The Map of Hierarchy and a Case of Autism
Amy Rothenberg, ND
After 25 years of practice, I find myself increasingly interested in how to follow up a patient over time. Is it enough to see a patient once or a few times? How do we fare 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 such a tool, the Map of Hierarchy, which was first delineated in Dr Paul Herscu’s book Stramonium: With an Introduction to Analysis Using Cycles & Segments (Amherst, MA: New England School of Homeopathy Press; 1996).
One of the things I have most loved about practice is the long arc of treating an infant or a small child and watching him or her develop over time. In many ways, this has mirrored my own evolution as a mother, first of little ones and now of 3 college-aged kids. With good naturopathic care and homeopathic prescribing, a person should reach his or her optimal level of health, such that his or her genetic potential has more of a chance of being realized. We all like overnight miracles, for example the patient who makes great strides in a few short months either from a brilliant prescription or more commonly from a joint effort by physician and patient and the healing power of nature. But with children, accomplishments can be both easier and more difficult. Lifestyle changes may or may not be relevant, and compliance may or may not be forthcoming. In the case of patients with autism, 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, because it has wide application for pediatric cases but also is relevant to all patients.
Perhaps more than any patient group, those on the autistic spectrum give us the chance to observe how homeopathy affects a patient over time. It is an area in practice where we can all use guidance in terms of long-term follow-up care.
Little Charlie was a 4-year-old towhead locked away in a world of his own when he was first seen in the office. With their son having no language skills to speak of, no self-help abilities, and seemingly no interest in interfacing with the world around him, his parents arrived at my clinic feeling desperate. They had implemented the Defeat Autism Now protocol; they had committed a small fortune and endless hours to an in-home Applied Behavioral Analysis program, on top of a state-of-the-art early intervention and top-notch preschool programming. Unlike other children on the autistic spectrum, Charlie seemed almost unresponsive and had 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 faraway 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? In the ensuing years, I have seen children with autism come running back into this world, although 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 child with autism is different, although there are often shared symptoms. For the homeopath, it is in the forest of varied presentations that we find the symptoms and particular characteristics on which to prescribe.
Charlie seemed 100% nonresponsive to sound and to touch. He sat in a lump most of the day, while others did things with him and for him. That said, he was a robust-looking child and ate 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 2 daughters were alive and well. He was a perfect baby, his mother recalls, except that 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 is not right. Babies should cry, should be demanding at least on occasion, and should make their physical and emotional needs known. Many kids who are diagnosed as having 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 3 thinks there is a problem, there usually is! It is known now that, the earlier that interventions take place, the better it is for any child on the autistic spectrum. As the rise in autism incidence occurs, all parents and the physicians 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, from top to bottom. He was chronically constipated and 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 Defeat Autism Now physicians. Charlie often had a runny nose, which seemed worse during hay fever season with regard to congestion.
When most homeopaths hear “big fat kid, sweaty head, chronic runny nose, constipation, and a desire for eggs,” they think, aha! It must be a patient who needs Calcarea carbonica! However, here is where the error is made and why.
Take a look at the Map of Hierarchy:
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 individuals with all sorts of complaints, but who are basically oriented to the world, mentally and emotionally, in more typical ranges. We can see a person who is depressed needing Natrum muriaticum or a person who is anxious needing the remedy Phosphorus, but the level and intensity of emotional and mental issues are generally worse as we move toward the right on this map. As we move to the right, we can see remedies that address deeper pathologic conditions. Relevant to Charlie’s case, all 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 he or she is a bit manic, self-absorbed, filled with ideas, somewhat crazed, or suffering with ulcerative colitis; as the patient gets better, healthier, and more balanced, we can see that he or she moves toward the left on this map, perhaps needing a remedy like Medorrhinum. Over time (perhaps years) as the patient becomes more and more healthy, he or she may need a remedy like Sulphur. As we observe a patient over time, if he or she starts out all the way on the right, you would expect movement toward the left. More on this is given a bit further on.
It is 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 issue 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 the expectation that we could bring Charlie out of his world and into ours.
I made sure to spend adequate time with his parents, preparing them and talking about what I had seen that remedy do with other similar patients. 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 (the next phase he would go through) would include some challenging behaviors. In Charlie’s case, I figured it was better that he should be unpleasant than not be there at all.
Indeed, at our 2-month follow-up visit, Charlie came in and was clearly different. He was running around like he had a train to catch; over and over, he picked up blocks and put them in the bucket, dumped them out, and started again. He ran back and forth to his mother with blocks. There was still no eye contact, no language, no real self-help skills. However, he had woken up; he had come into the world and had begun to interact, mostly with the materials around him, strongly preferring objects to people. He was positively obsessed with whatever he was doing, going over and over and over again to whatever caught his eye. He was doing some stimming, holding the object du jour a bit out in front of him and twisting his wrist this way and that. His parents were torn; on the one hand, they knew this was the right direction, but on the other, he was much more difficult to control. I personally was elated! Charlie was waking up! I also knew from experience that all the treatments and supportive approaches they had tried to no avail in the past would now be much more effective. I encouraged them to carry on in their efforts with diet and behavioral approaches with renewed hope and dedication.
In the course of that year, Charlie had 3 doses of Opium in ascending potency, and then one day at an office visit, it became clear that he needed a different remedy. Although he was 5 years old now, his behaviors were closer to those of a 2- or 3-year-old. That is because he had never done any of those things before, such as parallel play, repeated questions, and annoying his sisters. His speech had come along, with a big vocabulary. His accuracy with pronouns was poor, he often spoke in lines from favorite videos and songs, and he did not initiate dialogue. However, he could name objects and get across basic bodily needs and some rudiments of emotional expression.
Charlie also started to get sick more. He seemed to catch every cold his sisters brought home, unlike during his earlier years. With each infection, he developed swollen submaxillary glands that remained even when he was no longer ill. His repetitive actions and childish ways (in homeopathic repertory language, we use “childish” to describe behavior that is less mature than expected for the age of a patient), along with his chronically swollen glands, pointed me to the remedy Baryta carbonica, and I was happy to see him moving, albeit slowly, toward the left on the Map of Hierarchy. I anticipated that this remedy would help him to be less hyperfocused and more relational. I also knew that, if a child enters into the world from an isolated autistic state at the age of 4, 5, or 6 years, the child often has a serious deficit in his or her ability to relate to others and to be socially appropriate. I often have to remind parents that any steps into the world are good and that we can work with behavioral issues that arise.
Charlie gave us many issues to work with, from pushing and grabbing to hitting and biting. His one-on-one aid at school had a singular purpose to help Charlie learn to keep his hands to himself. As he came out of his shell, he seemed to have a lot of needs, and they could not be met fast enough. His sixth year was spent working first on his growing ability to talk rather than use physical urges to get what he wanted and, second, to toilet train. He managed to graduate from kindergarten that year, well on his way to both goals.
We had a hiatus of 2 years without a visit because of other issues in the family, so when I saw Charlie, a big 8-year-old who bounded into my office and gave me a big hug, I was happy and a little overwhelmed by his exuberance. In the intervening years, we had worked long distance through a colleague, and I had continued to recommend the Baryta carbonica, but it was clear he no longer needed that remedy. He had continued to move to the left on the Map of Hierarchy as though he had spread the map out on his lap and decided where to go.
Now he was about to begin the third grade, a strong reader and capable math student. He was still socially awkward, did not pick up on all the social cues, and had personal space issues, often standing too close or coming in too fast to another person’s space. However, he was loving and gregarious, helpful, and able to do most of the activities you would expect from an 8-year-old: he could dress and feed himself, put his laundry in a basket, complete basic homework assignments with support, and follow along in an age-appropriate movie or storybook. He still hyperfocused on various subject areas but now seemed to fit the word “quirky” more than any other. Like many kids, he was fascinated by trucks and building equipment and had become adept at LEGOs. His seasonal allergies had become year-round, making his mother wonder if perhaps it was allergy to dust or cat dander. He was basically healthy, still robust looking. He was no longer violent in any way, did not manifest the acute infections that had plagued him a few years back, and seemed much more typical in affect. He was still a hot kid, was very thirsty, and messy to the hilt. Any room he played in looked like a tornado had just whipped by. I asked if he still loved his eggs, and he looked at his mom; his mom looked at him, and they both shook their heads with a resounding NO! Somewhere along the line, on that Map of Hierarchy, he had lost that desire. At this point, what seemed to limit him most were his exuberance (actually a lovely quality that needed to be tempered to an appropriate expression for the setting) and his ongoing social challenges.
In a warm and thirsty kid who is messy and dislikes eggs, most homeopaths would correctly prescribe Sulphur. Charlie has taken Sulphur a few times a year over the past 2 years, when his allergies kick up or when he hits a social bump in the road. I expect he will need this and closely related remedies for a long time to come and am eager to treat him in the coming years. I imagine that the teenage years, with their onslaught of hormones, will be a particularly challenging time for him. I look forward to treating him into adulthood and supporting his and his family’s efforts.
Being privy to the lives of our patients, caring for a patient or a family over years and decades, is one of the greatest rewards of being a physician. With a simple tool like the Map of Hierarchy, which reflects a philosophical understanding, we can see that we are moving in the right direction with a patient. In treating patients with complex pathologic conditions or with overlapping diagnoses, it is helpful to have some guideposts along the way.
Amy Rothenberg, ND is author of The A Cappella Singer Who Lost Her Voice & Other Stories From Natural Medicine (New Delhi, India: B. Jain Publishers; 2011) (see www.amyrothenberg.com for ordering information). For details about the New England School of Homeopathy’s new class starting in Boston, Massachusetts, this fall, see www.nesh.com. Dr Rothenberg coteaches the New England School of Homeopathy with her longtime collaborator, Paul Herscu, ND. Clinical classes are ongoing, as well as mentorships for those who complete the 2-year class. For information about Dr Rothenberg’s practice in Enfield, Connecticut, see www.nhcmed.com.