A Case Study on Ayurvedic Management of Unmadam with special reference to Childhood Autism

Autism is one of the main concern of pediatrics in the present era. This neurodevelopmental disorder of unknown etiology begins in early childhood. The main characteristic features of Childhood Autism are impairment in communication skills, social interactions and reciprocity, and imagination and play. The features of Autism are much similar to that of Unmadam (disease of mind characterized by mental confusion etc.), a disease condition mentioned in Ayurvedic classics. Due to various etiological factors, the conjunction between Atma (the self) and Manas (mind) is disrupted resulting in the vitiation of Manovaha srotas (channels of consciousness that flow through mind). Along with this, the vitiation of three doshas ( Vata, Pitta, and Kapha ) will end up in the manifestation of Unmada . Manovaha sroto-dushti together with Tridosha dusti is the basic cause of Childhood Autism. A 7-year-old male child was presented with the complaints of poor eye contact, impaired socialization and communication, making a peculiar sound repeatedly, unaware of the situations of danger, thumb sucking and hyperactivity and facial dysmorphism. A systematic Ayurvedic treatment consisting primarily of Vata-Pitta hara chikitsa (treatment for pacifying Vata and Pitta ) along with Deepana-Pachana (drugs for enhancing digestive power), Snehana-swedana (oleation with lipophilic drugs and sudation therapies) , Sroto-sodhana (cleansing of channels which corrects the metabolism and does modulation of gut microbiome) , Brumhana (nourishing treatments) and Medhya rasayana (drugs for promoting intellectual and cognitive functions) and pathya krama (congenial diet and habits) resulted in considerable relief of the condition.


Introduction
Autism is a neurodevelopmental disorder of unknown etiology (1). The cardinal features of Autism are impairment of social interaction, communication and imagination, and restricted interests and repetitive behavior. Childhood autism has its manifestations usually at around 18-24 months of age and is well established by 3 years of age (2). World Health Organization has estimated that worldwide 1 in 160 children has Autism Spectrum Disorder (ASD) (3).
Latest survey by Autism and Developmental Disabilities Monitoring (ADDM) Network of Centre for Disease Control and Prevention (CDC) suggest a 15% increase in prevalence that 1 in every 59 children are being identified with Autistic Spectrum Disorder in the United States and is about 4 times more common among boys than in girls (4). These statistics calls for the urgency of evaluating this condition in scientific backgrounds. The exact cause of Autism is unknown (5). However, the various causes which are believed to contribute to the occurrence of Autism are genetic factors, various environmental factors, perinatal brain injury, hormonal imbalance etc. Abnormalities in brain structure and function have also recommended by neuro -radiological and neurochemical studies. But, the findings of various studies are conflicting and there is no diagnostic imaging or other tests specific for Autism (6). The factors like emotionally distant parenting styles (refrigerator mothers) and MMR vaccination were previously thought as etiological factors for Autism. But currently, the causation of Autism by above-mentioned factors stays invalid (7). As per Ayurvedic classics, Garbhopaghatakara bhavas (the prenatal factors which harm the product of conception) (8) are considered as major etiological factors in its causation. Among cases of childhood Autism, etiopathogenic factors and line of treatment varies from individual to individual. This case study is only an example of childhood autism case where remarkable improvement was found in the condition by adopting Ayurvedic management, especially with samana chikitsa (treatment methods for pacification of diseases rather than purificatory therapies). The case is analysed adopting the various parameters of assessment of Autism which corresponds to those mentioned under Unmada Nidana and Unmada chikitsa in Ayurvedic classics and the results are discussed with possible correlations in the light of principles of etiopathology and management explained in classical Ayurvedic textbooks. Indriya (sense organ), Indriyartha (object of perception) happens in the order (9). A tma (the self) is responsible for the cognition, and Manas is the substratum of Indriyas (sense organs) to perceive Indriyartha (object of perception). The factors responsible for the mental constitution of the fetus are satwa (mind) of mother and father, the objects of hearing, actions of the pregnant mother and past deeds (10). In children with Autism, the conjunction between A tma and Manas is disrupted. i.e.; Manovaha-sroto-dusti (vitiation of channels of consciousness that flows through mind) along with Tridosha dusti (vitiation of three doshas) is the characteristic feature of Childhood Autism. As per Ayurvedic classics, the same etiopathology is explained in the context of Unmada (Disease of mind characterized by mental confusion etc. By analyzing the etiopathology and clinical features of Autism, it can be included under the broad spectrum of Unmada. (12) In this case report, the Ayurvedic view of etio-pathogenesis of Childhood Autism along with its treatment principles are discussed.

Line of Treatment of Autism as per Ayurveda
The classical management of Unmada mentioned in Ayurvedic classics is found to be very effective in the management of Autism Spectrum Disorders. Deepana and Pachana which are the procedures in which various drugs are used for promoting digestion, Snehapana (oral intake of medicated ghee preparation), Mridu Sodhana (Mild purification of body by emesis or purgation), Niruha basti (decoction enema) and Sneha basti (oil enema), Siro V irechana or nasya (medicated nasal drops), Samjna prabodhana (medication to stimulate the mind). Apart from the Sodhana (purificatory) therapies mentioned in Ayurvedic classics, A bhyangam(oil massage of head and body), Siropichu (Overhead application of a piece of cotton dipped in medicated oil), Sirodhara (pouring of medicated oil over the forehead as a continuous stream), Sirolepam (Overhead application of medicinal paste), and Takra dhara(pouring of medicated buttermilk over forehead as a continuous stream) are various treatment modalities aimed to promote the development of brain and to reduce or control the troublesome behaviours found with Autism Spectrum Disorders (13). As per Caraka Samhita, the avoidance of Meat and intoxicating drinks, intake of Hitahara (compatible foods), following cleanliness and possessing a good mental strength can prevent the disease Unmada and, the person cured of Unmada will attain clarity of Indriyartha (objects of senses), Buddhi, Atma, Manas and normalcy of dhatus (14). Autism is regarded as a lifelong condition due to Bija dosha (genetic predisposition). But, by adopting Unmada chikitsa as a long-term intervention the triggering elements of Autism can be eliminated thereby the quality of life can be improved.

Case report Personal data and presenting complaints
A seven year-old male child was presented with the following complaints: poor eye contact, impaired socialization and communication, making a peculiar sound repeatedly, unaware of the situations of danger (foreg: fire, vehicles in road etc.), thumb sucking and hyperactivity and facial dysmorphism. He was Hindu by religion and was the second child born to a middleclass, literate, non-consanguineous parents.

History of present illness
The child was the second offspring of nonconsanguineous parents, the age of mother at the time of gestation was 29 years. There was history of abortions before the birth of first child. Blood group of mother was A-Negative and that of Father was B-Positive, and the baby was A-Negative. Because of breech presentation, LSCS was done at Full-term. The baby cried soon after birth, and birth weight was 3.5 Kg. The mother and baby were discharged from hospital on the fifth day after delivery. No other relevant post-natal events were reported. As months passed away, parents noted the delay in child's developmental milestones. i.e.; the child has not attained the social smile and he was found to be repeatedly making a peculiar noise, for which they approached a hospital and undergone the investigations like vision and hearing tests, Karyotyping and MRI Brain. MRI report suggested delayed myelination in both cerebral hemispheres. The child was identified to have deficient IQ level and so was undergoing education in special school.

History of past illness
The child had complaints of vomiting and indigestion more frequently till his fifth year of age.

Developmental History
Delay in Gross motor, Fine motor, and Social and Language skills were noted. Milestones and age of attainment: Gross motor:  Head control: 10 th month  Turning over: 4 th month  Sit with support: 5 th month  Sit without support: 6 th month  Crawling: 8 th month  Stands with support: 10 th month  Walking without support: 1 1 / 2 years Fine motor:  Grasping, Self-feeding, Buttoning: Attained  Drawing: Not attained

Immunization History
The child was immunized as per schedule

Dietetic History
The child was exclusively breastfed up to 6 Months. Weaning started at 6 months with ragi, banana etc. and he was breastfed till 5 years of age. Presently the child takes regular foods including fruits and cooked rice, pulses etc.

Family History
There was no relevant family history.

Personal History
Diet was Non-vegetarian and child had moderate appetite. Bowels and micturition were normal. But toilet -training was not attained and so had complaints of soiling of pants. Sleep was Sound. The child had a habit of making a peculiar sound repeatedly. Allergies of any kind was not reported.

General Examination
On general examination, the child was Hyperactive inattentive, making a peculiar sound repeatedly, with poor socialization and communication, having a normal attitude and posture, moderate built and nourishment, and facial dysmorphism.
Vital signs and Anthropometry were within normal limits.

Head to foot Examination
The head-shape and size appeared normal with no frontal bossing. The Fontanels were closed by 1 ½ year of age, and were non-pulsatile and normal. Hypopigmentation of hair was noted. Facial dysmorphism was present with normal eyes, low-set ears and flat nasal bridge. Dentition was normal. Neck, Skin, Limbs, Chest, Spine, Abdomen and Genitalia were normal.

Systemic Examination
No abnormalities were detected in examinations of Respiratory, Cardiovascular, Gastro-intestinal, Urogenital systems. Central Nervous System was affected. In the domain of Higher Mental Functions of the child, Appearance and behavior were noted as Hyperactive, Inattentive child, making a peculiar sound repeatedly, and with poor socialization and communication. The child was conscious with no delusion, Illusion and Hallucination and he was oriented to time and place. A deficiency was noted in memory and Intelligence. Impairment in both verbal and nonverbal communication was noted. The Cranial Nerves, Motor system, Reflexes, Sensory system and gait were normal with absence of Cerebellar signs.  (17). According to this criteria, the present case has a score indicating severe autism.

Provisional Diagnosis
The clinical condition was provisionally diagnosed as Unmadam which can be correlated to Childhood Autism.

Samprapti (Etiopathogenesis)
The analysis of etiopathogenesis reveals the involvement of multidimensional factors. The prenatal cause is Beeja dusti (18) (vitiation of sperm and ovum which is considered to result in genetic defects in offspring) of both parents which can be assumed from the history of previous abortions. Along with this, the Upaklista satwa (debilitated mind) and Utsanna Bahudosha (excessively aggravated doshas) (19) are involved as Garbhopaghatakara bhavas (prenatal factors negatively affecting fetus) (20), representing Manasika and Shareerika (mental and physical) factors respectively which has ended up in the formation of a Garbha (fetus) which is of Heena satwa (decreased mental abilities). Besides this, the breech presentation of the fetus which demanded LSCS resulted in Pranavahasroto dusti (vitiation of channels carrying the element of life) which lead to Upaksheena deha and Manas (debilitation of body and mind). The condition is predominated with vitiation of Tridoshas with more aggravation of vata and pitta and the doshas of mind, namely Rajas and Tamas. This has successively resulted in Manovaha sroto dusti (vitiation of channels of consciousness that flow through mind) in the child during postnatal period. Then the aggravated doshas get localized at the level of Manas and Hrdaya. Hrdaya is the seat of six angas (divisions of body), knowledge, sensual faculties, five senses, A tma, Manas and Chintya (an object of mind involved in thought process) (21). Therefore the objects and functions of manas (mind) are badly affected by the localization of doshas at manas and hrdaya. Moreover, the avarana (covering) of Prana vata (one among five subtypes of V ata which move towards the head) in Manovaha srotas hampers its normal functions like Budhi-hridaya-indriya-chitta dharana (maintaining the intellect, Hridaya, sense faculties, mind in normal condition). Sadhaka pitta, seated in hrdaya which is responsible for receiving the knowledge of objects of senses and memory etc. by the instruments like budhi(intellect), medha(ability of learning), abhimana (feeling of one's self) etc. is vitiated. The condition was further worsened by Annavaha srotodusti (vitiation of channels carrying the food) by affecting A gni (digestive fire) and Rasavaha srotodusti (vitiation of channels carrying rasa) which was characterised by indigestion and vomiting in child. All these factors together culminated in V ibhramsha (impairment) of Manas (mind), Buddhi (intellect), Smriti (memory), Bhakti (desires), Samjna Jnana (sensory perception), Sheela (manners and behaviors), Chesta (activities), Achara (learned skills) to manifest with hyperactivity, the deficit in social interaction, communication, intellect, behavior and abnormal mannerisms, etc. as Unmada (Childhood Autism).

Final Diagnosis
The condition was diagnosed as Unmadam (Childhood Autism) after analyzing Autism Treatment Evaluation Checklist and Childhood Autism Rating Scale and evaluating the etiopathogenesis and presentation of Unmada in Ayurvedic parlance. and ultimately to allow the circulation of Tridoshas and dhatus properly which paves the way for nourishment of subsequent dhatus from rasa to shukra) followed by brumhana (therapy to bring about nourishment), hridya (medication which is good for mind), samjna prabodhana (medication to stimulate mind), and medhya rasayana (drugs for improving memory and intellect) together with psychotherapy, behavior therapy, and speech therapy were adopted to manage the condition.

Analysis of Clinical Presentation
Samana chikitsa (pacification therapy) was prefered than Sodhana chikitsa (purification therapy) considering the age and strength of patient. Initially Kashayadhara was done with Drakshadi kashaya for five days. Kashayadhara is a procedure in which medicated decoction is poured throughout the head and body in a continuous flow. It was followed by Sirolepam (application of medicated paste over the scalp) with Baladi yoga for seven days. Baladi yoga is mentioned in the textbook A rogyakalpadruma in the context of Unmada chikitsa. Then A bhyangam (oil massage) with A arukaladi tailam followed by Ksheeradhoomam with Balaksheeram was done for seven days. Ksheeradhooomam is a procedure where the patient is treated with the steam coming from heating medicated milk through a tube. Then Sirolepa was done for seven days with Mustadi yoga. After this, for seven days, Pratimarsha Nasyam (nasal instillation of medicated nasal drops in low dosage) with Ksheerabala tailam 21 Avarti was done. Later Kayasekam followed by Sirodhara was done with Ksheerabala tailam for seven days. Kayasekam is a procedure in which fomentation is given by pouring warm medicated oil in a stream. Sirodhara is slowly and steadily dripping the medicated oil over the forehead. Shastika lepam (shastika sali, a special variety of rice cooked in medicated decoction and made in to paste and added with suitable oil is applied all over the body) with Aarukaladi tailam for seven days. These procedures and formulations are selected based on their predominant V ata-Pitta subsiding nature and their special effect on mind.
Internal medicines were administered in appropriate dose, formulation and potency as per the information gathered from Dasavidha pareeksha (ten points of examination) explained in Ayurvedic classics. Drakshadi kashayam was prepared as per toyapaka vidhi and dispensed as Muhurmuhu panam (frequent intake). Here, the medicines for preparing decoction are boiled in to a more diluted form for frequent intake. The powder Kalyanavaleha choornam was administered in the dose of half teaspoon with honey, and Tiktaka ghritam, medicated ghee was given as 10 ml with a pinch of Saindhava lavanam (rock salt) twice daily before food. The tablet Manasamitra-vatakam one tablet was given at bedtime with boiled and cooled water. A fermented preparation for childhood diseases namely Aravindasavam was administered as 15 ml with 30 ml boiled and cooled water, twice daily after food.

Dietary advices
In Ayurveda, the pathya (wholesome) and apathya (unwholesome) supplements, the do's and don'ts are the backbone of success of any treatment as well as for the prevention of diseases. The pathya for the present case are Medhya (that which promotes memory and intellect), Hrdya (that which is good for mind), Brumhana (that which is nourishing), Shastika Shali (a variety of rice which is grown and harvested within 60 days), Ghrita (ghee), Madhu (honey), Y ava (Hordeum vulgare), Dadima phala (pomegranate fruit), Amra phala (mango fruit). The apathya are Mamsa (meat), Rooksha (dry), Katu (pungent taste), Ushna (hot in potency), V idahi (that which creates burning sensation), V ata-Pitta vardhaka ahara-vihara (the diet and activities which aggravate V ata and Pitta.

Karyaphala (Improvements):
The outcomes of the treatment were evaluated using the Autism Treatment Evaluation Checklist (ATEC) and the Childhood Autism Rating Scale (CARS).

Discussion
Childhood Autism which is correlated to Unmadam is a condition with involvement of both mind and body. Eventhough it is regarded that the exact etiology is unknown, Ayurveda postulates very relevant etiology complex for this condition. The present case discussed here is merely an example where the etiopathology of childhood autism as per Ayurvedic classics can be explained elaborately so that the line of management can be formulated accordingly. The detailed history along with examinations like A shta Sthana pareeksha, Dasavidha pareeksha, Systemic examinations, along with investigations like Karyotyping, MRI and also the ATEC and CARS which are the specific tools for Autism evaluation greatly contributes to the proper evaluation and formulation of exact Samprapti (etiopathogenesis) of the condition. The subscales of ATEC are Speech/Language/ Communication, Sociability, Sensory/Cognitive awareness and Health/Physical/Behaviour. And CARS evaluates relation to people, imitation, emotional response, body use, object use, adaptation to change, visual response, listening response, taste, smell and touch response and use, fear/nervousness, verbal communication, non-verbal communication, activity level, level and consistency of intellectual response and general impression. All these parameters significantly contribute to the identification of childhood autism along with its dosha-predominance and in the understanding of changes happening over a particular period with more specificity to each and every aspect of behavioural development.
The samprapti of this case involve Beejadusti, Pranavaha, Annavaha, Rasavaha and Manovaha srotodusti , Vata-Pitta pradhana Tridosha-dusti along with aggravation of Manodoshas.The aggravated doshas get localized at hrdaya and manas. Manas is situated in siras (head) and hrdaya (heart region) even though whole body is its seat. Siras is an important marma (vital point) with its crucial role in various functions of mind as well as controlling it. The health of Manovaha srotas primarily depends on the health of Siromarma and Hrdaya. Pranavayu which traverses to Siras is holding the budhi, hrdaya, indriya and chitta. Hrdaya is a marma which holds the root of Rasavaha srotas. Rasavaha srotas has its close relation to manas, as manas is situated in hrdaya which is the root of rasavaha srotas and rasavaha srotas is vitiated by excessive thinking where the object of manas is chintya (power of thinking). The subtype of Pitta involved here is Sadhaka pitta seated in hrdaya which is responsible for achievement of one's aspirations by means of budhi (intellect), medha(ability for learning), abhimana (feeling of self) etc. Beeja dusti is responsible for the abnormalities of sperm and ovum which is manifested as the previous abortions in mother. Appropriate purification therapies, proper prenatal care can greatly help in tackling beejadusti. Agni (digestive fire) plays an inseparable role in the manifestation of autism. The unhealthy dietary habits like asuchi bhakshana (ingestion of unclean food) and viruddhahara (incompatible diet) is considered to result in Unmada. The theory of Gut-brain axis of Autism supports the concept of role of vitiated A gni in its causation. The human enteric microbiota has a potential relation to central nervous system. The disturbances in this gutbrain axis plays a major role in causing neurodevelopmental disorders like autism. In such conditions, the therapeutic interventions over gutmicrobiota causing its modulation can ultimately provide the solution to such disorders. (22) In the present case the role of disturbance to A gni is revealed by the history of episodes of vomiting and indigestion till the fifth year of age. As A gni is the fundamental necessity for metabolism in body, all the factors which contribute to its disturbance directly puts the condition to a more complicated scenario. The samana chikitsa (pacification therapy) was given preference over sodhana chikitsa (purification therapy) considering the age, delicateness, strength of the child etc. Drakshadi kashaya helps in subsiding the aggravated vata and pitta, corrects the agni and acts on rasavaha srotas and manovaha srotas. Manasamitra-vataka contains the drugs like Sankhapushpi (Convolvulus pluricaulis) , yastimadhu (Glycyrrhiza glabra) , godugdha (cow's milk) and gold etc. which are famous for enhancing memory and intellect and the formulation itself is explained as manodoshahara(alleviates the doshas of manas), prajna kara (provides wisdom), medhakara (promote memory and intellect) and pratibhakara (makes talented). The drugs of Tiktaka ghritam are predominantly bitter in taste. The drugs with bitter taste are good for alleviating pitta. The plain ghee subsides vata and pitta, and it promotes dhi (intellect), smriti (memory), medha (ability to learn), and agni (digestive fire). The ghee due to its ability called samskaravahitwa (carry the properties of drugs processed with it) imparts pitta-alleviating action as well as maintain its own functions like promoting intellect etc. Moreover lipophilic drugs are proved to penetrate Blood-brain barrier (23). Therefore it's the greatness of scholars of Ayurveda who explained a lot of medicated ghee preparations in the context of diseases of mind and also in seizures.
It is ideal to administer the ghee formulation in this condition. When saindhava lavana is added to ghee preparation, it spreads all over the body very quickly. well as it promotes memory. The innate lekhana (ability to scrap out excess tissues) property of the formulation and kapha chedana (breaking kapha) and kapha vilayana (dissolving kapha) property of honey clears the srotas (channels) effectively. This is very important for correcting the metabolism.
A ravindasavam is a nourishing drug explained in Bhaishajyaratnavali under Balaroga chikitsa and is used widely in pediatric disorders. It kindles A gni and promotes strength and longevity of life. It subsides the diseases caused due to graha (exogenous factors). Agantu unmada (disease of mind caused by exogenous factors) is considered to be caused by graha. So A ravindasava is an ideal formulation for this condition.
After the treatment, considerable improvement was noted in sociability and sensory/cognitive awareness followed by health/physical/behaviour and speech/language/communication. A 50% improvement was noted in listening response. The domains of Relation to people ,taste, smell and touch response and use, and non-verbal communication showed a 25% improvement. Besides this, the body use, adaptation to change, visual response, fear/nervousness, activity level and general impression were improved considerably. The total ATEC score has shown an improvement of 18.44% whereas CARS 14.17%.

Conclusion
The line of management of Childhood Autism is decided based on the etiopathogenic factors in each individual. As per the change in these factors, the treatment also varies from person to person. In general, childhood Autism is to be treated with therapies which work at the physical, psychological and spiritual aspects. Therefore the basic treatment principle in Ayurveda, consisting of Y ukti vyapasraya chikitsa (Rational Medical Management), Satwavajaya (Mind or self-control techniques) and Daivavyapasraya chikitsa (confidence building treatment) are adopted in the management of Autism (25). These are applied appropriately considering the age of the child, factors for causation, pathogenesis, clinical manifestation etc. Till date, no interventions have been proven to alter the genetic makeup of children affected with Autism. But, the application of appropriate treatment modalities as described in Unmada chikitsa as a long-term intervention can provide much better improvement in cases of childhood Autism. The principles for prevention of diseases put-forward by Ayurveda like codes of conduct for a healthy living including Dinacharya, Rtucharya, Swasthavrutta, Achara rasayana and the specific ways of living like rajaswala charya, rtumati charya, pre-conceptional care, garbhini charya, various samskaras pre and post birth of the baby are considered to protect the child from diseases by supporting physical, mental and spiritual aspects of health. The foundation stone in prevention of Autism as per Ayurvedic system is the promotion holistic health.