A.D.H.S. Anhang 9
https://pdfs.semanticscholar.org/dc0a/c2861936b64aa208f09fd66a8becce2689f5.pdf
[Megan Jones]
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).
PROBLEM STATEMENT
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.
OBJECTIVES
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.
CLINICAL PICTURE
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:
impulsivity:
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”
talks excessively
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).
DIAGNOSIS
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)
Visual problems
Learning difficulties related to visual perception
Speech, language and listening difficulties
Difficulties putting sounds together when learning to read
Emotional problems
Learning and remedial difficulties
Behavioural problems
Fine and gross co-ordination
Inappropriate sensory modulation
Delayed developmental milestones
Tourette’s Syndrome
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).
AETIOLOGY
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.
GENETICS
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).
BRAIN DEVELOPMENT
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).
NEUROTRANSMITTERS
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).
ENVIRONMENTAL FACTORS
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 INFLUENCES
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).
MANAGEMENT/TREATMENT
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).
PSYCHOLOGICAL TREATMENT
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).
REMEDIAL SCHOOLS
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).
MEDICATION
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).
PSYCHOLOGICAL TREATMENT
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).
REMEDIAL SCHOOLS
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).
MEDICATION
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.
PSYCHOSTIMULANTS
Conventional treatment for ADHD consists of psychostimulants (Davison
& Neale, 2001). The more commonly used compounds in this class include
methylphenidate
(Ritalin,
Metadate, Concerta), amphetamine (Dexedrine, Dextrostat and Adderall),
and magnesium pemoline (Cylert) (Wilens, 2008; Soreff & Chang, 2008).
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).
NON-STIMULANTS: ATOMOXETINE
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.
ANTIDEPRESSANTS
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).
ii. BUPROPION
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).
ANTIHYPERTENSIVES
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).
DIET
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.
MEASUREMENT TOOLS
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.
PROGNOSIS
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
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).
INFINITESIMAL DOSE
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).
HOMOEOPATHIC SIMILLIMUM
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.
MEASUREMENT TECHNIQUE
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).
DATA ANALYSIS
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).
ETHICAL CONSIDERTIONS
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.
RESULTS
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
CONCLUSIONS
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.
RECOMMENDATIONS
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.
CONCLUSIONS
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.
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