A mental health outreach program in child welfare centre with homoeopathy

INTRODUCTION

Mental health is one of the precursors of a state of well-being. It is determined by a range of socioeconomic, biological and environmental factors. Cost-effective public health and intersectoral strategies and interventions exist to promote, protect and restore mental health.¹

Emotional and behavioral problems (EBP) during childhood and adolescence are a common concern for parents and mental health stakeholders globally in the current millennium.² It is estimated that 10% of children and young people have mental health problems so significant that they impact not only on their social and academic functioning but, if left untreated, they will continue into adulthood or convert into major psychiatric problems.³ The five most common groups of childhood psychiatric disorders are hyperkinetic disorder i.e. attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder, childhood anxiety disorder, and depressive disorder.⁴

Multiple psycho-social and biological factors determine the level of mental health of a person at any point of time. Exposure to early environmental stress has been associated with suboptimal physical and brain development, cognitive impairment, and behavioral problems. Studies have reported that children who are abused are at high risk of behavioral problems, learning disabilities, communication and psychiatric disorders.⁵ Globally majority of children who need mental health care worldwide lack access to quality mental health services. Stigma, human resource shortages, lack of research capacity for implementation and policy change contribute to the current mental health treatment gap.⁶ Children in conflict with the law and children in need of care and protection have a higher prevalence of mental health-and substance use related-problems, similarly young people with mental health problems have a higher chance of coming in contact with juvenile justice system.⁷ Both toddlers (41.8%) and preschoolers (68.1%) in children welfare centers have high developmental and behavioral needs; however, few children are receiving services for these issues (22.7% overall).⁸ Hence, integration of different medical disciplines can be a possible option for the future child mental health strategies.

Homoeopathy with two unconventional theories: “like cures like” and “law of minimum dose” provides revolutionary approach in medicine.⁹ Samuel Hahnemann, the founder of homeopathy, was a pioneer in the treatment of the mentally ill, advocating for a humane approach to those suffering, which is a global approach towards the mental health preservation now.^10,11 There are significant number of studies demonstrating the effectiveness of homeopathy in management of behavioural disorders of the children like cognitive handicaps, traumatic brain injury, irritability, anger, restlessness, sleep disorders, enuresis, encopresis, apathy, tantrums, hyperactivity, hypersexual behaviour, autism spectrum disorder (ASD), mental retardation, seizure disorder, temper tantrums.^12-15 In analysis of a small consecutive sample of 20 children with a diagnosis of ADHD receiving homoeopathic treatment published by Fibert et al, the intervention was associated with improvements in criminality, anger and children with a concomitant diagnosis of autism spectrum disorder.¹⁶ A series of three cases of conduct disorder which have been treated exclusively with homoeopathic medicines without any supportive therapies are reported and outcome of homoeopathic treatment shows a positive role.¹⁷ Cost-effective public health strategies and interventions with an integrative approach are necessary to promote, protect and restore child mental health, especially among the high risk groups.

METHODS

An outreach OPD program was designed by National Homoeopathy Research Institute in Mental Health to conduct at a children welfare centre (CWC) with a preliminary intention to elicit the prevalent mental health issues and possible role of homoeopathy in the defined population. An approval for conducting such programme was obtained from the CWC in charge. A health team with multidisciplinary health personnel has been entrusted to visit the CWC. As an initial confidence building measures between the inmates and the team of health personnel, an interaction session was organised to break the inhibition of the inmates otherwise reluctant to initiate any activity. The health personnel explained the mode of activities which are going to undertake in the juvenile home, such as detailed history probing, inquiry into the available documents to get a further background check of each individual, interview with caretaker, and corroborating the stated story with the help of counsellors. Considering the number of inmates and the outcome of the preliminary assessment on mental health aberration, a regular follow-up of the inmates was designed for those who are found to be having mental health issues. Apart from the Physicians, psychiatric social worker and counsellors were part of the team. A monthly follow up was scheduled and data has been recorded in a prescribed, predefined proforma for each disease conditions.

46 inmates in the CWC were screened for emotional and behavioural problems to understand the prevalent mental health problems and the treatment to be adopted thereon. Out of these, 20 cases were identified to have a diagnosable psychiatric illness such as attention deficit hyperactive disorder, conduct disorder, oppositional defiant disorder, intellectual disability, and learning disability. The number of cases which were diagnosed with a specific condition are shown in Figure 1. Two children had physical co-morbidities i.e. nocturnal enuresis and pityriasis versicolor.

All the cases were taken in a specialized case record form (CRF) for child and adolescent mental health developed by the team as per homoeopathic guidelines. The symptoms of each child, including the presenting complaints, past history, developmental milestones, family history, aetiological factors, other homoeopathically relevant data, were analysed and the prescription was made in consonance with the homoeopathic principles. A minimum dose of the indicated remedy in centesimal potency is prescribed in the first prescription and is repeated as and when needed according to the principles of posology. 3 illustrative cases are presented below to show the methodology and approach to the cases.

Case illustration-1 (Conduct disorder)

Master PD, 17 years male was a quarrelsome adolescent, who starts physical fights almost every day. He used to deliberately destroy other’s property, stolen things of value from other’s houses and by shop-lifting. He had tendency to lie and use abusive language when angry. He was cruel towards animals and humans with hurting tendency. He has increased sexual impulses with history of forcing people into sexual activity many times. On enquiring about the family background, it is found that he has 2 female siblings who are intellectually disabled. His mother got remarried after death of husband and was diagnosed to have a psychiatric illness and cancer. His step father compelled him to consume alcohol and raped one of his sisters and was put in jail. Master PD was brought up in an orphanage from the age of 5 years and escaped from there along with a friend and was caught by child welfare inspector. After bringing to CWC he had frequent fights with authorities and the peers, in spite of regular counselling sessions and the situation seemed hopeless. He was forcing young boys into homosexual activities and threatening them if they refuse. PD was diagnosed to have conduct disorder (F91) and was treated with Lycopodium 200 after repertorization (Figure 2). There is a remarkable reduction of the disruptive behaviour within few weeks and improvement in his interpersonal relationship, which continued till the end of a year.

Case illustration-2 (Hyperkinetic conduct disorder)

Master SJ, 14 years male presented with over-talkativeness, inattention, restlessness, impulsivity, disobedience towards elders and mocking other children. He is a source of lot of trouble at the home and everyone labelled him as a naughty child until he revealed his inner loneliness and his family background. SJ’s father left home when he was 7 years old and his mother fell in love with another man and left SJ with his paternal grandmother. His sister was left at a rehabilitation centre as she has some unknown psychiatric illness. He feels rejected as even other children refuse to play with him as he is impulsive and gets hot temper easily if he loses. He has tendency to throw game coins and break game boards. He is short in stature and lean built, feels inferior because of his nutritional status and tries to dominate others by shouting loudly. The case is diagnosed as hyperkinetic conduct disorder (F90.1) and the child was treated with Sulphur 200 based on individualizing features. Figure 3 can be referred for the rubrics considered for repertorization. In the next 6 months Sulphur 200 was repeated twice. He became obedient with improved concentration and reduction of hyperactivity and impulsivity. His relationship with peers has improved considerably along with improvement in his academic performance.

Case illustration-3 (Oppositional defiant disorder)

Master AS, 9 years’ male presented with outbursts of anger, argumentative, disobedience, restlessness and provocative behaviour. He is an illegitimate child whom his unmarried mother left at sevagram, soon after birth. He was indifferent and revengeful to everyone. He has habit of nail biting, whistling loudly and tendency to say lies. He likes travelling, cycling especially and rides recklessly. He has borderline intellectual functioning (IQ-86). He is poor in studies and has despair of life. The case was diagnosed as oppositional defiant disorder (F91.3) and was treated with Lachesis 30, followed by Lachesis 200 and Medorrhinum 200, as intercurrent remedy. Rubrics considered for the selection of the remedy and the repertorial result is shown in Figure 4. The child became obedient, manageable and there were no outbursts of anger or restlessness after 6 months of treatment. The behavioural improvement persisted through the observation period.

RESULTS

55% (n=11) of cases were found to have marked improvement after 1 year of treatment. 30% showed moderate improvement (n=6), 10% showed mild improvement (n=2) and 5% (n=1) showed status quo (Figure 5). The remedies indicated are shown in Table 1. The above cases are among cases of behavioural issues who were managed well with individualised homoeopathic medicines. There is general improvement along with reduction in behavioural issues of most of the children. The remedies indicated in the first prescription for the different children along with the clinical conditions are shown in Table 1.

Acute remedies such as Aconite, Belladonna, and Rhus tox were given in between for physical complaints that occurred in between. Intercurrent or miasmatic remedies were given in the follow up visits as per the necessity. Modified Naranjo criteria (MONARCH) for causal attribution revealed a score of 9 in these 3 cases pointing to high probability.

DISCUSSION

Early identification and appropriate intervention for behavioural problems in children is very essential for building a healthy next generation society. There is a need to integrate alternative and complementary therapies into the mainstream to fill the treatment gaps. A multidisciplinary intervention with individualistic approach is necessary because each child is unique and the psycho-social issues they face and their response to the environmental influences is varied.

Research studies are consistent with the possibility that expansions in psychiatric medication usage have reduced crime and delinquency. Estimates suggest that medication usage has increased to as much as 9% of the youth population and up to 20% of the adult population in the United States and is high among populations associated with the criminal justice system. Studies show that the commonly used psychiatric medication do reduce aggressive behavior, and crime rates are lower among diagnosed patients receiving such medications compared to those not.¹⁷ Considering the rise in crime rates in recent times, homoeopathy and other CAM interventions are indicated in the treatment of juvenile delinquents so that they have an opportunity to overcome the social stigmas and channelized into the mainstream to run a normal life. Cases in this study who had chances of developing antisocial personality disorder were prevented to some extent by homoeopathic intervention.

In a study conducted to assess the relationship between the need for and use of mental health services among a nationally representative sample of children who were investigated by child welfare agencies after reported maltreatment, nearly half (47.9%) of the children aged 2 to 14 years (N=3,803) with completed child welfare investigations had clinically significant emotional or behavioral problems.¹⁰ In our study also it is identified that 43% of the children presented with diagnosable emotional or behavioural problems requiring treatment.

Children who have been exposed to maltreatment and other adverse childhood experiences (ACEs) are at increased risk for various negative adult health outcomes, including cancer, liver disease, obesity, substance abuse, and depression.¹⁸ In the current cases of behavioural disorders, considerable number of children had history of either physical or sexual abuse. This stresses the need for tracing the past history with emphasis on causal attribution of the disorder.

Most of the children in the study are from poor socioeconomic group. It is understood from current cases an unstable family environment with family poverty influences the mental, emotional, and behavioral health of children.¹⁹ Understanding family dynamics and underlying aetiological factors like predisposing factors, perpetuating factors and precipitating factors are vital for the management of children with behavioural problems.

The 2 children with Intellectual disability disorder (mental retardation) progressed fairly well on treatment for their behavioural issues. Intelligence quotient (IQ) couldn’t be assessed in the follow up visits due to lack of competent personnel. It must be noted that additional support for biological, foster, and kinship caregivers in encouraging development is important for the attainment of critical developmental skills, especially for children with developmental difficulties.²⁰ A systematic literature review of available evidence for using homoeopathy in patients with intellectual disabilities concluded that the currently available evidences are neither conclusive nor comprehensive enough to give a clear picture for the use of homoeopathy in patients with intellectual disabilities. There are large gaps in the body of evidence concerning the role of homoeopathy in the treatment of common disorders in intellectual disability.²¹ Hence, it is recommended to plan rigorous studies on usefulness of homoeopathy in intellectual disability disorder.

Children with conduct disorders were assessed with conduct disorder rating scale (CDRS) at periodic intervals. Two of the children with conduct disorder and depressive episode who required institutional care were admitted in NHRIMH and were treated with homoeopathic medicines along with occupational therapy and counselling. These two cases were discharged with remarkable improvement in their behaviour.

It is interesting to find that sulphur, a widely proved medicine in homeopathy, is indicated in 33% of cases in a variety of psychiatric conditions in this camp. This is in consonance with the fact that all the “mental diseases” are psoric in origin, as per Hahnemann’s exposition in Organon of medicine.¹⁰ The king of antipsorics is often indicated in mental diseases.

The outcome of this preliminary outreach program is very fruitful and is encouraging for use of homoeopathic medicines for reducing emotional and disruptive behavioural disorders in children, especially in a specific community like inmates of CWC.

Challenges faced

Case taking

As the children were brought from various part of the state to the welfare centre and their parents were not along with them, the detailed homoeopathic case taking was difficult in certain areas like past history, family history, life space investigation etc. This challenge was overcome by collecting some information from their records at CWC.

Other treatments

In the follow up visits, when children developed physical symptoms like tonsillitis, scabies etc. as an assumed process of exteriorization (as it is reappearance of old symptoms), the children were given conventional medicine such as antibiotics, topical applications etc. by the staff, who were not aware of direction of cure in homoeopathy. This could be overcome in the next follow-ups by educating the staff about concepts of homoeopathy.

Monitoring/reliability

As the children are partly monitored by supervisors and social worker and when there was change of the concerned staff, at times it was difficult to assess the progress and reliability of the report was moderate.

Outcome measures

There was limited time to access with children as they are mostly occupied with other activities during the scheduled visits. So, assessing the improvement of children’s behaviour using appropriate rating scales was difficult. Selection of appropriate scales was also a challenge as many rating scales are either parent/ teacher rated but the supervisors and social workers monitor the children.

Limitations

Although there were remarkable individual changes in the behavioural issues of the children, generalisation is not possible because the cases were of different diagnoses and few cases in each category. The improvement of the cases was not quantitatively measured using an appropriate rating scale as there was limited available time to spend with children. This must be overcome in the future experimental studies.

CONCLUSION

This report generates preliminary evidence for an outreach intervention programme using homoeopathic medicines in the management of children with emotional and behavioural problems in child welfare centres. In spite of all the challenges and inherent lacunae, it is perceived from this study that many children with emotional and behavioural problems are benefited from homoeopathic medicines. This work may be extended to other child welfare centres so that large number of such suffering children would receive hope of refinement and a bright future, that they deserve. Research studies with appropriate study design focussing on specific behavioural problems in juvenile delinquents are suggested. Positive outcomes could lead to the implementation of homoeopathy in public health programmes related to children’s behavioural issues at an early stage. There are compelling reasons to support and promote such research in homoeopathy.

ACKNOWLEDGEMENTS

Authors would like to thank superintendent and staff of CWC for their cooperation and valuable support. They would also like to thank consultant psychiatrist, Dr. N. D. Mohan for his immense support in diagnosis of cases, and post graduate scholars of department of psychiatry for assisting in case analysis and assessment of follow up of the children.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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