Abstract
Attention deficit hyperactivity disorder (ADHD) stands as the foremost neurobehavioral disorder, ranking among the most widespread chronic health conditions impacting school aged children. It represents one of the extensively researched mental disorders in childhood. ADHD is characterized by inattentiveness, which presents as heightened distractibility and challenges in maintaining focus; deficient impulse control and diminished self-regulatory abilities; and heightened motor activity and restlessness.
Keywords– ADHD, Homoeopathy, DSM IV, ICD 10, Homeopathic medicines, Rubrics
Abbreviation– ADHD (Attention deficit hyperactivity disorder), DAMP (Deficits in attention, motor/perception), DSM (Diagnostic and Statistical Manual), ICD International Classification of Diseases)
Introduction
▪ Attention deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder which is defined by persistent and maladaptive symptoms of hyperactivity/ impulsivity and inattention.(1)
▪ People with ADHD usually have serious impairments in academic, social and interpersonal functioning in life. ADHD is also associated with other comorbid conditions such as mood disorders, disruptive behavior disorders and learning disabilities.(1)
Symptoms of ADHD may emerge as early as ages 3 to 6 and persist into adolescence and adulthood. These symptoms might be misconstrued as emotional or behavioral issues, or they may be overlooked entirely in children whose primary manifestation is inattention, resulting in delayed diagnosis. Adults with undetected ADHD might exhibit a track record of subpar academic achievement, workplace challenges, or strained interpersonal relationships.
The symptoms of ADHD have the potential to evolve as individuals grow older. In young children diagnosed with ADHD, hyperactivity and impulsivity typically take center stage. As these children progress into elementary school, inattentiveness may become increasingly prominent, leading to academic difficulties. During adolescence, hyperactivity often diminishes, with symptoms potentially shifting towards restlessness or fidgeting, although inattention and impulsivity may persist. Many adolescents grappling with ADHD also encounter challenges in forming relationships and may exhibit antisocial behaviors. In adulthood, symptoms such as inattention, restlessness, and impulsivity commonly persist.
Alternative terms for ADHD
Hyperactive (hyperkinetic) child syndrome.
Brain-injured child.
Minimal brain dysfunction
Perceptually handicapped child.
Deficits in attention, motor/perception (DAMP)
Aetiology-
∙ Hereditary
∙ The lower birth weight, the higher is the risk for ADHD-related symptoms, as well as for several additional learning and motor problems.
∙ Exposure to prenatal toxins— including alcohol and potentially, nicotine. In childhood, exposure to heavy metals or metal poisoning has been linked to symptoms associated with ADHD, along with compromised intellectual abilities. The most notable impacts may manifest in individuals with a heightened genetic predisposition.
Risk factors
∙ Males
∙ Biological factors (e.g., prenatal substance use by mothers, low birth weight, environmental toxins) are relevant for aetiology, as well. yet discordant family interactions, as well as poor fit.
∙ Educational environments – low achievement, externalizing behaviour patterns. ∙ Risk for substance use, Self-injury
∙ Special learning problems – vocational problems and lowered independence.
∙ History presents father> mother in their childhood.
∙ First degree relatives
∙ Monozygotic twins > Dizygotic twins
Types
• Predominantly Inattentive Presentation
• Predominantly Hyperactive-Impulsive Presentation
• Combined Presentation
Core Symptoms of ADHD –
INATTENTION
HYPERACTIVITY
IMPULSIVE
| Inattention | Hyperactivity-impulsivity |
| Overlook or miss details and make seemingly careless mistakes in schoolwork, at work, or during other activities | Fidget and squirm while seated |
| Have difficulty sustaining attention during play or tasks, such as conversations, lectures, or lengthy reading | Leave their seats in situations when staying seated is expected, such as in the classroom or the office |
| Not seem to listen when spoken to directly | Run, dash around, or climb at inappropriate times or, in teens and adults, often feel restless |
| Find it hard to follow through on instructions or finish schoolwork, chores, or duties in the workplace, or may start tasks but lose focus and get easily side-tracked | Be unable to play or engage in hobbies quietly |
| Have difficulty organizing tasks and activities, doing tasks in sequence, keeping materials and belongings in order, managing time, and meeting deadlines | Be constantly in motion or on the go, or act as if driven by a motor |
| Avoid tasks that require sustained mental effort, such as homework, or for teens and older adults, preparing reports, completing forms, or reviewing lengthy papers | Talk excessively |
| Lose things necessary for tasks or activities, such as school supplies, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and cell phones | Answer questions before they are fully asked, finish other people’s sentences, or speak without waiting for a turn in a conversation |
| Be easily distracted by unrelated thoughts or stimuli | Have difficulty waiting one’s turn |
| Be forgetful in daily activities, such as chores, errands, returning calls, and keeping appointments | Interrupt or intrude on others, for example in conversations, games, or activities |
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
A. Either 1 or 2
| 1. Six (or more) of the following symptoms of inattention have persisted for at least 6 months, to a degree that is maladaptive and inconsistent with developmental level: | 2. Six (or more) of the following symptoms of hyperactivity/impulsivity have persisted for at least 6 months, to a degree that is maladaptive and inconsistent with developmental level: |
| a. Often fails to give close attention to details, or makes careless mistakes in schoolwork, work or other activities | a. Often fidgets with hands or feet or squirms in seat |
| b. Often has difficulty sustaining attention in tasks or play activities | b. Often leaves seat in classroom or in other situations in which remaining seated is expected |
| c. Often does not seem to listen when spoken to directly | c. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) |
| d. Often does not follow through on instructions, and fails to finish schoolwork, chores or workplace duties (not due to oppositional behaviour or failure to understand instructions) | d. Often has difficulty playing or engaging in leisure activities quietly |
| e. Often has difficulty organizing tasks and activities | e. Is often ‘on the go’ or often acts as if ‘driven by a motor’ |
| f. Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) | f. Often talks excessively |
| g. Often loses things necessary for tasks or activities (for example, toys, school assignments, pencils, books or tools | g. Often blurts out answers before questions have been completed |
| h. Is often easily distracted by extraneous stimuli. | |
| i. Is often forgetful in daily activities. |
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 years of age
C. Some impairment from the symptoms is present in two or more settings (for example, at school/work or at home)
D. There must be clear evidence of clinically significant impairment in social, academic or occupational functioning
E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder, and are not better accounted for by another mental disorder (or example,, mood disorder, anxiety disorder, dissociative disorder or personality disorder)
Difference between DSM IV & ICD 10 diagnosis basis- image 1(5)
Differential Diagnosis
▪ Anxiety Disorder
▪ Learning Disorders
▪ Oppositional Defiant Disorder (Children)
▪ Conduct Disorder (Children)
▪ Antisocial Personality Disorder (Adults)
▪ Borderline Personality Disorder
▪ Histrionic Personality Disorder
▪ Intermittent Explosive Disorder
Management–
▪ Treatments include medication, psychotherapy, education or training, or a combination of treatments.
▪ Medication
Stimulants- The primary medication utilized for managing ADHD. Despite the seeming contradiction of treating ADHD with a stimulant, its mechanism involves boosting the levels of dopamine and norepinephrine in the brain, crucial neurotransmitters involved in cognitive functions like attention and thinking.
Non-stimulants– They may require more time to take effect compared to stimulants, they can still enhance focus, attention, and impulse control in individuals with ADHD.
▪ Psychotherapy and Psychosocial Interventions
Studies have shown Psychosocial interventions to help individuals with ADHD and their families manage symptoms and improve daily functioning.
▪ Mental health professionals can educate parents about ADHD and how it affects a family. They also help the child and his/her parents develop new skills, attitudes, and ways of relating to each other.
• Behavioral therapy, a form of psychotherapy, seeks to facilitate behavioral change in individuals. This may encompass practical support, such as organizing tasks or completing academic assignments, as well as addressing emotionally challenging situations. Additionally, behavioral therapy instructs individuals on how to: Assess their own behavior, and provide self-affirmation or incentives for exhibiting desired behaviors, like managing anger or exercising thoughtfulness before acting.
• Cognitive behavioral therapy assists individuals in cultivating awareness and acceptance of their thoughts and emotions, thereby enhancing focus and concentration. Therapists also guide individuals with ADHD in adapting to lifestyle changes associated with treatment, such as exercising caution before making decisions or refraining from unnecessary risks.
• Family and marital therapy aim to support family members and spouses in discovering constructive approaches to managing disruptive behaviors, promoting behavioral modifications, and enhancing communication with the individual.
• Parenting skills training (behavioural parent management training) equips parents with techniques to promote and reinforce positive behaviours in their children. Parents learn to implement a system of rewards and consequences to modify their child’s behaviour, provide immediate and affirmative feedback for desired behaviours, and disregard or redirect behaviours they wish to discourage.
• Specific behavioural classroom management interventions and/or academic accommodations have proven effective in managing symptoms and enhancing school performance and peer interactions among children and adolescents.
• Stress management techniques can be useful in parents by increasing the ability to deal with frustration so that they can respond calmly to their child’s behavior.
Homoeopathic Approach –
Rubrics related to adhd from Synthesis repertory and Robin murphy repertory-
• Mind – Attention Deficit Hyperactivity Disorder
• Mind – Concentration – difficult
• Mind – Confusion Of Mind
• Mind – Delusions, Imaginations, Hallucinations, Illusions
• Mind – Destructiveness
• Mind – Disobedience
• Mind – Restlessness
• Mind – Impulsive
• Mind – Hyperactive
• Mind – Absorbed
• Mind – Absent minded
• Mind – Activity – restless
• Mind – Answering – abruptly
Cross Reference rubrics -> Mind – Answering – hastily; Mind – Answering – rapidly • Mind – Ardent
• Mind – frickle
Cross Reference rubrics -> Mind – Capriciousness ; Mind – Inconstancy; Mind – Irresolution
• Mind – Overactive
∙ Mind – Memory, Weakness Of Weakness Of (See Mistakes)
∙ Mind – Gestures, Makes
∙ Mind – Forgetful (see memory)
❖ Some main therapeutic drugs –(9,10)
▪ Anac. , Bell., Carc., Hyos., Merc. , Medo., Staph., Sulph., Stram., Tarent., Tub.
Anacardium Orientale – withdrawing – hyperactive – Destructive ▪ Timidity, Bashful, Timidity appearing in public.
▪ Want of self-control.
▪ Violent anger
▪ Unfeeling hard hearted. Indifferent.
▪ Ill-natured child
▪ Obstinate and malicious.
▪ Hatred, malicious, destructive.
Belladonna – Approach – Hyperactive – Destructive
▪ Talks fast, very restless. Biting, striking, tearing mania.
▪ Excitable. Full of energy. On the move constantly.
▪ Playful
Carcinosinum – Approaching – hyperactive – Destructive/ non destructive ▪ Restless children with destructive outbursts.
▪ Disobedience, refusal of parental control. Refusal to accept any authority. ▪ Fastidious
Hyoscyamus – Approaching – Hyperactive – Destructive
▪ Behavioral problems in children.
▪ Poor control over impulses., talking, joking, throwing tantrums at inappropriate times ▪ Biting everyone who disturbs him. Desires to break things. Abusive & insulting ▪ Precocious sexual behavior.
▪ Annoying silly behavior.
▪ Jealous.
Lycopodium Clavatum –
▪ mistakes in writing, irritable, contradiction intolerance, contradiction ▪ disposition to, weeping, mild; fear of dark, ghost, disobedience, timid
▪ Makes mistakes in writing especially misplacing words and letters as of a mirror image, makes spelling mistakes.
▪ Difficult to study new lessons or do new assignments.
Medorrhinum – Withdrawing – hyperactive – destructive
▪ Behavioral problems or excessive aggression in addition to physical complaints. ▪ Violent temper tantrums.
▪ Weakness of memory. Cannot be concerned. Forgetful of names, later of words. ▪ Makes mistakes in homework because of hurry.
▪ Responsibility aversion
▪ Irritable at little things.
Mercury – Approaching / Withdrawing – hyperactive – destructive ▪ Great restlessness. Internal hurriedness with slowness in action. ▪ Hurried & rapid speech.
▪ Hurried & impulsive without thinking, or considering. ▪ Rudeness. Impolite.
Staphisgaria – Withdrawing – Hyperactive – Destructive ▪ Infrequent period of emotional outbursts.
▪ Sensitive children
▪ Ill-humored child
▪ Great aversion to authority
▪ Suppress anger. In anger throwing things.
Stramonium – Approaching / Withdrawing – Hyperactive – Destructive
∙ Violent behavior
∙ Hyperactivity
∙ Bites, kicks and full of fears
Sulphur – Approaching / Withdrawing – Hyperactive – non Destructive ▪ Spoiled children, very selfish, have no regards for others. ▪ Timidity & great tendency to be frightened.
▪ Restlessness & sleeplessness in children.
▪ Dullness
▪ Bragging. Boasting about his belongings ( his toys).
Tarentula Hispanica – Approaching – Hyperactive – Destructive ▪ constantly doing something all the time.
▪ Very restless & in motion but irregular & abrupt.
▪ Children have tremendous strength despite him being lean thin. ▪ Hurried, intense, excited and restless.
▪ Lack of control.
▪ Mischievous
▪ Cunning, manipulative and dishonest.
▪ Destructiveness of clothes. Disobedience.
▪ Sensitive to music and better by music.
Tuberculinum– Approaching / Withdrawing – Hyperactive – Destructive ▪ Mentally active & precocious
▪ Averse to all kinds of labor, esp. Mental.
▪ Restless & Dissatisfied, desire for change.
▪ Desire to wonder.
▪ Doesn’t remain long in one place.
▪ Indifferent to punishment.
▪ Sensitive & worst from music.
Discussion and Conclusion
Discussion:– This comprehensive overview covers the spectrum of ADHD, from its definition and symptoms to its management and therapeutic approaches. It highlights the challenges in diagnosis, the potential causes and risk factors, and the various types and presentations of the disorder. Additionally, it discusses the differential diagnosis and the importance of early intervention. The management section delves into medication, psychotherapy, and psychosocial interventions, emphasizing a holistic approach to treatment. Finally, it explores a homoeopathic perspective, detailing therapeutic drugs and their corresponding symptoms.
Conclusion:- ADHD is a multifaceted neurobehavioral disorder that significantly impacts academic, social, and interpersonal aspects of life. It can arise in early childhood and persist into adulthood, with symptoms evolving over time. Genetic factors, prenatal exposure to toxins, and environmental influences contribute to its development, while various risk factors heighten susceptibility. Accurate diagnosis is crucial due to symptom overlap with other conditions. Management requires a comprehensive approach, including medication, psychotherapy, and psychosocial interventions. Homoeopathic remedies provide additional therapeutic options. Overall, a thorough understanding and holistic approach to addressing ADHD are vital for effective treatment and enhancing the quality of life for individuals affected by the disorder.
Reference
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About Authors
Dr. Ashok Yadav, Professor, Department of Practice of Medicine, Dr. M.P.K. Homoeopathic Medical College, Hospital & Research Centre, Homoeopathy University, Jaipur, Rajasthan, India
Dr. Virendra Chauhan, Associate Professor, Department of Practice of Medicine, Dr. M.P.K. Homoeopathic Medical College, Hospital & Research Centre, Homoeopathy University, Jaipur, Rajasthan, India
Dr. Mansi Saini, MD scholar, Department of Practice of Medicine, Dr. M.P.K. Homoeopathic Medical College, Hospital & Research Centre, Homoeopathy University, Jaipur, Rajasthan, India
Dr. Yashaswi Choudhary, MD scholar, Department of Practice of Medicine, Dr. M.P.K. Homoeopathic Medical College, Hospital & Research Centre, Homoeopathy University, Jaipur, Rajasthan, India
Dr. Kumkum Sharma, MD scholar, Department of Practice of Medicine, Dr. M.P.K. Homoeopathic Medical College, Hospital & Research Centre, Homoeopathy University, Jaipur, Rajasthan, India
