Reading, writing, Ritalin?

2008-12-04 00:00

The introduction of OBE (Outcomes-based Education) in the late nineties multiplied paperwork for teachers, largely because of the need to assess pupils’ progress continuously. In many schools, class sizes also increased. The banning of corporal punishment has allegedly also made it harder for some teachers to maintain discipline, especially in boys’ schools.

A Grade 3 teacher in a former model C junior school in the city confirmed that teachers are indeed under great pressure. “I have had classes as large as 36 which makes teaching very difficult. I hate OBE because of the extra paperwork it creates. But the banning of corporal punishment is the worst. The children know we can’t really discipline them so some of them behave appallingly.”

Under this combined pressure it is suggested that some teachers have turned to the mind-altering stimulant methylphenidate to help with classroom management. Better known by one of its trade names, Ritalin, methylphenidate is prescribed for children with attention deficit hyperactivity disorder (ADHD). It is a Schedule VI drug so the state requires dispensing outlets to keep a register. Ritalin can have a calming effect and enables children to concentrate. It counteracts the main symptoms that can make these children a challenge, possibly a problem, to teach: inattention, impulsivity and hyperactivity.

Having overly active children diagnosed with ADHD and put on a powerful drug to calm them down could sometimes be beneficial to overworked teachers. However, is there truth in the allegation that this is happening?

The short answer is “No”, because teachers cannot prescribe Ritalin (or the other methylphenidate option, Concerta) for their pupils. Because of the nature of the drug, having a child diagnosed with ADHD and put on medication should require a process of thorough medical/psychiatric and psychological assessment. Teachers commonly use a rating scale called a Connors questionnaire to assess a child’s symptoms and recommend professional assessment. The way parents proceed from this point seems to depend on financial means. This is where the long answer, “Well, perhaps ... maybe, possibly ... yes ...” comes in, and teachers’ use of rating scales seems to be central.

Parents who can afford private health care require a prescription from a general practitioner (GP), paediatrician or psychiatrist to obtain medication. They could bypass the possibly tedious professional assessment process and take a rating scale straight to a doctor for a prescription. That doctor could choose to prescribe the drug. This means it is possible for a child to be put on methylphenidate based largely on a Connors questionnaire filled in by a teacher. Dr Neil McKerrow, chief specialist and head of paediatrics and child health for the Pietermaritzburg Metropolitan Hospitals Complex, is aware of this and expressed concern.

Professor Anthony Pillay, principal clinical psychologist at Nelson R. Mandela School of Medicine and Fort Napier Hospital, is also uneasy. He said: “We often see rating scales over-zealously completed, which is a concern, particularly in relation to the underlying motive ... A diagnosis of ADHD ... can only be made by an appropriately trained health professional. [It] is not based simply on how many boxes are ticked on a rating scale. It is a clinical diagnosis, based on the child’s presentation, history, behaviour in different contexts, and reports from the parents and school.”

Dr Kay Jhazbhay, principal psychiatrist for child and adolescent psychiatry at Town Hill Hospital’s Child and Adolescent Unit (CAU), “strongly agrees” with Pillay. She said: “Connors is overemphasised. It is subjective and may give false positive results. Symptoms must be present in more than one setting.”

A Howick GP, who may not be named for professional reasons, said he was shown Connors questionnaires filled in by a child’s teacher and by the mother “which could have been describing two completely different children”. He does believe that Ritalin is being overprescribed because “there is a definite increase in the number of parents seeking prescriptions. At the same time, however, increasing numbers of parents are choosing not to go that route.” He said methylphenidate has a place, but believes that many children’s behavioural problems could be solved by addressing their diet.

Parents who use state health-care services have several options including the Learning Disorders Clinic (LDC) at Grey’s Hospital, the child outpatient psychology department at Fort Napier Hospital and the CAU at Town Hill Hospital. All of these involve a rigorous process of medical/psychiatric and psychological assessment. McKerrow explained why: “We are aware that there have always been teachers who have poor skills and/or difficulty with class discipline. This means there may be other motives behind children being referred to our services. Consequently, we insist on both a medical and a psychological assessment before initiating any therapy. Medical assessment rules out any neurological or other medical problems and psychological assessment diagnoses whether there is ADHD. We use Connors questionnaires administered before treatment as a baseline assessment to monitor drug therapy. Ritalin is dispensed from Grey’s or Edendale monthly and we monitor patients monthly too.”

He said there is “an upward trend” in the number of children being referred to the Grey’s LDC, although the figures also fluctuate. A total of 189 children were referred in 2006, 242 in 2007 and already 262 children up to the end of August this year, with an obvious increase in the number of children from black schools and “the public sector”. He could not explain the increase, but agrees that it could be related to teachers’ and parents’ increased awareness of ADHD and its treatment.

Jhazbhay said: “As the CAU is fairly recently established, comparative statistics are not available yet, but the commonest diagnosis is ADHD.”

She said that for children who genuinely have ADHD, “methylphenidate is very effective, as up to 90% of patients respond to treatment. It impacts positively on school performance, peer relationships, family functioning, self-esteem and long-term outcomes. It provides a window of opportunity to learn and develop.”

Bobby Nefdt, headmaster of Scottsville Primary School, does not believe that teachers in his school are misusing Ritalin. “Our class numbers have not changed. We believe that our classes are a manageable size, averaging at about 30.”

However, the number of children in the school taking Ritalin or the slow-release equivalent, Concerta, has doubled from a total of about 20 to 41 in a school of 946 pupils, which is within the normal range. Nefdt attributes this increase to lifestyle: “What has changed is children’s lifestyles. They spend less time playing outside and getting exercise, and more time watching TV or playing computer games.” He also expressed concern about their diet.

A local GP does not believe that Ritalin is being used inappropriately as the number of children she sees for prescriptions has not increased unduly. “I see fewer than one patient a month and in my opinion the majority of these cases have been appropriate candidates.”

Paula Barnard is an occupational therapist in Johannesburg and founder of RemSpecED, which specialises in remedial and special education services. Her daughter is on Strattera, which contains atomoxetine, a non-stimulant option to methylphenidate. She said: “I agree that doctors often overprescribe Ritalin. There certainly are teachers who send every second child off to the doctor for Ritalin, but this is not true of all teachers or doctors.” She said her daughter is “doing very well” on medication, “but it is well managed with regular consultation with her psychologist, teacher and doctor. As a result, she is learning effectively, sleeping well and excelling socially.”

Is the use of methylphenidate increasing?

The Witness phoned a random selection of city pharmacies to find out about sales of drugs for ADHD. Aidan Moffet, owner of Hayfields Pharmacy, said: “Overall, use of methylphenidate is rising.” He identified larger classes in schools as a possible cause and the growing use of the drug for adults diagnosed with ADHD. The owner of another pharmacy said sales of both methyl-phenidate (Ritalin and Concerta) and Strattera, are “definitely increasing”. He believes this is not only because of overworked teachers, but also because drug companies encourage medical practitioners to prescribe their products. However, sales at three other pharmacies are either stable or dropping.

Lesego Khantsi, medical manager at Novartis, the manufacturer of Ritalin, said: “ADHD has been recognised and studied for more than 100 years and is the most studied childhood psychiatric disorder.

“Ritalin has been used effectively for more than 50 years and is the most widely researched medication in the treatment of ADHD ... Novartis does not provide annual sales or production figures for our products, as the company considers this to be proprietary information.”

Abeda Williams, technical and medical affairs director for Concerta manufacturer Janssen-Cilag said there is no significant change in the usage patterns of that product.

What are the symptoms of ADHD?

ADHD is a recognised neurological condition that is listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. It is more common in boys than in girls. According to that manual, between three percent and seven percent of school-aged children may be affected. Diagnosis requires a comprehensive assessment and treatment should include medical, psychological and educational intervention, as well as behavioural management.

Although most people are restless and inattentive occasionally, these qualities are more severe, persistent and incapacitating in children with ADHD. For a child to be diagnosed with ADHD, these behaviours must cause difficulty in many areas such as at home, in school or with friends.

Children with ADHD have problems in certain areas.

• Inattention — difficulty sustaining attention, listening and paying attention to detail, easily distracted and forgetful, poor organisation and study skills.

• Impulsivity — tendency to blurt out answers, interrupt, or intrude on conversations, difficulty being patient or taking turns in school and in playing, and tendency to get into trouble for acting without thinking.

• Hyperactivity — being in constant motion, fidgeting, squirming, running, climbing or talking excessively.

There are three sub-types of ADHD.

• Combinedtype. This is the most common sub-type and involves inattentive, hyperactive and impulsive symptoms.

• Predominantly inattentive type. These children often lose things, forget their homework, daydream, and have trouble managing their time, planning and organising their things.

• Predominantly hyperactive-impulsive type. This is the least common type and is characterised by restlessness and fidgetiness, but few or no problems with attention or concentration.

— Health 24 and NYU Child Study Centre:

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