ADHD? Then pay attention

Attention Deficit Hyperactivity Disorder (ADHD) is being increasingly misdiagnosed, says Dr Das Pillay, a leading Durban Paediatrician who specialises in childhood ADHD. Even more worrying, he claims that Ritalin, a central nervous stimulant often used to treat symptoms of ADHD, is being over-prescribed.

Michael is a good example of alternative treatment. A confident eight-year-old boy, wise beyond his years, he’s keen to impress me with his knowledge of Greek mythology telling me tales of Zeus, while his mother, Nadia, prepares coffee for our interview. He appears to be a normal, bubbly boy, brimming with confidence. As his mother joins us, Michael is whisked off for ice-cream with his father and older brother.

“Last year Michael was diagnosed with ADHD and mild Tourette’s Syndrome which is a neurological disorder,” explained Nadia. “He is perfectly normal, but needs extra stimulation otherwise he gets bored and anxious, leading to restlessness.

“He attends a top private school in Durban, but had a teacher who did not understand or know how to deal with him last year. This left him extremely stressed which aggravates ADHD and less willing to perform in the classroom academically, despite being a bright child. As a result, we were referred to an occupational therapist who came up with a new diagnosis, then to an educational psychologist who felt that he had some other condition. As the complaints from his teacher grew, we were eventually advised by a paediatrician to put him onto Ritalin then a host of other drugs, which altered his personality dramatically.

“His teacher welcomed his demure state, even though it was not him. He had a meltdown every single day after school, which is when we decided to stop the medication and take him out of school two months before the end of the school year.

“We met Dr Pillay twice who recommended we try physiotherapy to strengthen Michael’s neck muscles which we did until he began school this year,” explains Nadia.

Today, barely two months into the new year, Michael has made a huge turnaround – without medical intervention.

“He is thriving, thanks to his new teacher who is experienced in dealing with ADHD children and so adapted Michael’s desk and amended her approach to fit in with his needs. He is not on any medication and his writing has improved within the first month which is remarkable.

“He loves his teacher, and so feels secure and wants to perform to his best ability, and this has made all the difference,” says Nadia, adding that they also changed Michael’s diet, including removing his beloved apple juice.

“A glass of apple juice contains the equivalent of 10 teaspoons of sugar, and he would guzzle up to a litre per day, which we thought was healthy until a paediatrician pointed out the sugar content last year. I firmly believe that the approach of the teacher along with a change in his diet has contributed to his progress,” explains Nadia.

Dr Pillay though, takes the debate a step further, and puts the misdiagnosis of ADHD down to the lack of tolerance to our multi-cultural society, particularly in private schools.

“I think one of the reasons ADHD can be misdiagnosed, and we definitely see more Indian children being referred for things like occupational therapy and ADHD observation than others, is because of a lack of understanding of children across the racial divide from teachers. Indian children for example are often closer to their parents with strong family values and less open to taking risks. As a result they can be perceived to be emotionally immature.

“There is also a very high expectation to perform in private schools and the intolerance can be higher. The demand on a teacher to produce results is also very high and therefore if a child is not performing to their expectation, the quick fix is to refer them and often ADHD or Ritalin is the answer despite inadequate assessment,” explains Pillay. Instead, Pillay says, parents should be seeking out other options first before settling for stimulant drugs for their ADHD child.

“Let me make it clear. Ritalin is a fantastic drug for the right patient. The problem is that there is an over-use of the drug because children are not being appropriately diagnosed. As one of the few experts who specialise in ADHD and neurodevelopment, I prefer to look at things like behaviour modification, other chronic conditions, low muscle tone etc and will, as a last resort, prescribe Ritalin only if absolutely necessary, not as a first choice which is the mistake that is being made by many doctors today.”

Top Durban education psychologist Felicity Tonkinson believes that team approach to observing a child is crucial before opting for the Ritalin route.

“The input from the teacher and the way a child with ADHD or any other condition is managed in a classroom is very important. I do think that ADHD or Ritalin can sometimes be an impulse referral and this should be avoided. Generally there must be a home visit, and a classroom observation of the child before proper diagnosis can be made.”

With a growing generation of demanding children who have become addicted to indoor play and less outdoor activity, the results over the past few years point to an alarming rise in the number of children being referred to occupational therapists and other experts, leaving parents confused and uncertain as to which route to take.

Ballito-based Cheryl Koening is a teacher with more than 30 years’ experience who now spends her time as SA’s “super nanny and behavioural consultant” and agrees that parents should explore other options before turning to Ritalin.

“Professionally I agree that in certain cases children do need and respond well to Ritalin and other similar stimulants. But I feel it is often over-prescribed without other options being considered. In my own experience, I have found that although it is a more difficult and time- consuming option, many children with learning difficulties can benefit from a more holistic approach, ie a change in diet, better management of behaviour, less screen activity and training for parents to manage their child,” she says.

While the debate on whether or not to go down the Ritalin route will continue for a long time, experts all agree that the key to a child with ADHD is not a quick-fix solution. It involves co-operation and partnership between the school, the parents and the professionals involved in diagnosing and treatment.

The trick, though, is ensuring the right diagnosis is made before treatments starts.