A

[Susan Margaret Nagle]

A survey of the perceptions and management of ADD/ADHD by homoeopathic practitioners in the Johannesburg Metropolitan Area.

1. Attention Deficit Hyperactivity Disorder (ADHD) - a disorder of attention and impulse control with specific DSM-IV criteria, appears in childhood and may continue through to adulthood though it usually subsides during adolescence. Hyperactivity may be a feature but is not a requirement for diagnosis (Stedmann’s Medical Dictionary, 1995).

2. Clinical Picture - The presenting pathological or functional disorder, or existing syndrome named according to conventional medicine (Bloch and Lewis, 2003).

3. Constitutional remedy - A remedy prescribed on the basis of temperament, character and general reaction of the person, as well as local symptoms of the disease (Bloch and Lewis, 2003).

4. Complex Remedy - A combination of two or more Homoeopathic medicines which are prepared from more than one stock and incorporated into one dosage form (Swayne, 2000).

5. D.I.T. – Durban Institute of Technology, as of 2002, now called Durban University of Technology, as of 2006 (ex- Natal Technikon).

6. Dopamine - a neurotransmitter secreted by the neurons that originate in substatia nigra. The terminations of these neurons are mainly in the striatal region of the basal ganglia. The effect of dopamine is usually inhibition (Guyton and Hall, 1997).

7. DSM-IV - Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)

8. Essential Fatty Acid (EFA) - any long chain monobasic organic acid required for normal functioning of the human body and which must be obtained from a food source (Stedmann’s Medical Dictionary, 1995).

9. Gamma-aminobutyric acid (GABA) - a neurotransmitter secreted by nerve terminals in the spinal cord, cerebellum, basal ganglia and areas of the cortex. It is believed to always cause inhibition (Guyton and Hall, 1997).

10. Glutamate - a neurotransmitter secreted by the presynaptic terminals in many sensory pathways as well as many areas of the cortex. It is believed to always cause excitation (Guyton and Hall, 1997).

11. Johannesburg Metropolitan Area - refer to APPENDIX 4 (MAP)

12. Law of Similars - “like cures like” (similia similibus curentur) – The remedy for any individual illness is the very substance that can produce similar symptom picture and pattern of illness in a healthy person (Bloch and Lewis, 2003).

13. Miasm - a mode in which the body reacts, the term used to reflect a certain predisposition, a defect that can be transferred from one generation to another (De Schepper, 2006).

14. Neurotransmitters - chemicals that make it possible for nerve impulses to travel from one cell to another and therefore play an essential role in the functioning of the brain (Guyton and Hall, 1997).

15. Simillimum - the single homoeopathic medicine, the drug picture of which most nearly approaches the total symptom complex of the patient (Gaier, 1991).

16. Simplex Remedy - A single medicine derived from a single source material (Swayne, 2000).

17. Totality of symptoms - The complete clinical picture of a patient during the “illness”, comprises all mental, general and local (particular) symptoms and signs; the complete symptom pattern from which the simillimum is found (Swayne, 2000).

18. Uni-Jhb – University of Johannesburg, as of 2005 (ex-Witwatersrand Technikon).

INTRODUCTION Attention deficit disorder with or without hyperactivity is the most frequent and fastest growing diagnosis among children in the USA and is increasing at a rapid rate in all developing countries. It is also currently one of the most researched conditions; yet it is not fully understood (Picton, 2004). It is estimated that ADD/ADHD occurs in three to seven percent of the school age population, and boys are diagnosed 3 – 4x more

than girls. Without proper intervention ADHD can continue through adolescence and into adulthood with research indicating that it occurs in approximately two to four percent of adults thus the prevailing belief among professionals that children “outgrow” ADHD by adulthood is false. Despite increased awareness, ADHD remains under-recognised with less than half of the affected individuals receiving treatment (Janessen-Cliag, 2005).

Thus the number of children affected by this condition is potentially higher than stated by formal statistics. It is thought that ADHD could be more common in rural areas since families do not have adequate access to health care and nutrition, their awareness and understanding of the condition is also minimal (Badat, 2004; Byram, 1998; Jannssen-Cliag, 2005). ADD/ADHD is primarily a neurophysiological disorder, caused by an imbalance in neurotransmitters. There is evidence to suggest it is also hereditary; that is, there is a genetic predisposition (Naude, 2004). A deficiency in Essential Fatty Acids as well as other vitamins and minerals seem to either contribute

or aggravate the symptoms associated with ADD/ADHD; therefore nutrition, diet and supplementation form an important part of the

treatment process (Picton, 2004). There is also a tendency for these patients to be ultra-sensitive to their physical and emotional environment. These children also frequently have learning, behavioural and social problems,

which need to be addressed (Allen and Harrison, 2004). A diagnosis can only be given once a comprehensive (multidisciplinary) evaluation has been conducted. An assessment should include, neurological, medical and developmental history, a thorough physical examination, psychometric testing and a concurrence with the DSM IV criteria (Erasmus, 2004). Although it seems that many children are hyperactive, only a relatively small

percentage are truly sick. Many children have boundless energy, get bored easily, and have little interest in learning certain school subjects (Ulllman, 1991). 2

The prescribing of the stimulant Methylphenidate Hydrochloride (the active ingredient in Ritalin®, Adaphen® and Cocerta®) is the conventional form of treatment used by neurologists and doctors. Depending on the symptomatology and the severity of the symptoms (such as emotional issues or sensory defensiveness), the use of other disciplines can be incorporated into the treatment plan such as: psychology, occupational therapy, speech

and hearing therapy and nutrition. In addition, other complementary therapies are available such as Homoeopathy, Chiropractic, meditation and relaxation and can be an alternative and/or adjunct to conventional treatment.

The ideal way to manage an individual with ADD/ADHD is with an integrated approach (Picton, 2004). Homoeopathy is becoming a preferred choice of treatment as parents seek to find alternatives to Methylphenidate hydrochloride (Badat, 2004). Anecdotal evidence indicates that homoeopaths consult with a significant number of ADD/ADHD patients but no formal evidence/study exists to support this. This is one of the rationales for this research project. It will explore the homoeopathic practitioners’ approach to patients as well as the treatment, management and success rate in treating ADD/ADHD. This research will also include a demographic study of the practitioners and their practices.

CHAPTER 2 REVIEW OF RELATED LITERATURE 2.1 ADD/ADHD – EPIDEMIOLOGY, PREVALENCE and PROGNOSIS

ADD/ADHD is currently one of the most researched childhood conditions, yet there is still so much controversy and misunderstanding about it. It is also one of the most commonly diagnosed disorders of childhood development (Picton, 2004). Although official statistics are not available for South Africa, the Hyperactivity Attention Deficit Disorder Support Group of South Africa (ADHASA) believes that about 5 - 10% of all South African children are affected (Health24, 2004). Unfortunately, statistics are affected by many variables, including the child’s socioeconomic status, gender and even place of birth (Epanchin and Paul, 1987).

More boys than girls are diagnosed with ADHD, the ratio of male to female being 6:1. ADHD tends to be under diagnosed in girls the reason for this is thought to be that boys more frequently present with the hyperactivity/ impulsivity symptoms, which are easily identified, whereas girls more frequently present with the inattentive symptoms, which are more difficult to identify (Riordan, 2004). It has also been suggested that ADHD could be more common in rural areas since these families do not have adequate access to good health care and nutrition as well as there is minimal awareness and understanding of the condition – some even believe it to be witchcraft (Badat, 2004; Byram, 1998; Janssen-Cliag, 2005). There is a research project underway, in the South Western Township in Johannesburg, with the main aim being to investigate the incidence of ADD/ADHD in this area (ADHSA Seminar, October 2006). It would appear that statistics vary from country to country; this could be because the definition of the disorder varies in different countries (Epanchin and Paul, 1987). About 33% of children who are diagnosed

with ADD/ADHD have reading problems and are also likely to have difficulties in mixing with other children; often because they are aggressive, these problems could extend into adulthood if not treated (Byram, 1998). Research indicates that this condition occurs in approximately 2% to 4% of adults. The gender ratio of adult males to females is 2:1 or lower. The belief among some professionals that children outgrow ADHD by adulthood is false, this

is due to symptoms becoming less severe and presenting differently in adolescence and adults because of the development of coping mechanisms to compensate for their impulsivity and disorganization (Janssen-Cilag, 2005; Wallis et al, 1994). At least 20-30%, and possibly as much as 80% of children with ADHD will continue to exhibit symptoms in adulthood.

Many adults only come to realize that they themselves have the condition when one of their own children is subsequently diagnosed (Stordy and Nicholl, 2002; Riordan, 2004) thus find relief that there is a name for their

condition (Hallowell and Rately, 1996). A diagnosis of ADD/ADHD can help both the child and the family understands that these problems are not just willful bad behaviour. According to Diller (1999) “We’ve learned that

in dealing with problem personalities, and the line between he won’t behave and he can’t behave is very hard to draw”. Many people with ADD/ADHD have a normal or above normal intelligence and the symptoms of ADHD

do not necessarily have to be an obstacle to leading a successful life (Janessen-Cilag, 2005). Early diagnosis and appropriate treatment in children is the key to maximizing positive outcomes and minimizing the negative long-

term effects of ADHD in adulthood (Janssen-Cilag, 2005). Many adults gravitate into the creative fields or work that provides an outlet for emotions. Unfortunately people with ADD/ADHD don‟t function well in standard

schools and typical office jobs. Increasingly, parents and lobby groups are demanding that accommodations in the classroom be made. About half the children diagnosed with ADHD receive help from inclusive-education

teachers in their schools, as they commonly also have co-existing learning disabilities (Wallis et al, 1994). 8

Despite increased awareness, ADHD remains under-recognised with less than half of the affected individuals receiving the appropriate diagnosis; and of those persons diagnosed, few receive proper treatment (Janssen-Cilag, 2005). An NIMH (National Institute of Mental Health) study in 2000 found that only half of the children positively identified with ADD/ADHD actually received care in accordance with the guidelines of the American Academy of Child and Adolescent Psychiatry (Stordy and Nicholl, 2002). There is “no cure” for ADD/ADHD but, without effective treatment, the risks associated with ADD are very great. Children with ADD fall out of the mainstream of positive social, educational and emotional life with their peers and family members and too often the label of ADD becomes a stigma with resultant long-term negative implications (Lawlis, 2005).

IMPLICATIONS OF SOCIAL FUNCTIONING

Generally on a social level, children with ADD/ADHD often have difficulty developing appropriate relationships with authority figures and peers. The disorder does not only impact on the diagnosed child but also on the child’s family and peers. A child with ADHD may often be labeled as disobedient or “strong willed”. This is often because of the difficulties in maintaining attention and missing important parts of the conversation or instructions.

Several studies show that children with predominantly inattentive ADHD may be perceived as shy or withdrawn by their peers.

Research indicates that aggressive behaviour in children with symptoms of impulsivity/hyperactivity may play a significant role in peer rejection. Other factors that contribute to peer rejection are poor impulse control, inability

to wait their turn and follow instructions and excessive talking (Janessen-Cilag, 2005). Once a child is diagnosed with ADD/ADHD, many parents become upset or confused; others may be relieved once a cause for their child’s problems is identified. Being a parent of a child with ADD/ADHD is not an easy task and can be very difficult and stressful, placing an enormous amount of pressure on family life. There are increased levels of parental

frustration, marital conflict, siblings may feel neglected and family bonds can be broken. However, on the other hand, it can also strengthen family bonds (Janssen-Cilag, 2005; Lawlis, 2005). ADD is also a problem for society

as a whole. The challenges associated with this condition have enormous implications. The following statistics were taken from the Attention Deficit Association and from material provided by Children and Adults with Attention Deficit/ hyperactivity Disorder (CHADD) – these figures relate to the USA:

35% of students with ADD never finish high school.

Individuals with ADD have significantly more hospital visits than non-sufferers.

Parents of ADD children divorce 3x more often than those whose children do not have ADD.

50 – 75% of incarcerated inmates in prison have some form of ADD.

52% of ADD sufferers abuse drugs at some time or other in their lives.

43% of male ADD students are arrested for a felony before the age of sixteen.

According to a study published in the Journal of American Academy of Child and Adolescent Psychiatry, the costs of ADD and ADHD are reflected in the entire family medical profiles. They would have more medical claims

and the direct medical care costs per annum per family member were found to be twice as high than non-ADD/ADHD families. The indirect costs for disability and absenteeism were 61% higher than non-ADHD families

(Lawlis, 2005).

AETIOLOGY There is much debate over what exactly causes the symptoms of ADD/ADHD therefore it is thought that there is no single cause, but rather a combination of contributing factors. A major report from the British Psychological Society argues that the concept of ADHD as a single condition is controversial for a variety of reasons. Many factors affect the way attention is displayed in a particular situation and doctors should be wary of describing children as having ADD/ADHD without a thorough investigation (McConnell, 1997). All children and adults are unique and their reasons for thinking and behaving as they do will differ. In this chapter the

contributing and aetiological factors will be discussed.

The Neurological and Biological Basis.

As ADD/ADHD, by definition, is a neurobiological condition, physicians and mental health professionals attribute symptoms to an imbalance in neurotransmitters (Reichenburg-Ullman & Ullman, 1996). It is thought that in individuals with ADHD there is a lower than normal level of the neurotransmitter dopamine in the frontal lobe (Riordian, 2004).

The frontal lobe, which is responsible for executive functioning (regulates impulse control, attention and other thought processes) is thought to be compromised in people with ADHD. Recent research was conducted in eight children aged 6 to 12, who had been diagnosed with the hyperactive-type ADHD and were taking stimulant medication. These children were compared to eight children without ADHD. It was found, using a type of Magnetic Resonance Imaging (MRI), that in children with ADHD, levels of glutamate were increased while levels of GABA (Gamma-aminobutyric acid) were decreased. The decreased levels of GABA (causes neuro-inhibition) and the higher levels of glutamate (causes neuro-excitation) might explain the poor impulse control these children seem to exhibit. The levels of neurotransmitters were measured in relation to each other. Therefore, it is not the overall levels but rather the relative proportion of the neurotransmitters that seem to be of importance (health24, 2004). Studies using PET (positron emission topography), a brain imaging technique that uses a radioactive tracer to show chemical activity of the brain, have shown significant differences in the frontal part of the brain between healthy subjects and those with ADHD (Janssen-Cilag, 2005; Prichard, 1996).

In 1990 Dr Alan Zametkin and his colleagues at the National Institute of Mental Health (NIMH), USA, found that in the PET scans, people with ADD showed lower levels of electrical activity and decreased blood flow in the frontal lobes the area of the brain’s cortex known to be involved in the control of attention, impulses and motor activity. This was compared to non-ADD adults and children. Those with ADD/ADHD showed slightly lower rates

of metabolism, which could mean that they do not use as much glucose and therefore their need for oxygen would be less (Stordy and Nicholl, 2002; Wallis, 1994). 13

It has been proposed that ADHD could arise from a number of complications during antenatal and postnatal periods as well as any trauma to the head, e.g. forceps delivery (Byram, 1998; Allan, 2004). Brain damage due to an illness, such as meningitis or encephalitis or a lesion in the frontal lobes could also cause hyperactive behaviour. Studies, using MRI, have discovered that children with ADHD often have smaller right brains – a finding that makes sense as the right brain is responsible for self-control (Stordy and Nicholl, 2002).

Genetic and Familial Factors.

Experts have documented a hereditary aspect of ADHD because it often occurs in families. Most children with ADHD are born with this disorder, but it is only diagnosed at school going age. Clear evidence that ADD/ADHD

runs in families comes from studies of twins. In as many as 80 – 90% of identical twins (who possess identical genes), if one had ADHD so did the other. In fraternal twins (who have just 25% identical genes) the likelihood of

both having ADD/ADHD drops to 32 – 50%. The hereditary aspect can also be seen in children who are mirror images of a parent; they tend to share behavioural and learning styles. The influence of genes is unmistakable. Researchers at the University of California at Irvine reported finding the first abnormal gene associated with ADD. The gene controls dopamine receptors in the brain and this abnormality causes less sensitivity to dopamine (Reichenburg-Ullman & Ullman, 1996; Stordy and Nicholl, 2002).

Genetic research has also indicated that a problem of fat metabolism may be involved. They found that some of the gene locations could be linked to specific enzymes, namely Fatty acid-CoA transferase (associated with the incorporation of fatty acids into the membranes) and Phospholipase C (associated with the breakdown of phospholipid membranes) (Stordy and Nicholl, 2002).

Environmental Factors.

It is thought that the high level skills affected by ADHD are also influenced by the child’s environment. ADHD behaviour could become manifest or be aggravated in unfavourable conditions and circumstances. Physical environmental conditions include: smoke, excess lead exposure, exposure to chemicals and pollutants. External factors such as birth injuries and maternal alcohol or tobacco consumption may play a role in less than 10% of cases (Wallis et al., 1994). A disorganized, unpredictable or unstable family and personal life as well as any emotional stress (divorce of parents) can affect behaviour and the ability to learn (Bryam, 1998 and Picton, 1997).

Social factors have also been implicated by Richman, Stevenson and Graham, who decided after research that children who grew up with inadequate housing and lack of financial security were more likely to display behavioural difficulties (Middleborough, 2003). DeGrandpre (2000) poses the question of whether ADD/ADHD is really a newly discovered medical disease or if it is a culture-induced brain dysfunction that results from our growing need

for speed. There is an idea of an over-stimulated, hurried society, i.e. as society moves faster so do the rhythms of our own consciousness. Children play Nintendo and watch TV rather than participate in sports or play outdoors,

and movies are scarier and more violent. With the growing atmosphere of hurriedness, intensity, urgency and pressure to perform it is no wonder that children behave as they do. We eat fast foods and consume caffeine and drugs to go faster and stay awake longer. Our society places little value on tranquility, quiet, solitude and the joy of being in nature (DeGrandpre, 2000).

Dietary Factors.

It has been claimed that diet has an integral and influential role in ADD/ADHD symptomatology. Food can affect our moods, concentration and behaviour, especially the typical eating patterns of today’s world, which does not necessarily ensure an adequate intake of essential nutrients (Picton, 2005). Sugar has received much negative publicity, but it is not necessarily sugar per se but rather the type and amount of carbohydrates consumed that

influence behaviour. The brain needs a certain amount of glucose to function but too much or the incorrect type of carbohydrate can cause symptoms associated with ADD/ADHD (Picton, 2005 and Merlin, SABC 3-Talk).

Keeping the blood sugar level balanced is probably the most important factor in maintaining energy levels. The level of glucose in the blood largely determines appetite. When glucose levels drop we feel hungry but can also

feel symptoms of fatigue, poor concentration, irritability, nervousness, depression, sweating, headaches and digestive problems (Picton, 2005; Holford, 1997). Essential Fatty Acids (EFA‟s) namely, Omega 3 and Omega 6,

are required for optimal brain function and are also important nutrients required for healthy tissue production and they act as lubricants for the body. ADD/ADHD has been associated with a deficiency in the reakdown/metabolism of the EFA’s. Zinc, Vitamin B6, Vitamin B3, Vitamin C and Biotin are some of the co-factors of EFA metabolism, so a deficiency thereof will interfere with conversion of Cis-Linoliec Acid to Gamma Linolenic Acid and Prostaglandin E1 (enzyme delta-6-desaturase is inhibited). A defiency in EFA’s can manifest in a variety of conditions including arthritis, eczema as well as allergies and hyperactivity. A defiency seems to aggravate

neurological and other symptoms. It was found that synthetic flavors, colors, some preservatives (including tartrazine) and certain natural foods (those containing salicylates) also had an adverse effect on behaviour (Picton, 2005; Holford, 1997). It has been stated that 90% of children’s behavioural problems can be attributed to food allergies, chemical sensitivities, malnourishment and even high levels of toxic metals in the tissues (Warren, 2004).

The Gifted Child

A child displaying behavioural symptoms of ADD/ADHD could actually have a high Intelligence Quotient (IQ) and their perceived ability to stay “on task” might be related to boredom, curriculum, mismatched learning or teaching styles as well as environmental factors mentioned before. Gifted children may demonstrate ADD/ADHD behaviour in some settings but not in others. These children may spend from ¼ - ½ of their regular classroom

time waiting for others to catch-up and even more time if they are in a mixed group class. (Reichenburg-Ullman and Ullman, 1996). The behaviour displayed by these children can closely resemble the behaviour of ADD/ADHD, that these children can be incorrectly diagnosed with ADD/ADHD.

DIAGNOSIS AND CHARACTERISTIC SYMPTOMS OF ADD/ADHD Diagnosis.

The diagnosis of ADD/ADHD is currently based on subjective opinion, with no scientifically accepted test available (Prichard, 1996). As there is no single test to diagnose ADD/ADHD, a comprehensive evaluation is favoured

in order to establish not only a diagnosis, but also investigate possible co-existing conditions and to rule out other causes of the presenting symptoms. Diagnosis rests primarily upon the history of the child (taken from parents, teachers, other care givers and the child itself) – this is the most reliable diagnostic tool. An assessment is made of the child’s academic, social and emotional functioning (Riordan, 2005; Hallowell and Rately, 1996).

ADD/ADHD is generally first diagnosed in childhood (during primary school years). The signs and symptoms (behaviour) are usually first noticed by teachers, who then inform parents (who may or may not have picked up on

the same/similar behaviour patterns described by the teacher). The parents will then often take the child to the family doctor (GP), who does a complete medical examination to exclude any underlying condition (Wallis et al., 1994; Picton, 2005). Generally, if the doctor suspects ADD/ADHD, he will refer the child to a specialist for further investigations and assessments. Unfortunately there are some doctors that prescribe medication without

referring to a specialist for further assessment/ investigation (Allan, 2004).

Further assessments can be made by a specialist (developmental) paediatrician, educational or clinical psychologist and occupational therapists (Picton, 2005; Erasmus, 2004) but the final definitive diagnosis should be made

by a neurologist (Allan, 2004). An educational psychologist assesses academic ability by means of verbal and non-verbal tests. They use the Wechsler Intelligence scale for children – Fourth Edition USA (WISC-IV) which provides a measure of general intellectual functioning and four index scores (verbal comprehension, perceptual reasoning, working memory and processing speed). The Conners Parent Rating Scale (CPRS), also available in a teachers version (CTRS), allows parents and teachers to rate the child’s cognitive, emotional, and behavioural status on a number of dimensions, including conduct problems, learning problems, psychosomatic problems, impulsivity-hyperactivity, and anxiety. This scale has been found to be sensitive to the effects of prescribed medicine for hyperactivity. These tests are frequently used in pharmacologic research studies. Another test used is

the Children’s Checking Task (CCT), which is completed by the child. Psychologists are able to identify problem areas and will assess the child’s behaviour as well as emotional well-being. The educational psychologist cannot prescribe medication but will refer the child to a specialist paediatrician or neurologist, who can prescribe medication if the case proves that it is needed (Epanchin and Paul, 1987; Picton 2005; Allan, 2004).

Paediatricians have been specially trained in childhood conditions and will conduct a full medical history and physical examination of the child. A developmental and or behavioural paediatrician are the best qualified to

diagnose this condition as they have been specially trained in behaviour and development and will conduct a comprehensive developmental, medical and behavioural assessment. A Neurologist will make the final decision

by conducting a further test, by means of an Electroencephalograph (EEG), which measures brain activity (Picton, 2005). Silberstein and his colleagues have developed a signal test that may provide the first objective and safe method for doctors to diagnose children with ADD/ADHD, but it is too early for the test to be made available for general use. The test (steady state probe topography) found significant differences in the activity in the frontal

parts of the brain in 13 boys with the condition, compared with 18 “normal” boys. The test also seems to confirm that there is a biological basis for this condition (Prichard, 1996). Currently EEG’s, MRI and PET (positron emission topography) scans are being used to detect abnormal brain function. In the past it was believed that brain injury was responsible for the condition and was therefore called Minimal Brain Damage, it was later changed

to Minimal Brain Dysfunction. In the seventies the focus was placed on the over-activity and then came the idea that these children also had poor concentration, and so the name changed to Attention Deficit Disorder (ADD),

which is now regarded as the umbrella term (Picton, 1997; Wallis et al, 1994).

Not all children (and adults) with ADD are hyperactive so the diagnosis is either made as ADD or ADD with hyperactivity (ADHD). The Diagnostic and Statistical Manual of Psychiatric Disorders, 4th Edition (DSM IV) sets

out the criteria that must be met in order for a diagnosis to be made (Picton, 1997; Wallis, 1994). For a person to be diagnosed with ADD/ADHD the problems of thinking and behaviour must significantly interfere with normal functioning: that is, it must severely influence or disrupt the child’s life in more than one area: at school, at home or in social situations (Reichenburg-Ullman and Ullman, 1996). The two most common errors in the diagnostic process are missing the diagnosis or making the diagnosis too often. The latter seems to be more common in today’s society as there are a number of conditions that can present just like ADD and most “normal” children can be distractible, impulsive and restless at any time (Hallowell and Rately, 1996). Before a diagnosis is made the following conditions should be excluded, as their symptoms can be similar or can mimic those of ADD/ADHD

DD.:

1) Visual impairment or hearing impairment.

2) Language and learning disabilities: dyslexia; autism; speech and language disorders; auditory processing difficulties.

3) Neurological conditions: Tourette’s Syndrome; seizure disorder (Petit mal epilepsy.); sleep disorders; language disorders; mental retardation.

4) Food allergies.

5) Medical conditions: hypothyroidism; hyperthyroidism; lead poisoning; severe aneamia; chronic illness.

6) Emotional and psychological problems such as: anxiety; depression; obsessive-compulsive disorder; oppositional defiant disorder; conduct disorder; low self esteem; boredom in the classroom; relationship

problems; significant life events or any change from normal routine.

7) Developmental disorders: low muscle tone, motor co-ordination difficulties, sensory modulation disorders (sensory defensiveness).

These conditions can also co-exist with +/o. be complications of attention deficit hyperactivity disorder. (Erasmus, 2005; Kewley, 1998; Picton, 2005; Riordian, 2004).

Characteristic Symptoms.

ADD/ADHD can be divided into 3 subgroups according to symptom presentation:

1. Primarily inattentive type: Fails to give close attention to details or makes careless mistakes; has difficulty sustaining attention; does not appear to listen; struggles to follow through on instructions (does not

complete tasks); has difficulty with organization; avoids or dislikes tasks requiring sustained mental effort; easily distracted or is forgetful in daily activities.

2. Primarily hyperactive/impulsive type: Hyperactivity symptoms: fidgets with hands or feet or squirms in chair; has difficulty remaining seated; runs about or climbs excessively (in a situation in which it is

inappropriate); difficulty playing or engaging in activities quietly; often “on the go” or “driven by a motor”‟ or talks excessively.

Impulsivity symptoms: Blurts out answers before questions have been completed; difficulty waiting or taking turns; interrupts or intrudes on others.

3. Combined type: individual meets both sets of inattention and hyperactivity/impulsivity.

The following criteria (summarized) must be met for the Diagnosis of ADD/ADHD:

1. Some of the symptoms of inattention +/o. hyperactivity that cause impairment must be present before 7 years of age.

2. At least 6 symptoms of inattention +/o. hyperactivity/impulsivity must have persisted for a minimum period of 6 months, to such a degree maladaptive and inconsistent with the individual’s developmental level.

3. Some impairment from the symptoms is present in two or more settings.

4. There must be clear evidence of clinically significant impairment of social, academic or occupational functioning.

5. The disturbance must not occur exclusively during a pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and symptoms are not better accounted for by any other mental disorder

(American Psychiatric Association, 1994).

Although ADD/ADHD is associated with “bad behaviour” and there seems to be a negative stigma attached to the diagnosis, children (and adults) with ADD/ADHD possess positive personality characteristics despite their difficulties in daily life. They can be enthusiastic (about things they enjoy); creative, imaginative and original (have more ideas than they can actualize effectively); charming, humorous, entertaining and interesting to talk

to and be with; spontaneous; intelligent and eager to please. They can be highly energetic and active; inquisitive, take risks and have little or no fear, which is not always something good in the eyes of parents (Hall and Naude, 2003; Hallowell and Rately, 1996; Riechenburg-Ullman and Ullman, 1996). 25

MISDIAGNOSIS, OVERDIAGNOSIS OR UNDERDIAGNOSIS?

This is a controversial topic for all concerned, parents, teachers and all the professionals involved in the treatment process. Many experts question whether Methylphenidate Hydrochloride is being over prescribed and whether teachers, doctors and parents are too quick to diagnose a child as suffering from ADHD. In reality, too often it is the teachers who are making the diagnosis. A Connecticut law prohibits schools and teachers from recommending psychotropic medication but a teacher could recommend a visit to a doctor (health24, 2001). Many teachers mislabel children as having ADD because they don’t have the time or the resources to develop real expertise. It is dangerous to label a child without a scientific basis for diagnosis and too often the treatment that follows treats only the symptoms and not the person affected (Lawlis, 2005).

The widespread labeling of ADHD (in North America) to difficult children means that most classrooms and many families have children so classified. Although ADHD is officially a term for a category of mental disorder,

it has become so widely used that it has a prominent place in contemporary culture (McConnell, 1997). As Dr van der Merwe reports, ADHD has become a fashionable diagnosis that is made far too easily and quickly.

There are innumerable studies of underdiagnosis and overdiagnosis and it is estimated that millions of children are incorrectly labeled and treated for nothing more than their immaturity. A review of these studies showed

clearly that 50% of children diagnosed with ADD/ADHD do not fit the officially accepted criteria and are therefore wrongly diagnosed (Goldberg, 2004). While much of the debate has focused on overdiagnosis and over medication, some doctors say a bigger problem is that of the diagnosis being missed (health24, 2001). A report in the JAMA in 1998 concluded that ADHD actually is underdiagnosed in the general population (USA) when compared with other countries such as Germany and New Zealand (Stordy and Nicholl, 2002). In Britain, ADD/ADHD is reported as being underdiagnosed and undertreated, but it could also be overdiagnosed because

hyperactivity is confused with more widespread difficulties (Kewley, 1998). An NIMH (National Institute of Mental Health) study in 2000 found that only half of the children positively identified with ADHD actually received

care in accordance with the guidelines of the American Academy of child and adolescent psychiatry (Stordy and Nicholl, 2002). Also, too many “problem children” don’t have adequate access to good health care in the first

place and so no informed decisions can ever be made (Warren, 2004). Troublesome aspects of how ADD is currently framed in official psychiatry (Diller, 1999):

1.) The process of establishing “objective” diagnostic standards for ADD has itself been quite subjective.

2.) Official guidelines for evaluating ADD symptoms are vague and open to interpretation, yet they lead to an all-or-nothing diagnosis.

3.) The ADD diagnosis has no definitive medical or psychological marker and so it is often made exclusively on the patient‟s history. Circumstances and biases of those reporting a child’s behaviour are seldom taken

into account. 4.) The diagnosis is overly focused on the individual and does not take sufficient account of family systems and other environmental factors.

5.) In its current phase as a “disorder for all seasons”, ADD has become too inclusive. It has lost relevance to the age-related, developmental nature of some core problems.

6.) ADD as officially described can look a lot like certain other childhood psychiatric disorders. And many children meet criteria for some, but not all of the symptoms of several different conditions.

TREATMENT AND MANAGEMENT

Most professionals agree that a team approach is required and this includes medicinal, psychological, educational, behaviour management and life style changes. Parents, teachers and the child all need to be involved in the treatment and management process. Lawlis (2005) a psychologist, offers advice and suggestions on methods that include drugs and medication, counseling and biofeedback, electromagnetic treatments, biocleansing, nutritional adjustments, strategies for sleep disturbances, neurotherapy, and self-development management. He will also touch on spirituality and examine how families can engage their own faith and beliefs in dealing with ADD.

Orthodox pharmaceutical intervention (medication). The most common drug prescribed is Methylphenidate Hydrochloride (Trade names: Ritalin®, Adaphen® and Concerta®). Methylphenidate Hydrochloride is a central nervous system stimulant. It is a schedule 6 drug (formally schedule 7), is classified as a psychoanaleptic (antidepressant) and is chemically related to amphetamines. It is indicated for the treatment of ADHD and narcolepsy. Medication is available in the form of tablets in strengths ranging from 10mg to 80mg, depending on which variant is prescribed. Dosage will depend on the individual‟s age, weight, needs and response (Snyman, 2006; Novartis, 2002; Stordy and Nicholl, 2002).

This drug should be prescribed and its dosage monitored by a neurologist, by whom the definitive diagnosis was made (Allan, 2004). When medication is effective, it can help the individual to focus better, sustain effort over

long periods of time, reduce anxiety and frustration and reduce irritability and mood swings. These primary effects can lead to the secondary effects of increased confidence, greater self-esteem and sense of well being

(Hallowell and Rately, 1996). Methylphenidate is also said to have a greater tendency to relieve the stress in the care giver than the child, and that the positive effects are important in preserving the self-esteem of the individual with ADD/ADHD and the sanity of their teachers, families and peers (Reichenburg-Ullman and Ullman, 1996). It is ironic that allopathic doctors prescribe Methylphenidate to children who are hyperactive. One would think that this drug would make the child even more hyperactive, but it has a noticeably opposite effect. Conventional physicians refer to the „paradoxical action‟ of drugs as the reason it works the way it does. This „paradoxical action‟

of a drug can also be seen in homoeopathic medicines (Law of Similars), a substance is capable of producing similar symptoms to a particular disease state is prescribed as a treatment for that very state. The drug does not

further relax children who are already calm; it only calms those who are hyperactive. Methylphenidate can treat hyperactivity effectively, as it normally causes hyperactivity (Ullman, 1991).

As a stimulant, Methylphenidate Hydrochloride is known to increase the levels of dopamine in the brain. Stimulants prevent the reabsorption of neurotransmitters into nerve cells or cause more or the neurotransmitter to be released, they block the receptors and without sites to bond to, excess dopamine will remain in the system (Diller, 1999; Warren, 2004). Stimulants seem to have a short-term effectiveness of 60-80% in reducing hyperactivity, distractibility and impulsivity in school-age children. When stimulant medication is not effective, individuals are prescribed other medication for example tricyclic antidepressants (Warren, 2004). Other medications, which

are used either in place of or together with methylphenidate, are:

Atomoxetine (Strattera®) – inhibits the reuptake of noredrenaline by the presynaptic neurons and is indicated for management of Attention Deficit Hyperactivity Disorder. Is a non-stimulant with a “favourable” side effect

profile and does not seem to cause dependence (Korb, 2005).

Dextroamphetamines (Dexedrine® and Eskatrol®) – more severe side effects have been reported, is habit forming/not recommended for children under 12 years. Amphetamines cannot be prescribed for ADHD in South Africa.

Pemoline (Cylert®) – is less effective than methylphenidate and takes up to one month before maximum effect is noted, can be habit forming and often leads to insomnia.

Risperidone (Risperdal®) - used for for the aggression, behavioural and Conduct Disorder associated with ADHD. It may assist in concentration. Often used in connection with methylphenidate.

Impiramide (Tofranil) - is used when a child reacts badly to methylphenidate especially where motor disorders exist (e.g. epilepsy). It is used when the child presents with depression or anxiety; is older than 5 years and still

wets the bed. Can have severe side effects including heart irregularities.

Citalopram Hydrobromide (Cipramil) – is an anti-depressant and is less cardio-toxic than Impiramide. It is often combined with methylphenidate to counter the relevant side effects.

Thioridazine (Melleril) - used for for behaviour disorders, hyperactivity and aggression; especially aggression in toddlers too young for methylphenidate. In too high a dose it can over-sedate a child and affect his ability to learn.

It does not increase attention span or reduce distractibility.

Haloperidol (Serenace®) - used for for over activity, destructive, aggressive behaviour. It is used for children with Tourette‟s Syndrome. It is an antipsychotic tranquilliser that reduces severe anxiety and agitation.

Sulpiride (Espiride®, Eglonyl® and Norton-Supiride®) – an anti-depressant (antipsychotic), sometimes used to treat the side effects of methylphenidate. Treatment of depression, schizophrenia and behaviour disorders.

Carbamazepine (Tegretol) – is an anti-convulsant and anti-epileptic drug. Used for temporal lobe epilepsy and can have a mood stabilizing effect. Epileptic patients cannot take stimulant medication such as methylphenidate,

so their symptoms are first controlled before stimulants are prescribed.

Sodium Valporate (Epilim®) - used for for treating petit-mal epilepsy and can also have a mood stabilizing affect but can increase hyperactivity or aggression. Used to control epilepsy before stimulant medication is administered.

Lamotrigene (Lamictin®) – an anti-convulsant used on its own or in combination with other anti-epileptic medication.

(Snyman, 2006; Picton, 1997)

Not all parents are convinced that their children should be given Methylphenidate because of the numerous side effects, special precautions and drug interactions as well as all the media and stigma attached to this drug.

Much of the stigma associated with psychotropic drugs for the treatment of ADHD comes from their potential for abuse (health24, 2001).

The Drug Enforcement Agency (DEA), USA, classes Methylphenidate hydrochloride as a “highly addictive controlled substance” because of its amphetamine structure, this make it fall in the same category as cocaine,

methadone and methamphetamine (speed) (Stordy and Nicholl, 2002). A report discovered that Methylphenidate is a more powerful stimulant than cocaine; research has shown that cocaine can block 50% of dopamine receptors, whereas a typical dose of methylphenidate, given to children blocked out 70% of dopamine receptors. A drug enforcement study in Wisconsin, South Carolina and Indiana found that as many as one-half of all teenagers in drug treatment centres said they had used Methylphenidate to get a high. As methylphenidate taken orally does not produce a high, many teenagers were crushing it and inhaling the powder – just like cocaine (Warren, 2004).

Possible Side Effects of Methylphenidate Hydrochloride: Sleep disturbances (insomnia), nervousness, decreased appetite, headaches, drowsiness, dizziness, dyskinesia, convulsions, choreo-athetoid movements, visual

disturbances, hyperactivity, cramps, tics or exacerbation thereof, blood dyscrasias, Tourette‟s syndrome, depression, toxic psychosis, cerebral arteritis and occlusion are all possible side effects (Snyman, 2006).

Special Precautions in the use of Methylphenidate Hydrochloride: It should not be given in cases of Epilepsy, hypertension, emotional instability, and depression. It may exacerbate symptoms of behavioural disturbances and thought disorders in psychotic patients. It should not be used for the treatment of normal fatigue states. Possible tolerance and dependance can develop, and mass loss and growth retardation can occur in children during prolonged therapy; therefore it is advocated that patients have one-month drug free periods or that the drug is not taken during holidays or weekends. Supervised withdrawal is recommended. Careful assessment is required before it is prescribed for children under the age of six years old (Snyman, 2006). Drug Interactions with Methylphenidate: It interferes with the antihypertensive effect of Guanethidine; and can cause decreased metabolism (inhibition) of coumarin anticoagulants, anticonvulsants and phenylbutazone (Snyman, 2006) It is largely unknown what the long-term effects of these drugs have on children (Ullman, 1991) but some of the possible long-term effects include stroke, hyperthermia, hypertension and seizures.

Homoeopathy

The Allied Health Professions Council of South Africa assists in the promotion and protection of the health of the population of South Africa; it governs, administers and sets policy relating to the professions registered with

the council; controls the practice of the professions and investigates complaints relating to practitioners and students; and corresponds with the Minister of Health on any matter falling within the scope of the Act.

The Homoeopathic Association of South Africa (HSA) is recognized by the AHPCSA as the official representative of the Homoeopathic Profession on South Africa (Allied Health Professions Act, 2001). HSA represents and promotes the Homoeopathic Practitioner, the Profession, Education and interests, for the better health and well-being of all South Africans and is the only organization that actively engages Government, Department of Health, Allied Health Professions Council and all other organizations and structures that influence the profession. Registration with the HSA is not compulsory (HSA, 2006).

Homoeopaths are able to treat the same range of conditions as orthodox medicine. Most Homoeopathic doctors will do a full medical assessment of the patient and will analyse the pattern of symptoms the individual presents with, taking into consideration the mental, emotional and physical states of the patient (Heritage Publishers, 1999). The Allied Health Professions Act stipulates that a homoeopath is qualified and registered to physically examine any person, taking into account the totality of symptoms for the purposes of diagnosing any physical defect, illness or deficiency. Also within their scope of practice is the treatment or prevention of any physical defect, illness or deficiency in any person by prescribing remedies, dietary advice or dietary supplementation in accordance with and based on homoeopathic principles. Registered homoeopaths are entitled to personally compound, dispense or supply remedies which are prescribed by himself, for the use by the patient under treatment, new legislation dictates that the practitioners must have a Compounding and Dispensing Licence to be able to do this (HSA, 2006).

Homoeopathy and ADD/ADHD

Homoeopathic medicine has been successful in treating ADD/ADHD and other behavioural conditions using specific, individualized homoeopathic remedies (Reichenburg-Ullman and Ullman, 1996). The success rate estimated

to be at least seventy percent, when individually chosen homoeopathic remedies are used to treat ADHD for one year, (Reichenburg-Ullman and Ullman, 1996 and Warren, 2004). Dr Weil (2004) claims that Homoeopathy has

been successful when other methods have failed. The child is treated as an individual, and the cause of the behaviour/symptoms, including all mental, emotional and physical aspects are addressed.

Homoeopathy does not need a name for disease as practitioners prescribe medication (remedies) on the totality of symptoms. Homoeopathic remedies are safe, non-toxic, and relatively free from side effects. An aggravation (temporary worsening of symptoms preceding alleviation of symptoms) may occur. Remedies have lasting results (long-term effectiveness). Homoeopathic remedies do not suppress symptoms and even when given for long periods of time, are safe and do not cause dependency. Homoeopathy will not interfere negatively with other medication, however if taken with conventional medication they may not work as effectively (Lawlis, 2005; Reichenburg-Ullman and Ullman, 1996; Ullman, 1991). Homoeopathic medicines not only improve the health of infants and children, but probably also help them to become healthy adults (Ullman, 1991). Research into the Homoeopathic Treatment of ADD/ADHD in South Africa has revealed the following:

1. Strauss, (1998) concluded that the use of the homoeopathic complex, Selenium Homacord (= D10, D15, D30, and D200 potencies), resulted in an overall improvement in the clinical picture of ADHD compared

to a control group. Selenium Homacord indicated for the treatment of diminished mental capacity; lack of concentration; forgetfulness; depression; exhaustion and deficiency of memory.

2. Muller, (1996) conducted a study involving the efficacy of mineral therapy in the treatment of ADHD, using mineralloid potassium phosphate in D6 potency. It was found that this decreased the overall hyperactivity

of the ADHD subjects and mineral therapy was advocated as an alternative to stimulate treatment in some cases and reinforcing treatment in others.

3. Smith, (2001) investigated the use of Cerbo® and Nerva 2®, both of which are homoeopathic complex preparations whose composition includes remedies that would cover the symptoms expressed by the majority

of ADHD individuals. Participants showed statistically significant improvement in teacher rating scores, however sustained attention did not show significant improvement. Although not conclusive, Cerbo® is indicated

for impaired concentration and Nerva 2® is indicated for nervous hyperactivity.

4. Middelborough, (2003) conducted a study to determine and compare the relative efficacy of supplementation using Evening Primrose oil and Homoeopathically potentised GLA, in the management of ADD/ADHD.

It was concluded that Evening Primrose oil was effective as an intervention as it managed to significantly improve the attention scores. Although the homoeopathically prepared GLA did no show any statistically

significant improvement, it was clear that there was slight improvement in the attention scores.

5. Lottering, (2005) conducted a study to determine and compare the relative efficacy of a nutritional supplement (Advanced Brain Food® = Phospatidylcholine; Phospatidylserine; Vitamin B3; Ginko Biloba;

Vitamin B12; Folic acid; Pantothenic acid and Pyroglutamate) and a homoeopathic complex (Quietude® = Chamomilla vulgaris (9C); Gelsemium sempervirens (9C); Hyoscymus niger (9C); Kali bromatum (9C) and Passiflora incarnata (3X) in the management of ADHD. It was found that Advanced Brain Food® was effective as an intervention as it managed to significantly improve the attention span of the subjects. Although

Quietude (homoeopathic complex) did not show any statistically significant improvement, it was clear that there was a slight improvement in the sustained attention levels.

Homoeopaths have always based, and continue to base the evidence for the effectiveness of Homoeopathy on clinical results with many patients. These results are shared in the professional Homoeopathic journals and at conferences. Double blind clinical studies have shown the effectiveness of homoeopathic medicine as compared to placebo in research on common medical conditions. A 1991 review of over 100 homoeopathic studies

published between 1966 and 1990 showed positive results in 76% of the studied conditions (Reichenburg-Ullman and Ullman, 1996).

Research conducted by Masters graduates from the University of Johannesburg and Durban University of Technology have illustrated a clear efficacy of Homoeopathy (HSA, 2004). The following international trials conducted

to test for effectiveness in the homoeopathic treatment of ADD/ADHD:

1. Lamont (1997), conducted a study on the homoeopathic treatment of attention deficit hyperactivity disorder. 43 children diagnosed with ADHD were alternately assigned either placebo or homoeopathic treatment (similimum)

in a double-blind, partial crossover study to determine the effectiveness of homoeopathy for this disorder. Statistical comparisons were made on the basis of parent or care giver ratings of ADHD behaviour before and after treatment. Statistically significant differences were found, supporting the hypothesis that homoeopathic treatment is superior to placebo treatment for ADHD. In the same study it was found that the following remedies were

the most successful in treating ADHD: Stramonium, Cina and Hyoscymus niger and to a lesser degree, Veratrum album and Tarentula hispanica. 43

2. A trial in Europe provided evidence of the effectiveness of homoeopathic treatment of ADHD (particularly in areas of behavioural and cognitive functions). A total of 83 children aged 6-16 years, with ADHD diagnosed using

the DSM-IV, were recruited for a randomized, double blind, placebo controlled crossover trial. Prior to the study; the children were treated with individually prescribed Homoeopathic medications. 62 patients, who achieved an improvement of 50% in the Conners Global Index (CGI), participated in the trial (13 patients did not fulfill eligibility criterion). At the beginning of the trial and after each crossover period, parents reported the CGI and patients underwent neuropsychological testing. At entry to the crossover trial, cognitive performance, impulsivity and divided attention, had improved significantly. The results of the trial provide scientific evidence for the effectiveness

of homoeopathy in the treatment of attention deficit hyperactivity disorder, particularly in areas of behavioural and cognitive functions (European Journal of Paediatrics [online], 2005).

3. A pilot study was conducted to evaluate the effectiveness of homoeopathy in the treatment of attention-deficit/hyperactivity disorder (ADHD). This was a randomized, double-blind, placebo-controlled trial in which 43 children received a homoeopathic consultation and either an individualized homoeopathic remedy or placebo. Homoeopathic physicians saw patients every 6 weeks for 18 weeks. There were no statistically significant differences between homoeopathic remedy and placebo group however, there were statistically and clinically significant improvements in both groups, suggesting that there may be some therapeutic value to the homoeopathic approach to ADHD (Jacobs et al, 2005).

Other Therapies: Psychotherapy: Psychological therapy is mainly required for the secondary problems that develop such as low self-esteem, anxiety and depression. Psychotherapies are especially important for those children who are unable to tolerate, or whose parents prefer them not to take medication. The parents as well as the child need counseling, advice and coping skills. Cognitive and behaviour modification is recommended with the hallmark of treatment being structure; e.g. routine (establish a predictable schedule of activities), boundaries and rules and children need to be taught organizational skills (use of a diary to record homework and other tasks to be completed). Tasks need to be tackled one at a time and as each task is completed the child needs to be given praise and encouragement (Hallowell and Rately, 1996 and Wallis et al, 1994). Support Groups such as the Attention Deficit Hyperactivity Support Group of South Africa (ADHASA) provide an important function for families, therapists, teachers and caregivers as well as the person with ADD/ADHD.

Diet & Supplementation: Healthy eating, improving essential fatty acid levels and stabilizing blood sugar levels can make a huge difference in the overall performance of an ADHD child (Picton, 2004). The diet should contain natural unrefined foods; avoid foods containing artificial flavors, artificial coloring, anti-oxidant preservatives, and mono-sodium glutamate; and eliminate foods poorly tolerated by the patient. Eating regular, small wholesome meals will stabilize blood glucose levels. Meals should consist mainly of carbohydrates, which are released slowly into the blood stream (low glycemic foods), combined with a small portion of protein. As a deficiency of EFA’s seems to aggravate neurological and other symptoms of ADD/ADHD, it is logical to increase levels of EFA’s by supplementing the diet with Omega 6 (Evening Primrose Oil), and Omega 3 (Salmon Oil). In addition, supplementing with Magnesium, Vitamin B6 and Zinc will assist with the metabolism of the fatty acids (Picton, 2005). By incorporating the above vitamins and minerals in the diet concentration will improve, as they are essential for brain development and function (Picton, 2004; Hall and Naude, 2003).

Anti-oxidants (proanthrocynidins), which protect the body from oxidation (destruction of the body’s tissues) have also been recommended as an additional supplement for example Zinc, vitamin E, vitamin A, vitamin C and Selenium (Holford, 1997; Hall and Naude, 2003). Meyer, (2001) revealed a significant improvement in the experimental group, who used Melotone Syrup for sustained attention and vigilance as assessed by the Children’s Checking Task (CCT). Melotone Syrup is a nutritional supplement specially designed for children and adults who require an essential Fatty Acid supplement in liquid form. This product contains: EFA’S (Evening primrose and Salmon oils); vitamin D; vitamin C; B vitamins; Calcium; magnesium; Zinc; Methyl Sulphonyl Methane; Glycine; Taurine; Chromium and Vanadium.

Herbs: The following herbs could be of some benefit:

Ginkgo Biloba. used to improve concentration by increasing blood flow to the brain and it also has anti-oxidant properties.

Chamomile. calmative, relieving irritability and promoting sleep. Induces clear thinking and increases attention span.

Valerian. calmative for restless children. In high doses can cause drowsiness so is used for insomnia.

Passion Flower. calmative with less sedative effects.

Lemon Balm (Melissa Officinalis.) relaxing tonic for anxiety, mild depression, restlessness and irritability.

It is best to use herbs under the supervision of someone suitably qualified as they can cause some side effects (Hall and Naude, 2003; Weil, 2004).

Bach flower remedies. a series of 38 preparations made from wild flowers and plants.

Biofeedback and Neurotherapy: Biofeedback is a learning process, in which people are taught to improve their health and performance by observing signals generated by their own bodies – a method of self-regulation training. Brain waves (as well as muscle tension, heart rate, respiration, skin temperature and blood flow) are measured and recorded by sensors attached to the brain and other parts of the body. Neurotherapy = biofeedback for the brain, using an EEG monitor and software connected to a computer. It has been suggested that children with ADD have brain wave patterns low in beta waves, which are associated with alert concentration, and children with ADHD have excess beta and theta activity. The goal of neuro- or biofeedback is to retrain the brain and change the brain wave patterns thus improving concentration and focused attention (Weil, 2004).

Occupational Therapy = recommended for individuals that suffer from “sensory defensiveness”. Occupational therapists use “sensory modulation”/“sensory integration therapy“ to assist patients overcome an over-reaction or under-reaction to everyday types of sensory input. Occupational therapists teach patients and parents activities/ methods specifically designed to meet the needs of the child’s own nervous system: calming activities/ alterting activities, organising activities and other suggested coping methods (Allen and Harrison, 2004).

Tomatis Method This is a unique form of sound therapy developed by a French physician. This treatment is designed to stimulate the brain and help a person with ADD to focus on sounds without being distracted. The goal of this therapy in ADD is to correct poor sensory integration (Weil, 2004).

Cranial Therapy This aims to adjust the body to allow the nervous system to function smoothly (helpful for hyperactive children who have experienced birth or head trauma) (Weil, 2004).

Applied Kinesiology This is a therapeutic modality that focuses on the art of energy balancing by means of energy and muscle testing and is used to identify imbalances in the body’s structural, chemical, emotional or other energy fields. It is based on the acupuncture meridian system and its connection to the muscles and organs (Weil, 2005; Bothes, 2005).

Other

Exercise or sport to release/ channel pent up energy.

Meditation or anything to relax the body and mind (Weil).

Art therapy – is the use of art materials for self-expression and reflection.

CHAPTER 3 MATERIALS AND METHODS

STUDY POPULATION

Seventy-two homoeopathic practitioners were registered with the Allied Health Professions Council of South Africa (AHPCSA) in the Johannesburg Metropolitan Area as at May 2005.

Inclusion Criteria

1. Practitioners had to be registered as a Homoeopath with the Allied Health Professions Council of South Africa (AHPCSA).

2. Registered homoeopaths had to be practicing in the Johannesburg Metropolitan area: Diepsloot/Midrand; Sandton/Randburg; Northcliff/Rosebank; Roodepoort; Soweto; Alexandra/Modderfontein; Johannesburg Central; Johannesburg South; Diepmeadow; Orange Farm/Enerdale.

The researcher limited the areas to the above because the entire Gauteng province is too vast an area to cover on a limited budget. Even though the area was limited the area selected represented an even demographic spread that covers the socio-economic factors as well as ethnic groups (Appendix 4).

3. The homoeopaths had to be proficient in the English language as the questionnaire and interview was conducted in English.

Note: Although there are eleven official languages in South Africa for practical purposes the researcher chose to conduct the study using the English language.

Requirements of the participants

1. Completion of the questionnaire within two weeks of receiving it.

2. A half an hour of practitioner’s time for the collection and checking of the questionnaire.

3. Participants were encouraged to reflect on personal issues and disclose personal principles and practices as a homoeopath.

STUDY SAMPLE

These were the practitioners who fitted the inclusion criteria and completed the questionnaire (n=41), initially 63 practitioners agreed to participate, so a final response rate of 65% was obtained

METHODOLOGY

Data collection started in August 2005 when initial contact with practitioners was made and continued until February 2006 when collection of the final questionnaires took place and raw data was handed to the to statistician for analysis.

Focus Group

Before the actual study could commence, a focus group was conducted at the Durban Institute of Technology on 24th August 2005 (Appendix 6). The aim of the focus group was to assess the face validity of the questionnaire. Face validity is determined when a group of experts in a particular field are required to judge the measuring tool, in this case the questionnaire. They must express their opinion as to whether, on the face of it, the measuring tool measures what it is supposed to measure. The focus group consisted of five homoeopathic practitioners and three senior homoeopathic students from the Durban Institute of Technology. The participants were given the participant information letter and questionnaire and were required to make comments and suggestions on the layout, questioning style, grammar and content. The suggestions and comments were considered and the amendments/changes were made.

Vorwort/Suchen Zeichen/Abkürzungen Impressum