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,
- often sick,
- generally disorganised,
- easily frustrated,
- struggles with social interaction, and
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 firstname.lastname@example.org 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,
- uncontrolled epilepsy, and
- motor tics or Tourette’s syndrome.
Recognised and reported possible side-effects are:
- insomnia or drowsiness,
- loss of appetite,
- weight loss,
- 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’.”
“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:
This helps channel natural energy and brings mental focus by releasing feel-good endorphins.
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.
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.
“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.
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.
“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.