Experience of parents in delivering pediatric tuina to children with symptoms of attention deficit hyperactivity disorder during the COVID-19 pandemic: qualitative findings from focus group interviews

Attention deficit hyperactivity disorder (ADHD) is one of the most prevalent neurodevelopmental conditions during childhood with average prevalence approximately 5% [1]. Its three core symptoms are inattention, hyperactivity, and impulsivity [2]. According to a 2016 national survey in the US, 64% of children with ADHD have one or more other mental, emotional, or behavioral disorders [3]. Psychiatric comorbidities in those with ADHD are varied and include learning disorders, sleep disorders, oppositional defiant disorders, anxiety disorders, intellectual disability, language disorders, mood disorders, and conduct disorders [4]. A longitudinal study with a 16-year follow-up on ADHD persistence in adulthood revealed that in 60% of children with ADHD, symptoms persist into adulthood [5]. Therefore, children must receive timely and cost-effective nonpharmacological interventions at a young age.

Conventional treatments for ADHD include medication and behavioral therapy [6, 7]. Even FDA-approved medications like methylphenidate, are frequently reported to have several potential side effects (e.g., dizziness, headaches, moodiness, and irritability) despite their immediate effects on the core symptoms of ADHD [8, 9]. Behavioral therapy is the first-line intervention for children under 6 years of age but requires a high level of family participation [10]. Pediatric tuina, also called pediatric anmo or traditional Chinese medicine (TCM) pediatric massage, is a special massage therapy for infants and children. Previous studies have attempted to explore the effects of pediatric tuina on numerous clinical conditions and diseases [11], such as diarrhea [12], anorexia [13], torticollis [14], cerebral palsy [15], scleroderma [16], constipation [17], infantile malnutrition [18], and fever [19] and in the promotion of the growth and development of healthy children in China [20]. Pediatric tunia is an external therapy involving the stimulation of specific areas or acupoints of the body through various manipulation techniques, such as pushing, kneading, pressing, rotating, nipping, circular, and pounding [20, 21]. Pediatric tuina produces various kind of stimuli on the skin, which could be sensed by surface sensory receptors and transferred to the central nervous system, inducing a series of protective adaptive homeostatic activities [22, 23]. A previous study also showed that in young children, the skin can rapidly regulate basic and adaptive homeostatic responses with a low compensatory basal level of stress-responsive enzymes, thus enabling a broad range of responses [24]. In a systematic review of 11 clinical studies on the use of massage in children with ADHD, seven works used pediatric tuina as the intervention. These studies reported that pediatric tuina might have beneficial effects on improving children’s concentration, flexibility, mood, sleep, social functioning, and overall condition [25].

In China, pediatric tuina has been increasingly developed as a parent-delivered intervention due to its simplicity and convenience [26]. Many experimental studies have demonstrated the multiple benefits of parent-administered behavioral interventions for ADHD [27‐30] or the feasibility and effects of parent-administered massage-related interventions [31, 32]. However, only a few clinical trials have been conducted on pediatric tuina for ADHD with validated outcome measures to explore its specific and nonspecific effects. In addition, in-depth qualitative feedback regarding the administration of pediatric tuina from parents is lacking. Therefore, we recently conducted a pilot randomized controlled trial (RCT) on parent-delivered pediatric tuina in children with ADHD. Focus group interviews were also performed on the participants. The aim of this focus group study is to provide an in-depth understanding of the facilitators and barriers in intervention implementation and to explore the other beneficial effects of tuina.

This project was registered in ClinicalTrials.gov (Identifier: NCT04237259). Ethical approval was obtained from Hong Kong Polytechnic University (HSEARS20190824002) and Shandong University of Traditional Chinese Medicine Affiliated Hospital ([2019] 伦审第 (044) 号–KY). This article reports on the qualitative component of a pilot RCT on parent-administered pediatric tuina for children with ADHD symptoms. In the RCT, parents were systematically trained on pediatric tuina intervention by TCM practitioners in five online training sessions (1 h for each training session) and delivered pediatric tuina to their children at home for 2 months. All study-related procedures were modified to online settings because of the COVID-19 pandemic. The details of the intervention and results have been described in other publications [33‐35], and the procedure of the intervention implementation is shown in Fig. 1. The consolidated criteria for reporting qualitative research (COREQ) checklists were used to guide the reporting of this study [36].

Three focus group interviews were conducted in Mandarin between November 2020 and January 2021. The interviews had the mean duration of 107 min and ranged from 77 to 127 min. Fifteen parents were invited and agreed to join. Three focus group interviews were conducted. The number of participants in each group ranged from 4 to 6. The participants did not know each other. Data saturation was applied to guide data collection [51] with themes and subthemes that were established in the first two focus group interviews and enriched after the third focus group interview.

This work is the first qualitative study to explore the facilitators and barriers in implementing parent-administered pediatric tuina. Qualitative data might enable the exploration of remarkable points that need to be examined quantitatively in further studies [53] and suggested that pediatric tuina has perceived benefits for the sleep quality and appetite of children and parent–child relationships but had little effect on improving children’s attention. The implementation of the intervention was feasible and acceptable for most of the parents and resulted in good adherence. The parents were satisfied with the professional support that they received and expected to receive long-term guidance and support. However, one component of the intervention, specifically, online TCM consultation was perceived to have limited accuracy, thereby leading to doubts about the accuracy of TCM pattern identification. This doubt was regarded as a major barrier.

The potential participant-centered improvements in the appetite and sleep quality of children found in this work were in line with the quantitative findings of previous clinical studies. Several clinical trials suggested the beneficial effects of pediatric tuina on children’s sleep quality in other pediatric conditions, such as adenoid hypertrophy [54], tourette syndrome [55], fever [56], and health maintenance [57], but no study on ADHD preschool children. A meta-analysis of 16 RCTs on the effects of baby massage for sleep quality showed that pediatric massage improved the sleep quality of infants (SMD = 0.70; 95% CI =  − 0.05 to 1.46; p = 0.07) [58]. In addition, the effects of pediatric tuina on children’s appetite was supported by several studies. A meta-analysis on pediatric massage for anorexia in children showed that massage was significantly better than medication regarding clinical effective rate (RR = 1.31, 95% CI = 1.24–1.38) [59]. Another meta-analysis suggested that pediatric tuina was superior to medication improving the food intake [13]. However, studies on improving sleep and appetite in ADHD children are lacking. Our finding suggested parent–child relationship has been improved during the pediatric tuina intervention. The effects on parent–child relationships might be related to parent training and administration patterns. A systematic review of five RCTs on parent training interventions for ADHD in children suggested that parent training might have beneficial effects on the behavior of children, reduce parental stress, and enhance parental confidence [60]. The improvements in parents and children might benefit the relationship between parents and children. Although these trainings were mostly on behavioral interventions, parent-delivered pediatric tuina increased family companionship, which is closely related to the progression of ADHD in children [61].

We conducted online focus interviews due to the outbreak of COVID-19. During this period, our pilot RCT was modified to be conducted online. Thus, the 64 parents who participated originated from different areas of mainland China (36 cities), and the sample of the focus group interviews was selected from these 64 parents. This method made data collection easy and safe for the parents and research team. Although online training programs for the parents of children with ADHD have been tested previously [62], this work is the first online clinical trial on pediatric tuina intervention. Some barriers emerged during the study process. They included the inaccuracy of TCM pattern identification due to the online diagnosis mode [63]. The diagnosis of pediatric tuina mainly uses inspection, listening/smelling, and inquiring instead of the four diagnostic methods of TCM for adults [64]. Among these diagnostic methods, inspection was usually limited due to online settings. Although we had taken several actions to improve the process of diagnosis (e.g., asking the participants to turn off the filter function of their video devices, sharing actual images of coated tongues taken by the TCM practitioner in advance, filling in forms with detailed conditions of their children, and booking multiple time slots to meet the TCM practitioner), some parents still have doubts about the intervention. The online study design met the demands of most participants after refinement. Given that image and audio quality vary among participants, we strongly suggest that researchers or therapists avoid completely depending on diagnoses made via video calls. The limits of online diagnosis were consistent with other evidence for telehealth supportive interventions [64‐66]. Further studies may compare the effects and accuracy of online and face-to-face diagnosis in pediatric tuina.

Although the online implementation mode had several limitations, most parents agreed on its feasibility, convenience, and safety during the special period of the interviews. Moreover, this mode facilitated monitoring the participants. The advantages of web-based intervention were confirmed by several previous studies [64, 67, 68]. The provision of professional support and guidance for pediatric tuina by the research team during the whole intervention period was praised by all the participants and was undoubtedly one of the most important facilitators. Online implementation enabled instant responding to participants’ queries and providing timely professional support. It also guaranteed that regular useful information could reach the participants on time. Therefore, a combination of online professional support and face-to-face TCM pattern identification might improve the effects of pediatric tuina. This combination must be explored in future studies. The online parent-administered pediatric tuina intervention presented here could be a feasible way to provide complementary and alternative intervention to children when drugs and necessary medical equipment cannot be accessed in certain situations, such as the COVID-19 pandemic, during which many online-based interventions were developed [69‐71].

Some factors, such as the parents’ expectations to improve their children’s health conditions or inattention symptoms, could be regarded as facilitators. However, the parents’ expectation to help their children can be a motivating factor for trying any new intervention and may not be a facilitator specific to parent-administered pediatric tuina. Therefore, we did not consider general factors for all interventions as facilitators but instead regarded them as a point related to the parents’ expectations. Pediatric tuina usually has slow effects for some chronic conditions, which is acceptable to the most. Therefore, the majority of the parents who attended the interview sessions expressed their intent to persist in using the intervention for its long-term effects. Similar to all parent-administered interventions, the implementation of pediatric tuina is inevitably time-consuming [72]. Many participants reported time management issues (e.g., they have to tend to their own business, or they have two or more children in their families, or else their children have to do homework, attend various classes, or receive physical training). However, in this project, the parents were clearly notified of the duration of intervention implementation before they signed the informed consent, and their adherence to this intervention was satisfactory. Furthermore, the intervention was implemented for 20–30 min for every other day and is thus more reasonable other parent-involved interventions. Therefore, time management was not regarded as a barrier to the implementation of this intervention.

The perceived beneficial effects on children’s sleep quality and appetite and parent–child relationships, as well as timely and professional support, mainly facilitated the implementation of parent-administered pediatric tuina. Slow improvements in children’s inattention symptoms and the possible inaccuracies of online diagnosis were the dominant barriers to the implementation of parent-administered pediatric tuina. Parents have high expectations for long-term professional support during their implementation of pediatric tuina. The online training of parents on performing pediatric tuina, especially during the Covid-19 pandemic, is feasible.