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Adolescents Anxiety Autistic Spectrum Disorder (ASD) Buddhi Stories Children Featured Neurodevelopmental Disability (NDD) Patient Stories

Surya – Conquering Anxiety

Biography

Surya was the first born, delivered full term by lower segment Caesarian section, the indication being a big baby weighing 3.4 kg with a large head and cephalo-pelvic disproportion. The Apgar score was 9/10 (excellent). There was no neonatal seizure or any other health-related event of significance in the neonatal period or in infancy. With the passage of a few months the parents noted that the infant’s response to familiar people, even to them, lacked spontaneity, and eye contact was sparing. He was preoccupied with repetitively examining one favourite toy over a long period of time and this form of restricted play continued into childhood. He did not walk till almost 2 years, and even when he did, he was awkward and had frequent falls in the early phase. It was, however, the delay in the speech/language milestones with the first few meaningful words expressed at 2 years, that caused greatest parental concern.

At this stage, a diagnosis under the broader umbrella of Autism Spectrum Disorder (ASD) – Pervasive Developmental Disability – not otherwise specified (PDD-NOS) was arrived at by the specialist in USA and early therapies were started. The parents stuck to the specialist advice to confine the child’s exposure to a single language and English served the school and home front. On joining school at three years, there was some improvement in his verbal expression, but by 4 years, with the family back in India, from abroad, he had achieved wider language and communication capability. This is the magic gift that Indian children born abroad receive on exposure to the Indian milieu, even short-term, where grandparents, aunts, uncles and cousins, chatter incessantly, not necessarily in English, but also in their child-focused affection, rally round to address the child face-to-face!

Exploring the Condition

Surya’s speech, which lacked clear enunciation, accent and prosody, and had a nasal quality, required special attention and the child had regular speech therapy from the age of 4 years, aside from occupational therapy and special education outside mainstream schooling. Surya manifested restlessness, easy distractibility, poor motivation, social anxiety and on occasions, impulsivity, which also required correction. When he was brought by his parents to TriMed-Neurokrish two years back, at age 9 years, they appeared as stressed as Surya himself. As a high performing ASD, he had managed to barely cope with mainstream schooling upto the primary grades (ICSE Board syllabus), with poor math skills and dyslexia. Anxiety was mounting as he progressed to high school level with its academic demands. To add to the displeasure at school, he was bullied by the other children, who did not let him join them in the ball games offered, as he was slow and clumsy. When this awkwardness was analyzed by the specialist, it pointed to poor hand-eye co-ordination as a main cause. School refusal started to set in and the parents recognized the red flag signal which called for more intensive professional attention. A close friend suggested TriMed-Neurokrish as a possible solution to the child’s learning disability and emotional  problems.

Surya had got this far academically, without major behavioural problems, as all along, the mother had dynamically participated in fulfilling his study requirements and emotional needs and the school had been supportive. His mother, a well educated, perceptive lady, continued to follow the special education methods at home, which she observed during the child’s sessions with the special educator. His spelling skills took a big leap forward when he was taught by the phonetic method. The mother spent long hours with Surya over his homework, partly by following rote learning methods, though by elaborating on the topics’ ramifications, she managed to bring in some conceptual learning, which ensured better retention and recall in him. Math skills were just picking up at a basic level, but Surya was happy to run up to the corner store to purchase some small items of grocery the mother requested, and managed every time to bring back the correct change.

Our Healing Approach

At TriMed-Neurokrish, a comprehensive assessment, by the team members was carried out with meticulous care. The child was thin built, with dysmorphic features, with a narrow face, low set ears, close set eyes, and a tendency to keep the lips parted slightly, the last due to a chronic sinusitis and nose block. No other abnormal systemic signs were observed and laboratory tests were unremarkable, except for low D3 levels, which was corrected with oral medication. We had a team meeting to formulate a list of priority moves to gain effective control in the management of Surya’s educational and psychosocial problems. A diagnosis under High functioning Autism Spectrum disorder – Pervasive Developmental disorder not otherwise specified (PDD-NOS)/Asperger’s syndrome (based on the Sohn Grayson Rating Scale) with Learning Disability (LD) was arrived at, and the broad management plan was discussed.

The immediate goal was:

  • To reduce Surya’s anxiety levels and get him to attend school regularly, a few hours initially, progressing to full day attendance
  • To overcome separation anxiety when the mother dropped him at school and left
  • To motivate him to engage in other activities than studies
  • To work on his fears and phobias of ‘robbed’, ‘kidnapped’, ‘killed’ which disturbed him
  • To offer caregiver support to the mother who was highly stressed

By way of medication, Surya was given Attentrol – (Atemoxitine) to improve his attention on tasks along with a anxiolytic.

The Clinical Psychologist found his academic performance adequate, based on the NIMHANS Battery (Specific Learning Disability Index). Regarding his special academic needs, with long term coaching outside school, Surya was able to cope with reading, writing (including spelling), at his 8th grade levels, with math ability at 5th grade levels. His handwriting skills were poor due partially to defective fine motor control and his focusing power on tasks required reinforcing with repetition. All these deficits put together made him very anxious regarding coping with studies.

Our intensive therapy for Surya followed our protocol for children with Neurodevelopmental Disorders (NDD) and included a combination of two Ayurveda treatments (Shirodhara & Abhyangam), Play Yoga, Neurodevelopmental Therapy (NDT, a combination of physical and occupational therapies, in his case with a handwriting focus) and psychological therapy (behavioral and family). Sessions of NDT and BT often continue for months in regular periodicity, and include weekend opportunities to meet with peers (also in therapy), socialize, and develop skills of emotional expression. Later, understanding his fondness for ‘gadgets’ we involved him in a cognitive enhancement program using structured computer based gaming to enhance specific cognitive skills.

Our team, after much deliberation, suggested to the parents, special education for Surya at a school of excellence, and with the Open School Examination system offered there, he settled to a comfortable pace of school work.

The special educators of the school, in dialogue with Surya’s parents, chose subjects for him that he would be able to comprehend and work out in a relaxed manner, and which would lead him to a future career as a high performing ASD. In this more relaxed school environment, the child overcame his fears and the separation anxiety was no longer a problem. Day-to-day, moment-to-moment caregiver stress was significantly reduced in the mother, who decided to expose Surya to other activities than studies as suggested by the TriMed-Neurokrish team. Coaching in swimming and keyboard playing were chosen as two diverse activities (with the mother joining the coaching sessions as well) which would benefit physical fitness, cognitive ability, concentration, fine motor activity, musical sensitivity, sensory integration and many other finer aspects of development in the child.

Surya’s motivation and empathy to go with the mother did not last for long and the ASD trait of preference for routine and repetitive activity prevailed. He preferred to unobtrusively sit watching his mother, as she completed the courses successfully and went on to the next level of training with the hope that perhaps Surya would get back to these activities some day with gentle persuasion and the slow but sure outcome of goal-directed CBT! She brushed aside this wishful thought and got back to the present with its encouraging progress in Surya.

He was however, enjoying his Behaviour Therapy and Cognitive Enhancement sessions at Trimed-Neurokrish and the team members gave of their best to sustain Surya’s interest through the sessions. He continued to listen to music, most often a favourite tune and beat repeatedly. He responded positively to engage in a short-term novel activity for which he was rewarded. In a BT session to learn how to tie his shoe-lace, his motivation was that he would get new shoes, and sure enough he mastered the skill in two days! What worked towards motivating Surya without fail was the reward in the form of a car ride, to undergo any new learning process. So the team went through BT for activities of daily living, interaction with strangers, mentoring and token economy, in a graded manner, to more advanced cognitive enhancement paradigms of arithmetic tasks, logical reasoning and critical thinking. Incorporating the subject’s areas of special interests in therapy, using visual aids and including parents in therapy sessions, the benefits of cognitive behavior therapy and cognitive enhancement became apparent.

“In this more relaxed school environment, the child overcame his fears and the separation anxiety was no longer a problem.”

Our Focus:

Autistic Spectrum Disorder

Autistic spectrum disorder (ASD) is a group of developmental disabilities that can cause significant social, communication and behavioral challenges. Autism represents an unusual pattern of development beginning in the infant and toddler years. Language  and communication, learning, thinking, problem solving, social interaction, stereotypy and other behavioural  patterns, lack of empathy and performance of activities of daily living may show varied levels of involvement. Neuropsychiatric and neuropsychological evaluations in Autism have revealed selective dysfunction of ‘social cognition’, with sparing of motor, perceptual and basic cognitive skills1. According to DSM IV the spectrum of autistic disorders comprise autistic disorder, Asperger’s syndrome, pervasive developmental disorder not otherwise specified, including atypical autism (PDD-NOS), Rett’s syndrome, and childhood disintegrative disorder. When full criteria of the five under this umbrella are not met, it falls under the category of PDD-NOS. High functioning Autism Spectrum disorder – Pervasive Developmental disorder not otherwise specified (PDD-NOS)/Asperger’s syndrome is diagnosed by employing an assessment questionnaire for the subject’s parents named the Sohn Grayson Rating Scale, a questionnaire for the subject’s parents, covering the academic, cognitive, psychosocial and other domains, which may indicate a higher performance and atypical pattern of the spectrum in the subject studied, as in our patient, Surya. Before this instrument is used, there are over seven diagnostic tools for ASD, including Autistic Behavioural Checklist, Autistic Spectrum Screening Questionnaire and observational tools which must be employed on subject to be tested.

Global prevalence of ASD is about 1.5 per 1000. There has been a 600% increase in prevalence over the last two decades. In a multinational study, the point prevalence of ASD was 7.6 per 1000 or 1 in 132 in 20102. In India more children with ASD are being identified, earlier than before and as a result, early intervention is possible with developmental disability institution being made available in the public sector as well. But these are few and far between. The average age at presentation to the clinic in India was 21.23 months (SD = 2.18)3. They present clinically in a manner similar to that reported internationally. Awareness among professionals and the public is increasing over less than a decade.4  As yet, there is no aetiology-based intervention for autistic spectrum disorders (ASD). However, symptomatic treatment and therapies with a cognitive-psychoeducational/behavioural approach  can be of value in moderate ASD5.   

References

  1. Vaghbatta. Shirodhara AshtangaMisra V. The social brain network and autism. Annals of neurosciences. 2014 Apr;21(2):69.Hridaya, Sutra Sasthana, Chapter 22
  2. Baxter AJ, Brugha TS, Erskine HE, Scheurer RW, Vos T, Scott JG. The epidemiology and global burden of autism spectrum disorders. Psychological medicine. 2015 Feb 1;45(03):601-13.Ajanal Manjunath, Chougale Arun Action of Shirodhara– A Hypothetical Review J Res. Med. Plants & Indigen. Med. Sept. 2012 1;  9 : 457–463
  3. Malhi P, Singhi P. A retrospective study of toddlers with autism spectrum disorder: Clinical and developmental profile. Annals of Indian Academy of Neurology. 2014 Jan;17(1):25.
  4. Malhotra S, Vikas A. Pervasive developmental disorders: Indian scene. Journal of Indian Association for child and adolescent mental health. 2005;1(5).
  5. Francis K. Autism interventions: a critical update. Developmental Medicine & Child Neurology. 2005 Jul 1;47(07):493-9.

Looking Ahead

Surya is relaxed in his new school, and stress and anxiety of school work has left him. He is catching up with many ADL, and is even more motivated to do so with a reward at the end of each novel learning process. With improved performance and by dispelling his fears and phobias through logical thinking taught to him at the CBT sessions, Surya has conquered many of his fears and phobias and to a considerable extent his social anxiety.

He continues his CBT/CET and follow up at Trimed-Neurokrish, twice a week and the team is more than pleased to receive him for his sessions, as there is good compliance and palpable progress with each visit to the clinic.

The parents are at peace and are relieved to have found a centre which offers a holistic approach towards Surya’s all round development.

Categories
Adults Anxiety Buddhi Stories Depression Featured Patient Stories

krishna – A Quest of the Mind

School days had been fun, playing team games at school and with the neighbours’ children in the sprawling campus all evening and on weekends. This did not deter him from achieving 90% and above in all the subjects in school and in the 10th standard Board Examination. 11th and 12th were in one of those cram schools, with 10-hour teaching schedules, which prepare children for the IIT entrance examination. IIT proved elusive and Krishna joined a reputed private engineering college and stayed in the hostel attached to the institution.

Biography

It is not clear whether it was the initial ragging, or the continuous teasing by the seniors in the hostel that made Krishna progressively more anxious and to withdraw socially; or indeed whether these were early manifestations of his mental health condition; whatever it was, seemed to viciously erode his self confidence in stages. He had been at the butt end of jokes even at school, as he was prone to get some facts wrong in areas of common knowledge, which he would blurt out impulsively. The inherent social awkwardness became magnified into loss of self-esteem and social withdrawal in the new environment, away from home and away from his childhood friends. Class grades plummeted by end of 2nd year at Engineering College and he had accumulated arrears in a few subjects. Clearing them seemed insurmountable even as his mental turmoil increased. By the 3rd year, he had to take a break from studies and later returned to the college, commuting from the home of his paternal grandparents (who lived in the same city where he attended college), for a period of six months, after which he opted to brave the hostel milieu, cleared the arrears and completed the course effectively, receiving a choice of campus placement.

Exploring the Condition

Krishna had thus been through a four year period of waxing and waning symptoms of social anxiety, with significantly reduced social interaction from about 17 years of age. He had a once in three month follow up with a psychiatrist over the previous couple of years and was on antidepressant medication, a low maintenance dose of Fluoxetine. On this medication and some counseling, Krishna was managing his daily activities and work performance satisfactorily, till 6 months prior to his consultation with us, when his condition turned for the worse.

In the competitive job scenario, Krishna found the IT project job very stressful as he could not grasp the concept of project ideas conveyed to him over the phone, often within a brief communication and consequently could not reply relevantly to suit the demands of the foreign clients. Being inherently a high achiever and wanting to please, he found this situation beyond his coping ability. An acute phase of illness set in, with marked loss of appetite, insomnia, loss of weight, fatigue, poor self-care, poor concentration, total inability to attend office, social isolation and subsequently led  to a state of almost catatonic mutism  During this period he had delusions of reference (others are talking and commenting about me) and experienced mental confusion. He appeared to be out of touch with reality and in a state of acute psychosis. Krishna was forced to go on medical leave.

It is at this point that the highly concerned, well educated, discerning parents made inquiries for a place that could offer sustained therapies and close follow up. He was admitted for a few days for comprehensive assessment and investigations and management of the acute psychotic state by the TriMed-Neurokrish team.

The case called for elaborate psychological testing. These assessment scores are touched upon here, without too much explanation, for the lay reader to appreciate the need for a scientific and evidence-based approach to a neuropsychiatric case which depends not only on the clinical acumen of the Neuropsychiatric Consultant as Head of the Group, but that clinical judgement is dependent on inputs from other team members, to estimate the degree of mental disturbance and to guide the course of management. 

Our Healing Approach

During assessment at Trimed-Neurokrish, Krishna admitted to have gone through similar, but less alarming phases of physical limitation and mental turmoil which he had not expressed clearly to anybody. Self perception and perception of the environment became progressively maladaptive in a range of social and personal contexts, and the subjective distress kept mounting. He had experienced suicidal ideation 2 years earlier.

He also described vividly ‘catastrophic scenarios that he had witnessed in his mind’ (possibly delusional) for e.g., an unknown person to the patient, whose tongue had been lengthened infinitely to be placed with precision under a running truck and  the vivid, gruesome picture of the resultant trauma and bleeding. On further questioning, there is no history of manic or hypomanic phase or of drug abuse; no clear family history of major depression.

On medical leave, out of the stress-inducing situation in his work space and on integrated therapy and medication at Trimed-Neurokrish, Krishna soon came out of his acute psychotic state dramatically and settled to a preparedness to face the real world. In this phase, he was reported to have improved insight and judgment, understood he had a problem which impaired his capacity to cope with workplace stress and to engage in social interaction with his peers. He wanted to overcome this state, and be able to get back to his routine in better shape. 

The patient was cooperative for the psychological testing. The 42 responses to the Rorschach test met the criteria for the Coping Deficit Index. Thematic Aperception Testing pointed to the need for achievement, security, nurture, the conflict arising out of lack of ego strength and fear of rejection. The Neuropsychiatric Inventory score was 4-5 on anxiety, delusion, night time behaviour and appetite, and low on the depression scale.  A diagnosis of late onset Persistent Depressive Disorder (dysthymic disorder) was arrived at.

Krishna was on regular medication for over 2  months:

  •  Dicorate ER 750mg ( Divalproex)
  • Olanzipine  (10mg + 2.5mg) at bedtime and (20 mg + 10mg) in the morning
  • Vitamin  and Calcium supplements

He responded well to the integrated therapy with a total of 15 sessions of Reflexology, Acupuncture and Yoga and over 10 hours of Cognitive Behaviour Therapy and some sessions of parental counselling.

An individualised short course CBT was initiated, setting attainable goals which helps in  bringing the  them back to their normal level of functioning.

In PERSISTENT DEPRESSIVE DISORDER, the patient suffers  a pervasive sad mood for over 4 years with barely any symptom-free period. The symptoms cause significant distress or impairment in social, occupational, educational, employment and other important areas of functioning.

Dysthymics however, may be pushed into major depression and subsequent acute psychosis Often this occurs at times of high stress and is linked to strong emotions and feelings, for example worry, anxiety, fear, depression or feeling overwhelmed by events. Lack of appetite, difficulty sleeping, lack of energy, poor self-esteem, difficulty with concentration or decision making,and a feeling of hopelessness, peaking to result in a phase of acute psychosis. It has been suggested that in dysthymic disorder, to compensate for the lack of social and real life interaction, the patient can create elaborate and complex fantasy inner worlds within their minds. According to DSM V criteria, individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder.

Our Focus:

Cognitive Rehabilitation

A person who suffers from dysthymic disorder has generally learned to live with a fair amount of chronic unhappiness in their lives and so the therapist cannot go by the mood on a particular dayl He must first identify the thoughts associated with the patient’s distress. In dysthymia, these thoughts may concern the patient’s self-view, his or her representation of a significant relationship, or a meaningful situation.

Goals will vary according to type of therapy. The emphasis in Cognitive Therapy is to effect changes in one’s faulty or distorted way of thinking and perceiving the world. Interpersonal therapy focuses on an individual’s relationships with others and how to improve and strengthen existing relationships and an attempt to accommodate new ones. Solution-focused therapy looks at specific problems affecting the person’s life in the present and examines how to best go about changing the person’s behavior to solve these difficulties. Social skills training focuses on teaching the client new skills on how to become more effective in social and work relationships.

REFERENCES

Dean Schuyler Evidence–based Review Short-term cognitive therapy shows promise for dysthymia Vol. 1, No. 5 / May 2002

Looking Ahead

Krishna continued to suffer from low self-esteem and a pervasive sad mood, with occasional congruent delusions of reference and delusional exaggerated fantasy, when assessed midway  from onset of the integrated therapy. By the end of the intensive integrated therapy sessions at TriMed-Neurokrish, he was much more stable, and was on the bench at his IT job, preparing with a greater level of confidence for active work to be initiated with the clients.

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