And how sure can you be that calming him down with Ritalin is the right thing to do?
By YVONNE BEYERS
Every day it becomes more obvious that your child is not like his friends. He gets the shakes from too much pent-up energy, becomes unruly when he should be concentrating, does impulsive and dangerous things and has been hurt so often his tiny body is black and blue.
You're sick with worry. Is your child suffering from something serious? How do you distinguish between natural boisterousness and a condition that plays havoc with your child's thoughts? And if he has attention deficit hyperactivity disorder, is Ritalin the answer? What should you do if medicine does not offer the relief for which you and your child so desperately yearn?
'We didn't realise there was a serious problem'
Sitting in a Cape Town coffee shop, Judith* remembers the first time she had to face the possibility her nine-year-old son, Peter*, suffered from attention deficit disorder. Seven at the time and in Grade 2 he suddenly burst into his parents' bedroom one night, crying and tugging at them to wake up.
Between sobs he revealed the truth. "Mom, Dad, I've been lying to you. I can't hide it any more. I can't read like the other children."
Judith was astonished. She had no inkling that the clever little boy who recited his homework so confidently in the evenings was petrified of the letters and numbers that resembled ants crawling across the page in unintelligible patterns. "We hadn't noticed he was reciting his lessons by heart. He had always been a busy little bee who struggled to concentrate but we didn't realise there was a serious problem.
"We thought his brother, Daniel*, was the quiet, shy type, and Peter the happy-go-lucky one who acted too impulsively." Judith swallows back her tears.
She blames herself for her youngest having to suffer in silence for so long. Should she not have noticed something a long time ago?
Even when he was tiny Peter rushed into dangerous, life threatening situations.
"Once he took a dive from the balcony. My husband, Simon*, caught him by the ankle at the last moment. Another time he opened the car door, dangling on the outside while we were travelling at 100 km/h on the highway. "He has put his hand on a hot stoveplate countless times even though I regularly warn him against it.
"About two weeks ago he almost got himself killed again. He took a wild dive across the bed and his head went straight into the wall." You sense defeat as her hands lie limply in her lap. "He doesn't know how to stop."
After a long night of listening to their son cry Judith and Simon decided to act. They took him to a child psychologist who diagnosed attention deficit hyperactivity disorder (ADHD).
'Mom, I feel like I want to hurt someone'
What's more, Peter also had a reading and learning problem, often associated with this disorder. The specialist prescribed Ritalin. Peter used it for about 18 months and although it helped him focus and do his homework it made him depressed and aggressive. "From time to time he said in desperation, 'Mom, I feel like I want to hurt someone'."
Eventually Judith could no longer watch the vitality being drained from her child. She heard of a new medicine called Strattera and asked the specialist to prescribe it.
Peter initially took the medicine in the morning but it made him nauseous and took away his appetite, causing the already slender boy to lose several kilograms. "Nowadays he takes his tablet before he goes to bed and it works much better.
"It still makes him nauseous occasionally and every now and again he says to me, 'Mom, what you're giving me is poison! Would you drink this?'
"Do you have any idea what it does to a parent to hear your child say that? It breaks my heart. But what should I do? It's an impossible choice: either Peter takes medicine that sometimes makes him feel sick or he struggles at school and feels inferior to his friends."
Judith has taken the extremely difficult decision to continue giving Peter the medicine for the time being. "He gets anxious in class if he has to read or write something.
"He'll do something naughty just to distract the teacher and the other children. Or act like a clown because he can't meet their expectations. A number of times he has said to me, 'Mom, you're sending me to school just to embarrass me'."
She looks away, talking softly. "He has even hidden in the dog's basket because he's so afraid of going to school. He's so ashamed, he feels stupid..." She has arranged for Peter to study with an expert educational therapist, Dokka Swart.
Reading therapy, combined with the Strattera, helps him to concentrate on his schoolwork - so much so that his marks have improved from one to three out of four this year.
"Peter was always petrified of opening his report. I can't describe the feeling when he brought it home and his marks had improved." He still struggles to read simple sentences and after repeated efforts even a basic word such as "the" sometimes disappears from his reading memory.
"I help him learn by listening and talking," Dokka says. And he does his maths orally rather than in writing. Dokka has no doubt he'll be able to complete his education. "Everything comes right with practice, even if it takes a long time."
Judith recently changed her job to spend more time with Peter and believes the added attention makes a world of difference.
His disorder affects the whole family and his father and brother also have to make sacrifices to help him adjust.
"Recently he wrote - with lots of spelling mistakes - in his notebook, 'Once upon a time there was a little boy and his name was Peter. He thought for a long time about what it was in life that he could do and decided it would be fishing'.
"He sits next to the water, fishing, for hours on end,'' Judith says. ''It's the one thing he can do without losing concentration. He doesn't mind waiting for a fish. He knows what he's waiting for."
Her approach says a lot about Judith as a mother. She still believes even if it takes a long time, even if every word, every line, every social code has to be drilled into his imaginative young mind, it will be well worth the effort.
* Not their real names.
Dreamer to achiever
Unlike Peter, Anneke Rautenbach (18) was a little dreamer who lived in her own world. She was in Grade 1 when specialists diagnosed attention deficit disorder (ADD) without hyperactivity.
Attention deficit disorder. A term that's bandied about to refer to children who either bounce off the walls or live in their own dream world. But when I was small you didn't hear it often.
I was the only girl in my Grade 1 class with the little white pill that had a neat indent in the middle so it could be divided in two. I still remember the bitter taste clinging to my palate. And to this day I struggle to swallow pills.
Every morning an older girl who looked like she was trembling with energy and I had to present ourselves for our mid-morning medicine.
We shared a smile but I didn't really understand what we had in common. At stop signs she would climb out through the car window; I was quiet and happy to sit still as long as there was a window I could look out of.
I sometimes lost my pills. And much else besides. Jerseys, pencil cases, homework and important notes. I underwent a lot of therapy at the time; something called brain gym. In Grade 3 I came first in my class and from then on I was fine.
I can't remember taking Ritalin after Grade 5 or during school holidays. Ever since then I've done really well at school but I struggle if I have to do lots of things at the same time or when I have to manage my time very carefully.
I'll never know whether it was the little white pill or the brain gym that saved me. Or whether I did in fact suffer from attention deficit disorder or was just a dreamy little Afrikaans kid who struggled with language in an English school.
My organisational skills have improved. I'm also a prefect and proud of my blue badge... which reminds me, where did I put that little blue thing?
Anneke's mom, journalist Elmari Rautenbach, writes:
The afternoon my daughter, then six, and I walked out of the Red Cross Children's Hospital in Cape Town I felt shell-shocked.
A few weeks earlier the Grade 1 teacher had called me aside and said my child was rapidly falling behind the rest of the class. She'd suggested we take her to a paediatrician and have her tested for ADD.
Anneke's diagnosis was attention deficit disorder, characterised by a lack of activity. She was the kind of child, he explained, who couldn't distinguish between all the stimuli around her and reacted by escaping to a dream world of her own.
I was still not convinced that medicine was the solution. Anneke started educational therapy and was moved to the front row in class. The teacher spent extra time with her after school. There was progress but very little.
Eventually Alan Wyborn, now head of Somerset College primary school in Somerset West, gave me advice I remember to this day. His answer about Ritalin was simple. "For the right child at the right time it's like turning on a light." It also helped when we put her in a small primary school and started brain gym therapy.
We gave her responsibilities around the house and refrained from taking over when she took too long. Anneke gradually learnt to organise her life. She still makes lists and uses notes for studying.
Attention deficit: the answers to your questions
How do you know your child suffers from ADD or ADHD? Are Ritalin and its cousins fashionable drugs for parents and teachers who're unable to control active children, or are they miracle cures? Will hyperactivity disappear as a result of omega-3 and -6 supplements and dietary adjustments?
If you've been worrying about an unruly child, this guide might help you understand things better. It contains up-to-the-minute information based on the latest international research and studies.
Does your child suffer from ADD or ADHD?
STEP 1: Understand the important background information
A quiet dreamer and an overactive child may suffer from the same problem. This is how it works: according to the latest international findings, attention deficit problems may manifest in three main symptoms. These are:
- Struggling to concentrate or sustain concentration
The main symptoms may occur on their own or in combination so there are basically three groups:
- Attention distraction without hyperactivity (ADD). This usually affects girls who're likely to be quiet dreamers such as Anneke.
- Attention deficit with mainly impulsivity and hyperactivity (ADHD). This usually manifests in very active boys such as Peter.
- A combination type where the child has definite problems with concentration and is also impulsive and hyperactive.
The problems don't end here. On average 40 per cent of children with ADD or ADHD also have reading and learning problems, depression or other problems.
Step 2: Know the symptoms
Answer the questions on:
Does your child:
- Struggle to pay proper attention to finer details and often make unnecessary mistakes doing homework and tasks around the house?
- Struggle to concentrate on one task?
- Often not pay attention or listen when you talk directly to her?
- Struggle to complete school assignments, duties around the house or a series of tasks, even though she understands what she should do and is not rebellious?
- Behave in a disorganised and muddled way?
- Avoid or hate tasks where she has to think a lot?
- Lose things required to complete a task, such as pencils, books and equipment?
- Become easily distracted by things that have nothing to do with the task at hand such as a dog barking, a cellphone ringing or the sound of music?
- Become forgetful when it comes to routine tasks?
If you've answered "yes" to six of these questions your child may be one of the "quiet dreamers". Quiet dreamers are disorganised and often live in a world of their own. They struggle to plan ahead and complete tasks.
Now answer these questions on hyperactivity and impulsivity:
Does your child:
- Forever fidget or have constantly busy hands or feet? Struggle to remain seated in the classroom?
- Run around, climb and clamber more than other children?
- Struggle to take part in any activity without screaming or talking at the top of his voice?
- Find it difficult to remain silent or talk softly while playing or doing something?
- Act as though he is being propelled by a battery?
- Talk incessantly?
- Spontaneously give answers before questions have been asked?
- Struggle to wait his turn or take turns at all?
- Often interrupt conversations or games by beginning to talk or forcing himself on others?
If you've answered "yes" to six of these questions your child may suffer from attention deficit disorder with hyperactivity and impulsivity. These children often pose a danger to themselves because they act so impulsively. (The last three questions refer to impulsivity.)
If you've answered "yes" to the same number of questions in each section your child's lack of concentration and hyperactivity are equally prominent. He probably fidgets constantly and does everything except what he's supposed to be doing.
Six "yes" answers or if you are in doubt mean you should take your child to a specialist rather than ignore the condition.
If you're concerned but have answered "no" to most questions your child is probably an introverted quiet type.
Step 3: Help the specialists
There is no such thing as a single or simple test for ADD or ADHD. When you decide to see specialists - who should be a child psychiatrist or paediatrician in collaboration with a clinical psychologist - they should evaluate and examine your child in your presence.
Attention deficit disorder is complex and the diagnosis is based on a specific and thorough medical examination and evaluation. ADD and ADHD are about chemical imbalances in the brain that have to be adjusted. The complex diagnosis cannot be made by a clinical psychologist or teacher alone. Not even general practitioners have the expertise to do so.
- Did the first signs manifest before your child's seventh birthday?
- Have at least six of the symptoms been present for a minimum of six months?
- Are the symptoms visible in at least two places, for example at home and at school?
- Do the symptoms affect your child's school achievements or his interaction with friends or other people?
Step 4: Be more observant
If your child has one of the following problems treatment and teaching methods may be used to help him:
Learning problems. Reading and learning problems and dyslexia are six times more prevalent among children with ADD or ADHD than among other children.
Oppositional defiant disorder and disruptive behaviour disorder. Your child may act destructively, oppose authority, argue a lot with you or his teachers, lose his temper easily, taunt others or refuse to obey rules.
Depression. These children often have violent tantrums. They are also often sad and weepy, don't mix easily with other children, don't want to eat, are derogatory about themselves and often have problems sleeping.
Anxiety. About one third of children with ADD or ADHD also suffer from anxiety.
Tourette's syndrome. About 75 per cent of children with Tourette's also have ADD or ADHD. Tourette's characterised by repetitive, involuntary mannerisms such as a continuous contraction of facial muscles (facial tics) or the sudden utterance of sounds or swearwords.
My child has ADHD/ADD. What now?
What treatment works?
Medicines such as Ritalin aren't the only answer and it's important to know what else can make a real difference.
Omega-3 and -6 supplements can make a difference in up to 40 percent of children. Dietary adjustments help about 20 per cent of children to a degree. Medicine helps 70 to 80 per cent of children with ADD or ADHD. But a child also needs emotional support from parents and a clinical psychologist because the disorder impacts at school, family and social levels.
An educational therapist will also be able to help a child with learning problems. The child requires a set routine to learn to organise his brain and things around him. Parents and the family often have to make great sacrifices to help with this.
There is unequivocal scientific proof that ADD and ADHD are caused by a faulty mechanism in certain parts of the brain. Children with these disorders have limited availability of two neurotransmitters (dopamine and noradrenalin).
The deficiencies occur specifically in the parts of the brain that regulate impulsiveness and concentration. As a result the children struggle to concentrate or control impulsive behaviour.
The medicines help to normalise the levels of those transmitters. They are not used to scramble messages in the brain but to try to make them normal, just like diabetics use insulin injections to supplement their own insufficient insulin levels.
One of the medicines is Ritalin, which helps specifically to restore the dopamine level in the brain. The effect of Ritalin lasts four hours, that of Ritalin LA six to eight hours and that of its cousin Concerta 12 hours. All three contain methylphenidate, which acts as a stimulant.
Strattera was recently approved in South Africa. It is not a stimulant and improves the concentration span. Its effect lasts 24 hours. Some children with a combination of symptoms need more than one medicine.
Tofranol is not a stimulant and can help some children. Some of these medicines may have side effects such as stomach- or headache, lack of appetite and emotional outbursts when the medicine has worn off.
"Medicine is not a cure but an aid. Children with ADD or ADHD will benefit from techniques which help them organise their thoughts and lives," says Dr Adri van der Walt, a Cape Town paediatrician.
Why do we fear Ritalin?
Professor André Venter, national chairman of Panda (Paediatric Neurology and Development Association) and head of paediatrics at the University of the Free State, writes:
Many parents are uncomfortable with the notion that their children require psychiatric medicine to help them get through the school day. They ask, "Don't you suppress your child's naturally boisterous personality by giving him medicine such as Ritalin to make him less active?"
Not to mention the bad publicity Ritalin has garnered over the years - on the one hand because doctors often prescribe it too readily and without sufficient motivation, on the other because it is indeed a controversial substance. It's a stimulant and moreover classified as a schedule 6 drug because it's sometimes abused. It may have a few unpleasant side effects such as loss of appetite and insomnia.
What's more, Ritalin is sometimes sold illegally on school premises because it's a stimulant. It's sometimes used as a rave drug. Obviously Ritalin (and its cousins, such as Concerta) may not be prescribed casually. However, research has shown that children who have had Ritalin prescribed are not more likely to become drug addicts.
The contrary is probably more likely: children with serious ADD or ADHD that remains untreated may become more susceptible to the drug culture at a later stage because they struggle to adapt socially.
One important new reservation about Ritalin is that it is dangerous for some children with latent heart disease. That's why a specialist should evaluate your child and refer him to a cardiologist if necessary.
Obviously one is careful to administer a drug that seems to interfere with a child's brain. But what is worse: the medicine or the anxiety, fear, self-doubt and isolation of someone with ADD or ADHD?
Or even becoming a maladjusted adult if the child's learning problems aren't addressed immediately?
Ritalin, just like any other medicine, should be prescribed with the utmost care. If it doesn't work, or if the side effects are worse than the problem itself, talk to your doctor. But it's not a crime to try to improve your child's life and make it easier.
Update on diet and supplements
Professor CF van der Merwe of the department of gastroenterology at Medunsa believes omega-3 and -6 supplements to be the solution for all children with ADD and ADHD as they helped his own child. New studies reveal these supplements could offer successful treatment for up to 40 per cent of children with ADD or ADHD.
You can give your child the right supplements and fish rich in omega- 3 fatty acids such as anchovies, sardines, mackerel, tuna, trout and salmon, as long as it doesn't come from a tin laden with preservatives. It may take four to six months before a difference is seen.
Studies also show that the elimination of foods containing tartrazine and other preservatives may help 20 to 30 per cent of children. This may yet prove to be a placebo effect and nobody is sure how long the effects last. Reduce preservatives by avoiding or limiting concentrated and fizzy cooldrinks, dessert (jelly in particular), smoked fish and canned vegetables, store-bought biscuits and confectionery, fish fingers, store-bought hamburger patties, margarine, tea and coffee, all food fried in oil, chocolates, sweets, chips, white bread, processed meat and polony.
Also limit your child's intake of sugar and sweets. Rather give him fresh meat, fish and chicken; fresh fruit (especially pears and pawpaw) and vegetables; unrefined carbohydrates such as wholewheat bread; and milk and other dairy products.
Don't be disappointed if this is a short-term solution only. "If this was the solution for all children with ADD or ADHD it would hardly be necessary to prescribe medicine," Dr Adri van der Walt explains.
Find out more:
Question: What are the causes?
Answer: Abnormalities in the brain may be hereditary, caused by a brain injury or fetal alcohol syndrome. ADD and ADHD occurs six times more frequently among boys than among girls and it seems to be transferred especially from father to son. It could be however that many instances in girls are not diagnosed because most girls with the condition are quiet dreamers. Children with fetal alcohol syndrome are brain-damaged because of the mother's alcohol abuse during pregnancy. This may result in various problems including ADD and ADHD.
Question: What percentage of children really need Ritalin?
Answer: If more than two children in a class of 40 (approximately five per cent) use Ritalin, parents should see the warning lights and ask questions. YOU Pulse has discovered that in some schools Ritalin is prescribed to up to a third of the class while only one in 20 children really need it. It's not in the interest of a child without ADD or ADHD to take medicine that affects the level of neurotransmitters.
Question: Will my child amount to anything in life?
Answer: Most children with ADD or ADHD react well to medicine and other treatment and will be able to lead a full life as adults. People with these disorders have many positive traits. They may be:
- Creative and good lateral thinkers - many become excellent researchers
- Inquisitive and true explorers
- Active and energetic
- Enthusiastic, spontaneous and keen to try new things
Question: If it's not ADD/ADHD, what is it?
Answer: It could well be emotional or serious learning problems. Some children are hypersensitive and become fidgety whenever something touches their bodies. Other possibilities include low muscle-tone, slow development, bipolar disorder, a kind of epilepsy or lead poisoning, to name a few. The child might also be growing up in a chaotic household.
Practical tips for parents
What you can do at home to help your child with ADD/ADHD?
Try the dietary adjustments and supplements described elsewhere.
If these do not work and the specialist prescribes medicine make sure your child takes it as prescribed so you will be able to report accurately on improvement and side effect.
Arrange with your child's teachers that he sits in the front row in class.
Teach him to make lists of things to do, pack or take with him.
Make sure there is a specific routine at home.
Eat at regular times and teach your child his homework must be done at specific times.
Give him an alarm clock and put up a year planner and calendar against his wall so he can learn to plan his day and see sport days and music lessons at a glance.
Check if and how he did his homework and make sure all tasks are done.
Don't help him. Allow him to do it himself, even if it takes a long time.
This article was compiled with the assistance of Professor André Venter, Dr Adri van der Walt and many scientific papers. It is an edited version of an article that originally appeared in Pulse magazine in September 2007.