A.D.H.S. Anhang 9
Attention-deficit/hyperactivity disorder (ADHD) is a syndrome of inattention, hyperactivity, and impulsivity. The DSM-IV states that approximately 3 - 7% of children worldwide currently have ADHD (DSM-IV-TR, 2000 pg90), and thus it appears to be a highly prevalent disorder. Many experts feel that ADHD is overdiagnosed, largely because criteria are applied inaccurately (Beers, 2006 pg 2483).
The 3 types of ADHD are predominantly inattentive, predominantly hyperactive-impulsive, and combined type. Diagnosis is made by clinical criteria, according to the Diagnostic and Statistical Manual of Diagnosis and Therapy (DSM-IV) (Beers, 2006 pg 2483).
Despite extensive research, a clear, single causative mechanism has yet to be established. Potential causes include genetic, biochemical, head trauma, prenatal alcohol, tobacco and cocaine exposure, physiological, and behavioural factors (Beers, 2006 pg 2483). Research to establish clear causative factors is ongoing.
Multimodal treatment is advised and should consist of medication, behavioural therapy, and educational accommodations (DuPaul & Weyandt, 2006).
Allopathic medicines used include psychostimulants, atomoxetine, antidepressants and antihypertensives, and these all have a substantial risk of side-effects. Common adverse effects associated with psychostimulants, the most commonly prescribed class of drug for this condition, include loss of appetite with subsequent loss of weight, headaches, nausea, abdominal pain, sleeplessness and depression (Picton, 2005). Health care providers, parents, and teachers are seeking effective therapies and methods that do not involve these medicines (Soreff & Chang, 2008).
The aim of this study was to evaluate the efficacy of homoeopathic simillimum in the treatment of ADHD in school going children, 6 - 11 years, by means of the ADHD Rating Scale- IV.
Both the Home and School Versions were applied to determine results across 2 settings.
1. objective proposed to determine the effectiveness of homoeopathic simillimum in the management of ADHD symptoms.
2. objective proposed to determine the effectiveness of placebo in the management of ADHD symptoms.
3. objective proposed to integrate the results of the placebo and treatment groups in order to determine if there is a difference in the efficacies of homoeopathic simillimum and placebo in the management of this condition.
4. objective proposed to determine the presence and significance of correlations between demographic descriptors, remedy breakdown and potency breakdown with responses to treatment.
ADHD is an Axis I childhood disorder, characterised by inattention, restlessness, impulsivity, and hyperactivity. Axis I disorders are clinical disorders and other conditions that may be a focus of clinical attention (DSM-IV-TR, 2000 pg 27, 85). ADHD characteristics cause disruption and create socio-environmental problems for the child (Kronenberger, 2000). They are not developmentally appropriate for the child’s age (DuPaul & Weyandt, 2006).
Parents are likely to first notice the characteristics when a child is 3 - 4 years old, or in some cases, even younger (Barkley, 2005 pg 112).
According to DSM-IV criteria, the child must have at least 6 of the below -mentioned symptoms of inattention or hyperactivity- impulsivity. They must be present for at least 6 months and be more severe than is normally observed in individuals at a comparative level of development. These symptoms must be persistent and noted before the age of 7. They should cause clinically significant impairment (e.g. in social, academic, or occupational functioning) and must be present in at least two settings (e.g. home and school).
Symptoms must not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder or be better accounted for by another mental disorder (Mood disorder, Anxiety disorder, Dissociative disorder, or a Personality disorder) (DSM-IV-TR, 2000 pg 85, 93).
Symptoms of inattention: fails to give close attention to details or makes careless mistakes in schoolwork, or other activities has difficulty sustaining attention in tasks or play activities does not seem to listen when spoken to directly does not follow through on instructions and fails to finish schoolwork, chores, or duties has difficulty organizing tasks and activities avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools) is easily distracted by extraneous stimuli is forgetful in daily activities.
Symptoms of hyperactivity:
fidgets with hands or feet,
squirms in seat
leaves seat in classroom or in other situations in which remaining seated is expected
runs about or climbs excessively in situations in which it is inappropriate
has difficulty playing or engaging in leisure activities quietly
is “on the go” or acts as if “driven by a motor”
blurts out answers before questions have been completed
has difficulty awaiting turn interrupts or intrudes on others
Many individuals present with characteristics of both inattention and hyperactivity-impulsivity, however there are individuals in whom one or the other pattern is predominant. The appropriate subtype (for a current diagnosis) should be diagnosed based on the predominant symptom pattern for the past 6 months (DSM-VR-TR, 2000 pg 87).
DSM-IV has created 3 subcategories, namely:
1. Attention-deficit/hyperactivity disorder, Combined Type.
This subtype is used if 6 or more symptoms of inattention and 6 (or more) symptoms of hyperactivity-impulsivity have persisted for at least 6 months (DSM-IV-TR, 2000 pg 87). The combined type
represents the majority of ADHD children (Davison & Neale, 2001).
2. Attention-deficit/hyperactivity disorder, Predominantly Inattentive Type This subtype is used if 6 (or more) symptoms of inattention (but fewer than 6 symptoms of hyperactivity-impulsivity) have persisted for at least 6 months (DSM-IV-TR, 2000 pg 87). An individual with this subtype is disorganized, distracted, and forgetful
(Sonna, 2005 pg v). They are commonly more passive, fearful or apprehensive about things. They may be lethargic, sluggish or slow-moving, and inattentive to what is happening around them, demonstrating considerably less aggression, impulsivity and over-activity than children with the more impulsive subtype. There appears to be
a significant problem with sustained attention, attention span and persistence of effort as well as memory, perceptual-
motor speed, and the speed at which the brain processes incoming information (Barkley, 2005 pg 43, 48, 162, 163). Problems regarding self-esteem and academic performance are common (Sonna, 2005 pg v), resulting in difficulties in school and in completing homework (Wilens, 2008).
3. Attention-deficit/hyperactivity disorder, Predominantly Hyperactive-Impulsive Type
This subtype should be used if 6 (or more) symptoms of hyperactivity-impulsivity (but fewer than 6 symptoms of inattention) have persisted for at least 6 months (DSM-IV-TR, 2000 pg 87).
An individual with the predominantly hyperactive-impulsive subtype is exceptionally active, restless and impulsive (Sonna, 2005 pg v), coming across as more uninhibited
and demanding. The hyperactive component is often demonstrated as fidgeting, pacing, excessive talking or other movement (Barkley, 2005 pg 6, 48, 51). They often have difficulty learning in a traditional academic environment, resulting in defiant behaviour (Sonna, 2005 pg v) yet some perform acceptably academically and show their difficulties at home or in situations with less guidance and structure (Wilens, 2008). It is found that different symptoms may dominate at different times of life yet most individuals will display characteristics of hyperactivity throughout their life (Picton, 2005 pg 4).
As with most conditions, there are degrees of the disorder within the population; some people have mild or even borderline ADHD, whilst others have moderate or severe ADHD. As far as intelligence, children with ADHD represent the entire spectrum of intellectual development (Barkley, 2005 pg 109, 121).
In the case where standard criteria for ADHD is not met, or where symptoms are not severe enough, they are diagnosed with an atypical form of ADHD called attention-deficit/hyperactivity disorder not otherwise specified, or ADHD-NOS (Sonna, 2005 pg 3).
Diagnosing psychiatric disorders in children is far from an exact science and the absence of objective evaluation methods and relying on the observations and opinions of parents and teachers introduces uncertainty into the diagnostic process (Barkley, 2005 pg 165). It is thus a highly subjective process and symptoms of ADHD vary across settings, making it hard to diagnose (NIMH, 2008 pg 2).
Because specific aetiology for ADHD is unknown, there are no laboratory tests, neurological assessments, or attentional assessments that have been established as diagnostic in the clinical assessment of ADHD (DSM-IV-TR, 2000 pg 88). Thus the diagnosis relies on behavioural symptoms and ruling out other disorders (ADHD In-Depth Report, 2008 pg 4). When a child’s hyperactivity, distractibility, poor concentration, or impulsivity impact performance in school, social relationships, or behaviour at home, ADHD may be suspected (NIMH, 2008 pg 2).
In order to diagnose ADHD, substantial information about the child and family must be obtained. This information must be sifted through to establish symptoms of ADHD and rule out other disorders or problems (Barkley, 2005 pg 152). Ideally the assessment gathers information from multiple informants who have observed the child in diverse situations. This multidimensional approach to behavioural assessment is crucial as ADHD children often behave differently in different situations. Both cognitive and behavioural components of ADHD must be assessed in order to understand the pattern of symptoms for the individual child. A comprehensive ADHD assessment leads
to conclusions as to the presence, severity, type, and characteristics of the disorder in the child (Kronenberger, 2000 pg 49). The final diagnosis of ADHD is made by careful clinical history, applying the DSM-IV criteria (Wilens, 2008).
Medical assessment focuses on identifying potentially treatable conditions that may contribute or worsen symptoms and signs (Beers, 2006 pg 2484).
The clinical history involves investigating the child’s genetic background, pregnancy and birth events, developmental and medical history, nutritional status, and gross
sensory-motor development. Thyroid problems, lead poisoning, anaemia and other illnesses that could produce symptoms that mimic ADHD must be ruled out.
A brief neurological exam to screen for relatively gross neurological problems may be conducted. Weight, height and head circumference must be measured and compared
to normal standards. Hearing and vision are screened. If a seizure disorder is suspected, additional tests such as an electroencephalogram (EEG) or computed tomography (CT) scan may be done (Barkley, 2005 pg 161).
Often with careful testing many of the children diagnosed with ADHD fail to meet the criteria. Factors contributing to misdiagnosis include children who are young for their grade and thus socially and intellectually immature. Social and economic problems single parent households also add to misdiagnosis (ADHD In-Depth Report, 2008 pg 2). Adequate diagnosis requires not only medical investigation but special psychological and educational assessment too (Methylphenidate, 2008). Psychologists are trained not only to evaluate psychological problems in children, but also to conduct psychological, learning and neuropsychological tests that can help pinpoint the type of disorder a
child has (Barkley, 2005 pg 146).
In this study, participants had to be diagnosed by a child psychologist or paediatrician to ensure legitimate diagnoses.
DIFFERENTIAL DIAGNOSIS (= DD) AND RELATED CONDITIONS
Two-thirds of children diagnosed with ADHD have at least one other psychiatric diagnosis (e.g. depression or anxiety disorder) (Sonna, 2005 pg 55, 57). These related conditions make it harder to diagnose and treat ADHD (Nordqvist, 2007).
Associated features vary depending on the child’s age and developmental stage. They include low frustration tolerance, temper outbursts, bossiness, stubbornness, excessive and frequent insistence that requests be met, mood liability, demoralization, rejection by peers, and poor self-esteem. It may be difficult to distinguish characteristics of ADHD from age-appropriate behaviours in young, active children (e.g. running around or being noisy).
The increased motor activity that may occur in the hyperactive subtypes of ADHD must also be distinguished from repetitive motor behaviour characterising Stereotypical Movement Disorder.
In Stereotypical Movement Disorder, the motor behaviour is mostly focused and fixed, whereas the fidgeting and restlessness seen in ADHD is more generalised. Characteristics of inattention are common among children with a low intelligence quotient (IQ) who are placed in academic environments that are intellectually inappropriate for their ability. In children with mental retardation, an additional diagnosis of ADHD should be made only if the symptoms of inattention or hyperactivity are excessive for the child’s mental age. Children of high intelligence may have problems with inattention that could be misdiagnosed as ADHD when placed in an academically under-stimulating environment. These characteristics must be distinguished from those of children with ADHD (DSM-IV-TR, 2000 pg 88, 91).
The difficulties faced by ADHD children may also be exacerbated by one or more of the following conditions: (Picton, 2005 pg 125)
Learning difficulties related to visual perception
Speech, language and listening difficulties
Difficulties putting sounds together when learning to read
Learning and remedial difficulties
Fine and gross co-ordination
Inappropriate sensory modulation
Delayed developmental milestones
As many as a third to half of children with ADHD -mostly boys- have oppositional defiant disorder (ODD) and 20 - 40% may eventually develop conduct disorder (CD) (NIMH, 2008 pg 10). Oppositional defiant behaviour is a disorder characterised by a recurrent pattern of negativistic, defiant, disobedient, and hostile behaviour toward authority figures. Conduct disorder is a disorder characterised by a repetitive and persistent pattern of behaviour in which the basic rights of others, or major age-appropriate societal norms or rules are violated (DSM-IV-TR, 2000 pg 93, 100). Between 7 - 10 years of age, at least 30 - 50% of children with ADHD are likely to develop signs of CD and antisocial behaviour (Barkley, 2005 pg 115). Some children with ADHD have
co-occurring anxiety or depression (NIMH, 2008 pg 10). They may also exhibit symptoms of anxiety and depression that do not qualify for a formal psychiatric diagnosis (Barkley, 2005 pg 127, 128.) If these disorders are recognized and treated, the child will be able to handle the problems that accompany ADHD more productively. There are no accurate statistics as to how many children with ADHD have co-existing bipolar disorder. Differentiating between the two in childhood can be challenging (NIMH, 2008 pg 10). Other associated disorders may include mood disorders and communication disorders (DSM-IV-TR, 2000 pg 88).
Children with ADHD are more likely to have learning disabilities. They may have specific problems in speech development, expressive language and fluency (Barkley, 2005 pg 122, 123). Academic deficits and school-related problems tend to be more pronounced in the types marked by inattention, whereas peer rejection and accidental injury are more common in the types marked by hyperactivity and impulsivity (DSM-IV-TR, 2000 pg 88).
ADHD appears in approximately 50% of clinic-referred children with Tourette’s Syndrome, a tic disorder, yet most individuals with ADHD do not have the accompanying syndrome (DSM-IV-TR, 2000 pg 88). It has been suggested that the same gene could be responsible for Tourette’s Syndrome and ADHD (Picton, 2005 pg 132) yet it seems more likely that ADHD is simply a co-morbidity of Tourette’s Syndrome.
There are not really any specific physical features associated with ADHD, although minor physical anomalies (e.g. hypertelorism (abnormal distance between two paired organs), highly arched palate, low-set ears) may occur more frequently than in the general population (DSM-IV-TR, 2000 pg 89). Children with ADHD seem more likely to have visual problems and seem to have more problems with general health, which is as yet a misunderstood association (Barkley, 2005 pg 124, 126). There may also be a higher rate of accidental physical injury (DSM-IV-TR, 2000 pg 89).
likely to be referred to clinics because they have a higher likelihood of aggression and antisocial behaviour (Davison & Neale, 2001). Thus more girls with ADHD may go unrecognised and untreated (Barkley, 2005 pg 112).
Not much is known about ADHD on the African continent. A study, published in the South African Journal of Psychology (2004:34) on cross-cultural similarities in ADHD-like behaviour amongst South African primary school children (Meyer, Eilertsen, Sundet, Tshifularo, & Sagvolden, 2004), was conducted using data from 6094 primary school children from six language groups in the Limpopo Province. The study aimed to shed greater light on social effects within South African cultures, and between South African, U.S. and European cultures, in the context of ADHD. In the
study, the teachers completed a shortened version of the Disruptive Behaviour Disorders (DBDs) rating scale a DSM-IV criteria-based scale, and this data was analysed.
The study proved that ADHD is not specific to US and European cultures and that the prevalence of ADHD sub-types was comparable to US and European rates.
Surprisingly small cultural differences in the prevalence of ADHD-like behaviour were also shown to exist between South African cultures (Meyer et al, 2004 pg 122 - 138).
Although ADHD is one of the most extensively studied of all the childhood psychological disorders, it remains misunderstood and controversial in the minds of the general public as well as the medical profession. The difficulties in producing direct scientific proof that any specific factor or factors cause a problem with human behaviour must be kept in mind. Behavioural scientists are often left with information that is highly suggestive of a cause but not proven with absolute certainty. Intense interest in understanding and treating ADHD has instigated voluminous research.
It is commonly accepted that ADHD has multiple causes and, since the mid-1980s knowledge of these causes and how they influence the brain and behaviour has increased significantly (Barkley, 2005 pg xiv, 29, 78). A vast number of different theories on ADHD have been suggested, but so far there has not been one that fully accounts for all aspects (and all occurrences) of the condition (Picton, 2005 pg 9).
Possible causes include genetics, brain developmental delays, brain injury or damage, neurotransmitter problems, environmental factors, complications of pregnancy and delivery, nutritional influences and heavy metal intoxication.
Most substantiated causes of ADHD appear to fall within the realm of neurobiological and genetic causes (NIMH, 2008 pg 7).
Evidence is quickly accumulating that suggests that ADHD is a disorder in brain development or brain functioning that originates in genetics (Barkley, 2005 pg 26).
Adoption studies (e.g. Van den Oord, Boomsma & Verhulst, 1994) and numerous large-scale twin studies (e.g. Levy, Hay, McStephen, Wood & Waldman, 1997) indicate
that this proposed genetic predisposition may play a role in ADHD (Davison & Neale, 2001).
The specific factors inherited in ADHD probably include a tendency toward problems in the development of the frontal cortex of the brain as well as the caudate nucleus (Barkley, 2005 pg 90),
however it’s precise neural and pathophysiological substrate remains unknown (Wilens, 2008).
There is a 40% chance that at least one parent of a child with ADHD also has the disorder and approximately 15 - 20% of mothers and 20 - 30% of fathers of children with
the condition may have it at the same time as their children.
Having a sibling with ADHD increases the likelihood to 25 - 35% that another child in the family will have ADHD. The risk is about 13 - 17% for girls and 27 - 30% for boys, regardless of the sex of the sibling. These figures point to genetic causative factors. Biological relatives of children with ADHD also have more psychological problems (particularly depression, alcoholism, conduct problems, antisocial behaviour, and hyperactivity) than those of 16 children without ADHD (Barkley, 2005 pg 89, 102, 132, 138, 139), further suggestive of a genetic link.
Researchers continue to study the genetic causes to ADHD and currently working at identifying the specific genes that cause a susceptibility to ADHD (NIMH, 2008 pg 8).
Differences in brain functioning, structure and development are indicated. It has been found that the frontal lobes of children with ADHD are under-responsive to stimulation and that cerebral blood flow is reduced. Parts of the brain, including the frontal lobes, caudate nucleus and globus pallidus, have also been found to be smaller that normal. There is also poor performance in frontal lobe functioning in neurophysiological tests. Neurological studies indicate that in ADHD children the brain has developed differently but is not damaged (Davison & Neale, 2001).
An Imaging study by Shaw, Rapoport & Evans, published in 2007 by the National Institute of Mental Health (NIMH) has revealed that the brain matures in a normal pattern in children with ADHD but is delayed an average of three years in some regions, compared to children without the disorder. They discovered a normal yet delayed pattern
of cortex maturation, which could explain why many children eventually outgrow their ADHD. The greatest maturational delay was seen in the circuitry of the frontal and temporal areas. This area integrates information from the sensory areas with higher-order functions. The motor cortex was found to develop faster in these children, possibly due to their hyperactive component. Although the ADHD group initially had a thinner cortex, after being re-scanned approximately 5.7 years later, changes between the ADHD and the control group were much greater in those children whose ADHD symptoms had not improved and, in the children who had much improvement the scans resembled that of healthy peers (NIMH, 2006). The findings of the study support theories that ADHD results from a delay in cortex maturation (NIMH, 2007).
Cross-cultural consistencies in ADHD behaviour may also be seen to support these neurobiological and genetic explanations of ADHD (Meyer et al., 2004).
BRAIN INJURY OR DAMAGE
Children who have suffered accidents resulting in brain injury may show signs of behaviour similar to that of ADHD, but only a small percentage of children with ADHD
have been found to have suffered a traumatic brain injury (NIMH, 2008 pg 8). Children suffering significant trauma to the frontal part of their brain are more likely to develop symptoms of ADHD as a consequence. Any process that disrupts the normal development or functioning of the frontal part of the brain, and its connections to the striatum (caudate nucleus and putamen) is likely to result in ADHD (Barkley, 2005 pg 27).
The neurotransmitters responsible for attention and motor behaviour are the catecholamines. These are namely dopamine, norepinephrine and epinephrine. The catecholamine hypothesis that ADHD is caused by a deficiency in these neurotransmitters stems from the fact that drugs (e.g. methylphenidate and dextroamphetamine) used to treat ADHD increase the amount of catecholamines in the brain. There is however no direct evidence that these children suffer a catecholamine deficit (Kronenberger, 2000 pg 48).
There are psychological theories for the development of ADHD (Wolfe, 2005). Although chaotic family life and parental psychiatric problems are associated with, and may well cause, serious defiant and aggressive behaviour, they are not causative of ADHD (Barkley, 2005 pg 100).
There is a scarcity of compelling evidence at this time that ADHD can arise purely from social factors or child-rearing methods.
Environmental factors may influence the severity of the disorder, and the degree of impairment and suffering the child may experience, but they do not appear to give rise to the condition by themselves (NIMH, 2008 pg 7). Many of these children’s problems may be exacerbated by inadequate teachers, unsuitable educational settings, or problems with their parents (Wolfe, 2005).
COMPLICATIONS OF PREGNANCY AND DELIVERY
Mothers who experienced complications of pregnancy or delivery are more likely to have children with ADHD than those without complications. Complications may cause ADHD by interfering with the normal brain development of the foetus (Barkley, 2005 pg 102).
Smoking cigarettes during pregnancy has been shown to cause significant abnormalities in the development of the caudate nucleus and the frontal regions of the brain. The combination of nicotine exposure both during and after pregnancy creates the greatest likelihood of significant behavioural problems (Barkley, 2005 pg 88). Nicotine stimulates dopamine release in the brain, resulting in hyperactivity (Davison & Neale, 2001).
Alcohol consumption during pregnancy has also been shown to have a similar effect on the development of the caudate nucleus and the frontal regions of the brain.
Foetal Alcohol Syndrome, a specific pattern of foetal malformation, found among offspring of mothers who are chronic alcoholics, leads to a heightened risk of ADHD (Barkley, 2005 pg 27, 88).
A very basic requirement that may be overlooked is optimum nutrition during pregnancy. The brain is the most vulnerable organ in the body and suboptimal nutrition during foetal development has a profound effect on the brain, learning and behaviour (Holford, 2004 pg 358).
Low birth weight (< 1000g) is sometimes associated with ADHD (Beers, 2006), yet most children with low birth weight do not develop ADHD, and most children with ADHD do not have a history of low birth weight (DSM-IV-TR, 2000 pg 88).
Babies born prematurely and with low birth weights may have a higher likelihood of developing ADHD in later childhood - sometimes 5 to 7 times that of the general population. This may be due to the fact that these babies have a high risk of suffering small brain haemorrhages during delivery (Barkley, 2005 pg 103). It seems that the combination of prematurity and low birth weight is the greater risk.
The following complications before or during birth increase the risk of ADHD: (Barkley, 2005 pg 103)
Number of cigarettes smoked by the mother per day
Seizures of the mother
Number of times hospitalised during the pregnancy
Breathing problems in the child during or after delivery
Amniotic fluid stained by meconium (a sign of foetal hypoxic distress)
Weight and health of the placenta when inspected after delivery
Child less healthy during infancy or preschool years, slow developed motor coordination at a higher risk for early and persistent ADHD symptoms later in childhood
(Barkley, 2005 pg 103).
Nutritional deficiencies in ADHD children could severely increase the problems they already face. Identifying and correcting existing deficiencies may not only clear up
some of the problems but may help the child cope more effectively with those that remain (Picton, 2005 pg 53). Some of the most important nutrients for brain development are absent in the average modern diet (Holford, 2004 pg 358).
Symptoms of essential fatty acid (EFA) deficiency are common in many children with ADHD. These include excessive thirst, dry skin, eczema and asthma. An aspect to consider is the fact that males have a higher EFA requirement than females and 4 out of 5 ADHD sufferers are boys. This suggests a possible correlation that requires more research. It is theorised that these children are deficient in EFAs due to inadequate dietary intake, higher requirements, poor absorption or poor conversion of them into prostaglandins. Prostaglandins are essential for brain communication.
Many of the foods claimed to cause symptoms of ADHD, such as dairy and wheat, inhibit EFA conversion into prostaglandins. Various enzymes are involved in the conversion and they require various vitamins and minerals to function.
These include vitamin B3, B6 and C, biotin, zinc and magnesium, all commonly found deficiencies in ADHD children (Holford, 2004 pg 358).
More than 60% of ADHD children are short of zinc. This is often a result of the refining process applied to certain foods, namely white sugar, white flour, and white rice. Consuming primarily refined grains increases the risk of nutritional deficiencies developing. Nutrients such as zinc and the B vitamins are found in the whole grain, but
not in the refined product. B Vitamins are important for regulation of the nervous system and metabolism of proteins, fats and carbohydrates. Hair analysis reveals that hyperactive children also often have very low levels of manganese (Picton, 2005 pg 47, 48, 55, 57).
Faulty digestion and absorption are also factors to be considered. Common problematic foods include wheat, high in gluten and dairy products containing casein.
These proteins are difficult to digest and may result in an allergy. The poor digestion of these proteins is a result of zinc-deficiency, and they enter the bloodstream due
to Vitamin A and EFA deficiencies. The peptides making up these proteins are able to mimic endorphins in the brain. They are referred to as exorphins and have a
damaging opioid-like effect on the brain, leading to symptoms seen in children with behaviour problems (Holford, 2004 pg 360).
It has been found that iron deficiency causes abnormal dopaminergic neurotransmission and thus this deficiency may contribute to the physiopathology of ADHD.
A study conducted by Konofal, Lecendreux, Arnulf & Mouren (2004) found that mean serum ferritin levels were twice as low in children with ADHD when compared
to age- and sex-matched children without ADHD. It was also found that the low levels correlated with more severe ADHD general symptoms, according to Conners’ Parent Rating Scale (available at http://www.pearsonassessments.com/tests/crs-r.htm), a 48-item scale that includes hyperactivity, cognitive, and oppositional subscales.
The reason for the low serum ferritin levels is unclear. Supplementing with iron could thus improve central dopaminergic activity in these children, decreasing the need for stimulants (Konofal et al, 2004).
Allergies or food intolerance can decrease the effect of any therapies being used to treat ADHD. Common signs and symptoms of food and chemical intolerance include fatigue, headaches, migraine, hyperactivity, disturbed sleep, restlessness, poor attention span, learning difficulties and aggression.
Foods that may affect hyperactive children include chocolate, wheat, tomato, eggs, cows’ milk, cheese and sugar (Picton, 2005 pg 75, 77).
Food additives and refined sugar have been blamed for ADHD in the past but have been found to only account for a very small percentage of the cases
(Davison & Neale, 2001).
HEAVY METAL INTOXICATION
Evidence has been surfacing over a number of decades that industrial chemicals can cause neurodevelopmental damage and that sub-clinical stages of these disorders might
be more common than previously realised (Grandjean & Landrigan, 2006 pg 1). Heavy metal intoxication results from the absorption of heavy metals. It can lead to autism, hyperactivity and psychosis. The main culprits are aluminium, lead
and cadmium. Aluminium foil, pots and pans should be avoided (Picton, 2005 pg 58, 59).
Lead, a neurotoxic chemical, produces lifelong changes in behaviour, attention span, impulsivity, aggressiveness, motor coordination, memory, and language skills (Grandjean & Landrigan, 2006 pg 8). It is a potential cause of inattention, hyperactivity or even fully-fledged ADHD in some cases (Barkley, 2005 pg 89). Other effects include mental retardation, temper tantrums, and emotional and behavioural problems. Increased levels of lead in the body cause a reduction in the levels of zinc, iron and copper. Levels of cadmium increased by cigarette smoke, tobacco and refined wheat flour. Too much cadmium in the body lowers zinc levels (Picton, 2005 pg 58, 59).
One of the most complex aspects in the treatment of ADHD is that it must evolve as a child grows up. A treatment that was successful at age 6 may not work at age 16 (Barkley, 2005 pg 112).
Most children require help from a variety of disciplines, and the period of time that they attend the different therapists depends on the individual needs of the child and the nature of the therapy. A team approach is usually needed with both the parents and the professionals playing a role in the child reaching his/her best potential
(Picton, 2005 pg 26).
The Multimodal Treatment Study of Children with ADHD was a 14 months randomised clinical trial of treatment strategies for the condition. It was conducted on 579 elementary school boys and girls with ADHD. The results of the study indicated that long-term combination treatments and medication-management alone were superior to intensive behavioural treatment and routine community treatment.
The advantage of combined treatment was that children could be treated with lower doses of medicine, compared with the medication-only group (NIMH, 2008 pg 11). Multimodal treatment should consist of medication, behavioural therapy, and educational accommodations (DuPaul & Weyandt, 2006). This is not quite a realistic goal
for standardised ADHD treatment in the South African context due to financial constraints.
The management of ADHD traditionally includes consideration of 2 major areas: nonpharmacological and pharmacotherapy (Wilens, 2008).
Behaviour therapy, emotional counselling, and practical support help ADHD children handle everyday problems (NIMH, 2008 pg 14), whilst environmental changes are implemented to decrease limitations caused by ADHD (Davison & Neale, 2001). Behavioural therapy teaches people how to develop effective ways to work on immediate issues, helping to change their thinking and coping strategies, thus leading to changes in behaviour. In social skills the therapist discusses, teaches and models appropriate behaviours that are important in developing and maintaining social relationships (NIMH, 2008 pg 15).
In some cases remedial schools may be of benefit. These schools have the facilities to accommodate specific learning problems, and after a few years the child is able to
return to the mainstream school system better able to cope with academic demands. These schools offer small classes with individualised attention. The teachers are qualified to handle learning problems. Many remedial institutes offer a multidisciplinary approach for assessing children and provide excellent service. Speech therapists, occupational therapists and remedial therapists are usually part of the support team (Picton, 2005 pg 27).
Currently, more than 2.5 million children in the United States are being prescribed ADHD medications (Mozes, 2008). These medications are probably the most widely publicised and debated treatment for ADHD (Barkley, 2005 pg 319).
The management of ADHD traditionally includes consideration of 2 major areas: nonpharmacological and pharmacotherapy (Wilens, 2008).
Behaviour therapy, emotional counselling, and practical support help ADHD children handle everyday problems (NIMH, 2008 pg 14), whilst environmental changes are implemented to decrease limitations caused by ADHD (Davison & Neale, 2001). Behavioural therapy teaches people how to develop effective ways to work on immediate issues, helping to change their thinking and coping strategies, thus leading to changes in behaviour. In social skills the therapist discusses, teaches and models appropriate behaviours that are important in developing and maintaining social relationships (NIMH, 2008 pg 15).
In some cases remedial schools may be of benefit. These schools have the facilities to accommodate specific learning problems, and after a few years the child is able
to return to the mainstream school system better able to cope with academic demands. These schools offer small classes with individualised attention. The teachers are qualified to handle learning problems. Many remedial institutes offer a multidisciplinary approach for assessing children and provide excellent service. Speech therapists, occupational therapists and remedial therapists are usually part of the support team (Picton, 2005 pg 27).
Currently, more than 2.5 million children in the US are being prescribed ADHD medications (Mozes, 2008). These medications are probably the most widely publicised
and debated treatment for ADHD (Barkley, 2005 pg 319).
A possible social cause of the rise in prescription ADHD medications may be the lowering of public education budgets, resulting in larger classes in which the teachers
are far less tolerant of hyperactive behaviour (Frei & Thurneysen, 2001).
Medications are not intended for use in cases where symptoms are secondary to environmental factors and/or primary psychiatric disorders, including psychosis (Methylphenidate, 2008). There is a need for detailed, accurate, and comprehensive assessment by trained and experienced practitioners before starting ADHD treatment (Coghill, 2004). The diagnosis of ADHD should not constitute automatic drug treatment (Barkley, 2005 pg 335).
At present much less is known about treating the inattentive subtype than the hyperactive-impulsive subtype. The hyperactive-impulsive subtype demonstrate a much
greater therapeutic response to medication, with a 55 - 65% lower response demonstrated by the inattentive subtype (Barkley, 2005 pg 163, 164, 335).
Psychotropic medication, whilst often being effective in improving attention and decreasing disruptive behaviour, is not always associated with marked enhancement of academic functioning (DuPaul & Weyandt, 2006), personal relationships or quality of life (Landgraf, Rich & Rappaport, 2002 pg 386).
Medications include psychostimulants, atomoxetine, antidepressants and antihypertensives.
Conventional treatment for ADHD consists of psychostimulants (Davison & Neale, 2001). The more commonly used compounds in this class include methylphenidate
Stimulants are sympathomimetic drugs, which increase intrasynaptic catecholamines (mainly dopamine) via inhibition of the presynaptic reuptake mechanism and the release
of catecholamines (Wilens, 2008). The precise mode of action is not completely understood but they are presumed to activate the brainstem arousal system and cortex, producing a stimulatory effect (Methylphenidate, 2008). They deal directly with the underactive part of the brain that is responsible for inhibiting behaviour and maintaining effort or attention to things (Barkley, 2005 pg 323, 327).
The stimulants improve the child’s attention, impulse control, fine motor coordination and reaction time (Barkley, 2005 pg 328), enhancing and normalising a child’s natural abilities to focus, reflect and achieve academically, socially and behaviourally (Green, 1997). They have shown to be effective in improving behaviour, academic work and social adjustment in 90% of children with ADHD, 30 - 45% of children will have significant behavioural improvements but not normalise (Barkley, 2005 pg 319, 323).
About 1/3 of these children do not respond, or cannot tolerate this class of drug (Wilens, 2008). The greatest benefit of this therapy seems to be that it increases the effectiveness of psychological and educational treatments. Thus, it is usually recommended that medication be used as apart of a combination of treatments, not as the sole form of therapy (Barkley, 2005 pg 328).
These drugs are available in short-acting and long-acting dosage forms. The short-acting forms are taken a number of times a day, including during school hours.
A rebound effect may occur as the drug effect wears off, intensifying ADHD symptoms. Thus the long-acting dosage forms have become more popular (ADHD
In-Depth Report, 2008 pg 8). Stimulants are usually given orally for ADHD treatment (Barkley, 2005 pg 329), with the exception of Daytrana, the first skin patch drug
for ADHD. The patch is applied to the hip daily and delivers a 9 - hour dose of methylphenidate (ADHD In-Depth Report, 2008 pg 8).
Common adverse effects associated with stimulants include loss of appetite with subsequent loss of weight, headaches, nausea, abdominal pain, sleeplessness and depression (Picton, 2005). Antidepressants and other medications can help control accompanying depression or anxiety (NIMH, 2008 pg 13). Although a causal relationship has not been established, suppression of growth (i.e. weight gain and/or height) has been associated with the long-term use of stimulants in children. Methylphenidate may lower the convulsion threshold in patients with prior history of seizures (Methylphenidate, 2008). ADHD stimulants increase a child’s heart rate and blood pressure. Children with underlying heart disease who take stimulants appear to face an increased risk for sudden cardiac arrest. The American Heart Association recommends cardiac screening
before prescribing stimulant treatment for all children diagnosed with ADHD. They recommend taking a detailed patient and family medical history, a full physical exam,
incl. blood pressure and heart beat monitoring; an electrocardiogram (ECG); and a paediatric cardiologist consultation prior to treatment if evidence of heart disease is uncovered. Children should continue to have blood pressure check-ups once every 1 to 3 months, as well as routine check-ups every 6 to 12 months (Mozes, 2008).
Some children experience “behavioural rebound” as the stimulant wears off at the end of the school day. Other potential side effects incl. an increase in hyperactive behaviour (Kronenberger, 2000) and approximately 15% of children placed on stimulants may develop simple tics or nervous mannerisms (Barkley, 2005 pg 332).
Magnesium pemoline (= Ritalin-ähnlich) may rarely cause hepatitis (Wilens, 2008).
Methylphenidate should not be used in children under 6 years of age, since safety and efficacy in this age group have not been established. Available clinical data indicates that treatment with stimulants during childhood +/o. adolescence does not seem to result in increased predisposition for addiction (Methylphenidate, 2008) however, there are no long-term studies on the potential long -term negative effects that might be causes by persistent use of these medications (Barkley, 2005 pg 331).
Strattera, a non-stimulant drug, works by increasing the levels of the neurotransmitter norephinephrine (NIMH, 2008 pg 13; ADHD In-Depth Report, 2008 pg 8), with 70% of children manifesting significant improvement in their ADHD symptoms (NIMH, 2008 pg 13). There is, however, a warning that Strattera increased suicidal tendencies in children and adolescents with ADHD (Aschenbrenner, 2006), thus patients on this treatment should be closely monitored.
Although not as effective as the psychostimulants, these drugs can be of some benefit in the treatment of ADHD in cases where there has been an inadequate response to stimulant medication, unacceptable side effects from medication, or in cases where a comorbid condition such as depression, anxiety disorder, is present. They are not as effective as the stimulants in improving the symptoms of ADHD and they are often combined with one of the stimulants to achieve optimal results (Barkley, 2005 pg 339, 340).
i. TRICYCLIC ANTIDEPRESSANTS
Tricyclic antidepressants act by blocking the re-uptake of neurotransmitters, including norepinephrine. They are effective in controlling abnormal behaviours and improving cognitive impairments associated with ADHD, but less so than the majority of stimulants (Wilens, 2008).
Possible side-effects include increase risk of seizures or convulsions, dry mouth, constipation, weight gain, blurred vision, nearsightedness, slowed heart rate, nervous tics, rash and photophobia. Children may develop a tolerance to the tricyclic antidepressants, so usually they cannot take these medicines for more than a year or two (Barkley, 2005 pg 341, 342).
Bupropion (Wellbutrin®, Zyban®) is an antidepressant with indirect dopamine and noradrenergic effects, often used as an initial agent for complex ADHD patients with substance abuse or unstable mood disorder. Possible side effects include increased activity, irritability, insomnia, and rarely seizures (Wilens, 2008).
The antihypertensives clonidine (Catapres®) and guanfacine (Tenex®) are used in the treatment of the hyperactive-impulsive symptoms of ADHD.
These alpha-2 agonists stimulate the neurotransmitter norepinephrine (ADHD In-Depth Report, 2008 pg 9), reduce motor hyperactivity and impulsiveness, increase a child’s cooperativeness and increase the child’s tolerance for frustration. They are best suited for very oppositional or defiant cases, in cases with associated conduct disorder or in
the treatment of children with ADHD who have adverse effects with, or get no beneficial effects from the stimulants (Barkley, 2005 pg 343, 344). They are also used to
treat the associated tics, aggression, and sleep disturbances of ADHD, particularly in younger children (Wilens, 2008).
Sedation is more commonly seen with clonidine, but both agents may cause depression and rebound hypertension (Wilens, 2008). Other potential side effects include a drop
in blood pressure, tiredness, headaches, dizziness, nausea, stomach-aches, vomiting, dry mouth, depression, erratic heart rate, disturbed sleep, increased appetite, with increase or decrease in weight, and increased anxiety, Raynaud’s syndrome or water retention (Barkley, 2005 pg 344).
Various diets have been suggested to treat ADHD. Studies are quite conflicting as to their efficacy. A number of well-conducted studies have shown poor efficacy in dietary restriction of sugar and food additives on behaviour, although there are improvements in a small percentage of cases. In other cases, behavioural improvements are shown with allergen-restricted diets (ADHD In-Depth Report, 2008).
The Feingold Diet was originally devised for patients suffering from allergies. It was soon noticed that the behaviour of many hyperactive children improved dramatically when put on the same diet. The diet avoids salicylates, synthetic flavours and colourants, selected preservatives and some natural foods. Chemical antioxidants are avoided and fried foods kept to a minimum. Unrefined and unprocessed foods are preferable and vitamin, mineral and essential fatty acid supplementation is important.
Most hyperactive children cannot tolerate artificial salicylates and these should be avoided. Many hyperactive children can tolerate natural salicylates but one must check for sensitivity to them. Some hyperactive children may be affected by the close relatives of salicylates found in some non-edible products as certain synthetic fibres, insecticides, detergents, some antiseptics, ventalin, and methyl salicylate which is found in many cough medicines (Picton, 2005 pg 39, 43, 44).
It is essential that a child with ADHD obtains optimal nutrition and supplementation may be necessary (Lesperance, 2006). From the time that the child is no longer breast-fed and is relying on solid food for nutrients, supplementation of a child’s diet is recommended. Most companies have a single multivitamin and mineral supplement formulated
for children. EFA supplements containing gamma-linolenic acid (GLA)(Omega 6) and docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA)(Omega 3) are recommended if the child is not eating oily fish 3 times a week and daily seeds (Holford, 2004 pg 361 - 365). A properly balanced diet aids in the development of healthy brain cells and healthy cellular functioning. It is important to ensure that the child has no deficiencies and it is advisable to remove as many processed and unnatural substances as possible from the diet. This will eliminate any dietary contributions to behavioural problems and hyperactivity Lesperance, 2006).
Further investigation by means of nutritional studies, need to be conducted in order to establish the validity of the role of nutrition in the treatment of ADHD. It is imperative that the scientific community puts greater effort in developing natural, effective treatments for ADHD. Results of a double-blind, placebo-controlled study on the efficacy of pine bark extract (Pycnogenol), showed promising results, with a significant improvement in symptoms of hyperactivity, poor attention, visual-motor coordination, and concentration in the treatment group (Barclay, 2006). More effort must be directed towards such studies.
Rating scales usually consist of a list of the DSM-IV criteria symptoms, rated by an observer according to frequency of occurrence. ADHD rating scales are widely used, and are relevant, and convenient for clinicians. They are valuable as they standardise the assessment of diagnostic symptoms (Kronenberger, 2000pg 57). On the other hand, current assessment scales fail to assess and fully gauge the effect that ADHD and its treatment have on everyday quality of life for the child and the family (Landgraf et al, 2002). Thus they do not incorporate a holistic view of the impact of the condition on the child and its environment. It is best to use an existing scale that has credibility and uniformity.
Questionnaires must not be too elaborate. School questionnaires give insight into the academic, social and behavioural history of the child from the school’s perspective (Levin, 2001).
Child questionnaires are not always utilized in studies, as the child is usually the last to notice any improvement in his/her condition (Picton, 2005). In this study both parent and teacher scales have been utilised.
ADHD RATING SCALE-IV
The ADHD Rating Scale-IV scales consist of both Home and School Versions. These rating scales use the diagnostic criteria as listed in the DSM-IV as their basis (Low, 2008). Both the parent/guardian and the child’s teacher complete the relevant scales. ADHD is defined as being present in more than one setting so true assessment must be over two settings, in this case, home and school (Levin, 2001). Thus the ADHD Rating Scale-IV scales are credible, commonly utilized scales for ADHD screening, diagnosing, treatment monitoring, and research.
They are both a tool for diagnosing ADHD in children and adolescents ages 5 - 17, and for measuring improvements with treatment. These scales contain 18 items and take
10 - 20 minutes to finish (School Psychiatry Program & Resource Center, 2008). The parent’s questionnaire asks the parents/guardians to rate children’s behaviour on a scale of “never” to “very often” and includes questions on activity levels, ability to finish work, forgetfulness and inattention. The teacher‟s version includes questions on organisation, activity level, disruption to the classroom, listening, and inattention (Low, 2008). The ADHD Rating Scale-IV was utilised in this study due to its credibility and affordability.
The economic, educational, social and personal costs of ADHD can be significant (Meyer et al, 2004). Once children with ADHD enter school, a major social burden is placed on them that will last for at least the next 12 years. Up to 30 - 50% of these children may be retained in a grade at least once and as many as 35% may fail to complete high school altogether. It is a major area of impact of the disability and may create the greatest source of distress for the child and parents (Barkley, 2005 pg 24, 114).
Uninhibited behaviour results in impairment in how well rules, instructions and a child’s inner voice or „conscience‟ helps that child to control behaviour. For 50% of ADHD children, social relationships are seriously impaired, and for more than 60%, seriously defiant behaviour leads to resentment by siblings, frequent scolding and punishment, and a greater potential for delinquency (Barkley, 2005 pg 24, 25, 41). They are at a higher risk for early onset cigarette smoking, and alcohol and drug abuse (Wilens, 2008). Adolescents may become sexually active at an earlier age and may be less likely to employ birth control when they do so. The antisocial behaviour and crime must be taken into account as greater than 20% of children with ADHD have set serious fires in their communities, 30% have engaged in theft, and 25% are expelled from high school because of serious misconduct. Fighting with other children is a problem for at least 25% of these children (Barkley, 2005 pg 115, 116).
A study conducted by Mannuzza, Klein, Abikoff & Moulton (2004) investigated whether low to moderate levels of childhood oppositional defiant disorder (ODD) and conduct disorder (CD) behaviours contribute to the development of clinically diagnosed CD in adolescence, in children with ADHD. Participants consisted of 207 white boys, aged 6 - 12, with ADHD free of CD.
They were assessed at the start of study (aged 6 - 12) then again at adolescence (mean age 18), with a final follow-up at adulthood (mean age 25). The findings of the study showed that childhood ADHD, even in children free of antisocial and oppositional behaviours, is a developmental precursor for conduct disorder in adolescence and antisocial behaviour in adulthood (Mannuzza et al., 2004).
Up to 80% of school-aged children given a clinical diagnosis of ADHD will have the disorder persisting into adolescence, and 30% - 65% will have it into adulthood
(Barkley, 2005 pg 112). It is seen as a chronic condition continuing into adulthood in approximately half of childhood cases (Wilens, 2008).
Adolescents and adults who overcome their symptoms are diagnosed as being “In Partial Remission.” This reflects the view that people do not outgrow this disorder but
learn to compensate so that the ADHD symptoms are no longer disabling (Sonna, 2005 pg 3), thus ADHD in adults is always a continuum of the childhood condition.
Adult-onset symptoms are likely due to other factors. Diagnosing adult ADHD can be difficult since hyperactivity typically decreases as children get older, whilst attention and organizational problems may be more prominent. As of 2005, it was estimated that ADHD affects approximately 4.1% of adults aged 18 - 44 years (ADHD In-Depth Report, 2008 pg 1, 3). It may cause educational as well as interpersonal problems (Wolfe, 2005 pg 467) and even though many of these adults will be employed and
self-supporting, their educational level and socio-economic status tend to be low, even when compared to those of their own siblings (Barkley, 2005 pg 116).
Between 19 - 37% of adults with ADHD have co-existing depression or bipolar disorder; between 25 - 50% have an anxiety disorder, and approximately 20% of these
adults have learning disorders, usually dyslexia and auditory processing problems (ADHD In-Depth Report 2008 pg 3). Only 10 - 20% of children with ADHD reach adulthood without any other psychiatric diagnosis, coping well and without significant symptoms of their disorder (Barkley, 2005 pg 116). Untreated adult ADHD leads
to under-functioning even if the person has average to above average intelligence (Picton, 2005 pg 120). On the other hand, many people with ADHD are able to channel their energy in a positive direction and many of the world’s highly successful people have been found to have the condition (Macnair, 2005).
Once ADHD has developed, how severe it becomes and how much it persists is partly related to how the condition is managed. Failure and under-achievement are likely to dominate the life of a child whose ADHD is left unrecognised and untreated (Barkley, 2005 pg 24, 25, 106, 107).
Homoeopathy is a medical art and science developed by Samuel Hahnemann. The word „homoeopathy‟ is derived from the Greek words homeos, meaning „like‟ or „similar‟, and „pathos‟, meaning „suffering‟. The foundations of homoeopathy are the Law of Similars and the infinitesimal dose (De Schepper, 2006).
THE VITAL FORCE
The entire concept of health and healing, according to homoeopathy, is based on the Vital Force, or the energy force within the body. The role of homoeopathy is to reduce
the patient’s susceptibility to external and internal factors, by strengthening the Vital Force through the application of homoeopathic remedies. Remedies achieve this by stimulating the Vital Force (De Schepper, 2006).
THE LAW OF SIMILARS
This is the principle that a substance, which produces certain symptoms in healthy people, can cure the same symptoms in the sick. In order to cure gently, rapidly, certainly
and permanently in each case, one must choose that medicine which can arouse a similar suffering to the one it is supposed to cure (De Schepper, 2006 pg 26).
The infinitesimal dose is based on the idea that much smaller doses of a drug are needed to bring about a reaction in the diseased body, as homoeopathy is based on the paradigm of healing that the patient brings about the cure after remedies stimulate the patient’s curative powers. This is achieved by administering remedies that are in highly diluted, potentized form, where almost no molecules of the original medicine are present. These remedies are prescribed in a number of different potency scales which all act differently on the organism. The potency is selected according to the clarity of the case and the state of the patient’s vital force (De Schepper, 2006 pg 39).
TOTALITY OF SYMPTOMS
The totality of symptoms is a comprehensive picture of the whole person (Reichenberg-Ullman & Ullman, 2000 pg 288).
The role of the homoeopath is to find the totality of symptoms through careful, thorough case-taking. This involves taking into account mental, emotional and physical states
of the patient in their current state (De Schepper, 2006).
The physician must find the remedy that is most similar to the totality of symptoms. This remedy is known as the simillimum and should cover the case on all levels; mental, emotional and physical. Treating with homoeopathic simillimum is the basis of classical homoeopathy. This also brings in the classical homoeopathic concept of the administration of single, simple medicines, as emphasised by Hahnemann in Aphorism 273 (O’Reilly, 2001 pg 246):
“In no case is it necessary to employ more than a single simple medicinal substance at one time with a patient.”
HOMOEOPATHIC TREATMENT OF ADHD
Homoeopathy provides a valuable service in the treatment of ADHD (Picton, 2005) as one of the most fundamental tenets of homoeopathy is that we do not treat a disease, but rather a patient with a disease (De Schepper, 2006).
A homoeopath observes and explores a child’s thought processes, emotional state, physical aspects and nutritional status (Picton, 2005). Advantages of homoeopathy over some drug treatments are the easy administration of the treatment, there is a continuous treatment effect over 24hrs, and there is no risk of abuse (Frei & Thurneysen, 2001 pg 187). Homoeopathic medicine is non-toxic and is not known to produce iatrogenic side effects. Homoeopathic prescribing is not easy, as the remedy of choice must correspond to the patient as well as the illness. (Jack, 2001 pg 11, 30)
HOMOEOPATHIC RESEARCH ON ADHD
Lamont (1997) conducted research into the homoeopathic treatment of ADHD using simillimum. He conducted the study on 43 children diagnosed with ADHD.
They were assigned placebo or homoeopathic simillimum in a double-blind, partial crossover study to test the efficacy of the treatment for this disorder.
Medication was administered in the 200CH potency. Statistical analysis was based on parent or caregiver ratings before and after treatment. A 5-point rating scale was utilized. The placebo group only received placebo for the first 10 days of the study, thereafter they proceeded with simillimum treatment. The comparison results for the initial placebo group versus the initial treatment group were mean improvement scores of 0.35 for the placebo group and 1.00 for the treatment group. At the follow-up interviews, 2 months after treatment was completed, of those that showed improvement on homoeopathic treatment, 57% had continued improvement, 24% showed improvement for several days or weeks after treatment but had relapsed before the follow-up, and the remaining 19% only had improvement whilst on the homoeopathic medication.
The results of this study thus showed homoeopathic treatment to have greater efficacy in the treatment of this disorder than placebo. This study has decreased credibility
due to the fact that the placebo group was known to the researcher, introducing the possibility of him inadvertently influencing the outcomes, and that it was not maintained
as a placebo group as the participants were given treatment after 10 days. An accredited rating scale was not utilised. The researcher also limited the treatment to one potency. In the current study the researcher remained blinded throughout the study, there remained a placebo group for the duration of the study, an accredited rating scale was utilised, and simillimum treatment was not limited to a specific potency. It was administered in the potency most indicated by the individual case.
Frei and Thurneysen (2001) conducted a study comparing homoeopathy and methylphenidate in a family setting on 115 hyperactive children, aged 3 - 17 years. Each participant had to have a predetermined level of severity of hyperactivity, measured by Conners’ Global Index (CGI), and each received individual homoeopathic treatment in LM potency. Once overall clinical improvement, summarised as a percentage by the parents, reached 50%, symptoms were re-evaluated. Those participants whose CGI had not improved sufficiently were changed to methylphenidate and re-evaluated after 3 months. After an average treatment time of 3.5 months, 75% of the participants had responded to homoeopathic treatment, with a clinical improvement of 73% and a decrease in the CGI of 55%. Methylphenidate was administered to 22% of the children,
with clinical improvement of 65% and a decrease in the CGI of 48%. Three children did not respond to either treatment. The parent ratings of clinical improvement and the CGI scores were slightly better under homoeopathic treatment than under methylphenidate. An interesting observation in this study is that in the intervals between homoeopathic medicines the children displayed a reappearance of hyperactivity symptoms, favouring the impression that homoeopathy is more of a palliative treatment for ADHD. Long-term follow up studies would be required in order to ascertain whether a curative effect can be expected (Frei & Thurneysen, 2001 pg 186). Only LM potencies were utilised in the current study.
Frei, Everts, von Ammon, Kaufmann, Walther, Hsu-Schmitz, Collenberg, Steinlin, Lim & Thurneysen (2007) conducted another study; this time a randomised, placebo-controlled, cross-over trial on 83 children with ADHD. This Swiss study was designed with an open-label screening phase prior to the randomised controlled phase.
During the screening phase the response of each child to successive homoeopathic medications was observed until the optimal medication was identified. 84% of the
children responded to treatment to a degree that they became eligible for the randomised trial. Only children who reached a predefined level of improvement participated
in the randomised, cross-over phase. The double-blind part of the study consisted of two groups of children who received either simillimum treatment for 6 weeks followed
by placebo, or placebo for 6 weeks followed by treatment. A significant difference between placebo and treatment was displayed, showing that the effects of homoeopathy are specific and cannot be attributed to placebo. However, two problems were encountered. There was a strong carry-over effect and an unexpected rise in the rating scale readings in the treatment group during the first cross-over period. These were attributed to parental expectation that their child would receive placebo during this period.
These problems reduced the size of the apparent treatment effect, could have been avoided had randomisation and closed labels been implemented at treatment start
(Frei et al, 2007, 35-41). Other factors in this trial are that only LM potencies were utilised and only a 10 - item rating scale was used to monitor treatment. In terms of South African homoeopathic studies, Middleborough (2004) conducted a study to determine the efficacy of supplementation using Evening Primrose Oil and Low Homoeopathic Potency Gamma Linolenic Acid (GLA) in the management of ADD and ADHD in boys. His results showed that there was no statistical significant improvement within the individual scores of the treatment groups. It was however apparent that there was an improvement with regards to the mean scores of the Evening Primrose Oil group, and to a lesser extent, the Homoeopathic GLA group, indicating slight improvement in the participants of these 2 groups.
Lottering (2006) conducted a study to establish the efficacy of Advanced Brain Food® and a Homoeopathic complex, Quietude® (Nux moschata 4C, Hyoscyamus niger 3C, Passiflora incarnata 3C and Stramonium 6C) in the management of ADHD in boys.
Using the ADHD Rating Scale-IV, the intra-group comparison of the results of each of the groups showed no statistically significant improvement within the individual scores. Inter-group omparison however revealed that there was improvement in the mean scores of the Advanced Brain Food® group, and to a lesser extent, the Quietude® group. This indicated a slight improvement (not statistically significant) in the participants of these 2 groups. Thus, to date, no studies have investigated the effects of homoeopathic simillimum in the treatment of ADHD in the South African context, emphasising the importance of this study in the development of the treatment of ADHD using homoeopathic simillimum in this country. [Leider kann ich die Quelle nicht finden]
Two double-blind studies compared
“Quietude” = a Complex. (Nux-m. C 4, Hyos. C 3, Passi. C
3, Stram. C 6), a combination of homeopathically prepared plant extracts that
has been very popular in
there was no daytime dizziness, as opposed to 13% of the diazepam group. Homeopathic remedy group suffered no daytime drowsiness, but 53% of the diazepam group felt drowsy. In addition, Quietude was better at reducing children's nightmares. 74% of the Quietude patients said the product was better than other treatments, as opposed to 48% of the diazepam group who felt this way. [John-John Brian Lottering theories for ADHS]
The relative efficacy of Advanced Brain Food® and a Homeopathic Complex (Quietude® in the management of Attention Deficit Hyperactivity Disorder (ADHD) in males between 8 and 13 years.
MATERIALS AND METHODS - STUDY DESIGN
The objective of this study was to determine the relative efficacy of homoeopathic simillimum in the treatment of ADHD in school attending children aged 6 - 11 years.
This was a clinical trial in which an experimental group was compared to a placebo control group. The study was conducted as a double-blind study. The 40 participants
were randomly divided into 2 groups prior to the study.
Group 1 was the treatment group receiving homoeopathic simillimum.
Group 2 was the control group receiving placebo.
The study required 3 consultations at The Homoeopathic Day Clinic with the researcher. These took the form of an initial consultation and 2 follow-up consultations.
The consultations were spaced 4 weeks apart. The parent/guardian and the participant had to be present at each of these. A homoeopathic case history was taken at the initial consultation and a physical exam was performed at each consultation. The purpose of the consultations was to find the simillimum for each case. After each consultation the case was analysed using Radar 9.0 Repertory Programme for Windows to find the simillimum (Appendix N). A treatment protocol was formulated for each child and this
was confirmed by 1 of 2 specified clinicians of The Homoeopathic Day Clinic. The script was then forwarded to a technician for dispensing.
Results were captured by means of the ADHD Rating Scale-IV. Both the Home and School Versions were utilized. These were completed by the parent/guardian and teacher respectively. The parent/guardian completed the Home Version at each consultation. The School Version was sent to school, and was completed by the teacher before treatment commenced and again just before each follow-up consultation.
Only subjective data was incorporated in the analysis.
LOCATION OF STUDY
The trial was conducted at The Homoeopathic Day Clinic at The Durban University of Technology (DUT). Permission to utilise the clinic was granted by the Clinic Director.
The ADHD Rating Scales-IV was utilized in this study. They were completed by the parent/guardian and teacher.
ADHD RATING SCALE-IV
The questionnaires are based on the diagnostic criteria for ADHD as described in the fourth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, 2000). The Home and School Versions of the ADHD Rating Scale-IV were utilized. The ADHD Rating Scale-IV is a tool both for diagnosing ADHD in children and adolescents ages 5 - 17 and for measuring improvements with treatment.
These scales contain 18 items and take 10 - 20 minutes to finish (School Psychiatry Program & Madi Resource Center, 2008). The 18 scale items were written to reflect
DSM-IV criteria as closely as possible whilst maintaining brevity (DuPaul, Power, Anastopoulos & Reid, 1998).
The DSM-IV provides diagnostic criteria organized into 2 dimensions of Inattention and Hyperactive-Impulsive, each of which consists of 9 symptoms, which are equally represented on the questionnaire (DuPaul et al., 1998).
Thus both versions of the scales consist of 2 subscales that are empirically derived and conform to the 2 symptomatic dimensions described in the DSM-IV.
3 scores (Inattention, Hyperactivity/Impulsivity, and Total) can be derived from each version. Raw scores can also be converted into percentile scores by using the appropriate scoring profile based on the child’s gender and age (DuPaul et al., 1998). For the purposes of this study these percentile scores, as well as the raw scores, were considered for statistical analysis.
ADHD is defined as being present in more than one setting so true assessment must be over two settings, in this case, home and school. The questionnaires ask the parent/guardian and teacher to rate the child’s behaviour on a scale of “never” to “very often” and include questions on activity levels, ability to finish work, forgetfulness, inattention, organisation, listening and inattention (Low, 2008).
To ensure the full co-operationof parents/guardians and teachers, questionnaires should not be too elaborate and cumbersome (Levin, 2001).
Thus the ADHD Rating Scale-IV was utilized, as it consists of credible, commonly used scales for ADHD screening, diagnosing, treatment monitoring, and research.
During the course of the study 3 copies of each of the Home and School Versions were completed. The Home Versions were completed by the same parent/guardian at
each consultation to ensure reliability of data. The School Versions were sent to school for the class teacher to complete. Thus the questionnaires were completed at 4 - week intervals.
Child questionnaires were not utilized in this study, as the child is usually the last to notice any improvement in his/her condition (Picton, 2005).
The data required for this study consisted of the parents/guardians and teacher’s subjective observations of the participant’s behaviour before, during and after the study.
The general perceptions of the treatment from the parent/guardian, teacher and child were also considered as qualitative results.
The subjective data was made up of the score symptoms from the ADHD Rating Scale-IV. The score of symptoms was further subdivided into 3 variables, namely Inattention, Hyperactivity-/Impulsivity, and Total score, being a sum of the 2 variables. The statistical analysis was conducted using
SPSS® for Windows™ (Version 17.0) and Excel® XP™.
For the quantitative statistics, raw data was analysed using interferential statistics, namely Wilcoxon’s Signed Rank Test (This compared the treatment and placebo group independently of each other across different time periods).
Further the Reliable Change Index (RCI) was calculated for each component and for each assessment period. This was calculated by dividing the difference between two assessments by the standard error of observation.
The RCI is a measure of the clinical significance of an observation rather than a statistical significance. It returns the value of the observations, given the age and gender of the subject being assessed as well as the component being assessed. This is a reflection of an adjustment for observer error, not sampling error or population differences. Raw data as well as the RCI’s were used in the inferential statistics.
The Intergroup Analysis was conducted using the Kruskal-Wallis-H test and the Mann Whitney U test. These were done using the RCI calculations. Both these tests were used to determine the effect of a factor on the observed results (e.g. dosage form, ethnic group or treatment group).
This was a double-blind, placebo-controlled study. ADHD is not a life-threatening condition. The parents/guardians and children participating in the study were informed
of the possibility that they may receive placebo before the trial began. Bearing this in mind the researcher considered it ethically acceptable to utilize a placebo group as a measure against which treatment could be compared. On completion of the study those in the placebo group were informed and offered free treatment.
Following the methodology described in Chapter 3, the study produced raw data in the form of completed assessment score sheets (both Home and School Versions).
Each subject was assessed three times, once initially, once on first follow up and once at final follow up. Each subject therefore had 6 score sheets representing behaviour assessments over the course of the trial. The specific objectives of the analysis were as follows:
(1) To describe the demographic characteristics of the subject group.
(2) To determine any statistically significant differences between the placebo and treatment groups with respect to demographic variables.
(3) To determine any statistically significant correlations between the responses on the Home and School Versions of the scale for both placebo and treatment groups.
(4) To determine any statistically significant changes in the severity of the subjects‟ symptoms (as measured by the Home and School Versions of the scale) for both treatment and placebo groups.
(5) To determine any statistically significant differences between the treatment and placebo groups with respect to treatment outcomes (measured by the Home and School Versions of the scale).
The analysis of the data was done using SPSS® for Windows™ (Version 17.0) and Excel® XP™.
OVERVIEW OF RESULTS CHAPTER
Vithoulkas (2004) describes in The Science of Homeopathy that the 3 levels of the organism are physical, emotional and mental and that advancement of pathology may be seen to move from the physical level to the emotional, then finally to the mental. The main symptom of ADHD can be seen as inattention and this sits on the mental level.
It is thus logical to assume that improvement in such cases would begin first on the mental level, and then move to the emotional level, and finally the physical level.
This is according to Hering’s Law of Cure that states: „cure proceeds from above downward, from within outward, from the most important organs to the least important organs, and in the reverse order of appearance of symptoms’ (Vithoulkas, 2004 pg 231).
Although the results of the study did not show statistically significant improvements in the ADHD symptoms, this was only measured according to the rating scales. Parents/guardians and teachers made numerous comments to the researcher regarding improvements that they had noted in the child’s ADHD symptoms. This could indicate that the right simillimum has been prescribed but more time was needed to exert a change on the desired level, or that the scales were not detailed enough to reflect these changes. On the whole, the researcher noted improvements in emotional symptoms. The most striking example was of a Veratrum album case in which the child had suicidal tendencies and serious aggression problems, which included incidents of threatening family members with knives. The improvement reported by the parents and participant, and noticed by the researcher were quite remarkable. The child was happier within himself and was interacting more positively with those around him. Some general feedback from parents during the course of the trial was a decrease in aggression, improved self-discipline and application, a feeling of being less bothered by their disorder, and improved relationships. It is also felt by the researcher that with longer treatment duration greater improvement of ADHD symptoms would become more apparent once possible pathology on the emotional level was addressed. With regards to the physical level, it was noted that in some cases physical symptoms showed improvement at
follow up consultations. One participant had severe constipation since infancy, which improved on the remedy in the absence of significant improvements in concentration. Some of the children who had decreased appetites had improvements in appetite (it is not conclusive as to whether this improvement in appetite was attributed to previous appetite suppression as a side-effect of allopathic drug treatment, or as a beneficial effect of the treatment.). The physical changes in the absence of improvement on the
mental level could indicate, according to Vithoulkas, that the wrong remedy had been prescribed as improvement should start at the mental level, move to the emotional,
and then only to the physical, but the researcher did not find any cases wherein there was improvement on the physical level without an overall improvement in well-being.
In this study an improvement on the mental level was mostly gauged by a perception in school performance, as this was the focus of most parents, participants and teachers. More subtle improvements on the mental level could very likely have been missed.
A more qualitative approach of assessing improvement (e.g. a Quality of Life Scale) would be useful but most of the changes would still not be statistically measurable. This is a challenge when conforming a homoeopathic trial into an allopathic mould.
5.9 TRUE PREVALENCE OF ADHD
During the course of the study it was felt by the researcher and the clinicians that many of the participants did not truly fulfil all criteria for the diagnosis of ADHD. Many experts feel that ADHD
is over-diagnosed, largely because criteria are applied inaccurately (Beers, 2006 pg 2483). It is felt that in a number of cases behaviour and attention problems clearly stemmed from problems at home or school. In other cases ADHD symptoms were barely demonstrated. It is felt that there is gross over-diagnosis of this condition and that it is being used as an umbrella term for various behavioural
problems. It is all too often the case that a paediatrician or general practitioner makes a diagnosis and prescribes medication after obtaining only a brief case-history from the parent (Sonna, 2005 pg 14).
The over-diagnosis may also be seen as an indicator of the break-down of the family unit, so prevalent in society today. Problems prevalent in the participants‟ families included, divorce, absent prents and family conflict. A number of the participants were from dual-income homes, where both parents were out at work all day, resulting in the child being in the care of school and aftercare teachers all day and not getting the attention that they need from their parents. Another aspect to consider is the school system. Classrooms are usually grossly over-crowded, preventing ndividualised attention and help. This also leads to teachers feeling over-whelmed and frustrated, with a lowered threshold for tolerating behavioural and learning problems. Many believe that the real problem is cultural and that life has become so stressful that most adults feel overwhelmed by normal children (Sonna, 2005 pg 7). An interesting avenue of thought as to whether the condition is overdiagnosed or an adaptive response to an over-stimulated society could shed more light on its prevalence (Reichenberg-Ullman & Ullman, 2000 pg 23) The over-diagnosis could thus be an indication of modern society and our culture of placing great emphasis on normalcy and academic achievement. Parents seem to have set xpectations for their children and they are more often chastised for their weaknesses than given encouragement to focus on and develop their strengths. Parents, teachers and the health professionals who diagnose them seem to forget that children are individuals.
CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS
There have been a number of treatment modalities introduced for the management of ADHD. Conventional treatment, consists mostly of pharmacological intervention (Davison &Neale, 2001).
The Multimodal Treatment Study of Children with ADHD was a 14-month randomised clinical trial on treatment strategies for the condition. It was conducted on 579 elementary school boys and girls with ADHD. The results of the study indicated that long-term combination treatments and medication-management alone were superior to intensive behavioural treatment and routine community treatment. The advantage of combined treatment was that children could be treated with lower doses of medicine, compared with the medication-only group (NIMH, 2008 pg 11). Multimodal treatment should consist of medication, behavioural therapy, and educational accommodations (DuPaul & Weyandt, 2006). This study confirms that a more holistic approach is required when dealing with this condition and that the medication does work at placating the problem behaviour but it is more effective and less medication is required when treatment involves other modalities.
The major problem with the ADHD medications is the incidence of side-effects. Common adverse effects associated with these medications include loss of appetite with subsequent loss of weight, headaches, nausea, abdominal pain, sleeplessness and depression (Picton, 2005). There is also a lack of long-term studies to determine the effects of continuous treatment.
Thus remedial schools, psychotherapy, behavioural therapy, nutritional and dietary modifications, and modalities such as homoeopathy should be taken into consideration and implemented before embarking on the pharmacological route.
On analysis, the results (Tables 4.8, 4.9 and 4.10) showed no statistically significant effect of treatment (i.e. no difference between treatment and placebo group), but across the whole trial and within each group (particularly the treatment group) subjects had significant reductions in symptoms (i.e. the reductions in symptoms were large enough that there was less than 5% chance that they were random fluctuations/effects). This was seen in both the treatment and placebo groups, as indicated by Tables 4.11, 4.12 and 4.13, but more significant reductions were seen in the treatment group, indicated by Table 4.14.
As discussed in Chapter 5, this by no means rules out the efficacy of homoeopathic simillimum for the treatment of ADHD, in fact it gives encouragement for the conducting of larger, more extensive research projects in this direction. A vast number of parents and teachers are looking for safe, effective treatment for ADHD (Soreff & Chang, 2008), as well as for other behavioural disorders in children. This double-blind placebo-controlled study has aided in bringing to light homoeopathic simillimum treatment as one of those treatment options. Due to the tremendous variations in the behaviours, personalities, and characteristics of children diagnosed with ADHD, individualised treatment
is highly recommended (Reichenberg-Ullman & Ullman, 2000).
Homoeopathy provides the individualised treatment and holistic approach that these children need to support and help them cope with their disorder and the demands of developing into healthy, well-adjusted adults in this modern day.
Many experts think that ADHD is overdiagnosed, largely because criteria (DSM-IV-TR, Appendix A) are applied inaccurately (Beers, 2006 pg 2483).
Comprehensive diagnosis would be recommended for each participant entering into the study to ensure that diagnostic criteria are fulfilled. In this study participants had to
be pre-diagnosed by a child psychologist or paediatrician but even though this criterion was applied, misdiagnosis was still suspected in some of the cases, as the participants did not seem to fulfil ADHD criteria.
A costly recommendation that would reduce the variable of misdiagnosis would be to involve professional experts in the field of ADHD in the study and only accept participants diagnosed by them.
Another option would be to insist that participants have 2 diagnoses from professionals such as paediatricians, neurologists, psychologists or occupational therapists.
Further studies could also be conducted that focus on particular subtypes of ADHD. This would make finding participants more difficult but would be more likely to ensure accurate diagnoses. Ideally, studies involving treatment with simillimum should be carried out by experienced practitioners. They should be experienced both in simillimum prescribing and the specific sample group or disorder that is being studied. This would decrease the variable of an inexperienced practitioner. To lessen the chance of conducting a placebo-controlled simillimum trial with the incorrect simillimum, a study design like Frei et al.„s (2007) whereby treatment with simillimum is carried out until the participant reaches a pre-defined level of improvement should be implemented. After participants reach this level
they are then randomly divided into a treatment and a placebo group and this second phase of the study is conducted as a double-blind placebo-controlled study, with treatment being the individual’s pre-determined simillimum. This would mean a very long-duration study but a far more accurate method of comparing simillimum with placebo. It would also lessen the impact of being in the placebo group, for the participants, as they would have had successful treatment before, and the placebo period was
of a relatively short duration (6 weeks), compared to the treatment period (mean time of 5 months). The current study could not be conducted in this manner due to time
and budget constraints. Although generally ethically unsound, a study design incorporating a non-intervention group could eliminate the complication of placebo effect improvements. The sample group was small in this study due to patient compliance, and time and budget constraints. A larger study (e.g. 100
participants) with a longer duration (e.g. 1 year) would produce more significant results. In spite of the reliability and validity of DSM-IV symptom rating scales (such as ADHD Rating Scale-IV [Appendices B and C], used in this study), as a useful metric for evaluating and monitoring treatment effects, this approach has limitations.
From a clinical perspective, the reasons patients seek treatment are clearly only secondarily related to the specific symptoms. In other words, it is not the symptoms themselves that lead patients to our offices, but rather the wide range of idiosyncratic functional impairments that arise in day-to-day living. By considering the broader context of impairment when evaluating treatment effects, clinicians can potentially be more effective at individualizing interventions (Kollins, 2007). Use of a combined quantitative and qualitative approach in evaluating results is recommended. Quantitative results show the amount of improvement whereas qualitative results show the nature of the improvement (Dirckx, 2001). Incorporating qualitative data would ensure a more rounded evaluation of the outcomes of the study.
A recommendation would be to incorporate a Quality of Life rating scale such as the Child’s Health Questionnaire (available at http://www.healthact.com/chq.html), into the study, as it may capture more general, or other improvements described in Chapter 5.
In terms of utilising home and school versions of scales, more care could be used in ensuring uniformity in the application of the rating scales to further decrease the disparity between the results of the home and school versions.
The researcher could either ask the parent/guardian to complete the rating scale before proceeding with any discussion about the case or, alternatively, could meet with the teacher when he/she completes the scale.
Teacher education about homoeopathy and how it differs to the allopathic approach would be useful to sensitise the teacher to notice more subtle changes, and changes on other levels in the child. This would lead to a more detailed and accurate school assessment. Increasing the time period of cessation of other natural or orthodox treatment before commencing the study is recommended.
This study only specified 1-week of ceased treatment but it is felt by the researcher that increasing this time period would give the parents and researcher a clearer picture of the child’s baseline state. Frei et al.(2007) noted in their randomised controlled trials of homoeopathy in hyperactive children that patients pre-treated with stimulants were more difficult to treat with homoeopathy and could be an obstacle in a double-blind clinical trial. This obstacle could be removed if participants were limited to those who had never taken allopathic medication for their ADHD symptoms.
Another obstacle to cure was the family dynamics seen in most cases. A study involving a family approach to treatment could lead to a more significant treatment outcome.
The diagnosis of Adult ADHD is becoming more common and a study addressing this group would further the credibility of homoeopathic treatment for ADHD.
A large number of parents, teachers and doctors are seeking a safe, effective way to treat this highly prevalent disorder (Soreff & Chang, 2008) and, although the study did not satisfy the hypothesis that homoeopathic simillimum is an effective treatment for ADHD in schoolgoing children, it did aid in creating awareness of the use of homoeopathy as a treatment option for this condition and highlighted the need for more extensive research to be undertaken for this treatment option. It is the researcher’s opinion that larger, longer duration studies, employing quantitative analysis, as well as qualitative analysis would yield more significant results.