A Case of ADHD with Specific Learning Disability treated with Homoeopathy

Dr Al Saba R

ABSTRACT
Attention Deficit Hyperactivity Disorder (ADHD) is characterized by developmentally inappropriate motor hyperactivity, inattention and impulsiveness leading to impairment at home and school.¹ Homoeopathy has a holistic approach to disease that is individualisation of each patient, where the child is treated as a whole considering the constitution, susceptibility, physical as well as mental symptoms. A male child aged 6 years presented with the complaints restlessness since 3years and makes mistakes while writing since 2years. Homoeopathic medicine Tarentula hispanica was selected and administered on the basis of Individualised case analysis. It shows a positive effect in the treatment of ADHD.

KEYWORDS: Attention deficit hyperactivity disorder, Specific learning disability, Tarentula Hispanica , Homoeopathy

INTRODUCTION:

Attention Deficit Hyperactivity Disorder (ADHD) is characterized by developmentally inappropriate motor hyperactivity, inattention and impulsiveness leading to impairment at home and school.¹

The American Psychiatric Association estimated that 5% of children have ADHD with lower prevalence in adults. From the Nationally representative data of Children and Adolescents in the United States, there is apparent increase in ADHD diagnosis in two decades from 6.1% in 1997-1998 to 10.2% in 2015-2016.²

This closed environment during the pandemic , inside a house with tight and forcible schedule, which is restricting the children had brought a great increase in cases of ADHD.³

ADHD can negatively affect many important aspects of life, academically to underachieve or fail in school, socially they have poor relationship with peers, teachers and parents, emotionally they often have poor self-esteem and are considerable increased risk for depression, anxiety or delinquent behaviour.⁴

As per global health report worldwide studies report prevalence of ADHD in children between 3-9%.ADHD affects both the genders with male female ratio of 3:1.Prevalance of ADHD in India vary from 5-15% with male female ratio being 3-6.4:1.¹ The prevalence of ADHD in individuals aged between 6-12years in Bengaluru was 2.3%.⁵

 A Comparative Case Series studies of 20 children with a diagnosis of  ADHD receiving Homoeopathic treatment, compared with 10 children receiving usual treatment suggest that Homoeopathy showed improvement in 3/4^th of the cases and may offer safe, effective adjunctive treatment which improves wider outcomes without side effects or alternative treatment for children who do not respond or respond adversely to conventional medications.⁶

In a study done by H Frie and A Thurneysen on Treatment of Hyperactive children: Homoeopathy and Methylphenidate compared in a family settings, children aged 3-17years conforming to the DSM-IV Criteria for ADHD with Conner’s Rating Scale score more than 70,were taken up. After an average of 3.5months treatment time,75% responded to Homoeopathy with amelioration in Conner’s Rating Scale score,22% children needed Methylphinidate,3% not responded to both.⁷

 ADHD , during the Pandemic situation children were at home due to lockdown and were not allowed out even for some time as schools, play centres, parks were all closed, loss of social and physical activities, including online class introduction. This closed environment inside a house with tight and forcible schedule, which was restricting the children had brought a great increase in cases of ADHD.³

DIAGNOSTIC CRITERIA:^1,4

The Diagnostic and Statistical Manual of Mental Disorders 5(DSM-V) criteria for diagnosis of ADHD¹¹ are as follows.

A)According to the DSM-V, a person with Attention Deficit/Hyperactivity Disorder must have either (1)and/or (2):

1)Six (or more) of the following symptoms of Inattention have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Inattention^1,4

(a) often fails to give close attention to details or makes careless mistakes in school work, or other activities

(b)often has difficulty sustaining attention in tasks or play activities

(c)often does not seem to listen when spoken to directly

(d)often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions)

(e)often has difficulty organizing tasks and activities

(f)often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

(g)often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

(h)is often easily distracted by extraneous stimuli

(i)is often forgetful in daily activities

(2)Six (or more) of the following symptoms of Hyperactivity-impulsivity have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Hyperactivity ^1,4

(a)often fidgets with hands or feet or squirms in seat

(b)often leaves seat in classroom or in other situations in which remaining seated is expected

(c)often runs about or climbs excessively in situations in which it is inappropriate

(in adolescents or adults, may be limited to subjective feelings or restlessness)

(d)often has difficulty playing or engaging in leisure activities quietly

(e)is often “on the go” or often acts as if “driven by a motor”

(f)often talks excessively

(g)often blurts out answers before questions have been completed

(h)often has difficulty awaiting turn

(i)often interrupts or intrudes on others (e.g., butts into conversations or games)

1. Several hyperactive-impulsive or inattentive symptoms were present before age 12 years.
2. Several hyperactive-impulsive or inattentive symptoms are present in two or more settings (e.g., at school [or work] and at home).
3. There must be clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
4. The symptoms do not occur exclusively during the course of Schizophrenia,  and are not  better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative  Disorder).¹¹

COMORBIDITIES ¹:

1. Opposition Defiant Disorder
2. Conduct Disorder
3. Specific Learning Disabilities

SPECIFIC LEARNING DISORDER ⁸ :

• Also known as Learning Disorder denotes “ disorder in one or more of the basic processes involved in understanding or in using language (spoken or written ) that may manifest itself in an imperfect ability to listen , speak , read , write and spell or to do arithmetic calculations’’
• In other words , this is a disorder that interferes with child’s ability to store , process or reproduce information.
• These disabilities usually occur in combinations
• Reading disorder (Dyslexia ) – responsible for 4/5^th cases of Learning disabilities
• Disorder of written expression (Dysgraphia)
• Mathematical disorder ( Dyscalculia)

“The celebrities Edison, Einstien and Leonardo da vinci reportedly suffered from Dyslexia and yet made it ‘big’ in their fields” ⁽⁸⁾

CASE REPORT:

A male patient aged 6years presented to the OPD of Government Homoeopathic medical college and Hospital, Bengaluru on 05/05/2022 with complaints of –

1). C/o restlessness since 3 years

2).  C/o makes mistake while writing since 2 years

HISTORY OF PRESENTING COMPLAINTS :

• According to mother
• The boy is very restless+++ , he does not sit in one place, always wants to move about from one place to other
• Doesn’t obey the instructions given by the mother .
• He is always on the go, He will never wait for his turn because of which he faces problems both at school and at play.
• He doesn’t wait until food is served, he starts banging the table with the spoon or hand
• It is very difficult to get him to go to sleep at night, he stays wide awake and wants to play at least till 12am
• Mother tries to tell stories to him to put him to sleep, but he doesn’t concentrate and speaks his own things
• When he finally fall asleep, he kicks off his blanket
• He started schooling at the age of 4years, when it was noticed that he is having difficulty in learning to write few alphabets +. They noticed that he is having  difficulty in writing
• Restlessness is noticed by the teachers and he used to run here and there in class.
• They started getting complaints  from school, that he uses abusive words, misbehave with others.
• He is unable to finish his daily routine activities
• He keeps misplacing his belongings
• He mimics his teachers in class, does not obey the teachers

NEGATIVE HISTORY :

• No history of head injury
• No history of fever
• No h/o prematurity
• No history of self injury
• No history of stereotyped movements
• No history of alcohol consumption in mother
• No hearing difficulty, no vision problem

PAST HISTORY:

• Patient was on medication for the above complaints from NIMHANS since 30months
• Treatment history:
• Tablet Methylphenidate 5 mg 1-0-0
• Allergic history:
• Not allergic to dust/diet/drug
• Surgical history : Nill

FAMILY HISTORY :

No h/o Psychiatric/ Behavioral disorder in family

SL NO	Relationship	Status	Healthy /  Diseased
1. 2. 3. 4. 5. 6. 7.	Father Mother Paternal grand father Paternal grand mother Maternal grand father Maternal grand mother Maternal uncle	Alive Alive Alive Died Alive Alive Alive	Apparently healthy Apparently healthy DM & HTN Old age Apparently healthy DM Apparently healthy

BIRTH AND DEVELOPMENT HISTORY:

• Non consanguineous marriage.
• PRENATAL : was a planned and wanted pregnancy
• Mother – ANC (3)  was done regularly
• All three trimesters – uneventful ( No h/o any infectious disease)
• No h/o anemia, hypothyroidism, HTN/DM, alcohol/drug use during pregnancy
• NATAL : Full term baby, LSCS( due to Breech presentation)
• Birth weight – 3.4 kg
• Cried soon after birth.
• No neonatal complication
• POSTNATAL : no congenital defects
• No h/o jaundice ,fever
• FEEDING HISTORY:
• Breast fed for 2 years, complementary food by the age of 6months
• Current diet: home made food
• Vaccination:
• done up to date, no post vaccination complications

MILESTONES :

• Gross motor :
• Neck holding- 3months
• Siting without support- 8months
• Walking without support – 13months
• Running – 2years
• Climbing – 2 years

Fine motor :

• Grasping – 4months
• Palmar grasp – 7months
• Pincer grasp – 12months

Social/ adaptive –

• Social smile – 2months
• Recognition of mother – 3months
• Smiling at mirror image – 6months
• Waving bye bye – 9months
• Plays simple ball game – 12 months
• Knowing name and gender – 3 years

Language –

• Cooing – 3months
• Monosyllable – 6months
• Bisyllable – 12 months
• Telling story – 4years

    MOTHERS OBSTETRICAL HISTORY:

• G1 P1 L1 A0
• Mother’s age during pregnancy -27 years
• Mother was stressed during her pregnancy due to heavy work load, where she was complied to meet the target set by the manager
• As her pregnancy approached towards term, she was worried whether the manager will approve her maternity leave.
• At 8^th month of her pregnancy she was granted leave for about 2 months, at that time she felt a relief
• Even at home, she stays only with her husband, so was worried as of who will take care of her.

   PERSONAL HISTORY:

• Diet :  Mixed
• Appetite : Adequate
• Thirst : Thirsty, 2-3litres/day
• Craving : Nothing specific
• Aversion: Nothing specific
• Bowel: Regular, once a day
• Bladder :4-5/day, 1/night .
• Sleep: Restless during sleep
• Dreams : Nothing specific
• Perspiration : On exertion over forehead
• Thermals: Towards hot ( season tolerable- winter, covering- not required, fanning- required)

LIFE SPACE INVESTIGATION :

• Child belongs to nuclear,  middle  class family. Born and brought up in Bengaluru. He  is    a single child, no siblings. Father and mother are software engineers. Relation with father and son is good , even father and mother relation is good
• Was very active child from his birth, playing cheerfully
• At age nearing 3 years, the activity that was since infancy was increased
• His toddler phase was uneventful
• He was fond of music always watching dancing videos on TV
• According to  mother  he is  very  obstinate, irritable gets  angry    As age progressed his complaints were getting worse.
• At age 5year, once there was a fight between mother and grand mother, by seeing his mother in trouble he got angry on grand mother and shouted at her.
• After that incident Mother noticed He became revengeful with friends.
• When there  is  a  need  he will  behave  nicely  to  that person.
• At play in a park always running about , cannot wait for his turn to on the slide or any other game , hitting his play mates
• When he is taken out for a mall, he always goes jumping, leaving mothers hand.

  SCHOOL HISTORY:

• Age of starting school : 4years
• Current Education level : 1^st std
• Attended mainstream school
• Regularity to school: Regular
• Adjustment in school: with Peers- poor, with Teachers – average
• Interest in studies: Absent
• Academic performance: Average
• Can do simple maths problems
• Can speak and read well
• Any change in performance in the school: Same since LKG
• Participation in school activity: No
• At school, Teacher complaints to the mother that he will never remain in his seat in the class, moves about from one bench to other bench. Does not write the alphabet properly, makes mistakes while noting down from the board.

GENERAL PHYSICAL EXAMINATION :

• Height : 120cms
• Weight: 25kgs
• BMI: 19.2kg/m2
• Moderately built and nourished.
• No signs of pallor , cyanosis, clubbing , lymphadenopathy
• Scalp : Healthy, no hair discoloration
• Eyes : Sclera – No icterus, Conjunctiva – Pink
• Ears : No discharge
• Nose: No DNS/ Nasal polyp/ discharge
• Lips : Pink
• Teeth: No caries
• Tongue : Clean
• Mouth: Hygienic
• Tonsils : No enlargement/inflammation/congestion
• Nails : No clubbing

VITALS :

• Temperature : Afebrile at the time of examination
• Pulse rate: 74beats/ min
• Respiratory rate : 14cycles/ min

SYSTEMIC EXAMINATION:

• Respiratory system: Normal vesicular breath sounds heard, no added sounds
• Gastrointestinal system: no distention, no organomegaly or tenderness, tympanic note heard with normal bowel sounds
• Cardiovascular system: S1 S2 heard, no murmur
• Central nervous system: Consious , oriented, alert

EXAMINATION:

BEHAVIOUR:

• Is the child interested in surroundings? Yes
• Is he/she able to make eye contact? Yes
• Is he/ she able to cooperate with the interviewer? No
• Is he/she able to stick with a particular activity? No
• Motor activity: hyper
• Any unusual movements? No
• Attention span :
• Is the child easily distracted to extraneous stimuli ? Yes
• Is the child able to sustain his/her attention while being interrogated? No

OUTCOME ANALYSIS: 

• Was done by using CORNER’S PARENT RATING SCALE revised (CPRS-R)

Parameters used: Conner’s Parent Rating Scale– Revised (CPRS-R)

• Recovered-Disappearance of symptoms and no subsequent attacks within the study period and CPRS score <60 will be considered as recovered.
• Improved- Frequency, duration and intensity reduced moderately with CPRS: T-score within 60-70 will be considered as improve.
• Not improved- No relief of complaints even after treatment within the study period and CPRS T-score>70 will be considered as not improved.

ANALYSIS OF SYMPTOMS:

Common	Uncommon
Restlessness	Irritability Anger Cunning Obstinate Revengeful Desire for music Makes mistakes while writing Thirsty Hot patient

EVALUATION OF SYMPTOMS :

MENTALS	PHYSICALS	PARTICULARS
Irritable Obstinate Angry Cunning Revengeful Desire for music Restlessness Makes mistakes while writing	Chilly  patient Thirsty Restlessness

CLINICAL DIAGNOSIS:
Attention deficit hyperactivity disorder with Specific learning disability (Dysgraphia)

OUTCOME ANALYSIS :
It was done using Conner’s Parent Rating Scale – Revised for ADHD. Before treatment score and after treatment score was considered

Before treatment score : 72

REPERTORIAL ANALYSIS : The following symptoms were taken for Repertorization  : anger, cunning, irritability, making mistakes while writing, desire for music, obstinate, revengeful, restlessness, thirsty, Chilly patient, restlessness

BASIS OF PRESCRIPTION : Repertorial result shows that the Tarentula 22/9 was covering 9 symptoms with marks 22 i.e 22/9 ,  China 16/9 was covering 9 symptoms with marks 16, Nux vomica 19/8 was covering 8 symptoms with marks 19, Lycopodium 18/8 was covering 8 symptoms with marks 18, Anacardium 16/8 was covering 8 symptoms with marks 16  . Based on the reportorial result the remedy selected was Tarentula hispanica

FIRST PRESCRIPTION :

Tarentula hispanica 1M/1 dose and PL for 1 month

Advice : Reinforcing Posivitive behavior and punishing negative one.

FOLLOW UP OF THE CASE :  20/05/2022

CPRS-R score : 68

Hand writing same ++

Generals : good

PRESCRIPTION : PL /tid for 15 days

2^nd FOLLOW UP: 05/06/2022

CPRS-R score : 67

Writes slightly clear

PRESCIRPTION : PL / tid for 15days

3^RD FOLLOW UP: 05/07/2022

• CPRS-R score : 62
• Hand writing slightly improved with school performance also
• Prescription: PL -30 days

4^th FOLLOW UP : 08/08/2022

• CPRS -R score : 59
• Much improvement in academics and hand writing
• Stoped taking allopathic medicine ( T. Methylphenidate )
• PL- 30days

RESULT AND DISCUSSION :
After first prescription, there was improvement in CPRS-R score from 72 to 68 in the first month of treatment itself . In the beginning of 2^nd month Child was able to write slightly better as shown in figure 4 (05/06/2022) and the CPRS-R score was  67.  In the next  follow up Hand writing was much improved as shown in figure 5 (05/07/2022) and CPRS -R  score was 62. In the next visit Hand writing was much better and clear as shown in figure 6 (08/08/2022) and CPRS-R score was 59 and even stopped the Allopathic medications. Child was followed up for nearly one year, there was no history of any recurrence of the complaints after the treatment. On 23/04/2023, mother reported the child is doing much better in school (Academic progress report from School  – Figure 7) and at home and is no more on allopathic medications.

CONCLUSION :  ADHD and it comorbid conditions can be successfully treated with Homoeopathic medicines based on detailed case analysis.

DECLARATION OF PARENTS AND CONSENT :
Parents consent was taken for images and clinical information to be reported for this article.

BIBLIOGRAPHY :

1. Gupta P, Menon P, Ramji S, Lodha R. PG Textbook of Pediatrics. 3rd ed. Delhi: Jaypee Brothers, Medical Publishers Pvt. Ltd.; 2022
2. Cabral I Demma Maria, Liu Stephanie, SoaresNeelkamal., Attention deficit hyperactivity disorder: diagnostic criteria ,epidemiology, risk factors and evaluation in youth. TranslPediatr 2020,p1 Available on : https://pubmed.ncbi.nlm.nih.gov/32206588/
3. Reddy, D., 2021. ADHD during COVID-19 and homoeopathic management. International Journal of Homoeopathic Sciences, 5(1), p.433-4 Available on:https://www.homoeopathicjournal.com/articles/349/5-1-59-212.pdf
4. Schor. St Geme. Stanton. Kliegman Nelson’s textbook of paediatrics. Volume 1,.1^st South Asia edition, Thomson Press India Ltd.published in 2016; p200-201.
5. Joseph, J. and Devu, B., 2019. Prevalance of Attention deficit hyperactivity disorder in India:A systematic review and meta-analysis. Indian journal of Psychiatric nursing, 16(2), p.119.Available on:https://www.ijpn.in/article.asp?issn=2231-1505;year=2019;volume=16;issue=2;spage=118;epage=125;aulast=Joseph;type=0
6. Fibert, P., Relton , C., Heirs, M. and Bowden, D., 2015. A comparative consecutive case series of 20 children with ADHD receiving homeopathic treatment for one year, compared with 10 children receiving usual treatment. European Journal of Integrative Medicine, 7(6), p.691-692.Available on: https://pubmed.ncbi.nlm.nih.gov/27211327/
7. Frei, H. and Thurneysen, A., 2001. Treatment for hyperactive children: homeopathy and methylphenidate compared in a family setting. British Homeopathic Journal, [online] 90(04), p.183-188. Available at: https://pubmed.ncbi.nlm.nih.gov/11680802/
8. Gupte S : Short textbook of Pediatrics . 12^th ed. JAYPEE Brothers Medical P ; 2019

DR AL  SABA R
MD Part 2 Paediatrics
Government  Homoeopathic Medical college & Hospital , Bengaluru – 560079
Email : sabakarobari786@gmail.com

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