Monthly E-Newsletter November 2007
Mental ,Emotional and Behavioural Disorders in Children AND A Brief Discussion of ADHD
Dr. Mansi Arya
Mental health disorders in children and adolescents are caused by biology, environment, or a combination of the two. Examples of biological factors are genetics, chemical imbalances in the body, and damage to the central nervous system, such as a head injury. Many environmental factors also can affect mental health, including exposure to violence, extreme stress, and the loss of an important person.
Families and communities, working together, can help children and adolescents with mental disorders. A broad range of services is often necessary to meet the needs of these young people and their families.
Below are descriptions of particular mental, emotional, and behavioral disorders that may occur during childhood and adolescence. All can have a serious impact on a child's overall health. Some disorders are more common than others, and conditions range from mild to severe. Often, a child has more than one disorder (U.S. Department of Health and Human Services, 1999).
Young people who experience excessive fear, worry, or uneasiness may have an anxiety disorder. Anxiety disorders are among the most common of childhood disorders. According to one study of 9- to 17-year-olds, as many as 13 of every 100 young people have an anxiety disorder (U.S. Department of Health and Human Services, 1999). Anxiety disorders include:
Phobias, which are unrealistic and overwhelming fears of objects or situations.
Generalized anxiety disorder, which causes children to demonstrate a pattern of excessive, unrealistic worry that cannot be attributed to any recent experience.
Panic disorder, which causes terrifying "panic attacks" that include physical symptoms, such as a rapid heartbeat and dizziness.
Obsessive-compulsive disorder, which causes children to become "trapped" in a pattern of repeated thoughts and behaviors, such as counting or hand washing.
Post-traumatic stress disorder, which causes a pattern of flashbacks and other symptoms and occurs in children who have experienced a psychologically distressing event, such as abuse, being a victim or witness of violence, or exposure to other types of trauma such as wars or natural disasters.
Many people once believed that severe depression did not occur in childhood. Today, experts agree that severe depression can occur at any age. Studies show that two of every 100 children may have major depression, and as many as eight of every 100 adolescents may be affected (National Institutes of Health, 1999). The disorder is marked by changes in:
Emotions—Children often feel sad, cry, or feel worthless.
Motivation—Children lose interest in play activities, or schoolwork declines.
Physical well-being—Children may experience changes in appetite or sleeping patterns and may have vague physical complaints.
Thoughts—Children believe they are ugly, unable to do anything right, or that the world or life is hopeless.
It also is important for parents and caregivers to be aware that some children and adolescents with depression may not value their lives, which can put them at risk for suicide
Children and adolescents who demonstrate exaggerated mood swings that range from extreme highs (excitedness or manic phases) to extreme lows (depression) may have bipolar disorder (sometimes called manic depression). Periods of moderate mood occur in between the extreme highs and lows. During manic phases, children or adolescents may talk nonstop, need very little sleep, and show unusually poor judgment. At the low end of the mood swing, children experience severe depression. Bipolar mood swings can recur throughout life. Adults with bipolar disorder (about one in 100) often experienced their first symptoms during their teenage years (National Institutes of Health, 2001).
Learning Disorders occur in three major categories: reading, mathematics, and written expression. Reading problems generally occur before the age of 7. This is followed usually by problems with spelling and written language expression by the age of 8. Mathematical learning disorders often are not detected until after rote memorization mathematics work has ended, and application of more abstract skills is necessary. These diagnoses are given only after standardized testing in the particular area is significantly below that expected by the child's chronological age, IQ, and educational level.
Difficulties that make it harder for children and adolescents to receive or express information could be a sign of learning disorders. Learning disorders can show up as problems with spoken and written language, coordination, attention, or self-control.
Dyslexia is a specific learning disability that is neurological in origin. It is characterized by difficulties with accurate and / or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction
Young people with conduct disorder usually have little concern for others and repeatedly violate the basic rights of others and the rules of society. Conduct disorder causes children and adolescents to act out their feelings or impulses in destructive ways. The offenses these children and adolescents commit often grow more serious over time. Such offenses may include lying, theft, aggression, truancy, the setting of fires, and vandalism. Those with this disorder are habitually in trouble, either with parents, teachers or peers. Despite presenting a tough image to those around them, they have a low self-esteem. Their frustration tolerance, irritability, temper outbursts and recklessness are hallmarks. Conduct Disorder may lead to adult antisocial personality disorder. Current research has yielded varying estimates of the number of young people with this disorder, ranging from one to four of every 100 children 9 to 17 years of age (U.S. Department of Health and Human Services, 1999).
There are 3 feeding and eating disorders of infancy or early childhood.
1. The first is Pica, in which the child persistently eats non-nutritive substances for at least one month. The behavior must be developmentally inappropriate, and not culturally sanctioned. It appears more frequently in young children than adults.
2.The second disorder is rumination disorder, in which the infant or child repeatedly regurgitates and rechews food, after a period of normal functioning. The symptoms must last for at least one month.
3.The last disorder is feeding disorder of infancy or early childhood, in which there is a feeding disturbance manifested by persistent failure to eat enough food and a significant failure to gain weight or weight loss.
Children or adolescents who are intensely afraid of gaining weight and do not believe that they are underweight may have eating disorders. Eating disorders can be life threatening. Young people with anorexia nervosa, for example, have difficulty maintaining a minimum healthy body weight. Anorexia affects one in every 100 to 200 adolescent girls and a much smaller number of boys (National Institutes of Health, 1999).
Youngsters with bulimia nervosa feel compelled to binge (eat huge amounts of food in one sitting). After a binge, in order to prevent weight gain, they rid their bodies of the food by vomiting, abusing laxatives, taking enemas, or exercising obsessively. Reported rates of bulimia vary from one to three of every 100 young people (National Institutes of Health, 1999).
Children with autism, also called autistic disorder, have problems interacting and communicating with others. Autism may manifest in early infancy, with the infant shying away from the parent's touch, not responding to a parent who returns after an absence, and inappropriate gaze behavior. The Autistic child may fail to meet early language and other developmental milestones. And there can be as much as a 3-year delay between the report of symptoms and the diagnosis, which is usually made at around age five. Autism appears before the third birthday, causing children to act inappropriately, often repeating behaviors over long periods of time. For example, some children bang their heads, rock, or spin objects. Symptoms of autism range from mild to severe. Children with autism may have a very limited awareness of others and are at increased risk for other mental disorders. Studies suggest that autism affects 10 to 12 of every 10,000 children (U.S. Department of Health and Human Services, 1999).
Mental Retardation is based on both IQ and deficits in functioning. It is not a single, simple syndrome, but rather a state of impairment. By definition, to have the label Mental Retardation, the person must have an IQ below 70, and impairments in adaptive functioning in at least two of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety. Finally, the onset must be before age 18. There are 4 levels of Mental Retardation, based on IQ: Mild, with a mental age of 8.5 to 11.0 years; Moderate, with a mental age of 6.0 to 8.5 years; Severe, with a mental age of 3.75 to 6.0 years, and Profound, with a mental age of 0 to 3.75 years
Young people with schizophrenia have psychotic periods that may involve hallucinations, withdrawal from others, and loss of contact with reality. Other symptoms include delusional or disordered thoughts and an inability to experience pleasure. Schizophrenia occurs in about five of every 1,000 children (National Institutes of Health, 1997)
OPPOSITIONAL DEFIANT DISORDER
Oppositional Defiant Disorder (ODD) is a disorder in which children ignore or defy adults' requests and rules. They may be passive, finding ways to annoy others, or active, verbally saying "No". They tend to blame others for their mistakes and difficulties. When asked why they are so defiant, they may say that they are only acting against unreasonable rules. They are different from children with conduct disorders in that they do not violate the rights of others. These behaviors are present at home, but not necessarily in other situations, such as school, or with other adults.
SEPARATION ANXIETY DISORDER
Separation Anxiety Disorder is a disorder that affects children who are afraid to be separated from the main caretakers in their lives, even to go to a friend's house or school. When separated, they are constantly afraid that something horrible will happen to either themselves or to their primary caretaker (they or the caretaker will die, for instance). When the subject of separating is brought up, the child begins to present with somatic symptoms ranging from headaches to nausea and vomiting, with anxiety
Selective Mutism is a disorder in which children may talk at home but due to severe anxiety, are unable to speak in certain social situations. Their anxiety may affect their ability to communicate in other ways as well. For a diagnosis of Selective Mutism to be made the communication problem must last at least one month, without treatment SM can persist for years. Onset is usually quite slow, with children showing inhibited temperaments as infants, often displaying Separation Anxiety through their toddler years. SM is often not diagnosed until the child begins school, and sometimes even later due to a lack of awareness in Pediatricians and other Healthcare workers.
Rett's Disorder is a disorder that is exclusive to females. For the first 6 months of life, development is normal. At that point, they begin to exhibit many of the symptoms of autism, such as stereotyped movements, poor social interaction, and impaired communication. In addition, they also have problems with both expressive and receptive language, psychomotor retardation, and poorly coordinated gait and/or trunk movements, along with decreased head growth. They will, as they mature, however, gain back a degree of positive social interaction
REACTIVE ATTACHMENT DISORDER
Reactive Attachment Disorder is characterized by the breakdown of social ability of a child. It is associated with the failure of the child to bond with a caretaker in infancy or early childhood. This can be caused by many factors, ranging from child neglect to the child being hospitalized for severe medical problems. The children may display either indiscriminate social extroversion as they grow older (treating all people as if they were their best friend) or showing mistrust of nearly everyone.
Stuttering is a disturbance in the fluency and time patterning of speech that is inappropriate for the patient’s age. It may contain sound repetitions, prolongations, interjections, pauses in words, word substitutions to avoid blocking, and audible or silent blocking
ATTENTION DEFICIT HYPERACTIVITY DISORDER
ADD or ADHD, as it is commonly known occurs in up to five of every 100 children (U.S. Department of Health and Human Services, 1999).It affects about 5% of the school going children, and about 60% of the suffering children retain the disorder as adults.* duke med news (Feb. 2002)
Although the medical fraternity is divided over the incidence, the exact criteria of diagnosis and treatment of ADHD, certain pointers are clear. On an average, there are 1 to 3 children who have ADHD in every classroom of thirty students. Three to six more boys are diagnosed than girls. The children may show varying symptoms; from apparently mild symptoms like poor attention span and increased fidgetiness to a more severe social and academic dysfunction along with poor impulse control.
The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) states that ADHD is a developmental disorder that presents during childhood, with at least some symptoms causing impairment before the age of seven. It is characterized by developmentally inappropriate levels of inattention and/or hyperactive-impulsive behavior, with significant impairment occurring in at least two settings
Adults with ADHD are diagnosed under the same criteria, including the stipulation that their symptoms must have been present prior to the age of seven.
The symptoms of ADHD fall into the following two broad categories:
Failure to pay close attention to details or making careless mistakes when doing schoolwork or other activities
Trouble keeping attention focused during play or tasks
Appearing not to listen when spoken to
Failure to follow instructions or finish tasks
Avoiding tasks that require a high amount of mental effort and organization, such as school projects
Frequently losing items required to facilitate tasks or activities, such as school supplies
Procrastination, inability to begin an activity
Difficulties with household activities (cleaning, paying bills, etc.)
Difficulty falling asleep, may be due to too many thoughts at night
Frequent emotional outbursts
Fidgeting with hands or feet or squirming in seat
Leaving seat often, even when inappropriate
Running or climbing at inappropriate times
Difficulty in quiet play
Frequently feeling restless
Answering a question before the speaker has finished
Failure to await one's turn
Interrupting the activities of others at inappropriate times
Impulsive spending, leading to financial difficulties
A positive diagnosis is usually only made if the person has experienced six of the above symptoms for at least three months. Symptoms must appear consistently in varied environments (e.g., not only at home or only at school) and interfere with function.
Since no factors are known to conclusively precipitate ADHD, a lot of research is being done. In this regard, certain genetic, environmental and social factors are seen to be more frequently associated with ADHD than others. Research suggests that ADHD arises from a combination of various genes, many of which affect dopamine transporters. They generally agree that dopamine imbalance is a telling factor in ADHD. Different studies have also found metabolic differences in these children, indicating that an inability to handle certain elements of one's diet might contribute to the development of ADHD, or at least ADHD-like symptoms. For example, in 1990 the English chemist, Neil Ward, showed that children with ADHD lose zinc when exposed to the food dye tartrazine. Some studies suggest that a lack of fatty acids, specifically omega-3 fatty acids can trigger the development of ADHD. It has also been observed that women who smoke while pregnant are more likely to have children with ADHD
Although widely perceived as a childhood disorder, ADHD is now known to have long – term detrimental effects. A long-term study published in May by researchers at Massachusetts General Hospital in Boston found that teenage girls with ADHD were more likely to have mood or anxiety disorders than those without the disorder. About 30 percent of the girls with ADHD were at least mildly depressed, compared with 10 percent of the control group the same percentages were seen in substance abuse.
There are many options available to treat people diagnosed with ADHD. The options with the greatest scientific support include a variety of medications, behavior modification, and educational interventions. The results of a large randomized controlled trial suggested that medication alone is superior to behavioral therapy alone, but that the combination of behavioral therapy and medication has a small additional benefit over medication alone.
One of the first - and sometimes ardently promoted - treatments for Attention Deficit Disorder is stimulant ADHD medications. The ADHD medications most commonly prescribed are Ritalin, Adderall and Concerta. They are found to have a short-term effectiveness of 60 to 80 percent in reducing the symptoms of Attention Deficit Disorder ADD ADHD in school-age children.
For these people, ADHD medications reduce their hyperactivity and improve their ability to focus, work, and learn. The ADHD medications may also improve physical coordination, such as handwriting and ability in sports.
However, there are downsides and side effects to Ritalin, Adderall, Concerta and other ADHD medications. Common side effects are headaches, abdominal pain, nervousness, insomnia, dizziness, cardiac arrhythmia and weight loss. Long-term use has also been linked to abnormalities in brain development similar to those found with Cocaine. Safety and effectiveness has not been established in children under 6 years of age. It is clear that stimulant ADHD medications can be helpful, at least in the short term.
The ADHD medications do not increase knowledge or improve academic skills, though the ADHD medications can help people pay better attention and complete their work. they only control the symptoms instead of addressing the causes of Attention Deficit Disorder.
Apart from mainstream pharmacological treatment, there are other options available. Behavioral therapy is often used as an adjuvant to all treatments. It is shown that it significantly enhances patient response.
EEG biofeedback and nutritional treatments are also known to be effective although not enough scientific data is available to support them
An Alternative to Ritalin: Homeopathy as a Highly Effective Treatment for ADD
The homeopathic approach is growing in popularity as an alternative treatment for hyperactivity in children. Homeopathy is gaining recognition in the conventional field of medicine and has been subject to many clinical trials.
The most common treatment for Attention Deficit Disorder (ADD) in children are Ritalin and Dexedrine, both amphetamines with common side effects such as headaches, appetite loss, insomnia, depression, and growth retardation. Homeopathic approach to ADD has fostered profoundly positive changes in about 80% of the children receiving the treatment without any side effects .
"Clinicians using homeopathy for ADHD have reported good results, but objective evidence has been lacking. Now, a double blind, placebo-controlled study of 43 children with ADHD shows that homeopathy can be effective in treating the disorder. In the study, children afflicted with ADHD were given either a homeopathic treatment or a placebo for ten days, then parents or caregivers rated the children on the amount of ADHD behavior they displayed. Those receiving homeopathic medicines showed significantly less ADHD behavior than those given placebos. When evaluated in a follow-up interview two months after the study's end, 57% of the children showing improvement with homeopathy had continued to improve, even though they had discontinued the homeopathic medicines; twenty-four percent relapsed by the time of the follow-up; and the remaining 19% continued to experience positive results, but only while taking the homeopathic medicines."
The homeopathic medicines found most helpful for ADHD were Stramonium, Cina and Hyoscyamus niger. Stramonium was specifically indicated when children had many fears, or suffered symptoms of post-traumatic stress disorder; children who were physically aggressive benefited most from Cina; and, children with manic or sexualized symptoms responded most favorably to Hyoscyamus niger.
Frequently Indicated Remedies…
Chamomilla: Indicated for those with bad temper, who are very irritable and impatient; who are complaining, frustrated, restless, and thirsty; who are contrary, not knowing what they want; who demand one thing and then want something else. The chamomilla child is fidgety and quiets down ones he has attracted attention. He wants to be carried everywhere, but will whine and scream. He will settle down if carried ,jiggled, or rocked. These children show aversion to being touched with hypersensitivity to pain, feel pain is unbearable, feel that everything is intolerable and can become so hyperactive that he will get exhausted and begin to cry. The child shows dullness of the senses with a diminished power of comprehension, as if they were hard of hearing. All symptoms are worse at night.
Cina: Indicated for children who are cross, contrary, and disobedient with very difficult behavior. These children do not want to be touched or looked at and turn away when approached. Nothing satisfies them for long. They are restless, fidgety and fretful, especially during sleep. They grind their teeth at night and wet the bed, and may have parasites, such as pinworms. Their sleep is restless, accompanied by jerking, frequent swallowing and coughing. They often sleep on their abdomen or the hands or knees (Medorrhinum). They may have an irritated nose causing a constant desire to rub, pick, or bore into it until it bleeds. Their ears can be itchy. They often show twitching of the face muscles and eyelids, and are even inclined to seizures. Their appetite can be ravenous with strong thirst, and craving for sweets. These children often have large bellies.
Hyoscyamus: Indicated for difficult children with poor impulse control, even though engaged in premeditated actions; talk excessively with episodes of mania and rage that might include hitting and screaming, also inclined to depression after manic phase; can be manipulative, lying and violent excitability with fear, delirium, and the delusion of being poisoned ; feelings of abandonment, jealousy, suspicion; fears of dark, dogs, water; delirious; delusions of animals, of being pursued by enemies, as if s/he might be injured by surroundings; sees ghosts ,specters; very animated ,seeming silly and foolish ;smiling and laughing at everything, often inappropriately; talks nonsense; acts out ridiculous gestures like a dancing clown or monkeys, trying to be center of attention, often with sexual overtones; giddy; love to run around naked, can be a totally shameless exhibitionist with bizarre behaviors for shock value, including cursing; tries to embarrass parents; jealous of their siblings ,often may injure them; cannot tolerate being covered up.
Stramonium: Indicated for children who are violent or fearful; who are severely hyperactive, easily terrified, and inclined to violent agitation and fits of rage; and whose speech is loud, fast, and possibly incoherent. These children show feelings of terror and abandonment ;are afraid of the dark, dogs, evil, suffocation and abandonment. They have fears of death; believe she/he is always alone, and are especially afraid to be alone at night, become overly vigilant to combat these fears and become violent if controlled. They often awake screaming; see ghosts, specters, spirits; have a horror of glistening objects; have delusions of animals, of danger; are clinging. They are aggressive; bite, kick, strike; use threatening language; can have seizures or personality change after a head injury, frightful episode , or trauma (especially being chased by dogs
Sulphur: Used for children who are egotistical; try to control feeling with mind; hate being scared; feel as if they are being scorned; have delusions that he has been disgraced; are messy and tattered but think they look fine. These children can be lost in thought, absent-minded, spacy; forgetful, loses things; has visions; full of theories and dreams, loves science fiction;can be a loner with limited social skills; prefers computers , reading, mechanical things
Tarentula Hispania: Indicated for children who are frenzied, are worse with music; act wild and crazy; love to sing and dance; feel as if never enough time; feel as if s/he has been insulted; sense of a stranger in a room. They see faces on closing eyes; have episodes of raving delirium; are mischievous and sneaky; tease and hide; cut things; hurried, always restless.
Tuberculinum: Is indicated for those who revolt against restriction and need to feel free. They always desire and seek change, travel and new experiences; always feel dissatisfied; and feel as if there is never enough time. They are afraid of dogs, cats; have delusions that he can fly, that someone is following him, that he is surrounded by animals; feel everything is strange; are compulsive and uncontrollable; are destructive; throw tantrums; break things; are precocious; and are often malicious.
Lesser Known Remdies…
Arenea Ixabola: Indicated for excessive teasing, especially teasing and manipulating by acting cute; for those who act as a mischievous leader, including others to disobey; and for those who are fascinated with spiders.
Baryta Iodatum: Used for those who are irritable, hurried, restless, and nervous; who have difficulty concentrating; and who have a canine like appetite.
Bufo: Used for those who have difficulty relating well to others; have narrow focus; don’t understand danger; have seizures or autism; have a slow, coarse appearance; can hug or bite you; masturbate or show a premature interest in sex. These children rely on basic instincts and need instant gratification; are upset when not understood; cannot tolerate music or bright objects.
Cannabis Indica: Used for those who feel isolated, disconnected, anguished, terrified, and even sometimes ecstatic. This remedy is indicated for those who feel spacy, confused, and inattentive; have time and space disorientation; fear going insane; feel like everything is a dream with even familiar things which seem strange or unreal (derealization); act as if in a dream or off in space; can’t pay attention for long; are absent minded; can be obsessive-compulsive. There are three common behavioral variations of this remedy: (1) presenting as laughing, giggling, and clowning around; (2) presenting as ethereal and airy; and (3) presenting as brassy, loquacious, and liking to dress up in olden-day clothes.
Crotalus Horridus: Indicated for those who are intense, animated, hurried, restless, and talkative. They have many fears, especially that someone might be following them or that they hear footsteps behind them. They fear being alone, spirits, ghosts, snakes; and can strike out in fits of rage. They resent and blame other children for getting them into trouble, report dreams of hairy spiders.
Kali bromatum: Indicated for restless children, who always have to be doing something, especially with the hands, including activities like throwing.
Lachesis: Indicated for those who are loquacious, agitated and hyperactive, and restless and moody with strong emotions. They may be very jealous of siblings, or even of the same sex parent, and tend to be vengeful, sarcastic and nasty. They can be especially hurtful (and intuitively accurate) with insults; and can have a self-destructive personality, with a marked lack of confidence and a tendency to severe depression, withdrawal, and hopelessness. They hate any kind of physical and behavioral restriction, like tight clothing or being “grounded; and can’t bear authority and run away from home. They tend to self-criticism and irritability; often reproach themselves severely; and may also show aggression which surfaces easily and makes them difficult to live and work with.
Lyssinum: Indicated for those who bite, growl, snarl, scratch and act rabid. They are easily eneaged; angry , but repent quickly ,have remorse. they feel tormented and abandoned ,as if he has suffered some wrong . these children feel as if they have been injured or abused . they often have a history of abuse ,and may be children of violent parents . they strike out at presumed tormentors; and are self destructive , with an impulse to cut his or herself
Scorpion : it is used for children who are violent if provoked or just for the fun of it, for children whose parents fear being harmed by the child ; for children who like conscience and compassion for the suffering of others . these children are detached , like solitude , can attack if bothered ; and are indifferent to pain or pleasure.
THE LINK BETWEEN ADHD and NUTRITION : Some Research Findings
· George Washington university school of medicine study found that hyperactive children who ate a meal high in protein did equally well or better in scroll than normal children
· An oxford study evaluated the effects of fatty acids supplementation in average intelligence children with significant reading and writing disabilities . ADHD symptoms I children receiving essential fatty acids significantly improved over the children in the control group on placebo.
· In 1996 Purdue university researchers found that boys with low blood levels of Omega-3 fatty acids had greater frequency of ADHD
AN OPPOSITE PERSPECTIVE: skepticism towards diagnosis
Many doctors researches and even lay men believe that ADD /ADHD might not be a valid diagnosis at all. In fact, In Dr. Lawrence Diller's excellent book Running on Ritalin, he discusses the way our unbalanced modern life creates circumstances that cause children to seem ADD/ADHD, even when they are not. In the book Driven to Distraction, respected ADD/ADHD researchers Dr. John Ratey and Dr. Edward Hallowell (who is himself ADHD) call ours an "ADDogenic society," because the sort of life we try to live in this age causes everyone to seem distracted and scatterbrained.
We tend to pathologize everything in this age and time. ADHD might not really be a disorder. But in this society, because an ADHD adult or child finds it so much harder to adapt to the demands of work, home, and school, we treat it as a disorder, and that is obviously better than beating the kids for noncompliance--though perhaps only slightly better.
The debate whether ADD is or is not a disorder will probably continue for some time, at least till we find out more about its cause and mechanism. However, it is important to know that some children DO need to be handled skillfully because their learning capacities are different from others. It is also equally important that such children be diagnosed and trained only by skilled professionals.
And above all, parents and teachers need to remember that adequate medical care and positive handling can ensure that an ADHD child blooms into a functional and productive adult.
A-113 , Shivalik , Malviya nagar , New Delhi-17
|Home About Us Publication Articles Cases Consult Guest book News Links PG Study Discussion Newsletter Contact us|