Rethinking Ritalin

Is Ritalin a solution for your child’s behaviour or a dangerous substitute for better parenting?
By Glynis Horning

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A mother describes what is becoming an increasingly common scenario in homes across South Africa and the western world. “My son was in Grade 1 when the teacher called me in,” says Lynne Visagie of Johannesburg. “She said he had concentration issues and couldn’t focus to finish work, he was getting bored and walking about disrupting the class.” Lynne immediately braced herself for the three-letter diagnosis currently handed down to an estimated one in 10 children: ADD, or attention deficit disorder. Then when an educational psychologist confirmed it, she braced herself again for the most commonly prescribed solution: Ritalin. “Today every other child seems to be on it,” Lynne sighs. “But everything I’d heard made me totally against it. I was afraid and confused.”
 
Like many parents, Lynne was reluctant to medicate her child with a drug at the centre of considerable controversy, and for a condition that is relatively new and not clearly understood. “ADD has been around some 60 years,” says Terry Wilke, educational psychologist and former director of the Attention Deficit and Hyperactivity Support Group of Southern Africa (Adhasa). It was first diagnosed as minimal brain dysfunction, then brain damage. “These children were seen as naughty troublemakers, and beaten in class or kicked out of school.” Around the 1980s, ADD was diagnosed as a separate disorder, and today the favoured term is ADHD, although you can have attention deficit (concentration problems) without hyperactivity (overactive behaviour), or with other conditions such as learning problems, obsessive compulsive disorder, bipolar disorder and depression.
 
While the formal definition may have helped end the punishment of many children, it has also created a label some consider stigmatising. And it’s now so liberally applied that it’s been estimated that a million children in the US alone may have been falsely diagnosed.
 
“The crux of the controversy is that there is still no single definitive biological, scientific test for ADHD,” says Lynne, who today runs the national office of Adhasa in Randburg. This has prompted US educator and author of Walking Targets (CreateSpace), Beverly Eakman, to protest that “children are being forced to take a drug that is stronger than cocaine for a disease that is yet to be proven”. And Dr Mary Ann Block, head of the (anti-psychiatry) Citizens Commission on Human Rights and author of No More Ritalin (Block Systems), has asked: “If there is no valid test; no data proving ADHD is a brain dysfunction, why in the world are millions of children being labelled with ADHD and prescribed these drugs?” The answer that they have come up with is that it is an attempt by certain teachers and sometimes parents to control “natural childhood behaviour”, which they are unwilling or incapable of coping with, and a conspiracy by pharmaceutical companies, for which Ritalin and similar medications are a multi-million dollar industry. But what are the facts?
 
Exploring the causes
 
There may be no professional agreement on the cause of ADHD, yet most doctors and psychologists say studies suggest a mix of factors, from genetics to smoking and drinking during pregnancy, food additives or dietary deficiencies, brain injury, and differences in the way children’s brains are formed or deal with neurotransmitters. “Specialised techniques indicate that ADHD is caused by insufficient levels of the neurotransmitter dopamine in the areas that control focus, cognitive planning and executive function, leading to distractibility, poor planning and organising and impulsive behaviour,” says Dr Johan Erasmus, a Pretoria-based developmental paediatrician with a special interest in ADHD.
 
Neuroimaging has shown differences in the thickness of these regions of the cortex with ADHD children, “but the clinical implications of these changes on ADHD are still not clear,” he says. “The problem with conditions of the brain is that, unlike the rest of the body, we cannot take biopsies to see what is wrong. We need to rely on indirect methods, which make diagnoses open to interpretation.” Theories for such differences therefore vary widely. Thom Hartmann, author of Complete Guide to ADHD (Underwood books), suggests that ADHD is an evolutionary adaptation, a throwback to hunter characteristics. But diet, lifestyle, family and personality are now all thought to play a part, and most professionals working with ADHD say these should be attended to before turning to medication.
 
The Ritalin dilemma
 
Methylphenidate, distributed as Ritalin or Concerta, increases or “stimulates” the dopamine levels that are too low, restoring focus, and functional and impulse control, says Erasmus. “It’s a stimulant, but it calms an overactive brain, so it works in children with ADHD if properly prescribed and supervised,” adds Wilke. “Sadly this isn’t always the case.”
 
“The dangers of medicating children who don’t need it into submission are quite tragic, and there are parents putting them on Ritalin who don’t have an option,” says Durban clinical psychologist Robin Vanderplank, a regional coordinator for Adhasa.
 
Lynne was one. “My son’s school told me unless I put him on Ritalin they wouldn’t take him back. I told them, ‘You’re the teachers, and you should be able to handle him without resorting to drugs.’ Then I changed schools and started other treatments.”
 
“Ritalin can have an important role in managing ADHD, but it’s only number 10 on the list of things to try, including diet and exercise,” says Vanderplank (see “managing ADHD”).
 
Lynne passionately agrees. She put her son on a low-GI diet with omega and vitamin supplements and minimal sugar, and encouraged him to swim competitively and cycle. “He got super-fit and his focus improved, but not enough to complete tasks,” she says ruefully. When academic pressures mounted at high school, she finally agreed to try Ritalin. “It was amazing from the get-go – my boy listened, his marks improved, he blossomed. I felt guilty for not trying it earlier.”
 
But side-effects slowly set in. “He’d get emotional when the Ritalin wore off, then one morning he came in from a bike ride with serious heart palpitations.” She rushed him to a cardiologist and has since learnt that this is a rare side-effect of Ritalin, and children predisposed to heart problems should not take it.
 
Today Lynne’s son is 16 and off medication. “He still eats well, takes supplements and exercises, but he’s up and down again with the ADD.” She has the following advice for parents who call Adhasa for help. “Bottom line is that it’s a personal decision,” she says. “But I tell them Ritalin works. If your child is properly diagnosed and monitored for side-effects, go for it. I’ve seen a bad side, but I’ve also seen it can be a life-saver for some children; improving their behaviour, helping them socially and academically, and giving them the confidence to fly.”
 
 
Could your child have ADHD?
 
It’s natural for children to be inattentive, hyperactive and impulsive at times, but if several of the following symptoms are severe and persist, affecting your child’s progress and family life, Adhasa advises professional assessment:
 
  • unable to concentrate at school or read for more than a few minutes,
  • fidgety,
  • often sick,
  • generally disorganised,
  • easily frustrated,
  • struggles with social interaction, and
  • under-achieves.
 
Get professional diagnosis to eliminate other explanations:
 
  • parental conflict, divorce or separation,
  • abuse or bullying,
  • uncontrolled asthma or other allergies,
  • hearing or vision problems, and
  • stress or depression.
 
Your GP may suggest a child psychologist, developmental paediatrician, child psychiatrist or child neurologist. For recommendations of specialists experienced in ADHD, contact info@adhasa.co.za or visit adhasa.co.za
 
 
How risky is Ritalin?
 
Ritalin is safe to use and has been in use for more than 60 years, says Dr Johan Erasmus, a developmental paediatrician. “Like any medication it can cause side-effects, but these subside if the medication is stopped or the dose adjusted, and no long-term side-effect has ever been described with it. Most of the negative effects people are concerned about were seen with the injection, which was taken off the market many years ago, not the tablets, which get metabolised.” Ritalin should not be taken by children with:
 
  • high anxiety and agitation,
  • glaucoma,
  • uncontrolled epilepsy, and
  • motor tics or Tourette’s syndrome.
 
Recognised and reported possible side-effects are:
 
  • nervousness,
  • insomnia or drowsiness,
  • hypersensitivity,
  • nausea,
  • loss of appetite,
  • weight loss,
  • dizziness,
  • headaches,
  • abdominal pain,
  • dyskinesia (involuntary movements),
  • blood pressure and pulse changes, and
  • palpitations, tachycardia, angina and cardiac arrhythmia. Ritalin, like many medications, should be used with caution by those with heart defects or abnormal heart rhythms.
 
“Reports of Ritalin encouraging addiction are a myth,” says educational psychologist Terry Wilke. “ADHD children not on Ritalin are more likely to use recreational drugs to ‘self-medicate’.”
 
 
Managing ADHD
 
“At a recent ADHD world conference, every delegate agreed that medication on its own is not enough to manage the effects,” says clinical psychologist Robin Vanderplank. Adhasa supports these steps:
 
exercise
This helps channel natural energy and brings mental focus by releasing feel-good endorphins.
 
drink water
Dehydration impairs concentration; we need six to eight glasses a day.
 
eat healthy foods
Avoid fast foods high in fat and refined carbohydrates, and serve protein and unrefined carbohydrates at each meal. Encourage a child to eat often if concentration slides.
 
diet
A 2011 review by researchers from the Chicago Children’s Memorial Hospital of studies on diets and supplements showed “limited evidence” that these help ADHD, says Durban-based dietician Priya Seetal. But anecdotal accounts abound, and Adhasa advises avoiding colourants, preservatives and other additives, as well as trans-fats and the sugar, caffeine and white flour some suspect cause spikes and dips in blood sugar levels. Adhasa also advocates professional testing for food sensitivities.
 
reduce stress
“This is a major contributor to ADHD, because to cope with increased stress levels we use up vitamins and minerals meant for our other important functions,” says Vanderplank.
 
take supplements
Our bodies can’t make essential fatty acids, vitamins and minerals. We get these from food, and some studies suggest today’s food is less nutritious because of soil depletion from poor agricultural practices. Give a quality omega oil supplement and multivitamin.
 
keep a calm home
“No one can think clearly and work things out when angry or upset,” says Vanderplank. “Don’t shout, rather say ‘let’s talk about this’.” Also, make sure children get enough sleep.
 
encourage emotional growth
“Try to see things from your child’s point of view,” Vanderplank urges.
 
respond differently
“Those with ADHD have challenges and opportunities on a different scale to ordinary people,” says Vanderplank. “They’re among our brightest and most innovative members of society,” adds Johannesburg psychologist Anita Decaires-Wagner. Work with professionals to learn what the unique problems are that your child needs to sort out. Explore behavioural therapy, which uses positive reinforcement to help them learn to control their impulsivity.
 
use medication wisely
“Ritalin may be crucial at times,” says Vanderplank, “but unless a child is in danger of abuse from frustrated parents, it should be a last resort.” Dr Johan Erasmus, a developmental paediatrician says, “If all other interventions don’t improve the child’s quality of life, medication must be considered to prevent the serious long-term consequences of inadequately treated ADHD. With it, many relationships and careers have been saved.” A study by Rodrigo Escobar, a doctor and medical researcher in Madrid, showed that the quality of life of people with untreated ADHD is much poorer than that of people with untreated asthma. “But we don’t have a problem treating asthma, even with a medication that has side-effects way more dangerous and that can be long-lasting.” It’s safe if well-controlled, he adds.

Comments

Anonymous wrote 1 year 3 weeks ago

Hi. My son, who is a friendly well-mannered and happy 7 year old, has been referred to a paed by his teacher because he has focus and concentration problems. He is not hyperactive or presenting any behavioural problems. The paed that I was referred to has prescribed Ritalin, which I am very nervous about. I sometimes wonder who's agenda the teachers push. Being only in the first 6 months of the school year, he has not been given the time to adjust. She wants to know if I was prescribed the Ritalin and when I am going to start giving it to my son as he is not focusing. The decision on whether I should or should not has me feeling stressed as I want to do right by my son and worry that I could be failing him, even though I only have his best interests at heart.

Anonymous wrote 2 years 7 weeks ago

Good day. I don't know which way to turn. My 11-year-old son has started to struggle in class and has been for an evaluation where we we're told he is performing below his level. I'm now feeling pressured by his teacher to put him on medication. We decided to wait it out an extra term to see if he will improve on his own but he unfortunately came home with the same poor results. He often cannot remember simple instructions and has a very lazy nature. His teacher has said his brain "goes missing" in class and he can see my son is just not with them. He doesn't complete work or his work is very untidy and rushed. Is 11 not too old for ADD to only now be showing its head? And what sort of price range do these drugs come in?

admin wrote 2 years 7 weeks ago

A psychologist or psychiatrist is best to answer your questions about about your son's diagnosis. Medication varies in cost, but may be covered by your medical aid.

Anonymous wrote 2 years 12 weeks ago

Desperate warning: Before you give your child medication for ADHD, have a QEEG test done. My daughter had ADHD symptoms, but it turns out that she had high delta high beta brainwave activity. She has above average intelligence, but low energy in her brain. She was so anxious that if anyone had prescribed her the usual meds, her brain would have gone into an epileptic state. Please get all the information before saying yes to medication – it is your right as a parent to decide.

Anonymous wrote 2 years 39 weeks ago

Please advise me of where to go now. My son is 8 and has been on Concerta 27mg for about 2 months. He was doing so well at school; at home he was calmer than usual. All in all I could see a huge difference. Over the past two weeks he has started to repeatedly clear his throat, every couple of minutes. The doctor says it's more than likely a 'vocal tic' caused by the Concerta and that we just need to change the medication to possibly Adderall. I did some research and have read that Adderell may also bring out underlying tics. I feel that I need a second opinion. What kind of specialist can help? I am so scared that my son will have to live with these 'tics' caused from the medication.

admin wrote 2 years 39 weeks ago

We recommend that you ask your doctor for a referal to a specialist or get a second opinion from another family doctor. You could also ask your child's school for any recommendations. They often work closely with occupational therapists, who in turn are able to refer you to the right doctor for your child's needs. All the best!

Teacher Bee wrote 3 years 26 weeks ago

My son is 6 years old and has a CVT (Chronic Vocal Tic), borderline Tourette's. His concentration has never been great but as the workload has increased, it has gotten worse as well as his relationships with his peers. Being a teacher I have seen how Ritalin can make the world of difference to a child. After looking at his diet, trying omegas etc, I have decided to put him on Ritalin and I can already see on the second day of taking it how his world has changed! As parents we have heavy hearts, but as a mom and a teacher, I know it is the best thing for him. For every three months you leave it, they can fall behind by almost a year.

Anonymous wrote 3 years 39 weeks ago

With much reluctance and a very sore heart we started our son on Concerta when he was nearly 7. The side effects were awful and I was close to taking him off it many times. However, after adjusting the dosage and switching to Ritalin LA the side effects were minimised. We try to follow an integrative approach, using supplements, exercise and adjusting his diet. My son has gone from a sad, lonely little boy with not much self-esteem to a confident, diligent and happy boy. I still doubt whether we are doing the right thing but I realised that in the absence of the meds he suffered constant ridicule. It's about him, not me. 

Anonymous wrote 3 years 48 weeks ago

Wow, what a good article. And very diplomatic look at drugs vs no drugs. I’m in the situation now, where it feels like teachers, remedial teachers and aftercare carers are all pushing me to place my 7 year old son on medication. Not one of them suggested looking at his diet, exercise or supplements. They just want a quick fix. They are all huffing at me when I tell them that Ritalin will be our last resort. Who can I take him to in Cape Town for a proper assessment as I think he has ADD not ADHD?

admin wrote 3 years 48 weeks ago

We recommend that you contact Adhasa, who are the leading support group for ADD and ADHD in the country. Email info@adhasa.co.za or visit their website.

Lusanda wrote 3 years 52 weeks ago

I have a 7 year old daughter who was diagnosed with ADHD in Jan 2013 and she's also farsighted, so she wears a very high prescription lens. She only started wearing glasses when she was almost 4. She also began to do educational and occupational therapy for 2 and a half yrs. Then after the diagnosis this year she began with Ritalin. I was not happy with the side effects such as. She's very gentle in nature but when she was on the pill she would get a bit aggressive towards her younger sister. She also changed a bit and I felt she was losing her personality. Then her paed decided to give her the slow release capsule. She used it for 5 months before I decided to take her of Ritalin. I felt like I was losing my baby; she looked like a depressed child. I've decided to put the whole family on a low GI diet. She's doing very well, her teacher hasn't complained at all and I'm very happy to have her personality back. Any advice for me?

admin wrote 3 years 51 weeks ago

Hi Lusanda. If you are happy that your child is healthy and doing well at school, it would seem that you have made the right choices for her. If you would like to speak to people about dealing with ADHD, we recommend Adhasa: www.adhasa.co.za

KM wrote 4 years 14 weeks ago

to Anonymous parent of 7 year old: I realise this is some time ago, but please take your son for a Sensory Integration Assessment with an occupational therapist. ADD and Sensory Processing Disorder (SPD) are look-alike disorders, and if he has SPD, occupational therapy can do a LOT to help him, without needing to consider medication.

Anonymous wrote 4 years 48 weeks ago

My almost 7 year old son (next month) has not been diagnosed as being ADHD, however the school and child psychologist is telling us to put him on Ritalin to help him focus and concentrate in a class environment. He is absolutely fine on a one-on-one basis and in a small group; however, when he is left to do the work unattended he often does not complete the tasks and is struggling to focus and sometimes disrups other children. My husband and I are totally against putting him on meds because of the side effects. Are we being selfish with this decision as the Ritalin could actually help him or are we correct with our decision? If you can offer some advice in this regard I would really appreciate it, thank you.

admin wrote 4 years 48 weeks ago

Hi. We cannot give medical advice, but we recommend you chat to Leila Benelli who runs informative workshops and who has done extensive research on this topic:
benelli.leila@gmail.com
0780904829

David Melvill wrote 5 years 7 weeks ago

Could you e-mail me this article please?

Tx my wife is a teacher and she would like to make this info known to others.

Tx David

admin wrote 5 years 7 weeks ago

Hi David. Thanks for your interest in this very important issue. Our articles are protected by copyright, however, so please direct people to our website to read the article. An easy way to do this is to copy the url for the article from the address bar and send the link to a friend or post it on social media channels such as Facebook and Twitter.

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