A.D.H.S. Anhang 6

 

[Georg Soldner, H. Michael Stellmann]

Attention Deficit Disorder with and without Hyperactivity

Abstract:

The terms “attention disorder” and “hyperactivity” are applicable not only to certain children but also to the social context of Western industrialized societies. 

Individual behavior problems are coupled with individual gifts and creative potentials—a fact which must not be overlooked in diagnosis or treatment. 

The article provides a differentiated discussion of the therapeutic options offered by anthroposophical medicine and homeopathy in general and of their remedies in

particular. These offer an effective curatively-oriented alternative to the use of stimulants (e.g. Ritalin), which are of dubious clinical value as they are purely symptomatic.

Keywords:

Attention deficit disorder

Hyperactivity

ADHD

ADD

Anthroposophical medicine

Rhythmic system

Anthroposophical remedies

Therapeutic eurythmy

Homeopathy

Craniosacral therapy

Stimulants

 

[H. Köhler]

We make a thorough, highly detailed biographical anamnesis and family anamnesis and from the start we place particular emphasis on describing not just the weaknesses,

but also -in fact, primarily- the strengths of the child.

What is an attention disorder?  The English term "Attention Deficit Hyperactivity Disorder" (ADHD) has supplanted the term "hyperkinetic disorder". 

Its leading symptoms are:

• inattention and increased distractibility (= ADD),

• impulsivity, with poor inhibition capacity in the mental and behavioral spheres, and also (optionally) 

• intense urge to move: motor hyperactivity (= ADHD)

The nature of the disorder from which these children suffer is expressed more clearly by the English language than it is in German:  "These symptoms" (see above)  " are pervasive and interfere with the individual’s ability to function under normal circumstances".  "Pervasive" indicates a behavioral disorder that is “dominant” and manifests

in different situations. “Normal circumstances” refers to “settings” typical of societies with a “Western life style”_family (nuclear), kindergarden and school. What it means

to “function” in circumstances that adults would consider “normal” today is clearly expressed by child psychiatrists Schmidt, Meusers and Momsen in their work on ADHD: “The hyperkinetic disorder is primarily a disorder of impulse control. Before carrying out an action, we all normally consider if it sensible, appropriate or right, while these patients” (referring to children) ”have the problem that the will shoots through before reflection and leads to an action that may later be regretted or lead to an unpleasant result”.

What is presented here as the “normal” relationship of thinking to acting reflects exactly the reigning paradigm of thought and behavior in technologically advanced Western societies. However it fails to take into account the evolution of a child’s consciousness and action. It also fails to acknowledge the existence of an artistic, creative type of thinking characterized by an intense openness to everything that is new and arises in the moment. As artists or inventors, human beings can free themselves from the calculated certainty of rationally determined action (theirs could rightly be called a “risk-taking” style of thinking and behavior).

It must be pointed out, however, that the leisure-time and parenting behavior of adults tends not to fit the criteria posited above. One need only think of adult behavior in regard to food, alcohol and tobacco. What is more, it has been proven that parents’ consumption of alcohol and nicotine during pregnancy promotes the very symptoms which medicine then diagnoses as ADHD in their children. There is much evidence that “partner conflict, psychological disturbance in the parents, parenting deficits and disorders in the parent-child relationship” strongly influence and may impair children’s attention, impulse control and movement behavior. The behavior modeled here seldom bears much relation to the paradigm of planned or considered action!

In fact it is technology learning to drive safely, having an occupation in a technologically based modern society, that educates the adult towards a behavioral style with:

• focused attention (shutting out the surroundings as a whole   in favor of exact, primarily visual attention to selected events)

• planful action directed towards a future result

• relinquishing one’s own physical activity, suppression of one’s own movement needs in favor of intellectual control by way of by machines

The same is true of the economic necessities connected with technology. Moreover, the style set by them penetrates into the upbringing and education of our children, into

our approach to dealing with patients and thus also into the way hyperactive children are dealt with: Medical, pedagogical and social norms take on the value of technical norms and are implemented as a form of “management” or “self-management.” The ability “to function under normal circumstances” is thus an historically relative criterion.

In this connection Schmidt, Meusers and Momsen cite a remarkable prognosis made by R.S. in 1920, the year of the inauguration of anthroposophical medicine: “...

The human being is not just an intellect, after all; he has something else in his being: He has sensations, he has feelings, and these have to come to terms with what comes

from the technological devices, from machines. And another feeling arises than what I spoke of before. I spoke of a feeling of longing arising out of deepest deprivation.

What is gathered by the soul in the unconscious from its encounter with technology ... rises up as a reaction; it enters consciousness in the form of thoughts and ideas, but

it comes up as something similar to fear. And in their longing out of deepest deprivation, the children we will have in school in the coming years and decades will begin to manifest an indefinite but very real fear of life, which will express itself in anxiety. It will express itself in fidgetiness, in nervousness—I mean this tangibility”.

This makes clear that the change in consciousness evoked by technology can also be experienced on the soul level as alienation from life, as imprisonment in an outwardly imposed set of circumstances, as loss of the experience of one's own presence and capacity for spontaneity. The question is, can the parents, teachers and doctors of these children recognize and consider this aspect, which is the “flip side” of the disturbing ADHD symptoms: the fear of losing one’s creative potential. In fact, under different circumstances the style of perception, impulsivity and driven motor activity that is labeled as ADHD today could even represent advantageous behavior (typical of the “hunter” of pre-industrial societies), and many creative personalities _in Western societies too_display traits of ADHD.

 

Thus, curative educator Henning Köhler juxtaposes negative aspects to the positive ones in the following table:

1. Compulsive drivenness                                       1. Dexterity in movement (“kinesthetic intelligence”) in many cases

            2. Distractibility                                                       2.“Boundless” interest in the world

3. Short attention span                                           3. “Panoramic view”: quick grasp and great intensity of attention during this short span

4. Poor listening ability;                                 4. Dominantly visual, frontally-oriented perceptual style

deficient auditory processing             

and relation to back-space

            5. Impulsiveness                                               5. Great flexibility and openness to what is new

6. Urge to assume  leadership                         6. Longing for trustworthy authority; genuine leadership qualities in some cases over peers  and adults                   

 

A personality that exemplifies these paired qualities well is that of Winston Churchill. Son of a “suspected-ADHD” father who devoted almost no time or attention to his son, as a schoolboy Churchill showed every sign of an attention disorder. He made progress only when motivated by a personal interest. Throughout his life what gave him most energy were military confrontations.

In 1940, after an already turbulent political career he led Great Britain through what seemed an irrational and hopeless confrontation with Germany, letting not even national bankrupcy stop him (which all previous “normally functioning” British politicians wished to avoid). Churchill, who had the longest and most successful political career in the history of Great Britain, was awarded the Nobel prize in literature for his powerful literary achievements and was also quite active artistically as a painter.

Another example is the successful inventor Thomas Alva Edison, who received more than 1,000 patents and was always working on several inventions at once.

He saw sleep as a waste of time and permanently revolutionized the life and sleeping habits of his contemporaries and future generations with his invention of the light bulb.

A total failure at school, at the age 12 he left home and got by for a time working odd jobs. How would he be diagnosed and treated in our times? Who would recognize and promote the talent in this “difficult boy”?

In literature, Astrid Lindgren created a figure, Michel of Lönneberga, who casts light on many facets of ADHD: his trying qualities, the suffering as well as the deep understanding of his parents, the lack of understanding of his fellow townsmen who want to buy him a one-way ticket to America (his mother throws all the money they collected out of the window), and finally his path to becoming chairman of the town council…

In view of these facts, we must object to the definition set down by well-known ADHD expert C. Neuhaus: “The moment abnormal behavior ceases to have positive repercussions and becomes a source of constant trouble for the individual, it is not creativity but a disorder”. Since the days of the Pharisees we have been aware that

getting into “constant trouble” is not just the fault of those who allegedly cause it, but equally that of those in positions of societal responsibility who react negatively

to abnormal behavior, seeing the mote in the other’s eye but not the beam in their own. Hence in composing the definition of ADHD, the authority who defines what is

normal must also be scrutinized. The reason this dimension goes unmentioned in much of the scientific medical literature is that medical training today is dominated by

the scientific paradigm. Yet there is no “normal value” that conclusively separates ADHD as a disorder or disease from the all the possible healthy paths of development

in children. The diagnosis, rather, is based preponderantly on an act of understanding of child behavior. This is underscored by the fact that there is no scientific test for

a diagnosis of ADHD. The German pediatric guidelines make this perfectly clear: "The diagnosis is to be derived from the patient’s life story". Even questionnaires have

a very relative value; and over extensive psychological testing, the guidelines give priority to making "a rough evaluation of the child's intellectual capacity and attentional behavior in school based on teacher's evaluations and grades. Examination of school bag and notebooks (orderliness, completeness, handwriting, organization) will provide

an indication of disorders of visuomotor coordination (writing), attention (careless errors) and weakness in reading and spelling." It becomes clear that what is being measured by these criteria is the child's adaptation to conditions in the modern nuclear family, the modern kindergarten (25 children, noise level around 85 dB) and the achievement expectations of modern education; to apply the term "disorder" here is to move quite far from the concept of pathology as applied to a case of meningitis, oligophrenia or

even a psychotic illness.

It is noteworthy that the diagnosis of ADHD is preponderantly applied to boys. The ratio of boys to girls varies between 3 : 1 and 9 : 1 (4, 12, 13)! For ADD without hyperactivity a ratio of 2 : 1 is assumed, although without hyperactivity "the validity of the ADD type is problematic" (Steinhausen), i.e. the dividing line from "normal"

can "no longer be validly distinguished." On the other hand, ADHD is considered to be genetically based to a high degree (a number of recent studies put the inheritance

rate at approx. 80%), yet the twin studies on which these results are based show no "boy-preference" (cf. 14)! The genetic aspect is assumed to act pathogenetically chiefly through a disturbance in dopamine metabolism (as yet unproven) as well as other possible neurotransmitter disorders in the brain, thus causing the abnormalities in these children. This thesis is equally incapable of explaining the sex difference in rate of affection.

Thus regarding the asymmetrical distribution of ADDH between boys and girls there is an obvious contradiction between the scientifically measurable aspects (genetics and neurobiology) on the one hand and phenomenological observation (pedagogical and clinical) on the other. Historically, the development of technology, the industrialization

of the workplace and the associated social changes have been enormously significant. On an historical and social background, some of the crucial traits of the growing-up experience in societies with a Western lifestyle today are that:

• modern media have dramatically affected family life, sharply reducing children’s mobility, the alternation of speaking and listening, collective play and family rituals (e.g. meals).

• the great majority of girls and boys are brought up by women (mothers, kindergarden teachers and most elementary school teachers).

• children generally experience their fathers only during leisure time or -if parents are separated- every other weekend at visiting time, or not at all.

• it is increasingly rare for children to experience their own movement as a meaningful necessity due to the mechanization of household and transportation.

• significantly, boys seldom experience “typically male” movement patterns -e.g. activities requiring physical strength and endurance- and when they do these are usually optional athletic activities, not ordered work with social significance and value.

• places of freedom (e.g. settings in nature) where children can experience their own movement, impulses and alternating attention, are increasingly disappearing.

An appeal is made here to the pediatric world, in a smuch as it is dedicated to serving the individual: Explain to all those in a position of responsibility—parents, teachers, politicians and those active in disease prevention—how the framework of children’s lives can be transformed so that problems such as ADHD lose their present pervasiveness and urgency.

In this connection, Henning Köhler’s book War Michel aus Lönneberga? (Was Michael from Lönneberga?) offers a great many concrete and practical suggestions that not

only help to successfully “manage” ADD as an adaptive strategy (cf. 15, 16), but also take seriously the special capacities and strengths of the affected children and turn them in a productive direction.

 

1 Diagnostic Aspects

Anamnesis

All authors are in agreement that a thorough and undisturbed anamnesis conversation with the parents -always both parents if possible- is of the highest importance for diagnostic purposes. Practically speaking, one may proceed as follows:

• Ask the parents to send an informal letter to their doctor explaining everything they know of the history of the illness and their own observations of the child and providing a description of the family’s life circumstances, a list of the child’s other illnesses and treatments received, as well as the

  observations of others (relatives, kindergarden and elementary school teachers).

The advantage of this procedure is that it eliminates the time pressure: Forgotten points can be added later. The parents can concentrate on gathering and discussing their memories and can express themselves freely without being constrained by the presence of the child. They can also give voice to the burdens they have borne. In this way the parents come to the anamnesis conversation prepared—and so does the doctor, who has read the letter beforehand. If the letter is handwritten, the doctor gains additional important impressions of one of the parents. At the same time a significant part of the anamnesis will already be documented, thus taking more pressure off of the conversation. A further recommendation is:

• Keep the anamnesis conversation separate from the presentation of the child.

In any case, whether physician is a pediatrician or a general practitioner, it is essential to allow for sufficient time: as a rule presently, one hour for the initial conversation in cases of suspected ADHD, regardless of what the fee schedule may permit (questionable norms come into question as soon as ADHD is involved!). This is the only way to provide the space needed for creative diagnosis and treatment selection.

Regardless of the patient's present age, it is crucial to begin by inquiring into the first 7 years of life. Leading symptoms of a disorder requiring treatment may be:

Infancy

• persistent recurrent symptoms of an overtired infant (cf. 17, 18), protracted crying phases, motor unrest, irritability, difficulty falling asleep, difficult to calm

• child is trying and unsettling for the parents; difficulty establishing a satisfying emotional bond between child and parents (cf. 19 and literature cited there.)

Early childhood

• temporal dissociation between language acquisition, motor development and other learning (e.g. toilet training), marked prematurity/retardation of specific “behavior competencies,” e.g. fine motor skills, language comprehension skills, etc.

• driven, restless motor activity, low endurance (usually with some significant exception!), unpredictable and frequent changes in activities, enjoys risky behaviors, increased accident-proneness

• “socially difficult” due to bursts of impulsiveness, disinterest in listening (often not true when they are told stories alone), frequent rule-breaking behavior, early and inappropriate need to lead, highly defiant assertion of autonomy. Because of this, child and family may find themselves socially isolated and siblings may be made into enemies or victims.

Disturbance in the ties of family and friendship (with this particular symptom, the reverse process may be operative, attentional and behavioral disorders may result from separation of parents or loss of a loved one, etc.)

• situational aggravation of the problems (kindergarden). Kindergarden in its present form is usually a particularly unfavorable setting for hyperactive and

  attentionally disturbed children. The picture is different in kindergardens with small groups that can move freely in natural settings, such as the “forest kindergardens.”

• This is also the place to inquire into any allergic illnesses and reactions, get a detailed history of eating habits and digestion (dysbiosis/fungal illnesses?) and ask whether

they have observed any aggravation of behavioral abnormalities connected with specific foods or improvements during an elimination diet.

As we have pointed out above, these behaviors are generally paired with special capacities and “behavioral plusses.” Thus, an early talent may be noticed for acrobatics

(many affected children love the circus and circus games), or a climbing ability, a creative gift, etc.

As a rule, given a careful anamnesis and observation of the 5-year-old child at the 9th preventive care examination, it will be possible to recognize an attentional disorder

with hyperactivity and to treat it satisfactorily without the use of stimulants. The symptoms linked with ADHD in school-age children are well-known:

• easily distracted, forgetful, lack of care and perseverance (at unappealing homework and household chores), disruptive, impulsive, defiant social behavior,

• strikingly bad handwriting, trouble with reading/spelling, continual speaking, rushed speech,

• affective lability and low self-esteem, outsider position in contrast to mental gifts.

Once again there is another side: Extremely hyperactive boys are also able to fish quietly with their father for hours, and in frightening or emergency situations (e.g. a fire) these children do the right thing with amazing sureness and presence of mind and later show excellent recall of even the smallest details.

Further features of the picture in adolescence:

• leaving school prematurely/repeatedly

• social isolation, continual conflicts with others, few or no friends

• attraction to dangerous sports, risky behavior in driving, etc.

• continual need for distraction, inner unrest

Issues relating to drugs, addictive dependency on media and computer games and socially problematic experiences with peers are of growing significance.

 

Much public attention is now drawn to the danger of leaving ADHD untreated in young people and adults. At issue, however, are not only those affected but equally

the society in which they live. At bottom, the only way to make a difference in the increasing marginalization of these individuals is though a genuine understanding of

their difficulties and specific gifts—not by a suppressive approach (e.g. use of stimulants)

The controllability of stimulant therapy is also generally unreliable; and for this reason as well, the therapeutic goal in adolescence must be to provide those affected

with the support, treatment and appropriate social integration they need to become and remain free from daily tablet taking at this stage in their life.

Making a Family Anamnesis

The most important aspects to ask about are:

• The course of the pregnancy and birth. A quick or difficult birth, intubation at birth, etc., may have caused lasting disturbances of the craniocervical transition and can be effectively remedied with appropriate therapy.

  In addition, we (the authors) have also observed what American classical homeopathists and ADHD experts  Ullmann and Reichenberg-Ullmann report, namely that

"the thoughts and feelings experienced by the parents just before conception and during pregnancy can have a direct effect on the condition of the child". In their book

Ritalin-Free Kids, these authors offer impressive casuistic proof (recognized by ADHD specialists) of the efficacy of

  homeopathically potentized remedies in these areas.

• Exposure to toxic substances (chiefly pharmaceuticals, nicotine, alcohol and other drugs). The importance of these factors is generally recognized today. Therapeutic remediation is possible to an extent (chiefly in the first 7 years of life) sing approaches requiring practice and habit change and to an certain degree employing homeopathic

and anthroposophic remedies.

• Constitution of parents and grandparents: During the ADHD discussion and diagnosis process many parents become aware for the first time that they themselves display certain traits (or did so as children) which now confront them in their children.

This realization can often lead to:

• a new understanding of how their child actually feels

• a certain calming of the situation, since in the course their lives many parents have ultimately made something positive of their difficulties and would not really want to

be "completely normal"

• a therapeutic opportunity, inasmuch as progress brought about by learning and behavior change in the parents is often the most productive.

Frequently when parents recognize that they have a particular style of attention and impulsivity themselves, they develop a new understanding for one another

(and this in itself is a good reason why the parents of a child with "differences" should be thoughtfully integrated into the treatment. Parents learn that by being more attentive to their own impulsiveness and mastering it—in some cases giving up drugs, etc.) they are helping their children by sparing them the kind of disappointments and unhealthy experiences they have had. This also enables them to work through even severe disappointments or difficult separations of their own.

Finally, also important are reports from kindergarten and school, etc., as well as taking up direct contact with teachers. During treatment a regular common meeting time can

be arranged with the parents and class teacher. School notebooks and any pictures, etc., done by the child should of course be personally perused by the physician.

 

DD.: and Examination:

The preliminary written anamnesis (parent's letter) and parent conversation free up the examination visit so that it can take place in a relaxed atmosphere.

The doctor's aim must always be to experience the child directly: in a one-on-one conversation, a play situation or at least a wordless dialogue in gestures followed by an appropriately designed physical examination. In this way constitutional traits often become evident from the first impression of the child's appearance and answering behavior. An essential question is the child's capacity for dialogue: How does (s)he respond to eye contact and how long will (s)he tolerate it?

What does (s)he notice in the examination room; how does (s)he relate to people and things; how quickly does his/her attention switch?

– Does listening closely to the child permit a successful dialogue? At pre-school age, the chief focus will be on behavioral evaluation in regard to attention, impulsivity and motor behavior (here again one can use playing to draw the child "out of his shell"). Surprisingly often, school-age children with ADHD issues are capable of voicing a deeply insightful self-evaluation of their situation when a free, unstressed conversation situation has been created (with parents absent or truly restraining themselves). In many instances issues that were long hidden come out, to the surprise of all involved, or interests are recognized that lead to important progress. The primary points to clarify in the anamnesis and examination are:

• Is there a hyperactive disorder requiring treatment according to the criteria defining ADHD?

• Are there grounds to suspect an attention deficit disorder (ADD) without hyperactive behavior?

For differential diagnosis, the primary focus is on reactive behavioral disorders caused by stress to the child from:

• family (problems in parents' relationship to child and in parenting, unrealistic expectations, parental relationship problems, occupational/economic stresses, problems with siblings and close relatives; "family secrets" that were never aired

• kindergarden or school (excessive demands for achievement, teacher with difficult personality, etc.)

• depressive disorders must also be identified. Among boys these may well be coupled with hyperactive behavior and in most cases impair attention (sometimes severely).

Also significant in this connection are:

• peripheral and central hearing disorders (these must always be eliminated.)

• autistic disorders; in rare cases, psychoses

• endocrine disorders (chiefly of the thyroid gland and adrenals)

Vegetative lability and hypotonic circulatory condition can be read from skin color, distribution of body warmth, perspiration and posture; particularly in the 2nd seven-year-period it is important to perform blood pressure checks (also when standing) and measure blood sugar level (a.m., 2 – 3 hrs. after leaving home). Disorders in the interaction

of upper and lower jaw, asymmetries in the cervical spine, alternation of tensed and hypotonic areas in dorsal musculature and postural anomalies may point towards

• disorders of the craniocervical transition area as a source of trouble. Preventive care visits (particularly the 7th – 9th) are valuable diagnostically, offering the opportunity

to observe the child's movement patterns and manner of speaking and answering while playing together (at ball or movement games such as pullstring puppets, etc.) and having

the child balance, draw pictures or figure eights, write (writing position) and manipulate objects in the examining room (fine motor skills). These observations, in conjunction

with the developmental anamnesis and possible later tests, —can provide diagnostic indication of

• competency deficits

An essential component (DD.: as well) is an evaluation of the child's intelligence and gifts, including a judgment as to whether the demands placed on the child are commensurate (under-/over-demand). The use of labels such as "highly gifted" may not always be productive here, since in reality these children largely suffer from great discrepancies - e.g. between their aptitude for mathematical/logical thinking and for social learning ("emotional intelligence"), or between their artistic gifts and their reading/spelling ability.

The level of DD.: certainty needed must be decided on individually - i.e., to what degree one should implement complementary psychiatric testing, pedaudiologic examination, allergological diagnosis including evaluation of intestinal flora, endocrinological diagnosis and an EEG.

In any case, however, the following aims should be borne in mind:

• Before diagnosis: The pediatrician or family doctor should develop a well-rounded picture of the child and out of it a preliminary diagnosis;

• After the diagnostic process described: The results and conclusions should be thoroughly discussed in a group conversation leading to common agreement on the therapeutic avenue to be taken. As a participant in the group, the child should feel helped and supported:

Köhler: "the personal relationship is the actual therapy." A conversation among all adults concerned has proven of the greatest value. Primarily, this should include the parents, kindergarden or class teacher, therapists/curative educators and the responsible physician (cf. the principle of the "protective circle," Köhler). Through this type of conversation a comprehensive view of the child, incl. both weaknesses and gifts, can arise. Diagnoses, goals and responsibilities can be discussed and clarified.

 

2 Therapy

In the authors' practice, the following ADHD-associated disorders have been found to be of diagnostic and therapeutic significance:

• Disorders involving a constitutional dominance of the metabolic-limb system which manifests as a hyperkinetic disorder (ADHD)

• Attentional disorders without hyperactivity (ADD). With this 2nd form particular, competency deficits (incl. acquired ones) have proven to be of considerable pathogenetic importance.

• Disorders in the area of the craniocervical transition.

• Vegetative lability, labile hypotonic circulation.

• Food intolerances; nutritional, digestive and metabolic disorders.

Therapeutically, a great deal depends on classifying the child's disorder correctly within this schema, so that one can implement a treatment that has a clear aim and also a curative orientation.

In contrast, the dominant treatment approach using stimulants (e.g. Ritalin) has a purely symptomatic effect; furthermore, around ¼ of all children considered to be affected

do not respond to stimulants or respond only negatively to them. Even if it is not always possible to avoid the use of stimulants during the 2nd seven-year period, the authors strive to find a path without stimulant therapy that aims towards at least partial healing/rehabilitation - i.e. a path towards progressive healing in the child's development.

Stimulants cannot accomplish this. The claim is presently made that stimulant therapy is a kind of substitution therapy for the metabolism of the central nervous system.

When it is contrasted with true substitution such as insulin treatment for diabetes, however, this claim is found to be a largely hypothetical justification for the therapy.

As a general rule, any substitution of substances can have problematic effects on the equilibrium and ultimately weaken the autonomous development of the child's metabolism. This in turn leads to continual medical checkups, with doctors warning their patients always to take their pills if they wish to avoid a relapse. In adolescence

at the latest, this frequently leads to massive self-doubts and mis-use of the substances to be taken.

The question is, do not stimulants rather deserve the status of an acute treatment_a last resort when a child remains unresponsive, socially isolated or unmanageable despite every measure attempted? To closer observation it will also be evident that stimulants do exercise a suppressive action on many children—particularly in the soul realm, the realm where originality and creativity reside. As long as the therapeutic aim is healing and not management of a disorder, the use of stimulant therapy on attentionally disturbed and hyperactive children will represents a sometimes necessary but ultimately unsatisfactory solution.

 

General therapeutic considerations

1st therapeutically significant step is to create a detailed clarification of the medical diagnosis that manifests an understanding of the child and his or her strengths and weaknesses. This creates new interest in the child as a human being_as an individuality that is only in the process of appearing and still has surprises in store for us. The aim here is to achieve a shared sense of how the child experiences important life situations and reference persons, and what (s)he is able and not (yet) able to do.

2nd step consists in pedagogical counseling of the parents and_in an appropriate way_of the teachers and caregivers (cf. the idea of the protective circle).

On this point there is excellent literature today; among many others we refer again to Henning Köhler and the work of Schmidt et al. For practical purposes the reference guides of Neuhaus and Aust/Hammer are quite helpful. As widely as their concepts may diverge, in dealing with the children one finds importance points of agreement.

Regarding the media question, the studies of R. Patzlaff are fundamental; numerous literature references are also provided in the general parents’ guide by Goebel/Glöckler. It is important to establish authentic conditions for pedagogical progress by_for example_drawing awareness to parental relationship crises, economic pressures, etc. and working these through separately so that they are not played out through the child. In every form of attentional deficit, individually suited dietary counseling also plays a significant role.

3rd step consists in evaluating if the kindergarden, school or nursery group is meeting the child’s needs. Frequently changes are advisable in group size, options for individual help, academic achievement standards, as well as in the amount of time the child spends in the institution. For example, an all-day school with qualified afternoon care may provide the family with critical relief. Finally, the authors have repeatedly seen children (age 10 and up) with massive hyperkinetic disorders and very difficult family situations make excellent progress without any stimulant therapy by spending several years at a curative-education boarding school based on Waldorf pedagogy. In any case, the children themselves say very soon if they are really profiting from the change and when this is the case they are willing to accept many unpleasant aspects of the experience. It is important for the advising physicians to acquaint themselves with the various schools and institutions in their area.

Once these initial steps have been taken, the therapeutic approach in a narrower sense can be formulated. For this purpose we cannot understate the value of

• anthroposophical and homeopathic remedies.

Their action is not substitutive or suppressive like that of stimulants. Rather, when correctly selected for the individual, they stimulate organismic learning processes. They address the regulation of vital processes, the body of life forces that works in bodily growth and organic functions_as well as in memory function_while these are maturing. The engagement of the soul element in bodily functions is facilitated in this way. These remedies act not in an isolated way on the nervous system, but integrally on the organism as a whole. This is important because it is precisely the relationship of the nerve-sense system to the rest of the organism that is impaired in ADHD (cf. Pohl 29, Schmidt et al. 25). As a rule the length of administration depends on how long the child needs before (s)he has accomplished the step in learning and maturation that the remedy has stimulated and is able to stabilize it alone. Composite remedies with broad indications may require longer periods of administration (several months), while single potentized remedies will be given for weeks, months or as a single dose, depending on their efficacy and potency. The most remarkable publication on classical homeopathic therapy in ADHD is a compendium of cases from Reichenberg-Ullmann (30); for anthroposophical drug therapy one might point to von Zabern (31, 32) and to the general survey by Schmidt et al.

 

In the authors’ experience, without a differentiated application of anthroposophical and homeopathic drug therapy it will appear necessary to resort to stimulants.

Since there are few up-to-date survey works based on personal therapeutic experience here, we shall concentrate on this form of therapy.

• Non-medicinal therapies for ADHD must be approached in a differentiated way. The following forms of therapy have the  advantage that the children acquire new capacities, or physical obstacles are eliminated (craniosacral therapy and rhythmic massage). These are steps towards real healing:

• curative play and practice therapy,

• therapeutic eurythmy and Wegman/Hauschka rhythmic massage,

• craniosacral therapy,

• artistic modelling (less often painting and speech or music therapy),

• ergotherapy in conjunction with breathing therapy exercises,

• therapeutic circus work, etc.

For the reasons discussed, these forms of therapy are also preferable to stimulant therapy, which takes a clear third place among therapeutic approaches. At the same time an ongoing stimulant therapy should not be simply discontinued. In such cases it should initially be complemented with the therapy forms mentioned above and later reduced

or discontinued to the extent possible. Depending on the child’s age, it is important for him or her to be included in evaluating the therapy from the start. Many school children are capable of judging the efficacy of their treatment very well themselves.

 

Constitutional Dominance of the Metabolic-Limb System Manifesting as a Hyperkinetic Disorder (ADHD)

The Constitutional Aspect

Constitutionally hyperactive, impulsive behavior with attentional impairment (ADHD) shows a marked relation to the male sex, although in rare cases it also occurs in girls.

It is not unusual for the family anamnesis to reveal disturbed development in earlier generations (father, male ancestors). Boys are characterized by a relative dominance of the limb forces over the centralizing head forces (which mediate inner calm and concentration); in these predisposed cases, the dominance appears particularly marked.

This type of constitution favors a “short-circuiting” between environmental stimuli and limb activity along with deficient control (and guidance) of limb movement emanating from the head (disturbed motor coordination is striking in many of these children).

From the embryological viewpoint it is noteworthy that the regulatory connection between the nervous system and the musculature does not emanate hierarchically from the nervous system, but rather arises as structures of the central nervous system and the muscle blastemes are “brought into agreement” by the organism (i.e. by an unspecified center!). When the central nervous system is recognized for what it is: a reflective organ necessary to the steering of body movement; and when the limb system is recognized for what it is: an independent system (34) which together with digestive and metabolic processes comprises the primary organ of the human will_then and only then does the mediating task become clear which the human being must accomplish during development. It is in the area of body and limb development that the female and male sexes

differ most markedly. An explanation based on brain metabolism (the dopamine hypothesis), on the other hand, casts no light on the sex-specific character of ADHD.

Interestingly, the primary effect of the nerve on the muscle cell is that of inhibition (embryonically, fibrillation of the muscle cell interrupted for the first time when the growing nerve fiber reaches and penetrates it), while the original “modus” of every muscle cell is movement. In reality, the success of the mediating task mentioned above is not

a process of the nervous system at all, but depends on the rhythmic system that mediates between the nerve and limb systems and on associated “soul” processes (respiration, circulation, spinal function and craniosacral rhythm – cf. (35). Movement and consciousness must be “brought into congruence” out of one’s own forces_that is the task.

As a rule, abnormal behavior on the part children with hyperkinetic syndrome becomes especially pronounced when they are in socially challenging situations. This too is connected with insufficient development of the rhythmic system, resulting in insufficient connection and interpenetration of the head and limb forces: The rhythmic system, which provides for a “breathing, resonating” kind of understanding, becomes “fragmented” by limb forces and impulses that take on a life of their own. The other children

in a group as well as their parents are soon aware of this and need to feel that their situation is understood by the doctor in detailed consultations. The hyperactive children themselves also suffer, however, feeling overwhelmed by their own limbs and their spontaneous actions.

In the metabolic area (just as in children with food intolerances), one should be especially watchful for a labile blood sugar curve. Otto Wolff points to the fundamental importance of the carbohydrate metabolism in hyperkinetic children. Many of them display a marked lability of the blood sugar level, which can lead to corresponding hunger phases (primarily in the a.m.) with increased sugar consumption and correspondingly greater, reactive blood sugar vacillations. Diet and medication can be effective here.

• It must be borne in mind that by its very nature, will-life proceeds without memory, comparison or plan; it moves from the now towards the future.

In order for this to occur, the past must be forgotten. In a child who is carried away by his will, this means that the function of conscience can be suppressed and things

of value from the past can be destroyed without any feelings of regret or guilt. Even an ability to lie without a bad conscience stems from the unbalanced dominance of

the will-life. At any moment, however, this state can switch to feelings of regret or guilt once the “intoxication of movement” has passed.

A crucial factor in hyperactivity is the child's relationship to the father: Is he present? Is he active in their lives? As a man, by constitution his role lies in the use of his limb forces; the more harmoniously he does this and models it, the more positive the effect on the child. It is very important to bring the father into the child's upbringing in an appropriate way.

Ergotherapy, artistic therapies, curative education, school-preparatory work in small groups should always be considered and—most importantly—implemented at the right moment. How deeply they can change the constitution depends on the time of their use. The aim is to enable the rhythmic system to mature in the second seven-year period, and in hyperkinetic children the ground must be prepared for this (particularly at pre-school age). An especially significant aid to children with constitutional ADHD is offered by therapeutic eurythmy (see below), which can be received quite positively when it is carried out correctly.

Concentration and perseverance is best learnt by these children through meaningful physical activity [can become very skilled and engaged in this area (in handicrafts)]. Constitutional remedies can have a decisive effect on the symptoms. A selection of important remedies is presented below.

 

 

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