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Attention Deficit and Hyperactivity Disorder (ADHD) Autistic Spectrum Disorder (ASD) Buddhi Stories Featured

From Tasmanian Devil to Mathematical Whiz

Master S first met the Neurokrish team (later to become the Trimed-Neurokrish team) about 6 years ago. Aged three years at the time, he was brought to us by his grandfather who had recovered fully from a stroke, under our care. S demonstrated clearly to us the features of both Autistic Spectrum Disorder (ASD) and Attention Deficit and Hyperactivity Disorder (ADHD). He refused to maintain eye-contact, engaged in fleeting social contact which was very poorly sustained and was yet to develop any language skills of note. More disturbingly, S was profoundly hyperactive and disruptive, so much so, that he could in a few moments literally tear apart a consulting or therapy room, when left alone. Needless to say, his mother was distraught, and his extended family members were dismayed. In our minds, S bore a striking resemblance to “Taz” the adorable but disruptive “Tasmanian Devil”, then a beloved cartoon character, much loved by the kids.

Taz was offered a combination of behaviour therapy, Neurodevelopmental therapy and family counselling. He was also prescribed medication to improve attention, stabilise his volatile moods and cut down his very disruptive behaviours. Over a 3 year period, our therapeutic relationship with Taz’s family evolved; together we walked many a milestone; his first words, his play school, kindergarden, and primary school. Therapeutic holidays from drugs during summer and winter vacations; the role of extended families, maternal and paternal; expectations of the many stakeholders, parents, both sets of grandparents, uncles and aunts; teacher and school interactions; our therapeutic relationship weathered these many storms. His GI problems responded to our Naturotherapy approaches; his limbs became dexterous and his fine motor skills including handwriting skills improved with Neurodevelopmental therapy and Ayurvedic massages. Thanks to sustained behaviour

therapy and parental counselling he became less disruptive, could follow parental instructions and began to sit for longer periods of time. His attendance and participation at school improved dramatically; his intuitive mathematical abilities started to shine; he learned to interact better with peers and teachers. Indeed, not only did he survive primary school, he had even topped his class in mathematics. Clearly Taz was endowed with “mathematical intelligence” that outstripped other “emotional and social” domains (see A Vital & Alternative Perspective To Enabling Potential).

Taz, with a combination of ADHD and ASD, was one of our most challenging child clients ever! Recently we met our “Taz” one final time, before he migrated with his family abroad. His evolved parents had declared his condition in the immigration visa application form and sought special assistance for him aided by a detailed summary from Trimed-Neurokrish.

Taz is still a little disruptive and impulsive, butts into conversations, slightly stilted in his speech, but we know he has come a long way. Our Trimed-Neurokrish Integrated approach judiciously combined medication and behavioural and neurodevelopmental therapy, with Naturopathy and Ayurveda, empowered the family with counselling, and awakened his “mathematical intelligence”, with progressive increase in his self-esteem. With this, his social interactions exude warmth and willingness to communicate. His onward life’s journey while abroad must follow the same trajectory.

We must admit that S’s remarkable progress was made possible by the wonderful therapeutic relationship our team had with his family. From S and his family we have learnt the importance of looking beyond terminology and the diagnostic label. Sustained therapy with vigilant monitoring and family and special school support, carry their own reward and hold hope for children, affected just like S. Prof. Dr. Ennapadam S. Krishnamoorthy

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Attention Deficit and Hyperactivity Disorder (ADHD) Buddhi Stories Dystonia Featured Neurodevelopmental Disability (NDD)

Deepak – Precious Child

Biography

Everything seemed against the birth, growth and development of Deepak, as if nature and nurture were conspiring against his very survival at every stage. However, he got past the onslaught of the catastrophic events around his birth, was diagnosed with Neurodevelopmental Disability (NDD) in his infancy, and associated conditions, namely ADHD in his childhood and Seizure Disorder in the adolescent phase. As a young adult he developed Dystonia (involuntary muscle spasm).

Deepak’s mother was an elderly primi at 32 years of age and conceiving for the first time 7 years after marriage and he was ‘a precious baby’. She was hypothyroid, on thyroid supplements, and was on psychiatric medication for 4 years prior to the delivery. The child was delivered by elective Caesarian section, and the mother suffered Post-Partum Haemorrhage (PPH) while the newborn had an Apgar score of 9, with some breathing difficulty.

Exploring the Condition

It was a non-consanguineous marriage. The father had a chronic health condition and his career never took off. It was thus a dysfunctional family, with an overanxious mother coping with a hyperkinetic child with NDD, the father shirking the responsibilities of fatherhood. Deepak’s father died when he was barely 6 years of age and the mother moved in with her parents with the child. There was a history of dementia on Deepak’s maternal side but no family history of suggestive of neurological, psychiatric or other general medical (including liver) condition to indicate Wilson’s disease (see box).

Motor milestones were delayed, and the child walked at 2 years. Unthinking TV viewing by the family saw Deepak at the same age jumping and clapping hands at every violent scene on the screen as if to cheer the hero and villain along! Language was delayed and he started saying a few meaningful words around 2½ years.  At school at age 4 years, he had poor attention span, would not sit in one place, and his learning ability was average. He did not mingle with his peer group in school, and this awkwardness in social interaction continued, into adolescence and adulthood. It is around 5-6 years that Deepak started showing significant aggression, especially aimed at his mother.

He had fears and phobias, and was reluctant to board the public bus to school with his mother, resulting in frequent tantrums. The mother sought a psychiatric consultation for Deepak and he was prescribed a mild tranquiliser. He managed to get through mainstream school (with only one change of school in the 5th grade). While in middle school, he was seen by a Neurologist and diagnosed to have ADHD  and was prescribed Dicorate ER (Divalproex) 250 mg – 1-0-1 and Modafinil (a stimulant drug) 100 mg – 1-0-0. In the 9th grade, he had difficulty coping with studies but managed to pass the 10th grade Board examination.

Before completing 12th grade examination, in 2009, Deepak had seizures manifesting as momentary loss of consciousness and stare. He had memory deficit following the seizure onset and could not cope with his studies.  He dropped out of school as a consequence and subsequently developed frequent minor involuntary movements of the limbs, later dystonic turning of head/neck to the right, with facial grimacing.  Lifting the arm spontaneously, without voluntary control, also followed. At this stage a Neurology Consultant  put him on Tab.Trihexiphenidyl 2mg – 1-0-1.

Our Healing Approach

After comprehensive assessment at TriMed-Neurokrish, at the age of 22 years, a diagnosis was arrived at of Neurodevelopmental Disability with Neurobehavioural Syndrome, borderline intelligence and Movement Disorder (MD). The management of the patient was planned carefully taking into account the multiple challenges that had to be dealt with effectively. The patient was on polypharmacy, and the first step was modification of the drug regimen to optimize benefit. He was on Tab.Divalproex ER 250 mg – 1-0-1 and Lamotrigine 50mg – 0-0-1 was added to this regimen, as effective mood stabilizing combinations in such conditions. Along with this, a novel antipsychotic, Clozapine 25 mg – 0-0-1½ was prescribed; later Atomoxetine 25 mg – 1 -0-0 was started to control ADHD features; to improve attention and concentration and to reduce hyperkinetic behaviour. Modifinil was eventually tapered and stopped as was Dicorate.

The patient did well on this new drug regimen with no further seizures and reduction in the frequency of involuntary motor disturbances. Multivitamin, Calcium Piracetam were added on at various stages of treatment. Deepak had severe musculo-skeletal pain all over the body with spasm of the limb muscles, and the trapezius muuscles in particular, bilaterally. Tab.Trigabantin (Gabapentin 300mg + Methylcobalamin 0.5 mg), Alpha Lipoic Acid 100 mg was added to the drug regimen, and with physiotherapy aimed at relaxing the muscle groups involved there was relief of spasms and with it, pain relief. He also received Podikizhi, an Ayurvedic massage therapy technique with dry herbal powder which is efficacious in the treatment of complaints associated with joints, musculoskeletal and neuromuscular pains in addition to rejuvenating, relaxing and strengthening the joints, muscles and soft tissues and as a result providing remarkable pain relief.

The integrated therapies of Neurorehabilitation and Cognitive Retraining sessions, combined Yogasana, Pranayama, Meditation 22 sessions, Acupuncture 10 sessions, Reflexology 20 sessions, ran parallel to the physiotherapy exercises and TENS 22 sessions. Following a few sessions of therapy, there was improvement in gait, involuntary movements were significantly reduced and ADL performance was returning to normal. The beneficial response to cognitive retraining was noteworthy, as his power of concentration and with it his retentive power and memory had stepped up remarkably with goal-directed cognitive activity. Behavioural problems were brought under control.

The NDD at birth with neurobehavioural problems, exaggerated neuropsychiatric symptoms with onset of the movement disorders/dystonia, the raised Aminotransferase, on LFT testing (indicative of disturbed liver function), the chronic constipation, and a high serum copper (196.4 micrograms/dL), suggested to the Neurokrish Consultant a drug challenge with Penicillamine (a chelating agent), even though the clinical and lab findings were atypical for Wilson’s disease. There was no KF ring, and serum caeruloplasmin and 24 hour urinary copper were normal. Penicillamine (250mg) was slowly increased from one to 2 tablets and was successful over weeks in     reducing dystonia considerably. Subsequently serum copper levels improved and LFT became normal. At the end of 6 months, the Penicillamine was tapered over a month and then stopped, with no return of the dystonia at monthly follow up, even at the end of 7 months.

Wilson’s Disease

Wilson’s disease is an autosomal recessive disorder of copper metabolism, characterised by excessive accumulation of copper in the brain, liver, kidney, cornea and other organs. The clinical manifestation of WD is due to the toxic accumulation of copper in these organs.

Copper is an essential metal that is an important cofactor for many proteins. The average diet contains adequate amounts of copper. The absorbed copper from the duodenum and small intestines enters the portal circulation and reaches the liver.  The liver utilizes some copper for its metabolic needs, synthesizes and secretes the copper-containing protein Ceruloplasmin, and excretes the excess copper via bile secretion. Defective excretion of copper (Roberts 2008)1, results in its deposition especially in the liver and brain.

Ceruloplasmin is the major carrier for copper in the blood, accounting for 90% of the circulating copper in normal individuals. In one series (Steindl 1997)2, 12 of 55 patients with WD and mainly liver involvement, had normal ceruloplasmin and no Kayser-Fleischer rings, though subjects in the same study with predominantly  neurological manifestation had  lowered serum caeruloplasmin and the presence of KF ring.

The gene for Wilson’s Disease ATP 7B, has been mapped to chromosome 13. There are multiple disease mutations of the gene described in proband with the disorder. Further, there are significant Indian studies (Mukherjee, 2014)3 on the genetics of WD, highlighting that some of the more frequently occurring mutations in Indians are different from those reported by  the West.

First-degree relatives of any patient newly diagnosed with WD must be screened. Serum aminotransferase activities are generally abnormal in WD except at a very early age. In many individuals, the degree of elevation of aminotransferase activity may be mild and does not reflect the severity of the liver disease. D-penicillamine (demethylcysteine) is an effective chelator of copper, well absorbed when taken orally , and it promotes the  urinary excretion of copper.

D-penicillamine – induced status dystonicus (Paliwal, 2010)4 is a unique but serious drug related complication in a subset of patients with Wilson disease  with good response to Gabapentin, but failing to respond to other antidystonia drugs.

References

  • Roberts E.A., Schilsky M.L. Diagnosis and Treatment of Wilson’s Disease: An Update (AASLD Guidelines) Hepatology, June (2008),47,(6)  : 2089-2111
  • Steindl P., Ferenci P., Dienes H.P., Grimm G., Pabinger I., Madl C., et al. Wilson’s disease in patients presenting with liver disease: a diagnostic challenge. Gastroenterology 1997;113:
  • Mukherjee S., Dutta S., Majumdar S., Biswas T. et al Genetic defects in Indian Wilson disease patients and genotype- phenotype correlation. Parkinsonism Relat Disord. 2014 Jan;20(1):75-81.
  • Paliwal V.K., Gupta P.K., Pradhan S. Gabapentin as a rescue drug in D-penicillamine-induced status dystonicus in patients with Wilson disease. Neurol India 2010;58:761-3.

Looking Ahead

Deepak has progressed well all round, much to the delight of the TriMed-Neurokrish team. The mother is thankful and has no words to express it. Deepak continues his follow up at Trimed-Neurokrish, is regular with his medication, and is advised short course of therapies if indicated. He continues his exercise regimen at home. He went through a short three-month computer course and is now employed for a computer data entry job, which he carries out efficiently, with all the concentration required. The  occasional flicker of involuntary movement is almost negligible. Behaviour problems have receded to the background, and he is less awkward socially though he continues to be introverted. Above all, there is an inner calm and peace that Deepak radiates, which tells the long story of pain and hardship of the past, and of the future which he knows will offer better hope and cheer. Life is good!

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Anxiety Attention Deficit and Hyperactivity Disorder (ADHD) Buddhi Stories Featured Traumatic Brain Injury

Dharmendar – A New Leaf

Biography

It was yet another of those days when the young man had taken out his father’s car, lent to him grudgingly, with the mother peeping through the bedroom window of the palatial mansion to warn her son not to speed on the road. Dharmendra turned around to wave reassuringly to the parents as he took off at a respectable pace towards the gate. Once on the highway, with the heady sea breeze blowing on his face and his companions cheering him on, Dharmendra pressed the accelerator. That ill-fated night, Dharmendra, at the wheel, swerved to avoid a speeding motor bike and hit the roadside tree. His two companions escaped with mild injuries but Dharmendra suffered Traumatic Brain Injury (TBI). The road traffic accident was to change the course of his life drastically.

Dharmendra was admitted to a reputed city hospital in a semi conscious state, and was under acute care and close neurosurgical monitoring for several days. No seizure was reported. He was treated with corrective surgery for major physical injuries, which needed immediate attention as these multiple injuries, if left unattended, could add to the burden of brain trauma. 

The traumatic brain injury (TBI) was managed conservatively. He mercifully escaped the worst immediate sequelae of TBI. He had recovered full orientation at discharge with loss of the right little finger in the accident, what appeared a small price to pay for the consequences of daredevil speeding on the highway.

But when Dharmendra was brought to us at Trimed-Neurokrish, 2 months later by the desperate parents, (who had heard of our holistic approach to neurorehabilitation from a friend) we knew at a glance that TBI had played havoc with his personality, mood and affect and to a lesser extent his cognitive ability. His explosive, impulsive behaviour was what we faced initially, with an air of intellectual superiority thrown in, which did not make our approach to him any easier. Management of behavioural complications of TBI is challenging and requires a multidisciplinary approach. With gentle persuasion, comprehensive all round assessment by our team members was made possible. We set about facing the major challenge we had taken on with that team spirit of hope and goodwill which has served us on many occasions.’’

Exploring the Condition

Dharmendra was in his 1st year Engineering course when he met with the accident. When he joined engineering college, the parents felt that he had become more mature, stable in his ways and was now a responsible individual, and breathed a sigh of relief. He had been a handful, especially for his mother, from childhood. He had performed below average in school. He had shown frequent irritability, anger and defiance towards figures of authority. He had been diagnosed with Attention Deficit Hyperkinetic Disorder (ADHD) with associated Oppositional Defiant Disorder (ODD) and treated for it as a child.

These underlying childhood behaviour disorders have an add-on effect on personality traits at the phase of post TBI recovery. The symptom complex was suggestive of a frontal lobe syndrome. After thawing the ice, during the first few difficult interviews, the clinical psychologist managed to record the chameleon-like changes in the colour of his moods and affect: easy going, emotionally expressive, cooperative, sensitive, keen to do the right thing on the one hand, on the other hard headed, adventure loving and prone to risk behaviours. He was prone to exhibiting high levels of anxiety, building up to a pitch to manifest anger, even rage, an episodic dyscontrol syndrome. Once the episode passed, Dharmendra was at peace with himself and with the rest of the world as if nothing had happened. Was he aware of these monstrous flare-ups in the early phase of his neurorehabilitation? Probably not.

Further psychological testing showed him to be intellectually average, with poor mathematical ability, but adequate ability in language and other subjects and fair visuomotor ability. He had taken to excessive substance abuse, smoking, and was addicted to video gaming. On physiotherapy assessment, the patient’s physical health was very satisfactory, free in activities of daily living (ADL), a Barthel Index of 100; normal gait and balance, poor ability to run due to poor endurance, with no subjective reporting of pain. 

Frontal Lobe Syndromes

The degree of dysfunction caused by frontal lobe damage depends on the abilities and traits before the TBI, as well as the extent, location, and nature of the damage as a result of the TBI. To assess the frontal lobe damage, your physicians should give you a complete neuropsychological evaluation. The testing measures speech, motor skills, social behavior, spontaneity, impulse control, memory, problem solving, language, and more.

In a direct injury, the frontal and temporal poles receive the maximum impact. MRI brain revealed only a brainstem injury, but multiple networks from and to the frontal lobe, the limbic system, subcortical structures, brainstem etc. may account for the manifest frontal lobe syndrome (mainly dorsolateral prefrontal syndrome) in the patient. Aside from this, white matter lesion in the network cannot be picked up by standard MR imaging.

Frontal lobe damage affects most aspects of behavior, mood, and personality. Patients with dorsolateral frontal lesions tend to have lack of ability to plan or to sequence actions or tasks, poor attention span, a poor working memory for verbal information (if the left hemisphere is predominantly affected) or spatial information (if the right hemisphere mainly affected) Patients with orbitofrontal lesions tend to have problems of disinhibition, emotional lability, and memory disorders, Personality changes from orbitofrontal cortex damage includes impulsiveness.

References

  •  Jeffrey L.Cummings, MR Trimble. Concise Guide to Neuropsychiatry and Behavioral Neurology. II ed., American Psychiatric Publishing Inc, 2002, chapt. 5: 71-86Andrea E. Cavana Tourette Syndrome – Clinical Review , BMJ, Aug 2013 ; 347 :1-6
  • RTA statistics – global and Indian: According to the WHO statistics, (2016) about 1.25 million people die each year globally as a result of road traffic accidents. Road traffic injuries are the leading cause of death among young people, aged 15–29 years. The newly adopted 2030 Agenda for Sustainable Development with over 150 nations participating, has set a road safety target of halving the global number of deaths and injuries from road traffic crashes by 2020.
  • The detailed age profile of accident victims in India other than the drivers (Ruikar 2011), revealed that the age group between 25 and 65 years accounted for the largest share, 51.9%, of total road accident casualties, followed by the age group between 15 and 24 years, with a share of 30.3%
  • WHO fact sheet on road traffic Injuries (reviewed in Nov. 2016) Manisha Ruikar National statistics of road traffic accidents in India –Symposium- Polytrauma Management, rehab- J  Ortho, traumatology,rehab 2013   Vol 6. :1 : 1-6

Our Healing Approach

Dharmendra was given long term medication with constant monitoring and titration of the drug dosage. He was on Oxcarbamazepine & Levitiracetam (both for the control of seizure/episodic dyscontrol), Sertraline (antidepressant), Atomoxetine (to encourage mental alertness, attention) and vitamin supplements. He had had long sessions of cognitive behaviour therapy, distributed over 24 staggered sessions.

The integrative therapy included apart from continued sessions with the clinical psychologist using an eclectic combination of Cognitive Behavior Therapy (CBT), Relaxation Training (Jacobson’s Progressive Muscle Relaxation) and Family Therapy; 15 sessions of Acupuncture, 15 of Reflexology, 10 Abhyangam and 10 Shirodhara. The scientific principle behind these therapies is to remove blocks in the energy channels of the body and to reestablish the free flow of bodily energies in the path to recovery.

On this regimen and the integrated therapies, the spells of anger and dyscontrol became progressively less frequent and less intense. Running parallel, his cognitive ability also improved. The Trimed-Neurokrish team came to a consensus that Dharendra was ready to go back to college after these three months of intensive therapy.

Formal parent education sessions, for them to understand clearly that Dharmendra’s behaviour was not willful, but part of the frontal lobe syndrome, was an important exercise, and was carried out meticulously, resulting in the full support of the parents towards medical management of their son. 

Dharmendra returned to 2nd year Engineering in the college after a long gap. He seemed to cope, but tended to sleep in class miss special classes, with increasing arrears, which made him anxious and as a result to increase the number of cigarettes he smoked. The parents showed great concern and follow up sessions with Trimed-Neurokrish had to be more frequent. Divalproex & Olanzapine- Fluoxetine were added to the drug regimen (replacing Levetiracetam and Sertraline), with subsequent control of these worrying symptoms. The patient went through the second year of Engineering College with occasional problems.

Looking Ahead

Dharmendra settled well, with improvement in cognition, better memory and attention and more stable behavior in his 3rd year Engineering. He still has rare dyscontrol episodes but these are few and far between. Periodic psychological sessions continue both scheduled and on demand. With improved academic performance, and in a mood of goal orientation,  he managed to clear his academic arrears  and seems well on his way to facing a professional career of significance. When will he be allowed to drive the car again, he wonders. His own, this time!