ABSTRACT

The COVID-19 epidemic brought about many unforeseen changes in people's social and personal life, putting the world in a new and challenging period. Adjustment disorder is defined as the inability to adjust to a stressful experience to a degree that is disproportionate to the stressor's severity or intensity. Undoubtedly, this has affected the most vulnerable children's survival systems. This article focuses on the MYMOP scale's assessment of children's physical and emotional well-being, as well as how different age groups of children exhibit different symptomatology and the homoeopathic medicine that corresponds with it.

KEYWORDS

Adjustment disorder, Post-pandemic period Covid-19, Homoeopathy, children, Lock down, Schooling 

INTRODUCTION

“Adaptability is being able to adjust any situation at any given time”

                                                                                            -  John Wooden

Adjustment disorder (AjD) is recognized as a stress-response syndrome, which is defined as a maladaptive reaction to an identifiable stressor(1) Stress is ubiquitous, and a person learns to deal with stress over time. However, when coping mechanisms fail to ameliorate stress effectively, adjustment disorder is precipitated. The key points of the ICD-11 AjD definition are as follows:

• Identifiable stressor(s), maladaptive reactions that occur within 1 month after exposure to the stressor and tend to resolve within 6 months if the stressor has ended,

• Symptoms of preoccupation and failure to adapt related to the identified stressor. It was also specified that symptoms do not justify another mental or behavioural disorder(2)

COVID-19, a highly contagious illness that resembles pneumonia, was discovered for the first time in December 2019. Nearly 14,000 individuals died as a result of this illness, also known as Coronavirus-2019, which afflicted about 334,000 people worldwide (WHO, 2020).(3)The COVID-19 lockdown measures may have more of an effect on children and adolescents' lifestyle choices and general well-being than the virus itself, according to some research. (4) The impact of COVID-19 varies among nations, in part because of the different steps each nation has taken to contain the epidemic. With the first patient reported on January 30, 2020, COVID-19 instances were also sharply increasing in India (Ministry of Health, 2020). On March 24, 2020, India's government implemented a nationwide lockdown that lasted until May 3, 2020. A complete shutdown of all businesses was ensured throughout this lockdown, including those in stores, banks, industries, schools, colleges, parks, theatre’s, gymnasiums, etc. After that, due to a second wave that devastated the nation in 2021, a second lockdown was implemented (state-wise). (1)

Many parents have seen personality changes in their children during this time of social restraint, including stranger phobia, anxiety, lack of focus and concentration, mood swings, boredom, and restlessness. There may also be times when stress levels are higher for both parents and children. Many young children around the world have been impacted by lockdown because they are unable to keep up with their grades in numerous disciplines. Additionally, these stresses people out and is bad for kids. Due to the closing of parks, clubs, swimming pools, and other kid-friendly activities, children have been losing out on a variety of physical activities and motor skills in addition to their academic performance in school. Robinson (2020) highlighted that children have been displaying greater intellectual development delays as a result of lockdown, particularly as a result of a lack of activities like music lessons, summer camps, library visits, and other such activities. (3)

  Over 90% of respondents reported a negative impact on mental health, including worse behavior, mood, fitness, and social and learning regression. In general, respondents reported negative effects of lockdown restrictions, with 61% reporting a reduction in physical activity levels. (5). only 36.3% of respondents said the relationship had not changed, while a sum of 24.7% claimed there had been a negative influence. Additionally, a subtotal of 32.9% of respondents noticed the child's health getting worse. (6) I used a self-made questionnaire to screen participants in my study, which was done in a government homeopathic medical college and hospital, as well as surrounding schools and outlying camps, and I discovered that 10% of children between the ages of 5 and 18 had adjustment disorder.

   Homoeopathy is a medical science in which medications are attributed to people rather than diseases. It is a therapeutic medical system based on the principle "Similia Similibus Curentur," which states that disease symptoms are comparable to the symptoms of a remedy capable of producing similar disease symptoms in a healthy human being. It not only treats patients holistically but also takes into consideration the individual's unique features.

   The adjustment disorder after the COVID-19 pandemic period will come under mostly mental diseases of doubtful origin (3rd type), where it is not certain that the mental disease arose from physical illness rather than from "faults in education, bad practices, corrupt morals, superstition, or ignorance", See if it can be improved by "friendly exhortations, consolatory arguments, serious representations, and sensible advice." In the future, there will be possibilities of forming a mental disease (4th type: psychosomatic), where one’s emotional illnesses will, if left alone, destroy the physical health due to emotional factors like anxiety, worry, and vexation. (7)

MATERIALS AND METHOD

1. STUDY SETTING

·  Study Area: Government Homoeopathic Medical College and Hospital, Bhopal

·  Study Population-

1. OPD of Government Homoeopathic Medical College and Hospital, Bhopal

2. Peripheral unit

3. Frequently organized camps and schools.

·  Study period -1 year

2. SELECTION OF SAMPLE:  

·  The subjects for the study were selected from OPD of Government Homoeopathic Medical College and Hospital, Bhopal and Peripheral unit, Villages, frequently organized camps and schools.

·      A self-made screening questionnaire done to  patients came in the OPD and camps then selected 61 patients  from them ,then among them 36 patients were selected on the basis of inclusion criteria and exclusion criteria . The effect and sample size sample size we assumed it moderate(0.5).Fixing α as 0.05 and power (1-β) as 80%, to detect a significant difference between two dependent means of MYMOP score (8)(matched pairs) by paired t test,  we require a sample size of 34.Alllowing a provision for 5% drop-outs, the target sample size becomes 36.

·      Detailed case history was taken by interview as per the proforma prepared for the topic. All patients for study were selected by Purposive sampling method, where the children which were registered between the periods of April 2022 to 2023 . All cases were followed up for minimum period of 6 months.

3. INCLUTION CRITERIA:

1. Children of aged 5-18 years and diagnosed under Adjustment disorder.

2. Patient of all religions

3. Patient of both sexes and irrespective of socio-economic status

4. Patient who are willing to participate in the study.

5. Patient who are coming for regular follow ups

 4. EXCLUTION CRITERIA:

1. Patient who already diagnosed to other psychiatric disorder and critical illness

2. Patient who is under treatment of other mode of treatment for adjustment disorder

3. Children below 5 years

4. Children who are already socially withdrawal (introvert) by nature before covid 19 pandemic.

5. STUDY DESIGN

Prospective, non- randomized, non- controlled, single arm, pre-post comparison, open label observational study design.

6. INTERVENTION

1. Proper case taking.

2. Selection of medicine.

3. Intervention was planned as administering indicated homoeopathic medicines in centesimal potency. In this scale each dose shall consist of a single drop of the indicated medicine (preserved in 90% v/v ethanol) in 5 ml of distilled water, to be taken orally with empty stomach; dosage and repetition depending upon the individual requirement of the cases. All medicines will be procured from a Good Manufacturing Practice (GMP)-certified firm.

4. Proper follow up of the case:

5. Duration of therapy: 3 to 6 months.

6. Thinking about second prescription where needed.

7. SELECTION OF TOOLS

1. Case taking in standard case taking preform provided by Govt. Homoeopathic Medical College and Hospital, Bhopal.

2. Repertorization sheet.

3. Drugs prepared under centesimal scale at Govt. Homoeopathic Medical College and Hospital, Bhopal.

4. Potency: Depending on the case.

5. Dose: As per strict homoeopathic principles.

6. Diet & regimen: As directed by Master Hahnemann in Organ on of Medicine' & Chronic Disease'.

7. Severity and improvement of Patient's complaints i.e., before and after treatment was assessed by MYMOP Scale

8. Severity of the patient's illness, before & after treatment, was assessed on MYMOP Scale

9. Patient's improvement after treatment shall be assessed on LIKERT -5 Point scale

8. OUT COME ASSESMENT 

Follow up of cases is done once in 15-30 days interval, consecutive for3-6 months

Primary:

MYMOP Scale

A broad patient-specific outcome instrument to evaluate general health is the Measure Yourself Medical Outcome Profile (MYMOP) tool(8),(9)Throughout the study period, the MYMOP2 Scale was tested each month. Each scale has 4 elements and 6 points, for a total of 24 possible scores.

Secondary

   LIKERT SCALE-5points

1.    Very much improved—complete regression of signs and symptoms till the end of my study periods. (from severe to mild)

2.    Much improvement -Regression of signs and symptoms partially till the end of my study periods( from severe to moderate, from moderate to mild)

3.    Slightly improved—a slight sign of improvement after sufficient time is given.

4.    No change in presenting symptoms till my study period

5.    Slight aggravation of signs and symptoms and patient stopped treatment.

9. DATA COLLECTION

     At the base line and after a 15- to 30-day interval, consecutive for 3 to 6 months.

10. STATISTICAL TECHNIQUE AND DATA ANALYSIS

It was following the intention-to-treat (ITT) approach, i.e., every included patient was entering the final analyses. Missing values were replaced by the series mean, the last observation carried forward, and/or the multiple imputations technique, as appropriate. Baseline descriptive data (categorical and continuous) was presented in terms of absolute values, percentages, mean, standard deviations (SD), confidence intervals (CI), etc. as appropriate. Parametric or non-parametric tests were used as inferential statistics as per the normality or non-normality of the data distribution, respectively. A dependent observation of continuous outcomes at baseline and at different points in time was compared using a paired t test. The P value was set at less than 0.05, two-tailed, as statistically significant.

11. ETHICAL ISSUES, IF ANY

No invasive methodology is involved, and there is no therapeutic experimentation. No investigation was done against the will of the patient. Inter-current illness, acute exacerbation of chronic conditions, adverse or serious adverse event(s), if any, was recorded and treated accordingly as per homoeopathic principles, irrespective of assigned codes. The study was based on the most probable hypothesis. However, the proposed plan of work has been placed before the concerned Ethical Committee.

RESULTS

The present study aimed to investigate  the role of Individualized homoeopathic medicine in adjustment disorder among 5-18 years old children after covid19 pandemic period. All patients for study were selected by Purposive sampling method, where the children which were registered between the periods of April 2022 to 2023. All cases were followed up for minimum period of 6 months. The difference between scores before & after treatment were statistically analyzed to obtain the following results under different heads: -

The study results clearly indicate that the distribution of some predominant symptoms is different among different age groups, and some are common among all age groups. i.e., communication skills are impaired mostly among the 5-8-year-old age group (12 cases), and their prevalence is decreasing as the age increases. This is substantiated by the data regarding 9–12 years, which shows 4 cases, and among the 13–15 year group, only 1 case is there. There is no lack of communication issue in the 16–18 year age group. Lack of concentration, increased screen time, and irritability/anger issues have affected all age groups, but as seen above, lack of concentration is more common in the 9–12 and 16–18 age groups, with 5 cases each. This is followed by the 13–15 group with 4 cases, and the least in 5-8 years comparatively with 3 cases. Increased screen time is seen equally among the 9–18-year-old section with 4 cases each, slightly less among the 5-8-year-old section with 3 cases. But this symptom is most prominent among all age groups. Irritability or anger issues are also present in all age groups, but 16–18 years old have shown 7 cases, followed by 4 cases among 5-8 year olds and 4 cases among both 9–12 year olds and 13–15 year olds. The next prominent symptom is fear of new people, which is seen in 5-8 years and 9–12 years, sharing 2 cases each, 1 case in the 13–15 year age group, and no case in the 16–18 year age group. Fear of disease is less common; only 1 case from the 9–12 year age group Memory impairment is also present in one case in all age groups except 9–12 years. Surprisingly, among physical symptoms, recurrent coryza was seen in 7 cases and in 2 cases for 5-8 years and 9–12 years, respectively. Then comes lack of appetite, 2 cases from 5-8 years, and 2 cases of sleeplessness between 16 and 18 years. Recurrent colic and nocturnal enuresis are 1 case each from 5-8 years, and weight gain also varies. 1 case each from 9–12 years and 16–18 years.

According to the analysis data, there were 5 cases of Phosphorus, 4 cases of Tuberculinum, and 2 cases of Natrum mur among children aged 5-8 years old, with 1 case each of Sulphur, Silicea, Ignatia, Pulsatilla, Causticum, and Mag carb. So, in the 5-8 year old age group, phosphorous, Tuberculinum, and Natrum mur are the most commonly used remedies. Among 9–12 year olds, sulfur and silica have more cases (2 each), followed by phosphorus, natrum mur, Calcarea carb, and Lachesis, which carry 1 case each. There were two cases of Sulphur and Tuberculinum, each with one case. Among 16–18-year-olds, Natrum mur is the most frequent remedy (2 cases), followed by Phosphorous, Calcarea carb, Tuberculinum, Lachesis, Sepia, and Staphysagria, which carry 1 case each

From the above data, the remedies Phosphorous, Tuberculinum, Causticum, Lachesis, and Calc carb gave relatively very much improvement. Phosphorous gave slight improvement (1 case) to much improvement (3 cases) and Tuberculinum had much improvement (1 case) and very much improvement (4 cases). Natrum mur and Silicea also gave good results with much and slight improvement. But more than Silicea (1 much improvement and 1 slight improvement), Natrum mur was given (4 cases showed much improvement and slight improvement in 1 case) to patients based on totality. Pulsatilla and Mag carb could give slight improvement (1 case each), and Sepia and Ignatia have given no change (1 case each) in the condition. Sulphur is a comparatively less good remedy, even though it gave a slight improvement (1 case), but cases of no change (2 cases) and slight aggravation (1 case) are also there. Staphysagria could slightly aggravate one case.

Comparison with the table values: 

The student "t" distribution with n-1 (33) degrees of freedom is followed by the statistical test "t". At a 5% level of significance, this table's "t" value is 2.032. As a result, the distribution with n-1 (33) degrees of freedom followed the critical ratio. The 5% level table value is 2.032.

Inference:

We reject the null hypothesis because the estimated value of 't' = 7.601 is higher than the table value at 5%.

CONCLUSION

 In summary, this study explored

• There are the highest incidences of adjustment disorder in the age groups of 5-8 years and 16 to 18 years had the lowest incidence.

• The illness appears to have a small female sex predisposition

 • The study concludes that Adjustment disorder was found in more of Hinduism followers than others. • This study demonstrated that the majority of patients come from rural areas.

• In this study's 34 total cases, there was a dispersion of the different symptoms for adjustment disorder. Maximum cases had the symptoms of lack of concentration and lack of communication skills followed by Increased screen time and irritability or anger issue .Among the physical symptoms, tendency to recurrent coryza came up as most common symptoms than impaired memory, recurrent colic, and sleeplessness followingly

 • The majority of patients had a mostly Psora background, followed by a Tubercular back-ground.

 • Out of 34 cases, 11 showed very much improvement, i.e., 32.4%), 10 showed much improvement, i.e., 29.4%, and 7 cases (20.6%) showed slight improvement. Among 34 cases, 4 cases (11.8%) showed no change before or after treatment, and 2 cases (5.9%) showed slight aggravation after treatment.

 • The distribution of some predominant symptoms is different among different age groups, and some are common among all age groups. i.e., communication skills are impaired mostly among the 5-8-year-old age group, and their prevalence is decreasing as the age increases. Here is no lack of communication issue in the 16–18 year age group. Lack of concentration, increased screen time, and irritability/anger issues have affected all age groups, but as seen above, lack of concentration is more common in the 9–12 and 16–18 age groups,

 • There are 4 cases each in the 9–18 year old area showing increased screen use, while there are only 3 cases in the 5-8 year old section. However, this symptom is particularly noticeable in older people. All age groups also have irritability or anger issues, but 16 to 18-year-olds have the highest rates, followed by 5-8-year-old children. Recurrent coryza was one of the more common physical symptoms during 5–12 years. Then comes a 5-8year lack of appetite and a 16–18 year sleeplessness.

• In the 5-8 years old age group, phosphorous, Tuberculinum, and Natrum mur are the most commonly used remedies. Among 16–18-year-olds, Natrum mur is the most frequent remedy

• The remedies Phosphorous, Tuberculinum, Natrum mur gave relatively very much improvement.

Conclusive Remarks­:- The results of the study are quite encouraging to adopt Homoeopathy as a treatment mode in cases of Adjustment disorder .This was a modest effort  to fulfil the aim of the study by aim to assess the role of Individualized homoeopathic medicine in adjustment disorder among 5-18 years old children after covid-19 pandemic period was quite satisfactory. This study was successful one in terms of fulfilling the aim & objectives set for it. The estimated value of ‘t’ = 7.601 is greater than the table value at 5%, according to the statistical analysis, hence the null hypothesis is rejected, and the alternative hypothesis is accepted. Therefore, homoeopathy has a useful role in the treatment of adjustment disturbance in children following the Covid-19 epidemic

Funding: This research received no external funding.

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. 

Data Availability Statement: Data presented in this study are available on reasonable request to the corresponding author. Data are not publicly available because they report private information about participants.

Conflicts of Interest: The authors declare no conflict of interest.

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