This is a detailed article/blog, which means it is also a longer read. For readers who want the quicker read, I have included a TL;DR (too long, didn’t read) version at the end of the article.
You may have seen the ads. A new chiropractic office opens in town, and maybe you see the ad on your Facebook feed, or you hear about it from a friend, or something similar. Among many other things the chiropractor treats, you see that they can also offer treatment for ADHD. But does this really work? Can a chiropractic alignment really improve ADHD symptoms? In this blog, I take a fair, measured approach to this question.
First, I’m a psychologist. So, when it comes to treating ADHD, I am already biased a little bit toward non-pharmaceutical approaches. Although medications can help tremendously with ADHD, they are not the only treatment, and there are many behavioral treatments that work well too, with fewer side effects. So, with my patients, I almost always recommend waiting before trying or considering a medication, trying non-drug-based options first. For brevity, I’m not going to go into all the behavioral treatments here. I’m also not going to talk about drug-based options. You can review my page on childhood ADHD for more information about those classes of treatments for ADHD. Here, I’m sticking only to chiropractic approaches.
To write this blog, and to give a fair treatment of the topic (so I’m not writing just based on opinion, but actually reading the source material), I reviewed numerous (10+) scientific articles on chiropractic adjustments for ADHD and other mental health issues. But first, before I get into my findings, I want to say that in my assessment below I am not judging the entire practice of chiropractic. I do not have the expertise to fairly judge everything a chiropractor can or cannot do for your overall health. My assessment, then, is limited just to the mental health side of chiropractic.
How is chiropractic for ADHD supposed to work?
Throughout my review of the literature, I was unable to find the original source theory from which the idea of chiropractic for ADHD was derived. However, chiropractic itself is based on the theory that spinal adjustments can improve the overall function of the nervous system. Since ADHD (and other psychiatric disorders) is a disorder of the nervous system, theories of chiropractic have recently (in the past decade or two) been extended to apply to ADHD. In my review of one registered clinical trial (Amjad, 2019), the primary hypothesis is that the “articular dysfunction component of … vertebral subluxation results in altered afferent input to the central nervous system (CNS) that modifies the way in which the CNS processes and integrates all subsequent sensory input. … [Altering] sensorimotor filtering, cortical and cerebellar motor processing, and multisensory processing [all] … may be important in the [treatment] of ADHD.”
Now, I went to a lot of school to become a doctor of psychology and become an expert on neuroscience and general brain functioning, but those sentences didn’t make a lot of sense to me at first either, so let me translate for the average reader what all of this means. The first term to define – articular dysfunction – is the one that is a little outside my area, but I will do my best to define it at least from an anatomical standpoint. The articular disc is a thin plate of fibrocartilage that can be found in joints and which separates the cavity (space) between joints to allow for more evenly distributed movement in that space. In a nutshell, the articular disc increases joint stability and helps direct synovial fluid (a fluid to reduce friction) to areas with the most friction. An example of the articular disc in the spine – called the intervertebral disc – is shown in a picture below. There are several spinal disorders related to the intervertebral disc, some of which you may have heard of, including herniated disc, bulging disc, degenerated disc, thinning disc, disc degeneration with osteophytes, and so on.
Vertebral subluxation is a term exclusive to chiropractic and basically refers to an unhealthy spine alignment. It is the bread and butter of chiropractic practice. There are a lot of nerves in the spinal cord. In fact, it’s the main way your brain communicates with the rest of your body. All the nerves that go from brain to body (and vice versa) go through your spinal cord. So, the theory is that a vertebral subluxation can affect nervous system function by blocking, pulling, or irritating nerve tissue, causing symptoms in various parts of the body, depending on the affected nerve.
Now, to go back and put the rest of that above quote in a more simplified context – the one that explains how chiropractic can help ADHD – what it basically means is that given every (electrical) message from the body to the brain has to go through the spinal cord, a messed up spinal cord can cause problems in how some of the messages get passed through, which may (theoretically) be a reason for the symptoms of ADHD.
What else should you know about chiropractic?
To fully grasp the issues I’ll discuss in this blog, I think it might be helpful to also outline some of the available data on chiropractic practitioners. Which I’ll address through some FAQs that I think are especially relevant to our discussion.
1) Are chiropractors medical professionals? I suppose the answer to this one depends on your definition of “medical professional.” A 1998 study (seriously outdated, I know) reported that chiropractors at the time were the third largest group of health care professionals in the United States who have primary contact with patients (behind physicians and dentists). Chiropractors are trained at a similar level as other healthcare professionals, with at least 4 years of doctoral education and an additional 2 years of practical training. However, of note, according the Council of Chiropractic Education (CCE), there are only 16 accredited Doctor of Chiropractic programs in the United States (accredited by the CCE). However, there are additional institutions that do not have CCE accreditation, and may be accredited by other bodies.
Still, assuming a person who calls themselves a chiropractor is following the law and has received the standard educational background of his or her colleagues, chiropractors are health care professionals. They are often classified, though, under an “allied health” umbrella, which is the same designation as many other healthcare professionals who do not hold an MD degree (like psychologists, physical therapists, and so on).
2) What is the practice philosophy of chiropractors? One proposed system for classifying the practice philosophies of chiropractors was proposed by Biggs, Hay, and Mierau (1997), which placed chiropractors in 3 different groups – conservatives, moderates, and liberals. In the Biggs survey, the conservative group was a minority, with only 19% holding the view that scientific validation should limit the scope of chiropractic concepts and methods. In other words, the conservative group limits their practice ONLY to treating musculoskeletal conditions, for which there is some evidence base supporting chiropractic as being helpful (in adults). The liberal view is the opposite, that chiropractic should not be limited just to musculoskeletal conditions but includes a broad scope of practice. In that same Biggs et al. survey, 22% of respondents classified themselves as holding the liberal viewpoint. The majority (59%) rated themselves between the two poles. Still, what should be taken from this survey was that (at least in 1997) 74% of chiropractors believed they should notbe limited to treating only musculoskeletal conditions.
3) Does chiropractic have any evidence base for use in pediatric populations? While there is some good evidence that chiropractic helps relieve acute back pain in adults, I was not able to find any hard (rigorous, well-designed) scientific evidence supporting its use in pediatric populations, at least with regard to spinal adjustments being effective for treating any pediatric conditions. Part of the reason for this, in my opinion, is that it appears chiropractors 1) do not routinely perform rigorous studies to investigate their practice, 2) those that do such studies tend to commit a number of errors in the design and conduct of their research that call into question the validity of published results. The second part of this is complex to explain without going into a long diatribe about all “validity” threats that can occur in a research study. I’ve listed several in a separate blog post. If you (as the reader) would like a refresher in threats to sound research design and methods, please review that post.
But, what you need to know for now is that I could not identify any studies in my search that found a meaningful, long-lasting effect of pediatric chiropractic adjustments for managing any childhood issue that were not invalidated by at least several threats to validity.
4) Are pediatric chiropractic adjustments harmful? If there is no evidence of efficacy, the next reasonable question would be “Well would it hurt to at least try it out and see what happens?” Most complications arising from chiropractic manipulation are minor: mild pain/discomfort, slight headache, fatigue. These are common and usually transient (short-lived). However, there are several reports of major neurological complications in adults, primarily consisting of vertebrobasilar accidents (the arteries at the back of your brain) after cervical rotation to the upper neck (this could cause a stroke or even death). The incidence of this is very low (ranging between 5 in 10,000 and 1.46 in 10,000,000, depending on the study); frankly, this incidence is lower than most other medical procedures. The rate is similarly low in children. So, realistically, the risk of major complications from chiropractic adjustments to children is pretty low. But, since there is also no real evidence of efficacy, it could be argued that the risk-benefit ratio may lean toward higher risk than benefit. A more thorough review on this can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2794701/#b4-pch07085
How do scientists classify research into different categories of evidence?
It is common for scientists (and doctors too) to develop new theories to explain different types of illness. The proper progression from theory to fact is through empiricism, which refers to scientific studies that support (or do not support) a theory. Now, one thing you should know about modern medicine and modern research is that very, very little of anything ever moves into being an indisputable “fact.” That’s because the world is complicated and there are exceptions to almost any “rule.” So, instead of trying to get to “fact,” most scientists work to achieve the highest standard of evidence. When it comes to treatments/clinical interventions, there are several levels of standards of evidence. These standards are outlined below:
Well-established
A finding that has been supported in multiple, well-designed studies (at least 2 studies) conducted by at least 2 different independent laboratories
Probably efficacious
A finding that has been supported by multiple well-designed studies, but all conducted by the same laboratory
Possibly efficacious
Supported by one well-designed study
Experimental
No well-designed studies are available that support the finding. Some studies may be available, but lack the rigor necessary to be considered “well-designed” by scientific research standards.
Unsupported or Harmful
The intervention has been carefully studied (through well-designed research) and found to be unsupported (has no meaningful effect) or harmful (actually causes harmful effects). For ethical reasons, the standard of evidence for a harmful treatment is not the same as establishing a therapeutic treatment. If a treatment is reported to be harmful in one study, it may be considered unethical to conduct continued research, risking harm to additional patients. Furthermore, many scientists fail to report harms through conventional academic means. As a result, many harmful interventions are discovered through good, investigative journalism, “uncovering” harms usually years after a patient (or more patients) has/have been harmed. The same is generally true for “unsupported” interventions. Scientists rarely conduct ongoing research on unsupported interventions, preferring instead to focus resources on more promising avenues. As a result, “unsupported” interventions are also not held to the same standard as above (requiring multiple rigorous studies to build a “well-established” finding).
So, as we explore in this blog the state of current research for chiropractic care for ADHD, I will classify it into one of the above categories. One important note, though, is the time it takes for an intervention to move from experimental to one or more of the above classifications. All new interventions start out as “experimental,” by definition. The timeline from experimental to “possibly efficacious” usually involves at least a couple of years of research. To progress to “probably efficacious” often takes 5-10 years. To move to “well-established” often takes decades. The same is true for unsupported and harmful treatments. Many unsupported interventions “die off” after a 2-3 years. However, others may persist for decades. Similarly, treatment harms may not be discovered until an intervention has been in use for decades. Unfortunately, science is slow!
So, just because a treatment is not well-established does not mean it is not a very good treatment. Often, very good treatments just need more time and attention to bring them into a well-established status.
What does the current evidence say about chiropractic care for children with ADHD?
Based on my review of the current literature, I would classify chiropractic care for children with ADHD as being “experimental,” which is actually the lowest standard of evidence in the table above, meaning that there is no (strong) evidence to make conclusions one way or the other. In other words, we can say neither whether spinal adjustments for ADHD are useful or harmful.
Let’s look at this in more detail. A 2010 systematic review published in the peer-reviewed journal Chiropractic & Osteopathy (Karpouzis, Bonello, & Pollard) explored the chiropractic care for youth with ADHD. Their review included 58 articles. Of those 58, 22 were intervention studies, but only three involved children with ADHD in their sample. All of the studies were classified as “poor quality,” with none of them using inclusion/exclusion criteria (determining who qualifies for your study before you conduct it, a way to reduce bias by preventing researchers from, for example, only recruiting people who are already pretty healthy, or, vice versa, very sick). The studies also lacked control groups and lacked relevant, standardized measures to properly monitor outcomes. Furthermore, of all the studies reviewed, few used a standardized treatment procedure between them (they didn’t use the same types of chiropractic adjustments). For interested readers, this full systematic review can be read online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891800/. It is a high-quality review.
Since this 2010 review, there has regrettably not been any improvement in subsequent studies conducted since then. Available studies continue to suffer from the same problems, with most being case studies lacking control groups, standardized outcome measurement, and agreed-upon treatment protocol. I was only able to locate one randomized clinical trial (a type of study design that has some of the best protections against threats to validity of findings) (which can be found here: https://clinicaltrials.gov/ct2/show/NCT03849807).
However, I was not able to review findings of this study, as the study itself was reported as being completed in June 2019 (only 8 months before the date of this blog). It is likely that the findings are still under review for publication. Notably, the study design includes two treatment groups (an experimental group and a control group). Both groups received “usual care” – which included Cognitive-Behavioral Therapy – for ADHD. The experimental group received chiropractic care while the control group received a “sham” chiropractic intervention (passive movement control), where they undergo similar procedures with the chiropractor, but no actual adjustments are made. This is actually a strong study design, and I will be interested to see the results when published. However, due to something called “publication bias” – where journals tend to only publish studies with significant results that show desired effects, it is possible that, if the study did not find any effect of chiropractic adjustments, the study may not ever get published. For now, only time will tell whether the above study added useful findings to the literature on chiropractic for pediatric ADHD.
If chiropractic for ADHD is “experimental,” what’s the probability/plausibility that it might be a reasonable treatment?
In short, not very. The detailed version follows below.
Every well-established, effective treatment was experimental once upon a time. So, “experimental” doesn’t always mean that a treatment isn’t worth considering further. Some scientists, then, have proposed looking at the “plausibility” or “probability” that a treatment might be effective. So, let’s explore next whether chiropractic for ADHD seems plausible.
The theory proposed by chiropractors, that vertebral subluxations contribute to ADHD symptoms, can be easily tested with common medical science. If a “disordered spine” can cause symptoms of inattention, hyperactivity, and/or impulsivity, then we would also see an increase in these symptoms in patients with known spinal disorders. Though I could think of no such connection in any literature I have ever seen, to be sure, I did perform a scholarly search for any articles that linked spinal dysfunction with symptoms of ADHD. The only such articles I found were completely within the chiropractic literature, which I reviewed above (and, which, to repeat here, suffer from serious methodological flaws). No other medical field has found any such link, not in orthopedics, neuroscience, psychiatry, or any other specialty. I did find some articles with titles like “Deletion of JMJD2B in neurons leads to defective spine maturation, hyperactive behavior and memory deficits in mouse” (Fujiwara et al., 2016), and, intrigued, I read them. Turns out that these articles are referring to “dendritic spines,” (a part of neurons/brain cells) and have nothing to do with any of the musculoskeletal system. Such articles are designed to explore genetics in various neurodevelopmental disorders, and thus ARE relevant to ADHD, but, again, have nothing to do with the assertions made by chiropractors.
There ARE, though, a number of genetic or other acquired developmental disorders that can cause both problems in the spine AND behavioral problems often associated with ADHD. For example, Down syndrome (trisomy 21) is associated with upper-cervical problems and many children with Down syndrome can also suffer from executive dysfunction that mimics ADHD. Similarly, Fetal Alcohol Syndrome (FAS) can lead to both behavior and cognitive problems as well as cervical spine problems. Many kids with FAS also have diagnoses of ADHD. As another example, mucopolysaccharidosis (MPS) constitutes a family of diseases related to the body’s ability to break down sugar molecules and can cause a wide variety of symptoms, including physical (including spinal) and behavioral symptoms. These 3 are just a few of many possible examples. In all of these, behavioral symptoms are never linked to the spine – they are simply a part of the greater syndrome of symptoms caused by genetic deformities and/or toxic exposures. So, while technically there is an association of spinal problems and behavioral problems in certain populations, these connections are always explained by other factors.
So, if there is no reliable association between spinal disorders and ADHD (people with spinal disorders are NOT more likely to have ADHD), what about the other way around? Do people with ADHD have an increased risk of spinal disorders? This is a bit more complicated to answer, but there actually IS an increased risk of spinal injury in people with ADHD. This connection makes sense though. People with ADHD tend to be impulsive and more likely to take risks without fully considering the consequences of their actions. As a result, they are more likely to incur a number of injuries, including spinal injuries. One study (Merrill, Lyon, Baker, & Gren, 2009) found that people ages 0-64 with ADHD were 3.07 times more likely to acquire a severe injury (i.e. fracture of skull, neck, and trunk; intracranial injury; and injuries to nerves and spinal cord). In this case, though, spinal (and other musculoskeletal) dysfunction is injury specific. Any chronic issues result from the injury, not from a developmental feature of ADHD.
The fact that chiropractic is the only healthcare field that connects anything spine related with ADHD is a red flag and significantly decreases the plausibility of this assertion.
Well, then, why are there case studies that suggest kids with ADHD do get better after chiropractic adjustments?
We don’t know for sure. That’s the problem with the current research. We just don’t have enough info to know it this is an actual connection or just “placebo.” However, most of the consensus among specialists who treat ADHD is that placebo affects are more likely than actual treatment effects. Some of the details of this are outlined in the Sidebar on research methodology, above.
So what’s the summary
Here is the TL;DR (too long, didn’t read) version of this article, along with some additional recommendations.
1) The current state of the evidence places chiropractic as an unproven, experimental alternative intervention for pediatric ADHD. There is no evidence one way or the other to call the treatment efficacious, ineffective, or harmful. Studies that do exist have numerous methodological flaws that limit applicability to clinical practice.
2) Not only is there no evidence to support chiropractic for ADHD, the plausibility of the intervention is not supported by any other medical field.
3) Consider there is a very small, but real risk of serious injury to your child from cervical (neck) adjustments.
4) There are plenty of well-established treatments that already exist for pediatric ADHD. Current standards of treatment recommend first a trial of behavior therapy, which, if unsuccessful, may then be complemented with pharmacological (drug) treatment. A review of these can be found here on my website. Both of these interventions are extremely well-researched, and we know a LOT about what to expect, what risks to monitor for, and how to act when a treatment is not successful. By comparison, we know nothing about chiropractic treatment for ADHD.
5) If you do meet with a chiropractor, watch out for red flags. If the doctor promises or suggests that they know chiropractic works for ADHD, consider this a misrepresentation of the evidence. A responsible chiropractor would inform you of the experimental nature of the practice and would inform you of the possible risks. They would also encourage you to continue your follow-up with more traditional medical and behavioral interventions. If a chiropractor encourages you to stop following your other doctors’ advices, then consider this another red flag.
6) Be careful not to be fooled by fancy medical jargon. I have personally seen reports from chiropractors who performed a neurological exam on some of my patients, and these reports suggested significant neurological dysfunction that was not supported by any other clinical evaluation (i.e. if I or a neurologist performs the same neurological exam, none of the same findings are found). These reports contained fancy medical terms (e.g. dysdiadochokinesia) that can be confusing to untrained readers, which can make the report sound more “official” and “accurate.” If those findings are not supported by other clinicians, consider this another red flag. A responsible chiropractor will work as part of a team with your other doctors.
a. At the same time, know that in the medical field, chiropractors often get a fairly bad reception amongst physicians, which may, at times, be unfair and may cause further division between their profession and the rest of the medical establishment. This division can cause some chiropractors to develop a distaste for working with other physicians, but it shouldn’t prevent them from still communicating with your child’s other physicians. We should all be communicating together, ideally.