To ADHD or not to ADHD, Part 2
ADHD in the South African Context
In the previous article we looked at some basic information regarding ADHD. In this article we will focus on ADHD in the South African context.
Cape Town based psychiatrist, Dr Renata Schoeman, postulates that one in 20 children or 5% of children in South Africa suffer from ADHD. Many children never receive a formal diagnosis of ADHD and are labelled as naughty or stupid due to lack of knowledge about ADHD in their communities. In 2015, Dr Schoeman conducted the first study in South Africa to investigate the prevalence and treatment of specifically adult ADHD. According to the study, the prevalence of adult ADHD was estimated at 1.09% lower than previously thought. However, according to the study the lower prevalence rate may be attributed to lack of awareness of the disorder, lack of access to diagnosis and treatment, and poor coding habits of healthcare practitioners (Schoeman, 2017).
The prevalence of ADHD in clinical psychiatric settings is as high as 52.5%. Conditions comorbid with adult ADHD is common, with psychiatric conditions in up to 20.43% of individuals. Psychiatric comorbidity was also more prevalent than in the general population for both anxiety disorders (13.1% vs. 8.1%) and mood disorders (13.8% vs. 4.5%). The presence of adult ADHD also more than tripled in the prevalence of multiple comorbidity (9.09 vs. 9.3%), and doubled the healthcare costs of individuals (Schoeman, 2015).
According to Dr Schoeman, even though adult ADHD is established as a recognised disorder abroad, in South Africa the diagnosis of ADHD is hampered by a lack of awareness of the disorder, non-recognition of the disorder, and a lack of access to diagnosis. Another obstacle to treatment is a lack of funding. It is therefore proposed that medical aid schemes should recognise adult ADHD as a chronic disorder, which needs chronic treatment and therefore remunerate for services and medication from chronic benefits. To decrease the risk to medical schemes, balanced regulation is suggested. The bar should be raised in terms of receiving the diagnoses of adult ADHD, for example through partnerships with psychiatrists or centres of excellence where comprehensive assessment is available to ensure that the threshold to obtaining the diagnosis is sensitive and specific (Schoeman, 2017).
Dr Schoeman is the co-founder of the non-profit Goldilocks and The Bear Foundation. This foundation offers free ADHD screening by way of a mobile clinic in underprivileged communities in the Western Cape. The screenings are aimed at early referral to public mental health clinics to ensure timely intervention. Dr Schoeman indicates that if ADHD goes undiagnosed it can negatively affect the person’s overall quality of life. Many children who have ADHD also have comorbid conditions such as learning disabilities, anxiety, depression, or oppositional defiance disorder. The foundation also aims at collecting data to better understand the prevalence of ADHD in South Africa.
Dr Anusha Lachman, a Child & Adolescent Psychiatrist (sub-specialist) at the Tygerberg Child and Family Unit, and lecturer in the department of Psychiatry at Stellenbosch University, supports the idea that a comprehensive assessment is needed before ADHD can be diagnosed in children. Dr Lachman points out that ADHD may be diagnosed far too frequently in children who have other symptoms that can be caused by poor nutrition, an iron deficiency, insufficient sleep, exposure to trauma, or poor routines. Children are often medicated in situations where there are specific learning problems. Usually children diagnosed with ADHD have a long history of poor functioning or impairment. Dr Lachman reports that ADHD can be successfully managed, but it is important that the correct diagnosis be made first.
In 2005, Prof Anneke Meyer investigated whether cultural differences influenced the epidemiology of ADHD and the assessment of the neurological component thereof. The first part of the study found that prevalence rates and sex ratios for ADHD, inattentive/hyperactive/impulsive, and combined sub-types were very similar to those obtained when applying DSM-IV criteria to US and European findings (Swanson et al., 1998). In the second part of the study the neurological investigation into cultural differences in answering the assessments, showed that there were marked differences in how children from different cultural backgrounds responded to the non-verbal assessments. The assessments were found to distinguish well between children with ADHD and children without ADHD. In a previous study conducted by Prof Meyer regarding the cultural similarities in ADHD-like behaviour among South African primary school children, surprisingly small cultural differences in the structure and prevalence of ADHD-like behaviour were found between various South African cultures as well as between South African and other ‘Western’ cultures (Meyer, 2004).
According to a 2014 article published by the Attention Deficit and Hyperactivity Support Group of Southern Africa (ADHASA), South Africa has one of the highest rates of prescribing medication for ADHD. Internationally prescribing medication for the treatment of ADHD is no longer considered the first option. They follow the eco-systemic approach, which first seeks to understand why the child is behaving the way they are. This approach looks at the impact the child has on the environment and vice versa. Adjustments are then tailored for a better fit. This article also advocates for better diets. ADHASA often hosts events around the country for parents and teachers to educate them about ADHD.
In a Health24 article, five other conditions often mimic ADHD and should first be excluded before an ADHD diagnosis is made. The five conditions are:
- Stress and anxiety: According to the South African Depression and Anxiety Group (SADAG), a lack of concentration may point to stress and anxiety levels that are not under control.
- Lack of exercise: Many children do not get enough exercise these days and may have pent-up energy. Exercising increases happiness, decreases anxiety, depression, and hyperactivity.
- Hypoglycaemia: Low blood sugar levels can also cause aggression, hyperactivity, inability to sit still and low concentration levels.
- Nutritional deficiencies: Specifically Magnesium, Vitamin B6, Zinc, Essential Fatty Acids, and L-Carnitine.
- Learning disabilities: Such as dyslexia, vision or sight problems, social skills issues, and intellectual disability.
Diagnosing ADHD is a tricky business that needs true expert information to rule out other conditions that can mimic ADHD.
ADHD has also caught the attention of the Democratic Alliance (DA). The DA in the Western Cape wants teachers to be more aware of the symptoms of ADHD. According to a study published by the University of the Western Cape in May 2015 in the SA Journal of Education, 200 Gr 1 to Gr 4 teachers were assessed on their knowledge about ADHD. The results from this study suggest that only 36% of teachers could correctly identify symptoms of ADHD. Furthermore, teachers were more knowledgeable about the general associated features of ADHD, than of symptoms, diagnosis and treatment. A majority of teachers indicated that they had received training. These findings suggest a need to consider improving evidenced-based classroom interventions for ADHD among South African teachers. Based on this study, the DA believes that it would be advantageous if the Department of Basic Education would revise their decision to abolish “special needs classes” or alternatively put in place support teams to assist teachers who work with children with special needs. Teachers should be equipped to assist children with ADHD and engage them in class.
More troubling than the sometimes misdiagnosis of ADHD, is the misuse or abuse of Methylphenidate Hydrochloride (MPH) by learners as young as 16. MPH is known in the market as, among others, Ritalin or Concerta. In 2014, eleven high school children were not only found to ‘deal’ in Ritalin, but they also coached other children to fake ADHD symptoms at the doctor’s office to get more medication for them to sell. Never underestimate the entrepreneurial spirit, albeit grossly misguided in this case!
In a recent study of 818 university students, Stein (2015) found that one in six respondents (17.2%) has used MPH in the past, even though only 2.9% have been diagnosed with ADHD. Nearly a third (31.7%) of users obtained MPH products illegally. The majority (69.1%) used MPH only during periods of academic stress. A significant association was found between MPH use and the frequency of use of alcohol, tobacco, cannabis, hard drugs (e.g., cocaine) and prescription medication. The results in this study appear to be similar to experiences abroad, especially in the absence of clinical diagnosis for ADHD (Stein, 2015).
Many parents worry that children who use stimulants, like Ritalin, are more at risk of developing substance abuse later in life. Substance Use Disorder (SUD) is considered a comorbid condition of adult ADHD. The prevalence of SUD in adults with ADHD ranges from 15-23%. However, it should be noted that the theory that early use of stimulant medication may alter the dopaminergic pathway, making patients more susceptible to SUD in later years, have been proven untrue. According to Dr Russell Barkley, Vyvanse®, a relatively new ADHD drug, cannot be used recreationally. The active ingredient will not be released into body unless the tablet enters the digestive system, where it reacts chemically and then only releases the active ingredient. Unfortunately, Vyvanse is not yet available in the SA market.
A growing area of interest in ADHD, particularly of interest in South Africa, is the impact of untreated ADHD on criminality. According to Dr Shaquir Salduker offenders with ADHD typically engage in opportunistic crime, presumably due to the impulsivity symptomology. Examples include shoplifting, smash and grabs, and burglary. When these offenders are incarcerated and ADHD is not identified and correctly treated, the patient group shows a decreased capacity to engage in the judicial system and receive appropriate rehabilitation.
The South African Association of Psychiatrists (SASOP) launched an ADHD Special Interest Group (SIG). The objective of SIG is to improve the care options of patients with ADHD. SASOP has also suggested guidelines on how ADHD should be diagnosed (Flisher & Hawkridge, 2013).
The amount of information regarding ADHD in South Africa is growing rapidly. We see many similarities in research studies between ourselves and the US and Europe in terms of prevalence and gender ratio. We also note that cultural differences do not really affect the diagnosis of ADHD, but we need to be careful of the type of assessments used and be aware that it might be culturally sensitive.
Some major concerns in South Africa seem to be that ADHD may be diagnosed too readily because of a lack of knowledge, or that the poorer communities are not diagnosed at all due to lack of access to healthcare and appropriate treatment. Another disturbing occurrence is the misuse of medication by students for academic success.
In the next article we will look at the different assessments and tools that can form part of a larger, more comprehensive diagnostic procedure as well as treatment options that can be considered.
Attention Deficit and Hyperactivity Support Group of Southern Africa (2014, May 26). ADHD and Medication – South Africa has one of the highest prescription rates [Press Release]. Retrieved from http://www.adhasa.co.za/index.php/adhasa-media/press-release
5 conditions that can be mistaken for ADHD. (2017, July 24). Health24. Retrieved from http://www.health24.com/Medical/ADHD/News/5-conditions-that-can-be-mistaken-for-adhd-20170623
Everything you need to know about attention deficit hyperactivity disorder. (2016, October 11). Living and loving. Retrieved from https://www.livingandloving.co.za/child/everything-need-know-attention-deficit-hyperactivity-disorder-adhd
Flisher, A.J., & Hawkridge, S. (2013). Guidelines: Attention deficit hyperactivity disorder in children and adolescents. South African Journal of Psychiatry, 19(3), 136-140. Retrieved from http://www.sajp.org.za/index.php/sajp/article/view/943
Free ADHD screening for children to be launched in South Africa. (2017, March 30). Living and loving. Retrieved from https://www.livingandloving.co.za/child/free-adhd-screening-children-launched-south-africa
Goldilocks and the Bear Foundation http: //gb4adhd.co.za/
Meyer, A. (2005). Cross-cultural issues in ADHD research. Retrieved from https://www.researchgate.net/publication/283438790_Cross-cultural_issues_in_ADHD_Research
Salotti, J. (2012, July 13). Essential Ideas for Parents [Video file]. Retrieved from https://www.youtube.com/watch?v=SCAGc-rkIfos
Schoeman, R. (2015, November). The Attention Deficit Hyperactivity Disorder Special Interest Group of the South African Society of Psychiatrists (The ADHD SIG). adhd in focus, Special Edition, p2-3.
Schoeman, R., & De Klerk M. (2017). Adult attention-deficit hyperactivity disorder: A database analysis of South African private health insurance. South African Journal of Psychiatry, 23(a2010). Retrieved from https://www.sajp.org.za/index.php/sajp/article/view/1010/766
Selwood, L. (2015, November). Biological psychiatry: presentation on comorbidities and outcomes of ADHD. adhd in focus, Special Edition, p4-7.
Teachers must be aware of ADHD symptoms, says DA. (2017, July 12). Health24. Retrieved from http://www.health24.com/Medical/ADHD/ADHD-and-school/Teachers-must-be-aware-of-ADHD-symptoms-says-DA-20150615
Topkin, B., Roman, N.V., and Mwaba, K. (2015). Attention Deficit Disorder (ADHD): Primary school teachers’ knowledge of symptoms, treatment and managing classroom behaviour. South African Journal of Education, 35(2), 1-8. Retrieved from