After 25 years of practice, I find myself increasingly interested in how to follow a patient over time. Is it enough to see a patient once or a few times? How do we fair as a profession in terms of long term follow up? What about treating children into adulthood? With regard to homeopathy in particular, are there any guideposts that let us know our patient is moving in the right direction? Certain philosophical and practical tools can be helpful. This article, through a pediatric case presentation, describes one such tool, the Map of Hierarchy*.
One of the things I have most loved about practice is the long arc of treating a baby or small child and watching them develop over time. In many ways this has mirrored my own evolution as a mother, first of little ones and now of three college-aged kids. It should be that with good naturopathic care and homeopathic prescribing, a person reaches their optimal level of health, that somehow their genetic potential has more of a chance of being realized. We all like the overnight miracles, the patient who makes great strides in a few short months either from a brilliant prescription or more commonly from a joint effort of doctor and patient and the healing power of nature. But with children, things can be both easier and more difficult. Lifestyle changes may or may not be relevant, compliance may or may not be forthcoming and in the case of autistic patients, some of the challenges seem insurmountable. In this patient narrative, I focus on the use of the Map of Hierarchy, as opposed to case analysis or the elucidation of materia medica, as it has wide application for pediatric cases but also is relevant for all patients.
Perhaps more than any group, those on the autistic spectrum give us the chance to observe how homeopathy impacts a patient over time and it is an area in practice where we can all use guidance in terms of long term follow-up care.
Little Charlie was a four-year-old towhead locked away in a world of his own when he first presented in the office. With no language skills to speak of, no self-help abilities and seemingly no interest interfacing with the world around him, his parents arrived at my clinic feeling desperate. They had implemented the DAN protocol; they had committed a small fortune and endless hours to an in-home ABA program, on top of a state-of-the-art, early intervention and top-notch preschool program. Unlike other children on the spectrum, Charlie seemed nearly unresponsive and made very little progress in the year since his diagnosis.
The first thing I noticed about Charlie was how strikingly beautiful he was, with wide and light blue eyes, porcelain skin and long, lush eyelashes. He made no eye contact with anyone in the room that day and wore only a far away look on his face. He had no history of seizure activity and had not sustained a head injury. His hearing and vision were intact. Early in my practice, patients like Charlie made me anxious and worried; what could I possibly do to help? But in the ensuing years, I have seen autistic children come running back into this world when they were once so remote. I have seen school-aged kids begin to talk when they had long been silent and I have seen violent, destructive children settle down and move toward the essential tasks of learning and relating to both objects and people. Every autistic child is different, though there are often shared symptoms. For the homeopath, it is in the forest of varied presentations that we find the symptoms and particular characteristics upon which to prescribe.
Charlie seemed 100% nonresponsive to sound and to touch. He sat in a lump most of the day as people did things with and for him. That said, he was a robust looking child and did eat whatever was put in front of him, without relish and with only a few food preferences.
His mother’s pregnancy, her third, had been uneventful with prenatal vitamins taken several months before conception, early and consistent prenatal care, and a natural childbirth. Her two daughters were alive and well. He was a perfect baby his mother recalls, except he did not nurse like his older siblings. He never got the hang of it and the family decided early on to use formula.
I never like hearing the phrase “perfect baby,” which, at least in this case, was defined as never crying, sleeping through the night and taking several long naps each day. It’s not right. Babies should cry, should be demanding at least on occasion, should make their physical and emotional needs known. Many kids who are diagnosed with autistic spectrum disorders will have a history of being quite difficult, colicky and restless, but a subset, likely related to homeopathic constitutional type, will be remembered as Charlie was: “perfect.”
He never seemed to make eye contact and his parents became worried by around 6 months. He did not seem interested in his older sisters and did not smile. Their pediatrician brushed aside parental concern saying that all kids bloom on their own schedule. To my ears, if a mother of three thinks there’s a problem, there usually is! It is known now that the earlier interventions take place, the better it is for any child on the spectrum. As the rise in autism incidence occurs, all parents and the doctors who care for families will be trained in observing and addressing early signs of autistic spectrum disorders.
Charlie had always been chubby with a big belly and poor tone, especially in his upper body. The main food he seemed to love was eggs and would eat them prepared in any way. He had a large head and sweat freely, top to bottom. He was chronically constipated, not yet toilet trained, having a bowel movement perhaps once or twice a week. His parents had tried gluten and casein free diets, good quality probiotics and many of the suggestions from their DAN doctor. He often had a runny nose and seemed worse during hay fever season with regard to congestion.
When most homeopaths hear big fat kid, sweaty head, chronic runny nose, constipation, desires eggs, they think, ahah! Must be a patient who needs Calcarea carbonica! But here’s where the error is made and why.
Take a look at the Map of Hierarchy, below:
Of course this is not a complete Map; there are many more remedies included. Paul Herscu ND, my husband and partner, conceived this Map many years ago and we have taught hundreds of homeopaths to think along these lines. The remedies to the left represent common remedies, ones we give often to all sorts of people with all sorts of complaints, but those who are basically oriented to the world, mentally and emotionally in more typical ranges. We can see a person needing Natrum muriaticum who is depressed or a person needing the remedy Phosphorus who is anxious, but the level and intensity of emotional and mental issues is generally worse as we move toward the right on this Map. As we move to the right, we can see remedies that address deeper pathology. But to the point of Charlie’s case: all of the remedies to the right will retain symptoms of remedies to the left. For example: if I have a patient who needs a remedy like Veratrum album, perhaps they are a bit manic, self absorbed, filled with ideas, a bit crazed, suffering with ulcerative colitis. As they get better, healthier, more balanced, we can see that they move toward the left of this map, perhaps needing a remedy like Medorrhinum. And over time, perhaps years, as they become more and more healthy, they may need a remedy like Sulphur. As we take a patient over time, if they start out all the way on the right, you would expect them to move toward the left. More on this a bit further on.
It’s also important in homeopathy, and probably all of medicine, to focus treatments on that which is most limiting to the patient at the time. So the fact that Charlie was chubby, craved eggs and was sweaty, was not really the point. The point was that he was totally unengaged, nonverbal and not doing the things a child must do that both reflect and add to development and growth.
Charlie’s history of severe constipation and his total detachment, perhaps best exemplified by the additional fact that he did not respond much to pain, brought to mind only a handful of homeopathic remedies. I needed a remedy that was unresponsive, slow in movements, constipated and incommunicado. Opium and Helleborus topped my list. I gave him Opium 200c that first visit with hopes that we could bring Charlie out of his world and into ours.
I made sure to spend adequate time with his parents, talking about what I had seen that remedy do with other similar patients and preparing them. Using the Map of Hierarchy, I knew that the right direction for Charlie was for him to move to the left on this map and that likely, the next remedy he would need would, the next phase he would go through, would include some challenging behaviors. But I figured, in Charlie’s case, it was better that he be unpleasant, than not there at all.