doi:10.1111/jpc.

13910

ORIGINAL ARTICLE

Pilot study of acupuncture to treat anxiety in children and

adolescents
Brenda Leung,1 Wendy Takeda2 and Victoria Holec3
1
Faculty of Health Sciences, and 3Institute for Child and Youth Studies, University of Lethbridge and 2Elements Physical Therapy and Acupuncture Ltd,
Lethbridge, Alberta, Canada

Aim: This pilot study investigated the use of acupuncture in the treatment of paediatric anxiety.
Methods: Children with anxiety, aged 8–16, were randomised to either the acupuncture or waitlist control groups. Anxiety was measured using
the Hamilton Anxiety Rating Scale (HAM-A) for children and adolescents with generalised anxiety disorder and Multidimensional Anxiety Scale for
Children 2nd Edition (MASC-2) self-rated and parent-rated forms.
Results: Twenty participants were enrolled in the study and 19 completed all the questionnaires to be included in the analysis. There were no dif-
ferences in socio-demographic characteristics at baseline between the two groups. At the second assessment, the mean MASC-parent score for
the acupuncture group was significantly lower than the waitlist group (65.6 (SD 15.0) compared to 81.0 (SD 11.9), P = 0.025) with an effect size =
1.13. The pre- and post-treatment comparisons were also significantly lower for both groups in the anxiety measures. In the acupuncture group,
MASC-parent (P = 0.008, effect size 0.75) and the HAM-A (P < 0.001, effect size 1.4). In the waitlist group, MASC-self (P = 0.022; effect size 0.4),
MASC-parent (P = 0.048; effect size 0.75) and HAM-A (P = 0.007; effect size 1.21).
Conclusions: This study provided promising results on the potential use of acupuncture to treat children and adolescents with general anxiety. Future
research using an randomised control trial with a sufficient sample size to control for confounds and sham (placebo) comparators is warranted.

Key words: acupuncture; paediatric anxiety; waitlist control.

What is already known on this topic What this paper adds

1 Anxiety in children and adolescent is a growing health concern.
2 Psychotherapy has been the first-line treatment, and medication
use has increased drastically.
3 There is growing interest in the use of complementary therapies
for children’s psychiatric disorders.
1 There are potential benefits of acupuncture for paediatric
anxiety.
2 Minor side effects and no adverse events associated with acu-
puncture were reported.
3 Acupuncture was well tolerated by participants.

Anxiety disorders are the most common mental health complaint
in the paediatric population, with prevalence estimated to range
from 2.6 to 41.2%.1 Anxiety disorders in children and adoles-
cents may have a protracted course, with 46% expected to expe-
rience symptoms for at least 8 years.2 Psychotherapy, such as
cognitive behavioural therapy (CBT), is often the first line of
treatment3,4 and is shown to be moderately effective with small
to medium effect sizes.5 Clinical trials showed CBT to have clini-
cal value (i.e. markedly improvement of symptoms) for about
50% of cases.6 Other studies reported that some children do not
respond well to CBT.4,7
Medications such as anxiolytics and anti-depressants are
increasingly being prescribed for paediatric anxiety.8 Short-term
Correspondence: Dr Brenda Leung, Faculty of Health Sciences, Univer-
sity of Lethbridge, 4401 University Drive, Lethbridge, AB T1K 3M4,
Canada. Fax: +1 403 329 2668; email: brenda.leung@uleth.ca
Conflict of interest: None declared.
Accepted for publication 25 February 2018.
use of selective serotonin reuptake inhibitors have shown some
efficacy to reducing paediatric anxiety9; however, there are also
concerns regarding drastic increase in medication use in this pop-
ulation.8 For example, there is a paucity of information about:
(i) the effects of off-label use in children10; (ii) the acceptable age
for which medications should be prescribed7; and (iii) the long-
term consequences (i.e. adverse effects) on endocrine and meta-
bolic function.11 Thus, the National Institute for Health and Care
Excellent in the UK recommends that medications should not be
routinely offered to children and adolescents.7
Currently, there is a growing interest in the use of comple-
mentary health approaches among parents and families for chil-
dren.12 In fact, therapies such as acupuncture have grown in
popularity in the treatment of various childhood disorders, from
chemotherapy-induced nausea/vomiting to musculoskeletal
pain.13 Moreover, acupuncture has been found to be a safe treat-
ment for paediatric patients as a review by Jindal et al. found a
1.55 risk of (paediatric) adverse events in 100 treatments of acu-
puncture.13 Thus, the authors concluded that acupuncture posed
a low risk as a therapy for children and adolescents.

Journal of Paediatrics and Child Health (2018) 1

© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
Acupuncture and paediatric anxiety
Acupuncture has gained popularity in Western countries over
the last 40 years and has been practiced for over 3000 years in
China as an integral component of traditional Chinese medicine.
Western theories of the mechanism of action for acupuncture
include the gate-control theory or the release of neurochemicals
such as endorphins.14 For example, the effect of acupuncture in
reducing anxiety and depression symptoms may be due to the
release of substances in the CNS, mainly 5-hydroxytryptamine,
and modulation of the serotonergic system imbalance.15 The
gate-control theory posits that the perception of sensations such
as pain may be modulated by stimulating alternative nerve path-
ways, thus effectively ‘closing’ the gate on the flow of initial pain
sensation.16
Research on the use of acupuncture for anxiety has been
mainly conducted in adults.17,18 A systematic review of 10 rando-
mised control trials (RCTs) reported positive results of acupunc-
ture in the treatment of generalised anxiety disorder or anxiety
neurosis, showing improvement in anxiety symptom scores
(e.g. Clinical Global Impression (CGI) measure) compared to con-
trols.18 However, the authors also reported that disparity in qual-
ity and lack of methodological details across studies made it
difficult to interpret study findings.18 Edwards et al. argued that
well-designed, adequately powered and suitably controlled clini-
cal trials on promising complementary and integrative modalities
are needed for children and adolescents with psychiatric condi-
tions.19 The authors noted that the high prevalence of use of
these therapies by families with children with mental health dis-
orders warrants the need to explore these therapies further.19
Currently, no study has investigated the use of acupuncture
for paediatric anxiety.20 Anecdotal evidence from parents and
practitioners indicate acupuncture may be a feasible and benefi-
cial treatment for children and adolescents with anxiety. A
review by Brittner et al. reported strong evidence of the safety
and feasibility of acupuncture in children and adolescents but less
evidence for the treatment of specific conditions.20 Thus, the pur-
pose of this pilot study was to evaluate acupuncture as a potential
treatment for paediatric anxiety. That is, we hypothesised that
participants who received acupuncture would experience reduc-
tions in measures of anxiety compared to baseline and to the
waitlist control group.
Methods
This pilot study was a randomised controlled trial of children with
anxiety, aged 8–16, living in Lethbridge, Alberta, Canada and
surrounding communities. Children were included if they:
(i) presented with a chief complaint of anxiety; (ii) met the cut-
off value of 14 on the Hamilton Anxiety Rating Scale for children
and adolescents with generalised anxiety disorder (HAM-A);
(iii) were not currently receiving medication for anxiety;
(iv) were able to understand that acupuncture may involved nee-
dling, cupping and/or ear seed placements; and (v) had parents
or primary caregivers able to provide consent.
Recruits were excluded if they: (i) were taking anxiolytic or
anti-depressant medications; (ii) suffered from acute or unstable
medical conditions such as seizure disorder or severe asthma; and
(iii) had an additional axis I or axis II psychiatric disorder
(i.e. major depressive disorder, obsessive–compulsive disorder,
mental retardation, pervasive development disorder, eating
2 Journal of Paediatrics and Child Health (2018)
© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
B Leung et al.
disorder, schizophrenia), as well as attention-deficit/hyperactivity
disorder or oppositional defiant disorder, all of which require a
disorder-specific treatment21 and may interfere or obscure our
ability to interpret the results of the effect of acupuncture on anx-
iety symptoms.
Recruitment came from three sources: referral from school
counsellors, posters at the co-investigator’s (WT) clinic and
advertising for participants in the local community.
Potential participants were screened by the principal investiga-
tor, BL, over the telephone. Parents were first asked seven
screening questions related to the inclusion and exclusion criteria
(e.g. age, anxiety diagnosis, current medication or other treat-
ment for anxiety; comorbidities; ability to understand acupunc-
ture treatment). If the child met the inclusion criteria, then he or
she was screened using the HAM-A. Children with a HAM-A
score ≥ 14 were randomly assigned to the acupuncture or a wait-
list (control) group. After screening, children were asked if they
wanted to be in the study. Child participants provided oral assent,
and parents (or a primary caregiver) gave written informed con-
sent. The location for assessments and acupuncture sessions was
at the acupuncture clinic of the co-investigator (WT).
Intervention
Acupuncture was provided by WT, who explained to the partici-
pants that acupuncture involved the application of needles, suc-
tion cups (cupping) and/or herbal ear seeds (tiny pellets).
Needling involved the insertion of needles through the skin and
into the muscles. Cupping involved a clear plastic cup suctioned
to the skin, creating negative pressure that is believed to loosen
muscles, encourage blood flow and sedate the nervous system.
Ear seeds are tiny pellets pressed against the skin of selected
points in the outer ear, wrists and ankles and kept in place by a
piece of tape. Bothe cups and ear seeds involved applying pres-
sure above the dermis. A child may be given any of the three
techniques over the course of the acupuncture treatments. In
addition, a child may receive a single technique (e.g. only nee-
dles) or a combination of techniques (e.g. needles, cupping and
pellets). Acupuncture points were selected based on the princi-
ples of traditional Chinese medicine syndromes,22 Zhang fu organ
diagnosis, tenderness on palpation of Japanese Hara points,23 ten-
derness on palpation over traditional acupuncture points for anx-
iety and Mu/Shu points. The number of needles was determined
at the time of treatments and varied according to the child’s com-
fort level and response to treatments. The acupuncture applica-
tions were consistent with Workplace Hazardous Materials
Information System guidelines and clean technique standards
required by the College and Association of Acupuncturists of
Alberta. Participants received a total of five acupuncture sessions,
30 min per session, one per week for 5 weeks.
Waitlist (control) group
The waitlist control method is a practical strategy to study mental
disorders in children and adolescents.24–26 Participants in the
Waitlist group did not receive acupuncture treatments during the
first 5 weeks but were assessed in the same way as the acupunc-
ture group, at baseline and then 5 weeks later. During the
5 weeks of waiting, participants in this group were asked to
B Leung et al.
Assessed for eligibility (n = 45)
Randomised (n = 20)
Acupuncture group (n = 10)
Baseline measures taken;
received 1 session per
week for 5 weeks
Post-treatment
assessment (n = 10)
Fig. 1 Flow of participants in the study.
follow the same requirement as the acupuncture group, for
example, refrain from using medication for their anxiety. After
waiting 5 weeks, participants were given five sessions of acu-
puncture and then assessed a third time (post-treatment).
Data collection and outcome measurements
Once enrolled in the study, the child participant and their pri-
mary caregiver were scheduled to meet with the registered nurse
(RN) for the baseline assessment. After the first assessment, par-
ticipants in the acupuncture group were scheduled for five con-
secutive acupuncture sessions (one per week for 5 weeks). After
the 5 weeks of either acupuncture sessions or waitlist period, par-
ticipants were given a second assessment (post-treatment for acu-
puncture group and post-waitlist for waitlist group). Following the
second assessment (post-waitlist), waitlist participants were then
scheduled for five acupuncture sessions and were then given a
third assessment (post-treatment). See Figure 1 for the timeline of
data collection.
Journal of Paediatrics and Child Health (2018)
© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
Acupuncture and paediatric anxiety
Excluded (n = 25)
Waitlist group (n = 10)
Baseline measures taken;
received no treatment for
5 weeks.
Did not complete
assessment (n = 1)
Post-waitlist
2 assessment (n = 9)
Received acupuncture
(n = 9): 1 per week for 5
weeks
Post-treatment
assessment (n = 9)
The RN, who was blinded to the participant’s group assign-
ment, administered the measurement tools, the HAM-A, the
Multidimensional Anxiety Scale for Children 2nd Edition
(MASC-2) and the CGI, at baseline and follow-up assessments.
The RN interviewed the parent using the HAM-A, which is a
14-item questionnaire that measures both psychic anxiety (men-
tal agitation and psychological distress) and somatic anxiety
(physical complaints related to anxiety).27 Each item in the ques-
tionnaire is scored on a scale from 0 (not present) to 4 (very
severe) and summed to a total value ranging from 0 to 56. Higher
scores reflect greater anxiety. We used the Structured Interview
Guide to administer the HAM-A. The psychometric properties of
the HAM-A are: test–retest reliability = 0.89 and Cronbach’s
α = 0.82.28 A cut-off score of 14–18 is considered to be ‘moder-
ate’ anxiety29 and provided the best balance between sensitivity
and specificity (71.4 and 74.6%, respectively).28 Thus, we used a
score of 14 or above for a child to be enrolled in the study. The
MACS-2 assessed the presence of symptoms related to anxiety
disorders in youth aged 8–19 years. It is a multi-rater assessment
3
Acupuncture and paediatric anxiety B Leung et al.

with 50-item self- (MASC 2–SR) and parent (MASC 2–P) rating
forms. The MASC has a reliability of 0.89 (total score) for child Table 1 Demographic characteristics of parents and children
report and 0.90 (total score) for parent report and Cronbach’s α Waitlist, Acupuncture,
of 0.89 and 0.90, respectively.30 The CGI scale is a 7-point scale n (%) n (%)
that requires the clinician to rate the severity of the patient’s ill-
ness at the time of assessment, relative to the clinician’s past Socio-demographics
experience with patients who have the same diagnosis. The CGI Parent’s relationship to child
measured overall severity and impairment of illness from 1 (not Biological mother 9 (100) 8 (80)
ill) to 7 (extremely ill).31 The HAM-A, MASC-2 (parent and self Biological father 0 2 (20)
Parent’s marital status
versions) and the CGI were administered twice (baseline and
Married/Common-law 6 (66.6) 8 (80)
week 6) for the acupuncture group and thrice (baseline, week
Divorced/Single 3 (33.3) 2 (20)
6, and week 12) for the waitlist group (see Fig. 1).
Parent’s education level
At baseline, information on demography and background
High school or less 1 (11.1) 1 (10)
(child’s age, gender, education, weight and height; household
Technical/Professional college 3 (33.3) 1 (10)
income; number of siblings; parental marital status; medical con- University or higher 4 (44.4) 8 (80)
ditions; and current therapies used), feasibility and side effects Family’s total income, $
profile were also collected. A side effect (adverse event) profile <60 000 2 (22.2) 2 (20)
was recorded by the acupuncturist after each acupuncture ses- 60 001–80 000 4 (44.4) 2 (20)
sion, and data on feasibility were collected as part of the exit 80 001 or more 3 (33.3) 6 (60)
interview. Children’s characteristics
The research assistant contacted the participants and their pri- Child’s gender
mary caregiver after the study period (varied depending on group Female 5 (55.6) 8 (80)
assignment) and conducted exit interviews using five prepared Male 4 (44.4) 2 (20)
questions to assess for feasibility, acceptability and feedback on Child’s overall physical health
the trial. Good 5 (55.6) 2 (20)
Very good 2 (22.2) 3 (30)
Excellent 2 (22.2) 5 (50)
Child’s overall emotional health
Randomisation Poor 2 (22.2) 1 (10)
32
Simple randomisation was used to allocate subjects to the acu- Fair 2 (22.2) 3 (30)
Good 4 (44.4) 4 (40)
puncture or waitlist groups (see Fig. 1). A list of random numbers
Very good 1 (11.1) 2 (20)
for each subject in the trial was generated using the STATA-11
Child’s age, mean (SD) 10.78 (1.86) 12.40 (2.27)
programme (StataCorp LLC, College Station, TX, USA). The par-
No. of people in household, mean (SD) 4 (0.71) 4.1 (1.52)
ticipant was assigned to a group on the basis of the random num-
No. of child’s medications, mean (SD) 0.33 (0.71) 0.80 (1.32)
ber. That is, odd numbers were assigned to the control group and
No. of child’s supplements, mean (SD) 1 (1.0) 0.90 (0.88)
even numbers to the intervention group. To ensure equal num-
ber of subjects in each group, we generated equal proportions of SD, standard deviation.
odd and even numbers.

Data analysis
Data analysis was conducted by the research assistant, indepen-
dent of the PI (BL) or the co-investigator (WT). Descriptive statis-
tics of demographic characteristics and health history are
presented as frequencies and percentages, as well as means and
standard deviations or medians and interquartile ranges where
appropriate. Independent t-tests assessed group difference at
baseline and follow-up. For the acupuncture group, data were
collected at baseline and after five sessions of acupuncture (post-
treatment), while the waitlist group provided data at three time
points: baseline, after waitlist period (post-waitlist) and after acu-
puncture sessions (post-treatment). Pre- to post-treatment
changes in anxiety for each group were assessed with paired
t-tests. Analyses were performed with IBM-SPSS Statistics 22 soft-
ware (StataCorp LLC, College Station, TX, USA). All tests were
two-sided, with an alpha level = 0.05.
Ethics approval was obtained from the University of Leth-
bridge’s Human Subjects Research Committee.
Results
A total of 20 participants were enrolled, but 1 participant did not
complete all the required questionnaires, resulting in 19 partici-
pants: 10 in the treatment (acupuncture) group and 9 in the
waitlist group. No statistical significant difference in the socio-
demographic characteristics between the two groups was calcu-
lated, likely due to the small sample size (see Table 1). However,
more parents of the children in the acupuncture group had uni-
versity (or higher) education, a higher proportion earning
$80 001 or more, while the children (participants) had a higher
proportion of girls and rated their health as excellent compared
to the waitlist group. At baseline, measures of anxiety were not
different between the two groups (all P > 0.05), regardless of self,
parent or clinician rating (see Table 2). For the waitlist group, the
scores were also similar at baseline and post-waitlist on all anxi-
ety measures. While one participant did not provide post-
treatment data, all participants completed all five acupuncture
sessions, which may be an indication of the feasibility of acu-
puncture for the treatment of paediatric anxiety.

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B Leung et al. Acupuncture and paediatric anxiety

HAM-A (P < 0.001), with mean baseline assessment score being

Table 2 Measures of anxiety by group at three time points more than 10 points higher than the mean post-treatment score.
Acupuncture Waitlist P value† Furthermore, the effect size for the MASC-parent measure was
0.75 and for the HAM-A was 1.4 (see Table 3).
Mean SD Mean SD For the waitlist group, there was no difference in any of the assess-
ments at baseline and post-waitlist (5 weeks later); P > 0.05 for all
MASC self baseline 74.30 10.79 68.22 9.05 0.204
three anxiety measures. However, there were statistically significant
MASC self post-waitlist NA NA 66.56 10.36 NA
MASC self post-treatment 68.00 12.07 60.13 12.72 0.198 differences between post-waitlist assessment and post-treatment
MASC parent baseline 75.10 9.67 81.89 8.25 0.120 assessment on all anxiety measures, with post-waitlist assessment
MASC parent post-waitlist NA NA 81.00 11.89 NA being significantly higher than post-treatment assessment for the
MASC parent post-treatment 65.60 15.00 74.75 13.53 0.198 MASC for self report (P = 0.022), parent report (P = 0.048) and the
HAM-A baseline 32.40 8.04 31.44 11.71 0.837 HAM-A by clinician report (P = 0.007). Furthermore, the effect sizes
HAM-A post-waitlist NA NA 28.44 10.57 NA for the significant measures were 0.75 for the MASC-self, 0.4 for the
HAM-A post-treatment 21.30 7.72 19.75 7.01 0.665 MASC-parent and 1.21 for the HAM-A (see Table 4).

†P value from paired samples t-test. Baseline, before treatment; HAM-A,

Hamilton Anxiety Rating Scale; MASC, Multidimensional Anxiety Scale for
Children; NA, not applicable; post-waitlist, 5 weeks after waitlist;
post-treatment, after acupuncture treatment completion; SD, standard
deviation.
Acupuncture treatments
Initially, all three methods (needles, cupping, ear seeds) were
used and then altered according to the child’s response. That is,
some preferred more cupping and others more acupuncture. The
number of needles increased if the response to the treatment was
very favourable. All 19 participants received a mixed number of
the three techniques: needling, cupping and ear seeds. The aver-
age number of needles was three, cups was six, and ear seeds
was two for a child over the course of the treatment period. The
acupuncture points selected varied by child and by session; exam-
ples of points included: LI4, Du20, He7, Pe6, CV4, CV6, CV,
AB14, B15, Du4, TW5, Yin Tang, CV12, Sp6, St36, Sp20, Ki3,
Ki7, B23 and B25. Cups were placed over the stomach and/or
the back as per individual assessment. At a particular session,
over the course of the consultation, some acupuncture points
were selected to address accompanying symptoms related to the
anxiety (e.g. stomach aches/excessive fears/headaches).
Anxiety measures by group assignment
At the second assessment for each group (after 5 weeks from
baseline), there was a statistically significant difference between
the MASC-parent scores of the acupuncture group at post-
treatment assessment and waitlist group at post-waitlist assess-
ment (P = 0.025), with the waitlist group (mean = 81.0, SD =
11.9) having significantly higher scores than the acupuncture
group (mean = 65.6, SD = 15.0). Furthermore, the effect size for
the significant MASC-parent measure was 1.13 (see Table 5).
CGI pre- and post-measures
The ratings from the CGI (by the RN who was blinded to the
group assignments) were similar at baseline for the acupuncture
group (median = 5, range = 2–6) and the waitlist group
(median = 4, range 1–7) and for the second assessment for the
waitlist group (median = 4, range 2–5). However, the rating at
the post-treatment assessment for both groups were lower
(median = 2, range = 1–3). While the sample size was too small
to obtain statistical significance, there was a decrease in the score
at baseline and post-treatment assessments for both groups, indi-
cating improvement due to the intervention (data not shown).

Anxiety measures pre- and post-treatment
For the acupuncture group, there were statistically significant dif-
ferences between the mean baseline assessment and post-
treatment assessment on MASC-parent (P = 0.008) and the
Adverse events
At each subsequent acupuncture session, participants were asked
about adverse events (side effects) of the previous session. A total
of four events were reported by four different participants: one
reported feeling dizzying at one point in the session, during

Table 3 Pre- and post-anxiety measure differences for acupuncture group

Baseline Post-treatment P value† Mean difference Effect size

Cohen’s d
Mean SD Mean SD

MASC self 74.30 10.79 68.00 12.07 0.070 6.30 NA

MASC parent 75.10 9.67 65.60 15.00 0.008 9.50* 0.75
HAM-A 32.40 8.04 21.30 7.72 <0.001 11.10* 1.4

*P < 0.05 is statistically significant. †P value from paired samples t-test. Baseline, before acupuncture treatment 1; HAM-A, Hamilton Anxiety Rating Scale;
MASC, Multidimensional Anxiety Scale for Children; NA, not available; Post-treatment, after acupuncture treatment completion; SD, standard deviation.

Journal of Paediatrics and Child Health (2018) 5

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Acupuncture and paediatric anxiety B Leung et al.

Table 4 Waitlist group anxiety measure at three data collection time points

Baseline Post-waitlist Post-treatment Post-txn effect size

Mean SD Mean SD Mean SD P value† Mean difference Cohen’s d

MASC self 67.88 9.61 68.50 9.15 NA NA 0.772 −0.62 NA

MASC parent 82.25 8.75 79.88 12.18 NA NA 0.355 2.37 NA
HAM-A 33.63 10.38 30.13 9.94 NA NA 0.087 3.50 NA
MASC self NA NA 68.50 9.15 60.13 12.72 0.022* 8.37 0.75
MASC parent NA NA 79.88 12.18 74.75 13.53 0.048* 5.13 0.40
HAM-A NA NA 30.13 9.94 19.75 7.01 0.007* 10.38 1.21

*P < 0.05 is statistically significant. †P value from paired samples t-test. HAM-A, Hamilton Anxiety Rating Scale; MASC, Multidimensional Anxiety Scale
for Children; NA, not available.

needling, but it was resolved; one felt ‘hurt’ during administra-
tion of the needle, which was resolved during the session; one
reported worsening of their headache after one session in the
study; and one reported increased tiredness after one session.
Discussion
This study may be the first to evaluate the use of acupuncture in
the treatment of paediatric anxiety. Using a waitlist control
design, statistical significant difference of anxiety measures was
found between children in the intervention group and the wait-
list group, as well as at pre-treatment and post-treatment com-
parisons for both groups.
Anxiety in children has become more prevalent, as a singular
condition1 or as a common symptom of other conditions such as
autism spectrum disorder.26 While acupuncture treatment for
adult anxiety has been shown to be beneficial, the results from
this study provide initial findings that acupuncture may be bene-
ficial to children and adolescents with anxiety. Of interest is that,
despite having anxiety, some were nervous about receiving the
needles, the children were receptive to receiving the insertion of
needles in the acupuncture session. Only one participant was lost
to follow-up after the second assessment in the waitlist group. In
addition, exit interviews with parents and children indicated that
participants tolerated the acupuncture and found the sessions to
be acceptable as a therapy. Furthermore, acupuncture appeared
to be relatively safe as few adverse events were reported by the
participants. Thus, acupuncture appears to be a tolerable and
acceptable treatment for children and adolescents with anxiety.
A number of strengths were associated with this pilot study.
One strength was that the outcome measures (MASC-parent,
MASC-self and the HAM-A by RN rating) were statistically signifi-
cant, which were further strengthened by the large effect sizes for
between-group differences and pre- and post-treatment compari-
sons. Secondly, the waitlist control method allowed participants to
serve as their own controls for pre- and post-treatment compari-
son, which addressed the issue of time bias. That is, there was no
difference in the measures between first and second assessments
(i.e. the waitlist period during which no acupuncture was pro-
vided), while there was significant difference within the same
group when comparing the second assessment (i.e. post-waitlist
period with no treatment) and after the acupuncture period (post-
treatment or third assessment). A third strength of the study was
the monitoring for adverse events, where few side effects were
reported, indicating that acupuncture may be tolerated and
accepted in this age group. An additional strength of the study was
the application of individualised treatments (i.e. acupuncture
points and techniques) for each child and session. Thus, treatment
was adjusted according the child’s presentation and progress over
the duration of the treatment period to address specific concerns
of the child. As Sniezek and Siddiqui concluded in their systematic
review, studies that used standardised acupuncture points often
mitigate the utility of patient-specific treatments and, therefore,
did not translate to clinical practice.33
We also recognised the limitations associated with this study.
First, participants and their parents were not blinded to the group
assignment, which may have resulted in bias in reporting the
outcome. That is, after the acupuncture sessions, respondents
may have been more perceptive of better outcomes than when
they did not receive acupuncture. While the RN using the
HAM-A and CGI was technically blinded to group assignment,
she may have been able to perceive whether the participants

Table 5 Comparison of anxiety measures by group assignment at second time point assessment

Post-treatment Post-waitlist Between group effect size

Mean SD Mean SD P† Cohen’s d

MASC self 68.00 12.07 66.56 10.36 0.784 NA

MASC parent 65.60 15.00 81.00 11.89 0.025* 1.13
HAM-A 21.30 7.72 28.44 10.57 0.108 NA

*P < 0.05 is statistically significant. †P value from paired samples t-test. HAM-A, Hamilton Anxiety Rating Scale; MASC, Multidimensional Anxiety Scale
for Children; NA, not available.

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B Leung et al.
received acupuncture or not based on interaction with them. A
second limitation is the lack of a true control using sham or usual
(standard) care. Thus, we do not know how acupuncture com-
pares to a true control. A third limitation is the lack of physician-
based assessment and diagnosis of anxiety. While large effect
sizes were reported, and both groups showed a drop of more
than 10 points on the HAM-A, the mean HAM-A score was >14
post-treatment. The study period offered five sessions of acu-
puncture based on clinical observation of the number of sessions
to likely produce an effect and to meet budgetary availability.
There was no expectation that five sessions of acupuncture
would decrease the HAM-A score to <14. It may be that addi-
tional acupuncture sessions are needed to reduce the HAM-A
score to <14. As the mean post-treatment anxiety scores were
within the ‘moderate anxiety’ range, future research should
investigate whether acupuncture can work for children with
more severe or complex presentations of anxiety.
The results demonstrated that we met our goal to investigate
whether acupuncture would reduce symptoms of anxiety and
whether the treatments were acceptable to children in this age
group. As the children included in the study had to be medication
free and had no comorbidities, they are likely to have mild to mod-
erate anxiety. Thus, the study sample is not representative of other
children with anxiety, and the results of this study would apply to
only to those children with mild, uncomplicated anxiety. Lastly, the
sample size in this study was relatively small, which prohibited an
examination of other covariates that may confound the results.
Conclusions
This pilot study provided promising results on the potential effi-
cacy of acupuncture in children and adolescents with general
anxiety. Given the small sample size and other limitations dis-
cussed above, future research should utilise a larger RCT compar-
ing acupuncture with a sham control or standard treatment,
accompanied by clinical diagnosis of anxiety. Future research
should also consider the value of longitudinal changes in the
quality of life using patient-reported outcome measurement tools
to measure patient well-being,34 as well as quality of life mea-
sures35 that are important to the patient and take into consider-
ation the patient’s perspective.34
Acknowledgements
This study was supported by a grant from the 2015 Canadian
CAM Research Fund. The authors thank Erica Chapman, Shan-
non Tomiyama and Sabreena Lastiwka at Elements Physical
Therapy & Acupuncture Ltd, Lethbridge, AB, Canada, for all their
support and assistance in the study. The authors also thank our
assessment nurse, Laurie McCune for her work on the study.
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