Children’s Development Disorders

By: Dr.S.Gopakumar MD (Ay) – Associate Professor, Dept of Roganidana Govt Ayurveda college, Kannur, Kerala, India.

A model man is one, who possesses a creative brain, skillful hands and an affectionate heart, told by Swami Vivekananda. Looking through the medical angle, both genetical and environmental factors play equal role in making an ideal personality. To be an effective learner and communicator, one must have a natural and focused growth and development. According to Vedic principles, growth and development is a synchronized and coordinated programme by biological factors. Growth is mainly acquired by proper genetic and environmental factors. Development is accomplished by proper growth and good social relations.

Only a good seed will give birth to a fruitful tree with the ability of independent living and existence. Growing period is marked by the dominance of kapha dosha. But the role of kapha dosha in cellular multiplication and growth of tissues is totally controlled by other doshas. Kapha dosha forms the substratum for cellular growth. The nourishment and maturation of a cell/tissue/organ/organ system largely depends upon kapha and related factors. The special properties of kapha, like guru and snigdha are absolutely needed for proper growth. When there is a good control by vatha dosha over cell division and differentiation, normal growth with normal pace results. The contribution of pitha dosha is in the form of biological fire at koshta, dhathu and bhootha level. The entire metabolic activities in the body are under the control of this biological fire. Thus it can be seen that a coordinated functioning of all the three doshas make a normal growth and development. Any error or imbalance in this coordinated programme results in developmental disorders in children. Along with thridoshas, there are many other factors which directly or indirectly influence normal growth and development. Now let us discuss the general aetiopathogenesis of neuro-behavioral developmental disorders through an Ayurvedic angle.

A. Aetiopathological factors

1. Prakruthi – the basic factor?

The prakruthi of an individual reflects his or her genetic constitution. As per Ayurvedic concepts, the prakruthi of an individual is determined by the quality of beejas, Aharas and Viharas of garbhini and other environmental factors. As per modern medicine almost all the neuro-behavioral developmental diseases are strongly associated with genetic factors. The beeja, beejabhaga or beejabhagavayava level of vikruthi is the deciding factor which increases the susceptibility of such developmental anomalies. The defective combination of Panchamahabhoothas at beeja level will result in the improper or delayed development of the concerned faculties and traits. These events occur during the embryogenesis and are largely influenced by the garbhinicharyas.This is followed by improper or deficient growth of dhathus and upadhathus due to the secondary effect of vitiated doshas in the later stages.

2. Environmental factors- the triggering agents?

Environmental factors have a considerable role in the course of developmental disorders. They include birth related injuries and problems, food habits, social relations etc. They may affect the body or mind or both. The exact effects of environmental factors may be at Sareerika and manasika dosha level. Such factors directly hinder the normal functioning of Raja and Thama, which are the essential components of mind. The Sara of Sathwa guna may be reduced to a considerable degree, thereby lowering the mental threshold. In other words the controlling and balancing effect of Sathwa is lost to such level that the concerned individual experiences developmental behavioral problems at various domains.

Dhee, Dhriti and Smruthi – Essential components of communication?

The cellular quantitative growth is mainly determined by the food and related factors of an individual. The learning skills, social interaction and normal behavior are the higher faculties of mind which are mainly contributed by Thridoshas and Thrigunas. The impaired Manodoshas along with thridoshas consequently affect the various functions of mind. The Dhee, Dhrithi and Smruthi are affected in varying degree and combination, leading to a faulty or delayed personality development. The recognition of a stimulus, its proper interpretation and a correct and timely response are the balanced activity of these three factors. The integrated system of Dhee, Dhriti and Smruthi, if impaired by genetical and environmental reasons, the coordinated developmental programme will also be altered. The level of error with different combinations of Dhee, Dhrithi and Smruthi with the specific involvement of different dosha-dooshyas results in diverse and complex clinical presentations.

The role of thridoshas may vary in different types of developmental anomalies as they are influenced by multiple factors. Normally mind is controlled by the vatha dosha and assisted by pitha kaphas. There is a functional association between vatha and kapha in growth and development. The kapha dosha may be undergoing any one of the following vikruthis due to the above nidanas.

• Kapha dosha may be seriously masked by other factors by which it fails to perform the normal tissue differentiation and maturation.
• Kapha dosha is made ineffective by exogenous and endogenous factors by which it may not do the Mana prasadana and Indriya prasada.
• There may the chance of quantitative kapha kshaya by which Sareera and Mana undergo a delayed development.
• Kapha dosha which has a significant control or inhibitory action over vatha (in special situations) fails to do that, resulting in uncontrolled vatha functions like hyper activity.

In most of the cases these factors may work together, often contributing each other.

The development of Jnanendriyas and Karmendriyas are the essential tools for an effective social communication. Both jnanendriyas and Karmendriyas are controlled and assisted by Mana which in turn is controlled by the Vatha dosha. There exists a harmonic functional equilibrium between Mind and nervous system especially in the developmental phase of a person. Thus it is important to think about the causes of the alteration of Vatha-Mana equilibrium in the context of developmental disorders.

The most important matter in this regard is the Panchamahabhootha dominance in each individual during the embryological growth. Each tissue in the body has a specific Panchamahabhootha configuration to suit its function. Again depending upon the mathruja, pithruja, rasaja, sathmyaja and Athmaja bhavas of a specific individual his/her embryonic Panchamahabhootha constitution may change. The sum total of such a human body can be called a specific genetic constitution or Prakruthi.

Now we have to discuss the role of various combinations of thridoshas and Mano doshas in the same individual with a particular prakruthi. The different types of Prakruthis with pre determined genetic features are due to the various combinations of Thridoshas and Raja and Thama. The Vatha-Raja combination may be comparatively hyperactive compared to a Kapha – Thama combination. Depending on the various possibilities of combination, the characteristic features of prakruthis may change. The involvement of different categories of vatha dosha like prana, udana, vyana etc decides the nature of clinical presentation along with other sub types of pitha-kapha doshas. Some of the resultant prakruthis are more prone to suffer from developmental disorders. Other factors including garbha upadravas, prasava upadravas, and environmental factors may work as Vyanjaka hethus. Thus a combination of Prakruthi formation during intra uterine life and the environmental factors after birth are the major aetiopathological factors in the Neuro-behavioral developmental disorders.

Now it is the time to discuss about two important developmental behavioral disorders- Autism and Attention Deficit Hyperactivity Disorder.

Autism

Autism is a brain development disorder that impairs social interaction and communication, and causes restricted and repetitive behavior, all starting before a child is three years old. Autism is one of the five Pervasive Developmental Disorders (PDD), which are characterized by widespread abnormalities of social interactions and communication, and severely restricted interests and highly repetitive behavior.

Autism is largely inherited, although the genetics of autism are complex and it is generally unclear which genes are responsible. In rare cases, autism is strongly associated with agents that cause birth defects. Autism affects many parts of the brain; how this occurs is poorly understood. Parents usually notice signs in the first year or two of their child’s life. Early intervention may help children gain self-care and social skills, although few of these interventions are supported by scientific studies. There is no cure. With severe autism, independent living is unlikely; with milder autism, there are some success stories for adults, and an autistic culture has developed, with some seeking a cure and others believing that autism is a condition rather than a disorder.

The manifestations of autism cover a wide spectrum, ranging from individuals with severe impairments—who may be silent, mentally disabled, and locked into hand flapping and rocking—to less impaired individuals who may have active but distinctly odd social approaches, narrowly focused interests, and verbose, pedantic communication. Sometimes the syndrome is divided into low-, medium- and high-functioning autism (LFA, MFA, and HFA), based on IQ thresholds, or on how much support the individual requires in daily life. Autism can also be divided into – syndromal and non-syndromal autism, where the former is associated with severe or profound mental retardation or a congenital syndrome with physical symptoms, such as tuberous sclerosis.

Characteristics

Autism is distinguished by a pattern of symptoms rather than one single symptom. The main characteristics are impairments in social interaction, impairments in communication, restricted interests and repetitive behavior. Other aspects, such as atypical eating, are also common but are not essential for diagnosis.

Social development

Social impairments become apparent early in childhood and continue through adulthood. Autistic infants show less attention to social stimuli, smile and look at others less often, and respond less to their own name. Autistic toddlers have more striking social deviance; for example, they have less eye contact and anticipatory postures and are less likely to use another person’s hand or body as a tool. Three- to five-year-old autistic children are less likely to exhibit social understanding, approach others spontaneously, imitate and respond to emotions, communicate nonverbally, and take turns with others. Making and maintaining friendships often proves to be difficult for those with autism. For them, the quality of friendships, not the number of friends, predicts how lonely they are.

Communication

About a third to a half of individuals with autism do not develop enough natural speech to meet their daily communication needs. Differences in communication may be present from the first year of life, and may include delayed onset of babbling, unusual gestures, diminished responsiveness, and the desynchronization of vocal patterns with the caregiver. Autistic children are less likely to make requests or share experiences, and are more likely to simply repeat others’ words (echolalia) or reverse pronouns. Autistic children may have difficulty with imaginative play and with developing symbols into language.

Autistic individuals display many forms of repetitive or restricted behavior. Stereotypy is apparently purposeless movement, such as hand flapping, head rolling, or body rocking. Compulsive behavior is intended and appears to follow rules, such as arranging objects in a certain way.

Restricted behavior is limited in focus, interest, or activity, such as preoccupation with a single television program. Self-injury includes movements that injure or can injure the person, such as biting oneself.

Other symptoms

Autistic individuals may have symptoms that are independent of the diagnosis, but that can affect the individual or the family. Unusual responses to sensory stimuli are more common and prominent in autistic children, although there is no good evidence that sensory symptoms differentiate autism from other developmental disorders. The responses may be more common in children: a pair of studies found that autistic children had impaired tactile perception while autistic adults did not.

Atypical eating behavior occurs in about three-quarters of children, to the extent that it was formerly a diagnostic indicator. Although some children with autism also have gastrointestinal (GI) symptoms, there is a lack of published rigorous data to support the theory that autistic children have more or different GI symptoms than usual.

Diagnosis

Diagnosis is based on behavior, not cause or mechanism. Autism is defined in the DSM-IV-TR as exhibiting at least six symptoms total, including at least two symptoms of qualitative impairment in social interaction, at least one symptom of qualitative impairment in communication, and at least one symptom of restricted and repetitive behavior. Sample symptoms include lack of social or emotional reciprocity, stereotyped and repetitive use of language or idiosyncratic language, and persistent preoccupation with parts of objects. Onset must be prior to age three years, with delays or abnormal functioning in either social interaction, language as used in social communication, or symbolic or imaginative play.

Attention-Deficit Hyperactivity Disorder (ADHD)

Attention-Deficit Hyperactivity Disorder (ADHD), or Hyperkinetic Disorder, is generally considered to be a developmental disorder, largely neurological in nature, affecting about 5% of the world’s population. The disorder typically presents itself during childhood, and is characterized by a persistent pattern of inattention and/or hyperactivity, as well as forgetfulness, poor impulse control or impulsivity, and distractibility. ADHD is currently considered to be a persistent and chronic condition for which no medical cure is available. ADHD is most commonly diagnosed in children and, over the past decade, has been increasingly diagnosed in adults.

DSM-IV Criteria for ADHD

There are two criterias for inattentive and hyperactive-impulsivity groups.

1. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
5. Often has trouble organizing activities.
6. Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
8. Is often easily distracted.
9. Often forgetful in daily activities.

1. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

1. Often fidgets with hands or feet or squirms in seat.
2. Often gets up from seat when remaining in seat is expected.
3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
4. Often has trouble playing or enjoying leisure activities quietly.
5. Is often “on the go” or often acts as if “driven by a motor”.
6. Often talks excessively.

Impulsiveness

1. Often blurts out answers before questions have been finished.
2. Often has trouble waiting one’s turn.
3. Often interrupts or intrudes on others (e.g. butts into conversations or games).

Ayurvedic view on Autism and ADHD

Aetiopathology

Since both Autism and ADHD come under the developmental disorders, aetiopathological and manifestation level similarities are seen in them. But on close cross examination,some differences in terms of samparapthi can be identified. Autism may be more related with a Kapha dominat clinical presentation where as ADHD is predominantly a Vatha dominant condition. The restricted behavior very well suggests the hypoactivity of Manovaha srothus which is mainly due to kapha dominant pathology. Delayed development of mental faculties are mainly due to the lack of a prasada kapha with good sara. The role of Thama dosha is more prominent in Autism.Mental retardation is associated with Autism in a good number of cases. This observation also proves the possible Kapha-Thama pattern of dushti in Autism.The prakruthis of such children will be of a Pridhwi dominant. Both Kapha and Thama are the derivatives of Pridhwi.There may or may not be the impairement of mental faculties like Dhee,Dhruthi and Smruthi in Autism based on the degree and level of vitiation.

When it comes to ADHD, the involvement of vatha is definite as it is marked by hyperactivity. VitiatedVatha with athipravruthi in Manovaha srothus and cheshtavaha nadis make the pathology different from Autism. The Raja dosha of Mana operates with Vatha to bring the psycho somatic disturbances. Here the genetic constitution or prakruthi of the child may be of Vayu dominance . Both Vatha and Raja are the derivatives of Vayu mahabhootha.

Vikalpa samprapthi

Generally,Autism is kapha derived manda guna dominat pathology. ADHD is vatha derived chala guna dominant pathology. In the case of ADHD,there is definite role for Raja guna in the samprapthi. When Vatha combines with Raja guna the resultant clinical presentation will be hyperactivity. The primary effect of Vatha-Raja based hyper activity will be seen in Manovaha srothus and Vathavaha srothus. Secondary effect may be seen in other srothuses as vatha has the super coordinator status on other micro and macro channels of biological functions.

Management strategy of Autism

• Agnisameekarana
• Kapha prasada by sodhana
• Vathanulomana by moordha thailas
• Samana by ghrithas with Kapha Vathahara
• Medhya Rasayanas
• Daivavyapasraya and Adravya chikitsa
• Counseling

Management strategy of ADHD

• Dhathwagni improvement
• Vatha samana
• Balakara and Kaphakara
• Chithaprasadana
• Counseling

The sahaja vyadhis are generally incurable. Majority of the Neuro behavioral developmental disorders show strong genetic association. Though they are called developmental disorders, the nature of intra uterine life decides the character of the diseases. Hence Ayurvedic garbhinicharyas.This and other garbharakshavidhis have more importance in the prevention of such anomalies. The research oriented approach on unexplored areas of Ayurvedic antenatal care and pediatric management can give new hopes to those children, to whom a model personality is denied.

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