A general overview of autism spectrum disorder and its homoeopathic approach

Authors: 

1. Nisha Sehrawat. Postgraduate Trainee, Dept. of Paediatrics, National Institute of Homoeopathy, Kolkata Email: drnisha0797@gmail.com

2. Abhijit Dutta Postgraduate Trainee, Dept. of Organon of Medicine, National Institute of Homoeopathy, Kolkata Email: drabhijitdutta1@gmail.com

Abstract
ASD is a neurodevelopmental disorder in which the children exhibits multiple symptom compelx with variability but in general they seems to be preoccupied with themselves and to live in a life of their own. ASD affects not only the child but due to his behaviour whole family, Society and the Globe has to suffer. At times the whole family compromises for the child by avoiding socializing with other people. According to DSM IV it was diagnosed under PDD (Pervasive Developmental Disorder) but in DSM V, ASD is itself an independent neurodevelopmental disorder. Although ASD belongs to one of the most important medical problems because of its complexity and lesser effective treatment approach. But in Homoeopathy it is important to understand the symptomatic array, their variations and its peculiarities in order to make a proper treatment plan. Along with homoeopathy a multi-disciplinary approach is needed. Rationale of this article is to create a general idea and proper approach towards patients in the mind of the reader.

Keywords: ASD, Homoeopathy, DSM, PDD

Introduction
ASD is a neurodevelopmental disorder, the term itself is derived from greek word “autos” (self) and is an apt description for the children with this disorder for they seem to be preoccupied with themselves and to live in a life of their own.

Autism spectrum disorder is a neurodevelopmental disorder which is characterized by persistent deficits in social communication and social interaction, along with restricted, repetitive pattern of behavior, stereotypic activities. ASD (DSMV) covers a continuum of impairment, from PDD-NOS, childhood disintegrative disorder, asperger’s syndrome to the most severe presentation with autism disorder. These symptoms penetrate so deeply into their lives that ultimately hampers their overall development both socially and personally. It affects children at a very tender age of around 2-3 years that parents often miss to understand the depth of the problem. Parents do not realize that a mere absence of social smile, poor eye gaze can be of such a major problem. These children do not interact much and do not respond to when called by their names (provided hearing is normal) they treat people as objects and  when they do notice being called  they often seem to treat them as objects rather than people. They are believed to have a deficits in their “theory of mind”. Theory of mind refers to children’s understanding of their own and other’s mental state.[1] In this era of technology parents often don’t have so much of time for their kids to notice such minor details at times, which if noticed on time could have changed/ helped the child.

The incidents of ASD are increasing day by day for last two decades from 1 in 88 to 1 in 68. The current estimates from Indian population is about- Overall 1.12/100, Rural 1.10 (0.67-1.8), Urban 1.19 (0.6-2.3)[2]. 

 Since ASD are diagnosed more precisely so its incidence is increasing and vice versa. Approximately 88% of the sample had either used CAM in the past or had recently used some type of CAM.  [3]

Risk factors for ASD
Both elderly paternal and maternal age of over 50 years and 35 years respectively are found to have increased to have an autistic child. A relative risk of 1.52 is estimated.[4]  The estimated relative (sibling) risk ratio is reported to be about 150 for monozygotic twins and 8–10 for dizygotic twins and full siblings .[5] 

Obstetric complications: -including medications (antiepileptic, antithyroxine) 46% increased risk of foetus autism[6], infections (TORCH), postnatal infections such as meningitis, mumps, varicella, unknown fever and ear infections on first 30 days of life are corrected with high risk of autism.[4]

Pregnancy obesity (90kg) and excessive weight gain during pregnancy are significantly associated with the incidence of autism.[4]

Neurochemical assays like decreased urinary catecholamine, increased dopamine metabolite homovanillic acid in CSF, increased blood serotonin, oxytocin and vasopressin involved in social attachment, autoantibodies and interleukin etc., are some of the factors believed  to be the cause of AD. But, this is not sure that these are the causes or the result of autism.[7]

Earlier faulty parenting “cold” or “refridgerator mothers”[8] and vaccines (especially MMR) [9]were believed to be the cause behind ASD. But many studies have proved that there is no scientifically substantiated association between these and ASD.

Pathology
Areas of the brain responsible for higher order cognitive, language, emotional and social functions are most affected. The patches of abnormal neurons were especially  found in the frontal and temporal lobes. Reduced or atypical connectivity in frontal brain regions as well as thinning of the corpus callosum. Functional abnormality of various neurotramsmitters like serotonin. Abnormally rapid increase in the head circumference from 6-14 months of age. These are some of the pathological findings found in ASD children.

So whom we need to suspect for ASD sibling with ASD, parental concern, other care giver concern or paediatricians concern. Also to label a child with ASD various scales, questionnaire are available which can be applied/ used by a parent, teacher, physician. CARS(childhood Autism Rating Scale) [10]used to detect, diagnose and differentiate  ASD from other developmental derangements  in individuals age around 3-22years. ISAA(Indian Scale for Autism Assessment)[11]  to quantify the severity of ASD. This scale was developed using/ on the basis of CARS only. INCLEN diagnostic tool for ASD[12]  is a more simpler version of ISAA , freely available in many regional languages by National Trust of India. 

Clinical presentation along with different variants [2,7-9]
ASD is a multi-factorial disorder, no single factor alone can be said to be the cause behind the development of ASD so is the presentation of ASD, no single symptom can be said to be pathogonomic  of ASD. There is a spectrum of causation and also a spectrum of presentation.

Social and communication impairment : a child may have an impairment in social or emotional reciprocity, he may have a poor eye contact (provided vision is normal) , he may not get along with other children, not able to make friends easily, have no separation anxiety, prefers solitary games. He may have a language or non verbal communication problems like abnormal or delayed speech (about half of autistic children do not develop useful speech[7]), semantics and pragmatics are affected    in language, absence of imaginative play. Non sense rhyming. Pronoun reversal- refer to themselves by “you” and others by “I”. Deficits in empathy. Does not understand jokes, sarcasm or teasing.

Repetitive behaviour: stereotypic activities, self stimulation (hand flapping, rocking back and forth, spinning in a circle, finger ficking, head banging etc.), distorted perception- smell, taste, or touch, underdevelopment of visual and auditory processing; oversensitive to under sensitive touch. Persistent preoccupation with parts of objects- like busy with the wheel of a car toy. These children have fixed interest.

A child can present with any of these symptoms in different combination, provided have symptoms from both the domains social and communication impairment, and restrictive or repetitive behaviour. Presentation from only one domain or single symptom can have all together a different diagnosis. 

Not just these ASD may have a number of co-morbidities which may divert the case. Some of them are Intellectual disability, Hyperactivity/ Inattention, Obsessive/ compulsive symptoms, Sleep Disorders, Epilepsy, GI disturbances (GERD/ Constipation).

Homoeopathic Approach: The complexity and variants of ASD as described are very much essential to understand in each and every cases and every cases are to be considered as a new and unique one. Physicians often over diagnose ASD, so be very careful about not only clinical scoring but also the whole clinical array before diagnosing it.[16,17] Here homoeopathic concept of individualization is applicable in a very strong manner for diagnostic as well as in therapeutic sense. Keeping in mind that every child of ASD are not only sufferer but the whole society is suffering. Strictly speaking the treatment portion will be special homoeopathic approach and symptoms has to be elicited mostly in objective manner with a correct interpretation, from parent’s reporting, and rarely from child’s response which is very hard to obtain. Among the parts the behaviour of child is very much important and reliable and among the histories, the intra-uterine history has an immense value. After forming the totality by means of peculiar, relevant, intensified symptoms we should direct our treatment in proper way suitable for each case. Over reliance not to be given on only oral medications but behavioural therapy, familial therapy, proper rehabilitation training, proper nutrition and other relevant approach i.e. multidisciplinary approach has to be taken. Finally very keen follow-up is necessary for indefinite period of time[18].

General therapeutics [13,14]

BELLADONNA

• The active time is always that of violence but there is sometimes  a more passive state when the patient will sit or lie in bed and tear the bedclothing or break anything that she can get her hands on.
• The bell in the most acute state must be watched, controlled handled and sometimes tied.
• Aversion to noise and company.
• Aversion to light; better in dark.
• Great anxiety runs through the remedy.

PULSATILLA PRATENSIS

• Warm blooded.
• She is mild, gentle and tearful, yet she is remarkably irritable, not in the sense of pugnacity, but easily irritated, extremely touchy, always fells slightly or fears she will be slightly; insensible to every social influence.
• They imagine that milk is not good to drink, so they will not take it. They imagine that certain articles of diet are not good for the human race.
• He will not answer questions unless hard pressed, when all he will say is “yes” or “no” or he will merely shake his head.
• In puls patient the skin feels feverish and hot, while the temperature of the body is normal. Often he cannot wear flannels or woollen clothing because they irritate the skin, causing itching and eruptions like sulphur and this is not surprising, as pulsatilla and sulphur are antidotes.

HYOSCYAMUS NIGER

• Talks as if he was talking to himself, but he really imagines that someone is sitting by his side whome he is talking.
• Picking his fingers just as if he had something in his fingers when there is nothing there. He picks at his bed cloths the same way, picking in the air, grasping as if he were grasping at flies.
• Mutters absurd things to himself. Cries out suddenly.

STRAMONIUM

• When considering stramonium the idea of violence comes into mind.
• Full of excitement, rage, everything is tumultuous violent; face looks wild, anxious,fearful, the eyes are fixed on certainobject; face flushed hot raging fever with hot head and cold exteremities, violent delirium.
• In his anxiety he often turns away from the light, wants it dark, is aggravated especially if the light is bright.
• It is useful in mania that has existed for sometime; attacks of mania coming on in paroxysms appearing with more or less suddenness, so that a single attack would look like belladonna, but the history differentiates. Bell would hardly be more than a palliative in the first attack, and the second exhibition of it would do nothing.

ARSENICUM ALBUM

• Nervy type.
• The anxiety that is found is intermingled with fear, with impulses, with suicidal inclination, with sudden freaks and with mania.
• Averse to meeting acquaintances, because he imagines he has formerly offended them because he imagines he has formerly offended them.
• They never spend their time doing nothing.

NATRUM MURATICUM

• Consolation aggravates the state of mind- the melancholy, the tearfulness, sometimes brings on anger. She appears to bid for sympathy and is mad when it is given.
• Cries from rage rather than terror.
• Natrum mur child appears to have a definite dislike of being handled; it has a very definite dislike of being interested with or is liable to burst into tears, which is unlike the shy terrified reaction of baryta carb.
• You can stop him from crying if you are firm; if try to soothe him, it gets worse.
• Sits in the corner and watch you.
• Delayed development, slow in learning to speak.

CALCAREA CARB

• Lethargic type.
• Slow at school, slow at games.
• Sluggish mentally and physically.

BARYTA CARB

• Shy characteristics covers quite a lot of the baryta carb child.
• It is nervous to strangers; sacred of being left alone; very often it is terrified in the open fields.
• They often get night terrors without any clear idea of what the terror is; and they always have a fear of people.
• The baryta carb will sit in a corner and plays with anything within reach.
• Baryta carb children tend to be passive. They do not make friends nor play with other children.
• Children and adults alike prefer to stay home in familiar surroundings.

Among other probable medicines like Cypripedium, Kali muriaticum, kali bromatum, Zincum picrata, Zincum metallicum, Chamomilla etc.  are also important. 

Discussion
ASD children have a predilection for certain hue of symptoms at certain age, age at which that particular milestone is achieved or is considered as delayed. Most of the parents report of delayed milestones or regression of milestones. As children of age 2years or younger displays unusual preoccupation hand and finger mannerism and repetitive use of objects.  Watt et al. found that young ASD children18-24 months demonstrated significantly higher frequency and longer duration of repetitive stereotypic behaviour as compared to children with developmental delay and children with typical development. Children with age around 3years are more aloof, does not interact with others, delayed speech, echolalia etc.[15] Since there is no evidence for or against the view that early intervention affects the basic impairment underlying autism, but early diagnosis do help the parents [16]. Antenatal care including maternal folic acid supplementation intake during early pregnancy is associated with less behavioural problems in offspring at 18 months age [17], and particularly decrease the risk of autism [18]. Fatty acids consumption of different diets has an inverse effect on risk of autism [19]. Good postnatal care, maintaining good hygiene, preventing infections, spending quality time with children, deliberately changing the daily activities or removing unsuitable objects before they become an obsession [16]. Even after this they develop obsession giving simple solutions can help the whole family not just the child, for instance a child is obsessed of a big blanket then how to get rid of it, by simply cutting a piece of it daily and ultimately the blanket will vanish and the child will adapt slowly as the blanket becomes smaller day by day. Simple ABA, cognitive behavioural therapies, speech and language therapies, psychotherapies, physiotherapy are available which the patient can be advised for, depending upon the requirement of the child. Proper Homoeopathic treatment protocol should be created along with the required interventions mentioned above for each and every child suffering with ASD. 

Conclusion
Presently the need of the hour is that the parents, teachers, physicians must take the responsibility of early diagnosis of ASD. As every case of ASD is unique and individualistic so its treatment requires a customised and personalised schedule for each child individually. Homoeopathic physicians required to do tremendous workout on those cases so that the future generation and the suffering humanity will be benefitted.  

Conflict of interest – There is no conflict of interest.

Acknowledgement – None

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