphenidate ( MPH) and atomoxetine, remain
extensively used for the treatment of ADHD and has been
Numerous studies have attributed a myriad of adversities
associated with MPH, the drug of choice for ADHD. These
include common side effects such as reduced appetite,
headaches, abdominal pain, and insomnia.9,10 For atomox-
etine, a nonstimulant, the common side effects include ini-
tial somnolence, gastrointestinal disturbances, and
decreased appetite.9 Thus, it is unsurprising that clinicians
and caregivers of children with ADHD have increasingly
advocated for alternative, effective, and well-tolerated
treatments.11

1
Department of Developmental Psychiatry, Institute of Mental Health, Singapore.
2
CareHub, Alexandra Hospital, Singapore.
3
Rogers Behavioral Health, Walnut Creek, CA, USA.

473
 474
Research has shown a rising trend of complementary and
alternative medicine (CAM) usage among children with
ADHD across various populations. Results of the 2012
National Health Interview Survey revealed that >1 in every
10 children had used some form of complementary therapy
for a multitude of common ailments, including ADHD in the
preceding year, whereas another study reported up to 12% of
822 children having used CAM for ADHD.12–14 CAM forms
part of holistic integrative medicine, which offers an alter-
native or adjunct to conventional pharmacological and
cognitive behavioral treatments of ADHD. Together with
other mind–body therapies (e.g., mindfulness, biofeedback,
and yoga), CAM aims to bring about positive effects on
psychosocial, emotional, and neurobiological functioning,
and overall better treatment outcomes.15,16
Traditional Chinese Medicine (TCM) is one frequently
used CAM and according to its ideology, human health is
characterized by ‘‘yin’’ and ‘‘yang’’ as well as five organ
systems.17 ‘‘Yin’’ denotes gentle quietness, whereas ‘‘yang’’
symbolizes impatience. Equilibrium of these two forces and
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the organ systems is required for sound physical and mental
health, whereas imbalances result in conditions such as
ADHD. Depending on the source of imbalance, different
TCM preparations can be formulated to address deficiencies
and restore harmony.18
A review of CAM that examined 16 randomized con-
trolled trials (RCTs) on herbal and nutritional remedies for
ADHD had indicated promising results for zinc, iron, Pinus
Marinus, as well as Ningdong, a TCM formula.19 An in-
teresting finding was that although Ningdong has shown its
efficacy through improvements in scores on Teacher and
Parent ADHD rating scales, side effects such as hy-
persomnia were associated with its use.20 Studies with
other TCM preparations have also documented adverse
effects such as loss of appetite, insomnia, and mild ab-
dominal pain, although limited when they were used ap-
propriately.21,22 These findings are contrary to the popular
notion that TCM herbal formulations have few or no side
effects.23,24 Hence, more research on the safety and ef-
fectiveness of TCM, especially on children, would be
prudent before TCM is to be considered a potential alter-
native treatment for ADHD.
Investigators have advocated that TCM is reliable, ef-
fective, and generally well tolerated, with low occurrence of
addiction or side effects for the treatment of ADHD.23,25,26
A review by Lan and associates systematically evaluated
the effectiveness of 34 TCM remedies and found that a
variety of TCM formulae were equally or more effective
than MPH in treating children with ADHD as reflected by
improvements in scores on various validated instruments,
including the clinical global impressions (CGI) scale, child
behavior checklist (CBCL), and ADHD rating scale-IV
(ADHD-RS-IV).22
It is also pertinent to note that most studies examined the
short-term effects of TCM medication, but only few have
attempted to evaluate the longer-term effects after cessa-
tion.27,28 Another limitation in this literature is that most of
the TCM studies were conducted primarily in China and
published in Chinese TCM journals, obscuring the validity
and replication of findings to other populations.17,22 This
emphasizes the need for replication of past studies and
validation of findings in other populations.
LIANG ET AL.
Singapore is a cosmopolitan country with a population
approaching 6 million people, comprising Chinese (74.3%),
Malays (13.4%), Indians (9.0%), as well as individuals of
other ethnicities (3.2%).29 Local studies have indicated that
a large proportion of the community have engaged in
CAM,30 with TCM being the most utilized.31 Koh et al.
conducted a local survey on knowledge, attitudes, and uti-
lization of CAM (including TCM), and found that among
814 participants, a vast majority (96%) were either ex-
tremely or moderately satisfied with CAM and 80.9%
agreed that CAM was safe and effective.32 However, no
local investigations currently exist with regard to the ef-
fectiveness, safety, as well as the satisfaction of TCM
treatment for neurodevelopmental disorders such as ADHD.
This feasibility study aims to examine the short- and long-
term effects of a particular TCM formula on Singapore
children with ADHD over a period of 6 months using val-
idated western instruments as well as to provide additional
data on the safety and user satisfaction of TCM. It is hy-
pothesized that the TCM formula will be well tolerated and
reductions in ADHD symptoms and related problem be-
haviors will be observed. It is also hypothesized that chan-
ges in ADHD symptoms are stable over a period of 3
months after treatment cessation. This study serves to pro-
vide preliminary data to evaluate whether it is viable to
conduct RCTs to examine the efficacy of the TCM formula.
Materials and Methods
Participants
A total of 130 children who presented at a local TCM
clinic between 2013 and 2015 with complaints of ADHD
symptoms were screened. Children with a primary diagnosis
of ADHD as assessed by TCM physicians according to the
Diagnostic and Statistical Manual of Mental Disorders, 4th
edition (DSM-IV)33 were referred to a member of the study
team. Individuals who assented to initiate TCM treatment
along with the consent of their respective parents were then
recruited into the study, regardless of their level of symptom
severity or functioning. Individuals with any prior diagnosis
of pervasive developmental disorders, psychotic and mood
disorders, substance abuse, intellectual disabilities, or a
history of serious head trauma were not accepted into the
study. Also excluded were individuals who were consuming
any form of medications or herbal remedies for ADHD
during or within 1 month of being screened. The study was
approved by the National Healthcare Group Domain Spe-
cific Review Board, which is the institutional review board.
TCM formula
A standardized formula named ‘‘Mind-anchoring Gran-
ules,’’ which was developed by Nanjing Chinese Medicine
University of China in collaboration with Science Arts Co.
Pte. Ltd. (Singapore), was used for the study. This TCM
preparation has been approved as a Chinese Proprietary
Medicine in Singapore by the Health Sciences Authority.
The formula was manufactured by Science Arts Co. Pte.
Ltd. and sealed into 4 g sachets containing granulized ex-
tracts equivalent to the following raw herbs: Poriacocos
3.8 g, Rhizoma Acori Tatarinowii 3.8 g, Alpiniaeoxyphyllae
Fructus 3.8 g, Polygalae Radix 3.8 g, Glycyrrhizae Radix et
 TCM AND ADHD IN SINGAPORE
Rhizome 1.9 g, Radix Codonopsis 3.82 g, Triticum Aesti-
vum 5.8 g, and Fructus Jujubae 1.8 g. Five Chinese herbs in
the formula were frequently prescribed for ADHD in TCM,
whereas other herbs have been used in previous TCM in-
vestigations.20,34–36 The contents of each sachet were dis-
solved in lukewarm water and consumed twice daily.
Instruments
Changes in ADHD symptoms and related behaviors were
measured by the ADHD-RS-IV, CBCL, children’s global
assessment scale (CGAS), clinical global impressions-
severity (CGI-S) and improvement (CGI-I) scales. The
ADHD-RS-IV37 consists of 18 items that examine the fre-
quency of ADHD symptoms as specified in the DSM-IV.33 It
has been widely used and has displayed good psychometric
properties.38,39 Parents completed the questionnaire based
on a scale that ranges from zero (never or rarely) to three
(very often). Inattention, hyperactivity/impulsivity, and total
raw scores were subsequently calculated, with larger values
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signifying more persistent ADHD symptoms. The CBCL is
a comprehensive parent questionnaire comprising 112 three-
point Likert scale items that examines a child’s behavior
across 10 domains.40 Higher scores indicate increased
presence of problematic behaviors. The CBCL has demon-
strated strong reliability and validity among children of
different ethnicities and populations.40–42
The TCM physicians consulting the participants com-
pleted the CGAS by rating the child’s level of general
functioning from 0 to 100, which corresponds to requiring
constant supervision and superior functioning, respective-
ly.43 The CGAS is an extensively used and reliable instru-
ment in clinical practice.44,45 In addition, TCM physicians
also rated the participant’s severity and changes of symp-
toms by using the CGI-S and CGI-I, both 7-point scales
indicating the degree of illness severity and the level of
improvement of an individual’s condition from baseline,
respectively.46 The CGI-S and CGI-I were reviewed to be
practical and easily grasped instruments that demonstrated
good psychometric properties.47,48 The TCM physicians
underwent training on the DSM-IV, CGAS, CGI-S, and
CGI-I conducted by two of the study authors who are both
licensed psychiatrists.
Finally, parental satisfaction on the use of TCM treatment
for ADHD was elicited using a simple self-developed
questionnaire scored on a 5-point scale that ranged from
‘‘Very poor’’ to ‘‘Very good.’’
Procedure
Potential participants who sought treatment at the TCM
clinic were approached by study team members and briefed
about the research study. After obtaining assent and consent,
participants were screened and suitable participants under-
went a full physical examination. Sociodemographic data,
medical, and surgical histories were collected using self-
constructed checklists before the baseline (T1) assessment
comprising the CGAS, CGI-S, CBCL, and ADHD-RS-IV
was administered. After completing the assessment, partic-
ipants were advised to take the ‘‘Mind-anchoring Granules’’
twice daily for a period of 3 months. Participants were in-
structed to return to the clinic at the end of first and second
month to surrender empty sachets in exchange for additional
475
supply of TCM granules to monitor and encourage com-
pliance. Any potential adverse events or side effects were
tracked by a study team member during follow-up phone
calls to participants’ parents at the first and second month.
At the end of the third month (T2), participants and their
respective parents returned for a second assessment to ex-
amine the short-term effects of the TCM formula. In addi-
tion to the instruments given during the T1 assessment, the
CGI-I and parent satisfaction questionnaire were adminis-
tered. Any reported side effects were recorded using a self-
constructed 21-item checklist that encompassed common
adverse reactions such as constipation and lethargy. Parti-
cipants were then advised not to take any form of ADHD
medication or herbal supplements for the subsequent 3
months and to return to the clinic at the end of the sixth
month (T3).
During the final assessment, participants and their parents
repeated all measurements of the T2 assessment. Additional
details of the sample flow and study procedure are illustrated
in Figure 1. All participants received a small monetary re-
muneration after each assessment.
Statistical analyses
The data of all 79 participants were analyzed using SPSS
(version 17) repeated measures linear mixed models to ac-
count for missing data due to participant attrition. The
compound symmetry covariance structure was selected for
analyses after performing the two restricted log likelihood
test. All analyses were adjusted for age and sex and an a
level of 0.05 was used for all statistical tests. As this is an
initial observational study, the sample size was calculated
based on the referral rates of ADHD children to the TCM
clinic. Postulating that the pre- and post-treatment differ-
ence is 10% higher with a standard deviation (SD) of 12.5%,
a sample of at least 60 participants who completed all three
assessments would be sufficient with a power of 80% and
two-tailed test of 5%. The final recruitment target of 100
was set after accounting for possible attrition due to un-
suitability, the longitudinal nature of the study, as well as
voluntary withdrawal of participants.
Results
The final sample comprised 79 participants (77 Chinese
and 2 Malay). Mean (SD) age was 9.34 (1.65), range was 6–
12 years, and 81.0% were male. Participant data for the
various instruments across assessments as well as the cor-
responding pairwise comparisons are summarized in Table 1.
Analyses revealed significant differences [F(2,145.96) =
32.32, p < 0.001] between the total ADHD-RS-IV mean
scores across the three assessments, with scores decreasing
from T1 to T3. Pairwise comparisons with Bonferroni cor-
rection indicated that scores at T1 differed significantly from
scores at T2 and T3, p’s < 0.001, but no difference was
found between scores at T2 and T3 ( p = 1.00). Similar re-
sults were obtained for the Inattention [F(2,145.52) = 32.40,
p < 0.001] and Hyperactivity and Impulsivity [F(2,145.60) =
24.23, p < 0.001] subscales, with pairwise comparisons
showing T1 scores being significantly different from T2 and
T3 ( p’s < 0.001), whereas scores between T2 and T3 were
not different ( p’s = 1.00).
 476
FIG. 1. CONSORT flow dia-
gram—modified for non-
randomized trial design.
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CONSORT, Consolidated Stan-
dards of Reporting Trials; TCM,
Traditional Chinese Medicine.
Participants’ total raw scores on the CBCL differed sig-
nificantly across time, F(2,143.92) = 25.48, p < 0.001. Pair-
wise contrasts revealed that scores decreased remarkably
from T1 to T2 and from T1 to T3 ( p’s < 0.001). However,
there was no difference between total CBCL scores at T2 and
T3 ( p = 1.00). Similar results were obtained for other sub-
scales, for instance, attention problems [F(2,144.74) = 29.90,
p < 0.001], social problems [F(2,144.33) = 23.42, p < 0.001],
and delinquent behavior [F(2,144.83) = 8.58, p < 0.001],
with pairwise contrasts indicating a significant reduction
of all scores at T2 and T3 ( p’s < 0.05) from baseline,
whereas scores at T2 and T3 were not remarkably differ-
ent ( p’s > 0.05), with exception of the Withdrawn sub-
scale scores, which were substantially different between
T1 and T3 ( p = 0.002), but similar between T1 and T2
( p = 0.27).
Mean scores on the CGAS changed significantly across
time, F(2,146.64) = 129.11, p < 0.001. Post hoc analyses
indicated that increase of T2 (mean [M] = 72.39, standard
error [SE] = 1.24) and T3 (M = 70.51, SE = 1.25) scores from
T1 (M = 54.66, SE = 1.20) was significant, p’s < 0.001,
LIANG ET AL.
whereas the reduction of scores from T2 to T3, however,
was not significant ( p = 0.40).
Analyses of CGI-S mean scores indicated a significant
main effect of time, F(2,146.99) = 99.00, p < 0.001, with
scores varying across baseline, third month, and sixth
month.
Further inspection of means indicated that scores at T1
(M = 4.01, SE = 0.10), which corresponded to between
‘‘Moderately Ill’’ and ‘‘Markedly Ill,’’ differed significantly
from scores at T2 (M = 2.49, SE = 0.11) and T3 (M = 2.75,
SE = 0.11), p’s < 0.001. The increase of scores from T2 to T3
was not significant ( p = 0.09) and both scores were between
‘‘Borderline Mentally Ill’’ and ‘‘Mildly Ill.’’
Participants’ clinical improvements on TCM treatment
were assessed at T2 and T3 accordingly. Analyses revealed
that the increment of CGI-I scores from T2 (M = 2.63,
SE = 0.11) and T3 (M = 2.82, SE = 0.11) was significant,
t(1,69.17) = 4.45, p = 0.04.
The frequencies and percentages of the Parental Sa-
tisfaction Questionnaire responses are displayed in Table 2.
At T2, 95.83% of parents rated the TCM treatment as
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Table 1. Participant Scores for Clinician and Parental Scales Across Assessments with Pairwise Comparisonsa
Difference between Difference between Difference between 3
Baseline, M 3 Months, 6 Months, baseline and 3 months baseline and 6 months and 6 months (95%
Scale (SE) M (SE) M (SE) (95% CI) p (95% CI) p CI) p
ADHD-RS-IV
Inattention 17.85 (0.76) 13.41 (0.78) 12.91 (0.78) 4.44 (3.10 to 5.78) <0.001 4.94 (3.58 to 6.30) <0.001 0.50 (-0.87 to 1.87) 1.000
Hyperactivity/impulsivity 14.20 (0.78) 10.25 (0.80) 9.74 (0.81) 3.95 (2.56 to 5.35) <0.001 4.46 (3.05 to 5.87) <0.001 0.51 (-0.92 to 1.94) 1.000
Total 32.05 (1.41) 23.66 (1.46) 22.65 (1.46) 8.39 (5.83 to 10.95) <0.001 9.40 (6.82 to 11.98) <0.001 1.01 (-1.60 to 3.62) 1.000
CBCL
Anxious/depressed 7.33 (0.56) 5.89 (0.57) 5.62 (0.57) 1.43 (0.60 to 2.26) 0.002 1.70 (0.87 to 2.54) <0.001 0.27 (-0.57 to 1.11) 1.000
Withdrawn 4.42 (0.35) 3.95 (0.36) 3.46 (0.36) 0.47 (-0.08 to 1.02) 0.274 0.96 (0.41 to 1.52) 0.002 0.49 (-0.07 to 1.05) 0.250
Somatic complaints 3.70 (0.33) 2.92 (0.34) 2.73 (0.35) 0.78 (0.15 to 1.41) 0.043 0.97 (0.34 to 1.61) 0.008 0.19 (-0.45 to 0.83) 1.000
Social problems 8.94 (0.51) 6.75 (0.52) 6.37 (0.52) 2.18 (1.38 to 2.99) <0.001 2.57 (1.76 to 3.38) <0.001 0.39 (-0.43 to 1.21) 1.000
Thought problems 6.60 (0.46) 4.76 (0.47) 4.95 (0.47) 1.84 (1.02 to 2.66) <0.001 1.65 (0.83 to 2.48) <0.001 -0.19 (-1.02 to 0.65) 1.000

477
Attention problems 13.18 (0.51) 10.55 (0.52) 10.35 (0.52) 2.64 (1.82 to 3.45) <0.001 2.84 (2.01 to 3.66) <0.001 0.20 (-0.63 to 1.03) 1.000
Delinquent behaviour 5.08 (0.41) 3.93 (0.42) 3.83 (0.43) 1.14 (0.48 to 1.81) 0.002 1.25 (0.58 to 1.92) 0.001 0.11 (-0.57 to 0.78) 1.000
Aggressive behaviour 14.01 (0.93) 11.39 (0.95) 11.16 (0.95) 2.62 (1.35 to 3.89) <0.001 2.85 (1.57 to 4.13) <0.001 0.23 (-1.06 to 1.52) 1.000
Internalizing problems 15.44 (1.00) 12.77 (1.02) 11.82 (1.03) 2.67 (1.18 to 4.15) 0.001 3.62 (2.11 to 5.12) <0.001 0.95 (-0.57 to 2.46) 0.644
Externalizing problems 19.08 (1.28) 15.31 (1.30) 14.97 (1.31) 3.78 (2.03 to 5.52) <0.001 4.11 (2.35 to 5.87) <0.001 0.34 (-1.44 to 2.11) 1.000
Total 69.67 (3.34) 55.08 (3.42) 53.19 (3.43) 14.59 (9.57 to 19.61) <0.001 16.49 (11.41 to 21.56) <0.001 1.90 (-3.22 to 7.01) 1.000
CGAS 54.66 (1.20) 72.39 (1.24) 70.51 (1.25) -17.73 (-20.15 to <0.001 -15.85 (-18.29 to <0.001 1.88 (-0.60 to 4.36) 0.399
-15.31) -13.41)
CGI-S 4.01 (0.10) 2.49 (0.11) 2.75 (0.11) 1.52 (1.29 to 1.75) <0.001 1.26 (1.03 to 1.49) <0.001 -0.26 (-0.50 to 0.089
-0.03)
CGI-I NA 2.63 (0.11) 2.82 (0.11) NA NA NA NA -0.20 (-0.38 to 0.039
-0.01)
a
Values adjusted for age and sex.
ADHD-RS-IV, attention-deficit/hyperactivity disorder-rating scale-IV; CBCL, child behavior checklist; CGAS, children’s global sssessment scale; CGI-I, clinical global impressions-
improvement; CGI-S, clinical global impressions-severity; CI, confidence interval; M, mean; SE, standard error; NA, not applicable.
 478
Table 2. Frequency Table for Parent
Satisfaction Questionnaire
Timea
3 Months 6 Months
Satisfaction rating Frequency % Frequency % side effects.23–26 Accompanied by the high parental satis-
Very good 4 5.56 16 22.86
Good 40 55.56 27 38.57
Moderate 25 34.72 22 31.43
Poor 2 2.78 4 5.71
Very poor 1 1.39 1 1.43
a
Number of participants at 3 months = 72. Number of participants
at 6 months = 70.
‘‘Moderate,’’ ‘‘Good,’’ or ‘‘Very Good,’’ whereas the re-
maining 4.17% opined that the intervention was ‘‘Poor’’ or
‘‘Very Poor.’’ Similar findings were obtained at T3 assess-
ment. No side effects or adverse events related to the TCM
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formula were reported at T2 or T3.
Discussion
The CGI-I scores at T2 indicated that participants were
between the range of ‘‘Minimally Improved’’ and ‘‘Much
Improved’’ after undergoing TCM treatment for 3 months.
The significant drop in scores on the CGI-S, as well as all
ADHD-RS-IV and pertinent CBCL subscales from T1 to
T2, suggests that the TCM formula may reduce ADHD
symptoms as well as most related problem behaviors. Im-
provements in general functioning as reflected by a re-
markable increase of CGAS scores from baseline to the third
month were also noted, which can possibly be attributed to
the decrease of ADHD symptoms and psychopathology.
Furthermore, scores across the various instruments indicated
reduced psychopathology and improvements in functioning
from T1 to T3. These preliminary findings may lend support
to other similar studies that demonstrated the short-term
effectiveness of TCM in treating ADHD.49,50
Although there was a significant increase of CGI-I scores
from T2 to T3, which shifted toward the direction of
‘‘Minimally Improved,’’ both scores still lie between
‘‘Minimally Improved’’ and ‘‘Much Improved’’ categories,
indicating that participants generally became better over
time with TCM treatment as compared to baseline. The
consistent scores on all other clinician and parental mea-
surements between T2 and T3 may indicate that improve-
ments were sustained and that ADHD symptoms and related
behaviors did not return to baseline levels. This supported
the hypothesis that the effects of TCM formula could be
sustained over a period of 3 months after treatment cessation
and may back the findings of other investigations that have
asserted the long-term effectiveness of TCM.28,51
Although there were no significant differences on the
CBCL Withdrawn subscale between T1 and T2 as well as
T2 and T3, the decrease of observed withdrawn behavior
from baseline to the sixth month was significant. A possible
explanation could be that withdrawn behavior was depen-
dent on improvements in other symptoms (e.g., anxiety/
depressed) and thus changes in this domain could be more
gradual overtime. The general reduction of ADHD symp-
LIANG ET AL.
toms and related psychopathology, improvements in func-
tioning accompanied by the absence of side effects among
participants suggest that the TCM formula has potential
therapeutic benefits and is safe for consumption among
children with ADHD, and may be consistent with research
that have reported that TCM is well tolerated with limited
faction rates that were also observed in previous local
studies,32 the potential for this TCM formula as an adjunc-
tive treatment for children with ADHD is thus encouraging
and permits future RCTs to evaluate its efficacy.
Limitations and future research
This feasibility study is the first of its kind in Singapore
and employed standardized diagnostic criteria, reliable and
well-validated instruments to examine both short and long-
term changes in psychopathology among CAM users. How-
ever, despite the positive findings observed, this study does
not demonstrate efficacy of the TCM formula due to the lack
of controls as well as participant, parental, and physician
blinding. The significant short-term reductions in ADHD
symptoms and improvements in functioning could be the
result of placebo effects as well as reporting biases. This
possibility is further supported by the finding that these
benefits appear to be sustained even after treatment cessation.
As the majority of participants were of Chinese ethnicity,
cultural influences and practices could potentially generate a
large placebo effect. With TCM being deeply rooted within
the Chinese heritage,32 the accompanying cultural accep-
tance, generally positive attitudes and beliefs as well as
consequent better medication adherence could explain the
present observed findings, which has been asserted by other
research.52 In the same vein, because participants were pre-
dominantly of Chinese descent, the treatment response, atti-
tudes, and acceptability of this TCM preparation may not be
generalizable to individuals of other ethnicities. Previous
studies have indeed shown that the response and tolerability
of TCM intervention varies across ethnicities.53,54
As perceptively indicated by Lan et al., many TCM in-
vestigations lacked randomization, with most being open
label trials and vulnerable to selection, performance, and
measurement biases.22 There is hence a need for double-
blind RCTs using representative multicenter samples to
support efficacy and overcome the low methodological
quality of many TCM studies. Furthermore, more objective
biomarkers such as blood, urine, and stool analyses can also
be employed to objectively examine the safety and tolera-
bility of TCM formulations, as demonstrated by a notable
study.20
Although TCM has been purported to have a delayed
onset of therapeutic effects as well as having sustained ef-
fects, the duration of sustained therapeutic benefits cannot
be readily established. This is further complicated by a
combination of different varieties of herbs in TCM formu-
lations, the majority of them have not been assessed for their
pharmacokinetic profiles. Nonetheless, TCM treatment
emphasizes on restoring functional balance and harmonizing
the body, mind, and spirit19,20 by adopting principles of
compatibility and syndrome differentiation to determine the
precise treatment of childhood ADHD.55,56 In addition,
TCM physicians tend to prescribe customized interventions
 TCM AND ADHD IN SINGAPORE
for each patient according to their experience and exper-
tise.57 Although these factors distinguish TCM from other
treatments, they inadvertently also render it difficult for
western medicine practitioners to comprehend and validate
due to differences in clinical methodologies assessing safety
and efficacy.58–60 Despite its various limitations, TCM has
been gaining popularity among children with ADHD25 and
seems promising as a viable adjunctive treatment for
ADHD. With greater appreciation of TCM over time, more
health care institutions internationally have started incor-
porating TCM interventions, paving the way toward a more
holistic model of treatment.
Conclusions
This study suggests that TCM is relatively safe and has
potential therapeutic effects in a group of children with
ADHD. However, the findings could be subjected to placebo
effects and reporting biases from physicians, participants, as
well as their respective parents. Future double-blind RCTs
Downloaded by 60.52.98.23 from www.liebertpub.com at 10/31/21. For personal use only.
should be conducted on this particular TCM formula to
examine its efficacy.
Acknowledgments
This study would not have been possible without the
invaluable contributions and dedication of the TCM phy-
sicians and staff from Science Arts Co. Pte. Ltd. The au-
thors would also like to thank the Neuro-Behavioral Clinic
at the Institute of Mental Health for their guidance and
support.
Authors’ Contributions
S.H.O. and Z.W.L. are the principal investigator and co-
principal investigator of the study, respectively. S.H.O. and
Z.W.L. both conceptualized the study, and wrote the article.
Z.W.L. also provided statistical analysis of the data. Y.H.X.,
C.G.L., and D.F. gave significant inputs to the running of the
study and to the article.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This research was supported in part by a grant from the
Institute of Mental Health Institutional Block Grant and
Woodbridge Hospital Charity Fund.
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