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Utility of coping mechanisms in children with learning disabilities to arrive at the similimum: A case series
*Corresponding author: Dr. Madhavi Prashant Tamboli, Geet Govind, 116/3969, Tilak-Nagar, Chembur, Mumbai - 400089, Maharashtra, India. madhavitamboli@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Tamboli MP, Dhawale KM. Utility of coping mechanisms in children with learning disabilities to arrive at the similimum: A case series. J Intgr Stand Homoeopathy 2020;3(1):13-9.
Abstract
Objectives:
In India, learning disabilities (LD) constitutes about 10–20% of scholastic problems in children. The standard way of treating these children is through remediation. An extra-mural Research Project supported by the Department of AYUSH (2008–2011) comprised a single blind, case–control study conclusively proved the value of homeopathy intervention in the treatment of LD. It is difficult to locate the characteristics in the written expressions of LD. This paper, explores through the use of a case series the most appropriate method, of identifying and incorporating the characteristic coping techniques used by these children to deal with their disability into the totality. The totality, thus erected, is processed through the use of various repertorial or nonrepertorial approaches.
Materials and Methods:
Detailed case histories of the children diagnosed with LD including data from the caregiver/s and the child were studied. The evolutionary behavioural expressions of the children were noted and analysed to derive the coping mechanisms utilized. These contributed to the characteristics which in turn defined the approach to the totality and further the similimum.
Results:
Incorporation of coping mechanisms with expressions at the mental and physical level was invaluable in leading to the similimum. The results indicated a significant change not only in the expressions of the LD but also in a better adaptation of the child to the environment.
Conclusion:
Identifying and valuing the coping mechanisms are of value in arriving at the similimum in children with LD.
Keywords
Learning disabilities
Remediation
Coping mechanisms
Homeopathy approach
INTRODUCTION
The term learning disability (LD) is generally accepted as a descriptive term for children with complex learning problems, given that they have an average or above average intelligence quotient (IQ), minimal sensory impairment and no significant emotional disturbance contributing to the disability. In addition, comorbidities such as Attention Deficit Hyperactive Disorder (ADHD)/attention deficit disorder may coexist, which further dampen the prognosis.[1] Research studies have identified large number of LD children in rural areas of Kerala, indicating that LD could be prevalent in considerate numbers.[2] Although the majority of surveys have been conducted on children studying in English medium schools, recently, considerable research on literacy and language learning and LD in various Indian languages including Kannada, Hindi, Odia and Bengali has been initiated to address the specific needs of the Indian population.[3-7] The studies conducted by Dr. M.L. Dhawale Memorial Homoeopathic Institute[8] have shown the prevalence rate of specific learning disability to be 8.32% in Marathi medium. Other studies have also reported that 10–20% of children have LD.[9]
An extra-mural research project supported by the Department of AYUSH was completed by the Dr. M. L. Dhawale Memorial Trust (2008–2011). This case–control, single blind study, conclusively proved the value of homeopathy intervention and has been reported.[8] The types of homeopathy remedies and their use were explored and illustrated.[10]
In general, a disability is any impairment that makes it difficult for a person to interact effectively with the world. These impairments may be developmental, cognitive, intellectual, mental, physical, or a combination of multiple factors. Disability is thus not just a health problem. It is a complex phenomenon, reflecting the interaction between the person and the environment. These interactions bring about stressful situations, which need adaptation/coping by the individual. The coping mechanisms/expressions assume immense importance as they are a general reaction to the disability.
LD can be perceived as one such disability. Children with LD are often aware of their inability to perform, especially in academics. This is coupled with motor clumsiness, poor visuospatial skills, problematic social relationships and poor organizational skills.[11] With these incapacities, their relationships with family and friends are also affected. These contribute to major stresses in the school-going years. These children, through interaction with the environment, devise coping strategies. Coping, as defined by Lazarus and Folkman, as ‘constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person’.[12] Each individual will cope according to his/her disposition. The child copes through defences at the subconscious level, observed through the behaviour. These behavioural expressions characterize the individual. The expressions could be on the emotional, behavioural, intellectual or physical plane. These peculiar expressions enable us to identify characteristics at the level of disability and thus arrive at the totality and thus at the similimum [Figure 1].
- Homoeopathy and coping mechanisms.
MATERIALS AND METHODS
Children having scholastic difficulties were thoroughly evaluated and after undergoing the Wechsler Intelligence Scales for Children (Mahendrika Bhatt’s adaptation for Indian population) for measuring the IQ,[13] testing for vision and hearing, paediatric and psychiatric evaluation, and standard appropriate informal educational assessment, were diagnosed as learning disabled. The children’s cases were defined taking inputs from the children themselves, parents/ care-takers, teachers and general observations made by the physician. The expressions at the level of emotions, behaviour, intellect and physicals were noted along with their intensity and characteristic nature. The analysis and evaluation of the symptoms gave an idea of the type of presenting symptomatology. The patterns of these expressions provided an understanding of the nature of the coping mechanism utilized by the children. An appropriate approach was then selected considering these characteristic expressions to find out the similimum.
Illustrative cases
Case report 1
The patient is an 11-year-old girl studying in the 5th standard, Marathi medium. She was referred to the clinic with complaints of difficulty in memorizing, reading, comprehension, written expression and writing. The mother also complained of her repeated falls while walking.
Physical generals
Weakness <Hunger
Cravings: fish3, salt3, sour3, spicy2, Aversion: sweets2
Perspiration – General: + Partial: Palms + Soles+
Thermal state: Chilly Headache ++ <Strong odours
Emotional state during pregnancy: Stress++: Financial and domestic
Early development: Delayed walking and talking
Life space
The child stays in a nuclear family with parents and an elder brother. Her father, a short-tempered man, works in the BMC hospital as an X-ray technician. He is an alcoholic, and beats her mother over trifles. He also shouts at her for not getting good marks and blames the mother for her academic failure. From 2 years, it has been observed by the mother that child is more scared of these reprimands and fights and cries a lot. She also feels scared to sleep alone and sleeps holding her mother tightly. She shares a close bond with her mother who is very understanding and cooperative. Her mother observed that the patient does not leave her at all. Even when the mother is bathing, the patient will sit outside the bathroom, telling her to hurry up! The patient is very scared of the dark and animals, especially cats. She does not interact much with guests, until she is familiar with them.
In school, the patient is shy and does not participate in extra-curricular activities. She has few friends. Teachers have no complaints against her except for her poor academic performance. She seldom gives answers in class, feels children will laugh at her if she is wrong. Despite all this, the child is very regular at school.
O/E: Lower extremities: No neurological abnormality detected
Diagnosis: Dyslexia and dysgraphia
Analysis of the case
In this case, her father’s reprimands about her falling academic performance and parental fights have had a detrimental effect on the child’s emotional and intellectual development. They have created a lot of insecurity in the sensitive child, which are exhibited in the form of fears. She has coped with these by forming strong attachments (evidenced in her clinging behaviour – a changed behaviour) with her mother and developing fears. There is also an intense need to be cared for. This is the hallmark of the case. The pressures from her father about her academic performance have led to low self-esteem and low confidence. The child is reserved, does not participate in extracurricular activities nor does she answer in the class for the fear of others laughing at her if she was wrong. The stumbling while walking becomes a characteristic in the absence of neurological signs.
Considering the coping of the child at the mental level, with qualified mental symptoms such as fears and clinging behaviour, Kent’s approach was considered for repertorization.
| Totality | Potential differential field |
|---|---|
| Fear of dark Fear of being alone Fear of animals, cats Hunger aggravation Stumbling while walking |
Clinging to Mother Craving: sour, salt Chilly patient |
Result of Repertorization: Calc 6/9, Sepia 6/8, Stram 8/3, Sil 7/7
Final remedy with differentiation
Considering the insecurity, fears and the peculiar sensitivity to ‘what others will think/laugh at her’, Calcarea group was considered from the above group. The child needed a lot of attention and care, which is predominantly seen as a property of the muriaticums (according to Jan Scholten) and was exhibited through her clinging behaviour. This aspect of need of care and attention with fears was considered important in the case. Calc mur was a synthetic prescription considering the theme of ‘Calcium’ and ‘muriaticums’.[14] The clinging observed in the patient is also observed in Borax, where the clinging is because of the fear of falling and in Bismuth, wherein the child clings because it cannot be alone. Calc silicata comes close for differentiation at the level of sensitivity and anxiety that pertains predominantly to health and anticipation, with sensitivity to reprimands, both of which are not prominent in the case.[15]
Sepia children are also quite nervy with fears, but they dislike being handled and cuddled. Although the stramonium child fears dark and always wants company, this arises out of fear of losing the parent rather than the need to be cared for. This is also coupled with lot of destructiveness and defiant behaviour.
Remedy prescribed: Calc mur
Potency and repetition: Calc mur 200, one powder weekly.
Evaluation of result
Improvement was seen in all the areas of LD, attention, memory and clinging behaviour. The change in the behaviour was seen in a month. The changes in the academic performance began in the first 3 months and gradually improved over a year. Early changes were seen in reading and handwriting, followed by writing.
Case report 2
Master ANM is an 11-year-old child studying in 6th standard with complaints in reading, comprehension, writing and written expression.
The child also complained of throbbing headache since the past year that increased when he was shouted at2, while studying2, when playing in the sun/afternoon2, at times also in the night, when he exerted himself2 and was better with sleep2 and pressure.
Physical generals
Appearance: wheatish, short height, thin straight hair Hunger: <2 Irritability
Craving: potato3, sweet2, salt, pica2 Aversion: milk2, spicy2
Perspiration: palms2, scalp2, soles2, offensive2
Sun: < headache
Sleep: Sleeps on abdomen and salivation during sleep
Thermals: Chilly
Developmental history: Diarrhoea, fever during dentition, talking at 1½ years.
Life space
The patient is a short, lean, thin and dark complexioned child with very straight hair. He stays in a joint family with his parents, sister and his uncle’s family. As the patient is the eldest of all the siblings, he is pampered a lot by his grandmother. His father is short tempered and is constantly shouting at the patient for his falling academic performance and beats him daily. The child is scared of his father, cries a lot and gets a throbbing headache. His mother too shouts at him for not being like his sister (who is very good at academics). He does not participate in extracurricular activities. He feels very anxious before exams. He feels like studying but cannot. He hates school and feels like leaving school and going off somewhere.
Diagnosis: Dyslexia and dysgraphia
Case analysis
The parents are constantly picking on him for his low academic performance. There is an evident academic stress, to the extent that he does not want to go to school! He has coped with the effects of the stress with a headache, which has characteristic modalities. Considering somatization as a defence mechanism and a mode of coping, and generalizing the modalities expressed at the mental and physical level, Boenninghausen’s approach (what is true to part, is true to the whole) was used.
| Totality | |
|---|---|
| A/F admonition <Hunger <Studying while <Sun <Physical exertion <Afternoon <Night <dentition >Sleep after >Pressure Perspiration offensive Perspiration scalp Perspiration palms Perspiration soles |
Aversion milk Aversion spicy Craving potato Craving sweet Craving salt Craving pica Chilly |
Final remedy with differentiation
After repertorization, Sil, Calc and Phos came up for differentiation. The child has fears, with sensitivity to reprimands, shyness and dissatisfaction due to sibling jealousy, and perspiration of palms and soles with offensiveness. Calc Sil was given as a synthetic prescription. Phos also has fears and is sensitive to reprimands but is an extrovert, whereas the patient is shy.
Considering Boenninghausen’s approach, the finer differentiation was done based on the mental symptoms.
Remedy prescribed: Calc sil
Potency and repetition: Calc sil 200, one powder weekly.
Evaluation of result
There was a marked reduction in the frequency and intensity of headache. He started liking going to school and developed interest in studies. The handwriting improved first, followed by reduction in the number of mistakes.
Case report 3
Mast. SRG, 12 years old, studying in standard 7th, Marathi medium was referred to the clinic with complaints of difficulty in reading, writing, memory and concentration. Parents and teachers complained of him not paying attention in class and being constantly restless and fidgety.
Physical generals
Perspiration – General: + Partial: Chest++ Back++ Odour: offensive2
Appetite: Less2 Cravings: Spicy2, chicken2, milk2, Sweet2
Thermal state: Chilly
Mother’s obstetric history: G4 P4 L4 A0
Health during pregnancy: Oedema: +, BP: Hypotension from 8th month Emotional state during pregnancy: The family always wanted a male child. There was lot of tension in the family. His mother used to cry and felt anxious throughout pregnancy.
Early development: Delayed talking.
Life space
This child was born after three daughters. His father pampers him a lot. His mother is a housewife. She is very short tempered, beats the patient, shouts at him and compares him with his sisters. His eldest sister is very fastidious and has strained relations with the patient as she is constantly correcting his behaviour. The second sister helps him with his studies and constantly shouts and beats him for his poor academic performance. He dislikes both his sisters, but his mother wants him to score good marks like them. He shouts and fights with them.
He is very obstinate even now and will go on nagging until his demands are fulfilled. He also feels that he is a boy and is not supposed to work in the house. He does not report if his class teacher scolds him; if his mother confronts him, he just laughs and says that he forgot to tell. There are times when the patient is beaten up by his sister or his mother, but he will just laugh back and will say, ‘You can beat me to death’. His mother feels that he is never serious, he laughs if he is reprimanded, he has never cried, just laughs it off.
His mother added that he has also started telling lies. Two years back, he had fallen from the terrace and he attributed the fall to a boy with whom he had a previous fight having pushed him when the boy was not present at the site at all. When confronted, he said he wished to teach the boy a lesson!
He mixes easily with new people. He is very curious and will open up his toys, instruments and electrical equipment.
Diagnosis: Dyslexia and dysgraphia with ADHD.
Analysis of the case
The child holds an esteemed position in the house. He considers doing domestic work below his dignity. He will not admit his mistakes. The child’s self-image is very high. The inability to perform in academics has led to anxiety, which has been repressed. The child has developed a ‘happy- go-lucky’ attitude, evident from his ‘laughing’ behaviour. He is definitely sensitive to reprimands, but a sensitive soul is portraying himself as outwardly insensible! The most important aspect of this case is the expression of the child, ‘laughing at everything’. This is very characteristic in this case. This behaviour seems to be his way of coping with his disability. He harbours negativity about his sisters. He feels jealous that they perform better than him.
Approach taken for the case: Keynote approach
The hallmark symptoms of the case are “laughing at everything,” “insensible to external impressions” and “jealousy.” These three characteristic expressions form the keynotes to prescribing the remedy.
Final remedy with differentiation
The “laughing at everything” can be compared to that of Hyos and Nux Mosch, where the patient laughs at everything, in the latter there is an alternate state of crying, which is absent in this patient.
Evaluation of result
The child has shown good progress with regard to LD and ADHD. Early changes were seen in reading and handwriting formations. The remedial educator also noted that his laughing and hyperactivity had reduced and he was more serious in applying himself to his work. In one of his follow- ups, he was very annoyed that in the next standard, his division would be changed. Against the expected response of laughing, he started crying! A considerable change in the maladaptive response brought about by homoeopathy.
Case report 4
Miss TTK, 10 years old, studying in standard 5th, Marathi medium was referred to the clinic with complaints of difficulty in reading, writing, memory and concentration.
Patient as a person
Tall for her age, well built Hunger agg2
Thermal state: hot Sun <Headache2
Cravings: pickles2, sour3 Aversion: milk2
Early development
Sitting, standing and walking delayed, talking unclear till the age of 3 years.
Life space
This comprises three accounts, namely data from the patient, aunt and grandmother
Interview with the patient
The patient was very talkative3 during the interview. She comes from a small village near Pune, where her parents and younger brother live. At present, she is staying with her maternal uncle, aunt and maternal grandmother (MGM).
The patient feels very anxious about her exam result. She also gets palpitations before the exams and fears making mistakes in writing her paper. She has 4–5 friends and does not talk to people whom she does not know. She is fearful of the dark.
The patient’s rapport with her aunt is not good. She feels her aunt is of a nagging type and shouts at her for trifles. Patient feels a lot of anger toward her.
Interview with the aunt
She described the patient as a highly irritable child by nature who always wants things her way and screams/at times throws things, if not listened to. Patient does not like anyone telling her to work and has no interest in household work.
The main complaint since the last year was of stealing things and telling lies. The usual reaction of her MGM to this behaviour was to beat her. When MGM beats her, she gets very angry and will not talk with anyone, nor eat her food for a day.
Her aunt also said that the patient does not like her maternal aunt (mausi)’s daughters when they come home and fights with them. She feels that her uncle’s house is her house and others should listen to her. She dominates them a lot. She does not share her things at all with them nor with her friends. Her aunt also mentioned that the child is fearless.
Interview with the MGM
The MGM agreed to the fact that the patient is very irritable, screams when angry and this occurs especially when she is reprimanded for not studying. The stealing aspect was enquired into and her MGM acknowledged and confirmed. She dominates over children of her age. MGM also confirmed her fearless nature. She is extremely talkative.
Diagnosis: Dyslexia and dysgraphia.
Totality by structuralization
This case was approached by structuralization. Structuralization is evolved from concepts derived from the facts of the case and the drug in Homoeopathic Materia Medica, in which homogenous blocks are linked together to form a whole. Thus, we are able to consider the entire structure as a unity and we do not break down the individual components and hunt for their correspondence in the Materia Medica.[18]
Final remedy with differentiation
There is a lot of insecurity and rejection felt by the patient with a lot of attention seeking behaviour. If the block of the current behavioural pattern of the patient is taken into consideration, Lachesis comes in strongly in this case. Loquacity is well marked and there is manipulative-ness and irritability with violent expression. Although the patient is fearful, the fears are not expressed. The patient also exhibits anticipatory anxiety. Nat mur comes very close in discussion, with anger and sensitivity to criticism, but lacks the coping mechanism of manipulation adapted by the patient.
Remedy prescribed: Lachesis
Potency and Repetition: Lachesis 200, one powder weekly.
Evaluation of result
There was an improvement in reading in the first 3 months. Handwriting also demonstrated early changes. Spelling mistakes in writing and reading comprehension were better over the year. There was also an improvement in her irritability and behaviour. Her relationship with her aunt also showed positive improvement.
DISCUSSION
As per the definition by Lazarus and Folkman, we have understood coping mechanisms as cognitive and behavioural These are seen at the level of behaviour/expressions are those of clinging (Case 1), somatization (headache in Case 2), escapism (laughing in Case 3) and repression and acting out (lying, stealing in Case 4). These mechanisms occur at the subconscious level and are seen through behaviour/physical symptoms. Depending on the coping mechanisms exhibited by the child and the available symptom complex in the case, the approach can be selected. The cases demonstrate the manner in which coping mechanisms may be used in the management of cases of learning disabilities. Since this is an initial study, it would be worthwhile expanding it to study the differentiating ability of coping mechanisms and their unique presence in our remedies for an expansive understanding of the latter.
CONCLUSIONS
The case studies provide a strong evidence of detailed history in arriving at the coping mechanisms used in arriving at the similimum
The case studies also facilitated the consolidation of the experiences, adding to the educational value
Remedies also take care of the comorbidities and improvement is evident in all the cases mentioned above.
Acknowledgment
We are deeply grateful to the Ministry of AYUSH, GOI, New Delhi, for the support given for the EMR project and CCRH, New Delhi, for the technical assistance.
Declaration of patient consent
Patient’s consent not required as patients identity is not disclosed or compromised.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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