The Term Attention Deficit Hyperactivity Disorder Psychology Essay

Published Date: 23 Mar 2015

Attention Deficit Hyperactivity Disorder (hereafter referred to as ADHD) as defined by the DSM-IV-TR, is "a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development." It is as yet not very well known in our small island of Mauritius but it is now starting to be recognized and treated as such in the Mauritian setting. Mental disorders, however, are still a taboo subject in the island and if compared to the United States in terms of the measures taken to treat and support people suffering from this disorder, ADHD has been squarely ignored for a very long time in Mauritius. Methylphenidate (MPH) or Ritalin a stimulant drug has been the principal therapy for ADHD for decades. However with the new medical advances, new treatment options are emerging such as Atomoxetine (ATX) or Strattera which is a non stimulant drug in contrast to Ritalin.

ADHD are actually considered the most controversial disorders in our society. Children with attention problems create a unique population of children with a variety of needs. Hence, the most commonly diagnosed childhood disorder among children is Attention Deficit Hyperactivity Disorder, also known as ADHD (Kronenberger & Meyer, 1996). The controversy on the subject is: could we be drugging healthy children into submission? Though over diagnosis is not common, it still exists. Other factors might influence parents into giving in to the use of medication.

Chapter 2 - Literature Review

Definition of ADHD

Attention deficit hyperactivity disorder (ADHD) is a developmental, neurobiological condition defined by the presence of severe and pervasive symptoms of inattention, hyperactivity and impulsivity [American Psychiatric Association (APA) 1994], as cited by Daley and Birchwood, 2009.

The fundamental feature of Attention-Deficit/Hyperactivity Disorder is an unrelenting pattern of inattention and/or hyperactivity/impulsivity that is more often displayed and more severe than is typically observed in individuals at a comparable level of development. [DSM-IV-TR, APA, 2000]

ADHD can be defined as a Neurobehavioral disorder which is characterized by an amalgamation of inattentiveness, distractibility, hyperactivity, and impulsive behaviour. [Psychology Today]

ADHD is marked by developmentally inappropriate inattention, impulsiveness and motor hyperactivity (Rosenhan & Seligman, 1995).

Generally, ADHD is defined by the presence of socially disruptive behaviours, either attentional or hyperactive, before the age of seven, which persist for at least six months (Sue, Sue, & Sue, 1997).

Characteristics of children who suffer from ADHD primarily include inattention, impulsivity, and deficits in rule-governed behaviour, not the restlessness or squirminess that has often been the centre of adults' concern. Therefore, children identified as having ADHD may show difficulty in focusing and sustaining attention, controlling impulsivity, and showing appropriate motivation (Kauffman, 2001).

According to Dr. Vinita Poorun, paediatric consultant at the Sir Seewoosagur Ramgoolam (SSR) Hospital, Pamplemousses, this condition is considered as a disease, diagnosed by specific tests. In addition, the hyperactive child often loses his things and may have language problems, anxiety, or depression. (Radha Rengasamy, Defi Plus, 11th August 2012)

It is a neurobiological disorder that alternates the thought of the child and needs to be treated. Child psychologist, Véronique Wan Hok Chee, continues by arguing that the child is full of energy and never gets tired. The child also has mood swings. "When his parents ask him to sit, he is stressed and anxious. He can become aggressive. There is also a problem of socialization that comes in. The child is not able to play with his friends because of his unusual behaviour. He may also not be able to make friends for the same reason. He is often the leader who loves to impose on all the other children. He is impatient. For example, he cannot wait for his turn to have something," she describes. (Adilah Mohit, Defi Quotidien, 10th May 2012)

Diagnosis

Children grow differently. They have different personalities, temperament and energy levels. Most of them are bound to get distracted, act impulsively and struggle to concentrate at one point in time or another. These are normal factors which can often be mistaken for ADHD. The disorder can be hard to diagnose as the symptoms vary from one person to another and they usually appear between the ages of 3 and 6. It is very often first noticed by teachers at school when the child has trouble following rules or spaces out in class. (NIMH ADHD Booklet)

According to the DSM-IV-TR, there are five diagnosis criteria for ADHD. They are:

Criteria A: Persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and is more brutal than is typically observed in individuals at comparable level of development.

Criteria B: Some hyperactive-impulsive or inattentive symptoms must have been present before seven years of age.

Criteria C: Some impairment from the symptoms must be present in at least two settings.

Criteria D: There must be clear evidence of interference with developmentally appropriate social, academic or occupational functioning.

Criteria E: The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorders and is not better accounted for by another mental disorder.

The DSM-IV-TR (American Psychiatric Association, 2000) classifies ADHD into three separate subtypes: Predominantly Inattentive Type, Predominantly Hyperactive-Impulsive Type and Combined Type. Predominantly Inattentive Type is used if six (or more) symptoms of inattention (but fewer than six symptoms of hyperactivity-impulsivity) have persisted for at least six months. Predominantly Hyperactive-Impulsive Type should be used if six (or more) symptoms of hyperactivity-impulsivity (but fewer than six of inattention) have persisted for at least six months. Combined Type: This subtype should be used if six (or more) symptoms of inattention and six (or more) symptoms of hyperactivity-impulsivity have persisted for at least six months.

However, there is no X-ray, blood test or CT Scan to determine who needs medication for ADHD. The diagnosis of ADHD remains as much art as science (Hancock & Wingert, 1996). The Psychologist or Psychiatrist has to gather information about the child, his behaviour and his environment. The Health Professional should firstly try to rule out any other possibilities for the symptoms. Some example would be middle ear infection, undetected hearing or vision problems, learning disabilities or other psychiatric problems such as anxiety or depression. The specialist should also check the child's school and medical records for clues as well as interview teachers, parents, coaches, babysitters and other adults who are well acquainted to the child. The specialist will also take into consideration the duration of the episodes and what aspects of the child's life it affects, compare the happening to the child's peers, determine whether the behaviours are a continuous problem or simply a response to a temporary situation, as well as where these behaviours usually occur. The child's behaviour is closely observed and evaluated on tasks. It is only if all the clues and symptoms meet the criteria for ADHD that the child will be positively diagnosed with the disorder.

What can have a serious impact on a child's overall development is the early detection of a child with ADHD by the teacher. Teachers can contribute to the prevention of secondary disorders. The findings of a study by Kypriotaki and Manolitsis (2010) showed that teachers detect far more students with ADHD than the number expected from the norms based on the standardised test. Teachers identified more boys than girls as ADHD but made more precise identifications for girls than for boys.

Critics

Are we drugging healthy children into submission? Main (1957) as cited by Pozzi (2000) studied the use of sedatives in hospitals. Main found that a nurse would only administer a sedative when she had reached the limit of her human resources and unable to stand the patient's problem without anxiety, impatience, guilt, anger or despair. And it was never the nurse who took the sedative. His result therefore was that sedatives were used to relieve the feelings of frustration, aggression, guilt and despair of the therapists, doctors and nurses rather than for the patient's sake. Over diagnosis of ADHD is not common. However, it does exist. It is common knowledge that symptoms similar to those of ADHD may point to problems other than ADHD. An example would be the case of a nine year old boy thought to have ADHD when the latter actually had a mildly impaired hearing and therefore misunderstood directions and often asked to repeat questions. Further testing showed that he was not able to process auditory information normally (Adesman, 2000). The description of the symptoms of ADHD have been highly unstable over the years with descriptions such as "organic drivenness", "minimal brain damage", "hyperkinetic impulse disorder", "minimal brain dysfunction", "hyperkinesis", "hyperactive child syndrome" and "attention deficit disorder".

Stimulants used in the treatment of ADHD has dose related side effects such as decrease of appetite, delay in bed time, moody, irritable, headaches, stomach aches and slow physical growth as compared to other peers. Parents have to make sure that their children eat healthy meals and consult the child's doctor if this side effect persists. This side effect will also affect the child's growth and weight gain. In case of sleep problems, the doctor may have to a low dose of anti depressant to help the child sleep. Some children also develop a rare side effect of tics. Tics are the repetitive and sudden movements or sounds. Other children may suffer from a change in personality such as appearing emotionless. Studies show that children and teenagers who take Atomoxetine (ATX) are more likely to have suicidal thoughts than children and teenagers with ADHD who do not take it.

Medications do not cure ADHD. They simply control the symptoms and help the child pay attention and complete their school work. Medication has to be regularly monitored by the prescribing doctor and adjusted to the needs of the child.

There has been a drastic increase in working mothers in the last few decades. When both parents in the household start working there is an increase in parental stress and decreased tolerance for disruptive behaviours associated with ADHD. ADHD is also more prevalent among kids in step families, cohabiting parents and children in joint custody. As cited by Hancock & Wingert (1996), Dr Sharon Collins, a paediatrician in Cedar Rapids, Iowa, it takes time for parents and teachers to sit and talk to kids and it takes a lot less time to get a child a pill. Eight percent of children of the region were on Ritalin at the time.

From the year 1988 to 1990 there was a decrease of almost 40% in the number of Ritalin prescription in the United States. This was due to twenty highly and negatively publicized lawsuits lead by known T.V personalities of the time such as Oprah Winfrey [1] , Geraldo Rivera [2] , Phil Donahue [3] and Morton Downey Jr. [4] Under an organization called the Citizens Commission on Human Rights, they targeted local physicians, school districts and individual school personnel around the country for the inappropriate use of Ritalin (Mayes & Erkulwater, 2008).

Two factors caused an easier access to Ritalin. Under managed care, paediatricians were allowed to diagnose and prescribe stimulants for ADHD. This was brought about due to a discouragement of expensive referrals to specialists such as child psychologists. Secondly, the price of Ritalin dropped in the mid 1980's after its patent ran out. It became less likely to see a diagnosed child without a stimulant prescription. It meant that parents who really needed Ritalin for their kids could now afford it. But it also meant that due to its easy accessibility, it was easier to give a prescription instead of trying less drastic solutions. The impact is portrayed by Table 1 [5] .

Even after the great success at the treatment of ADHD, many doctors in the US are convinced that Ritalin is over prescribed. Teachers seek out parents of active children and suggest Ritalin. School psychologists (average of 1 for every 2100 students) are overwhelmed with referrals and feel pressured to prescribe pills even before they have had time to conduct a proper evaluation. Nationwide, Psychologists say that half of the children sent to them on ADHD referrals are actually suffering from a variety of other ailments which look like ADHD such as depression, learning disabilities or anxiety. Some of them do not even suffer from anything. Some paediatrician even revealed that parents of normal children have asked for Ritalin to improve the grades of their children. If the psychiatrist does not agree, they simply move on to another one. Doctors even admit to a hasty diagnosis. The essential diagnostic elements such as talking to teachers, reviewing educational levels are not performed and the children simply get a prescription. On top of that, ADHD experts say that most children need Behaviour-modification Therapy and special help in schools but most surveyed paediatricians rarely propose anything more than pills. They hold the belief that they are doing more good than harm which might be really true. There are no definitive long term studies to reassure parents that this stimulant is not causing some hidden havoc to their child. (Hancock & Wingert, 1996)

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Table 2.1: Characteristics of Patient population diagnosed with AD / HD between 1980 - 1990 in USA

Another critic is the question of what is considered normal child behaviour? The line between normal child behaviour and abnormal child behaviour is blurred. Therefore all diagnostics cannot be 100 percent accurate (Hancock & Wingert, 1996). Dr Kessinger raises another issue. How do we exactly diagnose ADHD? What tests do we use to prove or disprove the existence of a "brain chemical imbalance"? Furthermore, how can we test a chemical imbalance on a pen and paper test? It does not all make sense to him. (Kessinger, 2011)

Causes

Looking briefly in the causes of ADHD it is found that some research done in this line hint at biological factors as the primary cause of ADHD. Brain research suggests that lower activity levels in the part of the brain that controls attention (the frontal cortex) cause ADHD. This lowered level of brain activity can be caused by genetics and by substance use and abuse during pregnancy. Genetic research shows that 90% of children with a full diagnosis of ADHD shared it with their twin, which strongly points to a genetic link. Researchers have also examined the genes that regulate the neurotransmitter dopamine. Sternstein (2003) in her article states that there may be a link between ADHD and faulty regulation of dopamine regulating movement and emotional responses. These people unconsciously medicate themselves with sugar in childhood, and caffeine, cigarettes or cocaine later in life to help them focus. Use and abuse of substances such as cigarettes, alcohol, drugs and exposure to toxins in the environment during pregnancy also has an adverse effect on the child which can later manifest itself in the form of ADHD. Though inheritable effects clearly contribute to at least 65% of the risk for ADHD, multiple other factors, including low birth weight, fetal alcohol syndrome, and prenatal exposure to toxins, combine to explain the significant remaining variability. A simple and probable cause put forward by Kessinger is that the child lacks sleep. He argues that this is the only thing that can explain how a stimulant is having the reverse effect on a child. Speaking from personal experience, he explains that when he does not get enough sleep, he gets "grouchy". However, research is yet to prove this theory.

Researchers at the National Institute of Mental Health (NIMH) are looking into the possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD. According to the NIMH, results from several international studies of twins show that ADHD often runs in the family. Finding out which genes are involved in the manifestation of ADHD would help researchers prevent the disorder and provide better treatments. NIMH researchers found that children with ADHD carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention and also found that this difference was however not permanent. As the child grows up, the brain develops the normal level of thickness and the symptoms of ADHD improved. Studies on the environmental factors suggest a possible link between cigarette smoking and alcohol use during pregnancy. Moreover, preschoolers who are exposed to high levels of lead which can be found in plumbing fixtures or paint in old buildings may have a higher risk of developing ADHD. Studies also show that children with a brain injury may show similar behaviour to ADHD but very few ADHD children have gone through a traumatic brain injury. (NIMH ADHD Booklet)

The NIMH is also conducting research on Sugar and Food additives as contributing to the causes of ADHD. However, research results do not support the theory of excess of sugar consumption as causing ADHD. As to Food Additives, British research points towards a possible link of certain food additives and hyperactivity but research is still under way and cannot yet confirm this theory.

Treatments

Looking briefly in the causes of ADHD it is found that some research done in this line hint at biological factors as the primary cause of ADHD. Brain research suggests that lower activity levels in the part of the brain that controls attention (the frontal cortex) cause ADHD. This lowered level of brain activity can be caused by genetics and by substance use and abuse during pregnancy. Genetic research shows that 90% of children with a full diagnosis of ADHD shared it with their twin, which strongly points to a genetic link. Researchers have also examined the genes that regulate the neurotransmitter dopamine. Sternstein (2003) in her article states that there may be a link between ADHD and faulty regulation of dopamine regulating movement and emotional responses. These people unconsciously medicate themselves with sugar in childhood, and caffeine, cigarettes or cocaine later in life to help them focus. Use and abuse of substances such as cigarettes, alcohol, drugs and exposure to toxins in the environment during pregnancy also has an adverse effect on the child which can later manifest itself in the form of ADHD. Though inheritable effects clearly contribute to at least 65% of the risk for ADHD, multiple other factors, including low birth weight, fetal alcohol syndrome, and prenatal exposure to toxins, combine to explain the significant remaining variability. A simple and probable cause put forward by Kessinger is that the child lacks sleep. He argues that this is the only thing that can explain how a stimulant is having the reverse effect on a child. Speaking from personal experience, he explains that when he does not get enough sleep, he gets "grouchy". However, research is yet to prove this theory.

Researchers at the National Institute of Mental Health (NIMH) are looking into the possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD. According to the NIMH, results from several international studies of twins show that ADHD often runs in the family. Finding out which genes are involved in the manifestation of ADHD would help researchers prevent the disorder and provide better treatments. NIMH researchers found that children with ADHD carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention and also found that this difference was however not permanent. As the child grows up, the brain develops the normal level of thickness and the symptoms of ADHD improved. Studies on the environmental factors suggest a possible link between cigarette smoking and alcohol use during pregnancy. Moreover, preschoolers who are exposed to high levels of lead which can be found in plumbing fixtures or paint in old buildings may have a higher risk of developing ADHD. Studies also show that children with a brain injury may show similar behaviour to ADHD but very few ADHD children have gone through a traumatic brain injury. (NIMH ADHD Booklet)

The NIMH is also conducting research on Sugar and Food additives as contributing to the causes of ADHD. However, research results do not support the theory of excess of sugar consumption as causing ADHD. As to Food Additives, British research points towards a possible link of certain food additives and hyperactivity but research is still under way and cannot yet confirm this theory.

Alternate Methods of treatment

ADHD has been found to have strong academic repercussions. To counter these negative influences, Raggi and Chronis (2006) as cited by Daley and Birchwood (2009), propose several interventions for the benefit of children and adolescents with ADHD. One of the interventions is Peer and Parent Tutoring. In this intervention, the child is provided with a peer tutor who will provide one-on-one instructions and assistance to the child with ADHD at the latter's own pace.

Dexmethlyphenidate, another MPH based stimulant drug, known as Focalin, offers a better balance between symptom relief and the side effects of Ritalin. Margaret Weiss proposes another way to evaluate clinical trials. Weiss proposes the Therapeutic Index (TI) which considers a drug's potency (dose required to produce a given effect) as well as the drug's undesired effect. It is the ratio of the undesired effect to desired effect. According to Weiss the clinical measures that reflect TI are Remission rates, Failure rates and duration of action. Using the TI will the use of children as guinea pigs to find out the right dosage to be administered thus resulting in more effective treatment.

Dr Gillespie in an exploratory paper demonstrates the use of the Corrective aspect of Craniosacral Fascial Therapy in the treatment of ADHD in a case study. The Cranio Sacral system is comprised of the membranes and cerebrospinal fluid which form the fluid-filled sac around the core of the nervous system - surrounding, nourishing, and protecting the brain and spinal cord. Like the pulse of the cardiovascular system, the Cranio Sacral system has a rhythm that can be felt throughout the body. The craniosacral concept was discovered by William Sutherland D.O. in 1899 when he found that the brain had a slight "breathing" motion. Anatomically in the craniosacral fascial system, the cerebrospinal fluid begins in the choroid plexus of the ventricles, gently fluctuates through the craniosacral tissues, and flows within the cranial and spinal nerve sheaths out into the fascial collagen tubules. Researchers confirmed this whole body system upon discovering cerebrospinal fluid in these tubules with amazingly no usual ground substance like blood or lymph present. (Gillespie, 2008)

The therapy aims at relieving the causative strain patterns around the brain. These traumas can occur at anytime, for example the natural pressures of birth. The amount of seconds the brain takes to expand and contract or the brain cycle is the best indicator to measure the function of the craniosacral fascial system. The clinical goal is a minimum brain cycle of fifty seconds, twenty-five seconds in the expansion phase and twenty-five seconds in the contraction phase. As brain cycles may well go over a hundred seconds, it appears that the longer the brain "breathes" and the easier the cerebrospinal fluid flows, the better the brain can function. MPH has helped millions of children over the years, but now clinicians can work on correcting a possible neurological origin to the problem. (Gillespie, 2008)

The treatment results of the Craniosacral Fascial Therapy are impressive as Dr Gillespie found after treating hundreds of patients over the last 30 years, is a key factor in the healing of the central nervous system. It merits further research on the therapy so that it may be used as an alternative to MPH or ATX and any other medication used in the treatment of ADHD. (Gillespie, 2008)

Comparison

ADHD in the United States

According to Mayes and Erkulwater (2008) 8 percent of youth aged between four to seventeen years in the United States are diagnosed with ADHD and a little more than 4 percent have both the diagnosis and are taking medication for the disorder. In the 1990's 900 000 youth were diagnosed with ADHD in the US. By the mid 1990's 3-4 million children were diagnosed with ADHD, the majority of which were using stimulants as treatment. This rapid growth was due to the convergence of trends, alignment of incentives and the considerable growth in scientific knowledge about ADHD and stimulants.

Furthermore, three apparently trivial changes in federal disability, education and public-health insurance policy in the early 1990's brought about an important and rapid growth in the diagnosis of ADHD and stimulant use. Firstly, a Supreme Court ruling led to the modification of the Supplemental Security Income (SSI) program [6] to include low income children diagnosed with ADHD. The policy was later rescinded but the duration in which it was in force, the rate of new children enrolling in the program with a qualifying diagnosis of ADHD increased almost threefold. Secondly, in the years 1990 and 1991, the association Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) was significant into successfully lobbying Congress and the Department of Education, for ADHD to be officially included as a protected disability under a major federal law (IDEA [7] ) that made ADHD diagnosed children eligible for special educational services. And thirdly, the Congress tremendously expanded the number of individuals, especially children, eligible for Medicaid. This led to the spending per child in stimulants to grow nine fold and the number of prescription six fold between the years 1991 to 2001. The effect of these changes can be shown in Table 2 [8] .

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The Individuals with Disabilities Education Act (IDEA, 1990) requires schools to offer children with disabilities a free and appropriate public education according to an individualized education plan drawn up by a team of school officials, teachers, counselors, psychologists, and social workers and in consultation with parents. The law also grants parents extensive due process guarantees, including the right to sue the school district in federal court if they oppose its assignment of their child. The Social Security Administration had a restrictive interpretation of disability which kept the SSI children's program small. In the 1990's, a wide alliance of medical professionals, antipoverty activists, and disability and children's advocates banded together to urge the SSA to loosen its interpretation of childhood disability. The coalition supporting the liberalization of SSI included the American Medical Association, the American Academy of Pediatrics, the American Psychiatric Association, the National Association of Mental Health, the Bazelon Center, Easter Seals, the Arc, and the March of Dimes. The SSI became an important source of support families. Recognition of ADHD led to changes in the home and school environment of children.

ADHD in Mauritius

The situation in Mauritius is very difficult to establish. ADHD is not a disorder most parents are aware of. Parents simply assume their children are naughty and lacking discipline. They are far from suspecting that their child might be suffering from a mental disorder and are most likely to deny the possibility for fear of being stigmatized, mental problems being still a taboo subject in the small island. However, we can note a change in the attitude of the new generation of parents which we can assume is due to open mindedness, a better education and a more informed group.

The growing number of cases of hyperactive children is mostly identified at school. These children often adopt a rude behaviour. They struggle to concentrate in class, are disruptive, or are the origin of squabbling. Gradually, they are being supported in schools. Teachers are looking for ways to ensure that these children expend themselves otherwise. (Adilah Mohit, Defi Quotidien, 10th May 2012)

Véronique Wan Hok Chee, the paediatric consultant, finds that parents are now more aware of the importance of seeking the help of health professionals to oversee their hyperactive child. The Mauritian education system does not provide a special framework for children suffering from ADHD. Most teachers are not even aware of ADHD and are therefore not equipped to deal properly with the child. She adds that the child is often sidelined by his teacher since he cannot afford to give him individual attention. (Radha Rengasamy, Defi Plus, 11th August 2012)

Véronique Wan regrets that there is no structure to help parents whose children are hyperactive. Hyperactive children are unfortunately not as they should be supervised at school. A psychologist must be specialized in child psychopathology framework for hyperactive children, who offers behavioural and cognitive therapies to help them. She advises parents to address the issue as soon as possible so that the child does not get worse, which would make it difficult for professionals to treat the child. On the other hand, hyperactive children should be encouraged to practice the sport in which they excel or have an interest in. (Radha Rengasamy, Defi Plus, 11th August 2012)

Sometimes parents become very punitive in such circumstances, believing that their child is naughty. But Véronique Wan says, the child must be understood by his parents and requires a case management. She adds that the punishing the child each time will also not do much good. Rather, it may cause more harm. (Radha Rengasamy, Defi Plus, 11th August 2012)

Children no longer have parental guidance in the form of grandparents and uncles and aunts as they did in the past in extended families. With the increase in nuclear families, children spend less time in adult company. Wan also draws attention to the fact that parents encourage their hyperactive child to play video games or watching TV just to get some peace. It is unfortunately not of a great help. On the contrary, academic performance will suffer. The child will be all the time in the rear the other children. The child often has his own level of intelligence but simply cannot concentrate on his studies. This is the reason why academic failure is so common among hyperactive children. (Radha Rengasamy, Defi Plus, 11th August 2012)

Very often, hyperactivity is over-diagnosed. Dr. Ryad Joomye, paediatrician at Apollo Bramwell Hospital says that sometimes parents feel that the natural turbulence is a pathological hyperactivity. This is not the case. However, it is possible that, by nature, a child is full of energy. The diagnosis should therefore be very carefully performed. (Adilah Mohit, Defi Quotidien, 10th May 2012)

Dr. Joomye describes a hyperactive child as a child who does not stay in one place, that keeps moving, which is unable to complete a game or a project that cannot stay 15-30 minutes before the TV, responds to the characteristics of hyperactivity. The ability to focus in front of the cartoons is a simple way to reassure parents of non-pathology. (Adilah Mohit, Defi Quotidien, 10th May 2012)

Regarding the management of unruly children (non-pathological), the paediatrician suggests that supervision of these children by parents is important. In the actual Mauritian context, the child is king and parents are slaves. However, they must have respect for parental authority. This also means establishing house rules with penalties for non-compliance. (Adilah Mohit, Defi Quotidien, 10th May 2012)

In some cases, grandparents intervene too often. This fact, they spoil their grandchildren. In doing so, they prevent parents from taking the necessary sanctions to correct boisterous behaviour. It is to be noted that these grandparents are only occasional visitors and not active participants in the rearing of these kids. (Adilah Mohit, Defi Quotidien, 10th May 2012)

Interview with Dr Joomye

Something we should be very careful about is that people from the general population they see it these children as turbulent kids. Turbulence is not really ADHD. The real ADHD is a deficit of attention. ADHD is under diagnosed. People will usually say that the child is naughty/mischievous or an academic fallback. It is frequent but he doesn't have any precise numbers. There is a test that is given to these kids. If their result is below a certain level, they we can diagnose ADHD. There are some risk factors for children to develop ADHD. There are prematurely born babies, not well adapted at birth, with an infection or cranial trauma or a child might have a fall resulting in cranial trauma. These children may develop ADHD in the future. They have to be followed carefully in case they develop ADHD. Unfortunately, follow ups are not that rigorous in Mauritius

To help these children there is the Association de Parents d'Enfants Inadaptés de l'Ile Maurice (APEIM) who takes care of children with academic difficulties. Specialized psychologists and speech therapists are also involved with children with academic difficulties. However, there is a whole network which allows these children to receive specialized attention.

Very often, if not in all the cases, the parents have no idea of what is ADHD. These children are often diagnosed as Autistic. It's like a melting pot, they mix different diagnosis. But in general, ADHD is confused with natural turbulence of kids who might have been spoiled by parents. They need a framework.

Each time that a case of ADHD is suspected, the child is made to take the ADHD test as well as an eye check up in case the child is unable to read. In case of academic fallback, it is mostly the teachers who raise the alarm. The child then undergoes a thorough check up in case he cannot see or hear properly. The child will also go through an IQ test and eventually an ADHD test. It is also possible that ADHD is only a symptom of another illness. Co morbidity is possible. For example, the child could be suffering from Epilepsy and ADHD is simply a symptom. When you treat the Epilepsy, ADHD will automatically disappear. They are referred to Psychologists. Unfortunately there are not any child psychiatrists on the island. Sometimes it is psychiatrist who will follow the child or the paediatrician himself does. Parents tend to think that if their child is seeing a psychiatrist it means that their child is crazy or mad and react like: "What is this doctor saying… my kid is not crazy." It is not easy to send a child to see a psychiatrist. Therefore the child is sent to a psychologist and the parents have to be explained clearly why they are sending the child to see a psychologist and reassure them that they are not treating the child of depressed or crazy. And as stated earlier, the child will go through auditory and eye check up and the psychologists will test the child on his IQ or ADHD.

Is there a link between diet and hyperactivity in children?

According to Faheema Korumtollee, nutritionist, it cannot be said with conviction that the eating habits of a child has any influence on his behaviour. To date, there is no study that has been done about it. We cannot have children as guinea pigs. However, it is possible that consumption of food dyes has an impact on hyperactivity. In addition, if the child consumes too much sugar but does not spend it, he will be agitated. An excess of sugar in the blood may be the cause of hyperactivity. But there is no evidence in this direction. (Adilah Mohit, Defi Quotidien, 10th May 2012)

On the other hand, according to a U.S. study, a balanced diet may be beneficial for hyperactive children. However, it could not be determined if it was a placebo effect thereafter. Another study highlighted the link between diet and hyperactivity. It was again noted that changing diet, banning sweets and soft drinks, would reduce symptoms in a hyperactive child. (Adilah Mohit, Defi Quotidien, 10th May 2012)

Ritalin in Mauritius

Small interviews were conducted in three pharmacies of the capital. Two out of the three pharmacies neither sold Ritalin nor did they know anything about it. Medactiv, La Chaussee Pharmacy at Port Louis was the only pharmacy to be able to give more information about Ritalin. It was one of the rare ones to keep Ritalin in stock. According to the pharmacian, there is not a high demand for Ritalin. It is actually a drug which is highly controlled by the Ministry of Health and Quality of Life. It is a drug of level 2 to 3, the security level around which is highly controlled. It is only sold upon presentation of a valid prescription. There is not much of a market for Ritalin in Mauritius as only around 60-120 tablets are sold on a monthly basis according to the pharmacian. It can thus be assumed that there are very few diagnosed patients of ADHD. As it can be seen, Ritalin is a highly controlled drug and therefore, it has been very difficult to retrieve data about it. There is practically no recorded data about Ritalin in Mauritius.

CPE Performance

The Certificate of Primary Education (CPE) is one of the determining exams of a Mauritian child's life. The Mauritian education system is such that, there is no evaluation of a child's ability; neither psychological evaluation nor IQ testing. Should the child have a poor, average or high grade, he/she will still be promoted to the next level. It is extremely rare to see a child repeating Standard 2 or 3. Repeaters are only common at CPE level. Below is a table of the pass rates of the past 10 years.

As we can see in the table, there are approximately 25-30% of students who fail consistently at the 1st sitting every year. Approximately 60% fail again every year at the 2nd sitting. The government has been focusing on what to do of the students who failed the exam instead of trying to look at the causes of these high rates of failure. Nothing can confirm this assumption but part of the reason may be an underlying mental disorder, be it ADHD, Dyslexia or simply slow learners. These children may be as bright as the other 'normal' students but are unable to fully exploit their potential due to some other problem. Since our teachers are not trained to identify the symptoms and risk factors, it is highly possible that a lot of children are losing the possibility of further studies because no one has detected their problem.

CPE Pass Rates (2003-2012)

Year

1st Sitting (%)

2nd Sitting (%)

2003

69.9

37.3

2004

71.2

37.4

2005

73.2

39.5

2006

76.2

40.4

2007

74.1

36.1

2008

75.4

39.6

2009

75.8

39.8

2010

76.0

37.1

2011

75.7

39.5

2012

76.4

39.3

Chapter 3: Discussion

Research Questions

Is it ethical to use Ritalin, knowing its various side effects and its influence on adulthood? Is Ritalin the only way out?

The various side effects of Ritalin are decrease of appetite, delay in bed time, moodiness, irritability, headaches, stomach aches and slow physical growth as compared to other peers. Other side effects are Tics disorder and a change in the personality of the child, such as appearing emotionless. Furthermore, its effects on adulthood have not yet been properly established. Many doctors in the US are convinced that Ritalin is over prescribed in USA as school psychologists are swamped by referrals and feel pressured to prescribe Ritalin before even conducting a proper evaluation. The proper diagnosis of ADHD is a lengthy process which requires several steps. As a drug itself, Ritalin is highly controversial as the reason why it has reverse effect on children compared to adults is still unknown. Can we presume that the effects will insignificant?

Before Ritalin is considered, the children need Behaviour Modification Therapy as well as special help in schools. But, this is not the case actually. Pills are prescribed without even considering the other options. Therefore, is it ethical to use Ritalin? The answer to this question is relative to the situation. If the aim is to help a child in distress, then yes, it would be ethical but the parents ought to take responsibility and be fully aware of the risks. However, if the diagnosis had not been properly made and other options not applied before shifting to Ritalin, it would definitely not be ethical as firstly, as firstly it is against the proper procedure and secondly, the doctor is knowingly subjecting the child to a drug which has several adverse effects and the future effects of which are unknown.

Is Ritalin really a treatment for the kids or a convenient way for the parents to find relief?

Moreover, parents are no longer as present in a child's life as they used to be. There has been a drastic increase in the number of working mothers in the last few decades. Parents are high on parental stress and have a very low tolerance for the disruptive behaviours displayed by ADHD children. It takes time for parents and teachers to sit and talk to kids and takes a lot less time to get a child a pill. (Hancock & Wingert, 1996). According to Hancock & Wingert, parents of normal children ask for Ritalin prescriptions to improve the grades of their children. Some doctors even admit that they make hasty diagnosis.

Therefore, we can see that in the US, parents are very aware of the effects of Ritalin. However many fail to put the best interest of their children before their own. We live in a world which has become used to instant gratification. Ritalin requires fewer efforts on behalf of the parents and teachers. A lot of children are therefore not treated but sedated. For example, a nurse would only administer a sedative when she reached her limits. Sedatives were used to relieve the feelings of frustration, aggression, guilt, and despair of the therapists, doctors, and nurses rather than for the patient's sake (Main, 1957, as cited by Pozzi, 2000) and in this case to relieve the parents and teachers.

ADHD may have serious implications for a child as it affects the child's academic performance. Some of them certainly need help and Ritalin may be the only way out for some of them. However, parents should assume their responsibility and not give in to Ritalin unless it is inevitable. ADHD is practically unknown in Mauritius. Therefore the probability that these might occur in Mauritius is almost non existent. Furthermore, there is no data to refer to. All data about ADHD were found only from studies made in the US and other countries.

Is ADHD treated as such in the Mauritian context as compared to America?

Firstly, ADHD is under diagnosed in Mauritius. The symptoms of ADHD resemble that of many other problems. According to Dr. Joomye, a lot of ADHD cases are misdiagnosed. Very often, they are diagnosed as autistic which is quite far from ADHD. Where ADHD is common knowledge in the US, it is more or less unknown to Mauritians. America also has special provisions for ADHD in the Law (IDEA) as well as schools equipped to integrate ADHD children with the mainstream. It is only very slowly starting to be recognised in Mauritius. Doctors are little by little educating their patients and Special Education Needs schools also are provisioned to take care of children with ADHD, though, inclusion in normal schools would have been preferable. Therefore, we can safely assume that the answer to this question is No, but we are on the road of progress.

Hypothesis

The side effects are not worth the temporary effects of Ritalin.

This section is inevitably linked to the previous section and this one to section 3.1.1. Though controversial, Ritalin is an effective drug against ADHD. It allows thousands of children around the world to overcome their complications. The side effect is not very desirable but is a price to pay for a semblance of normality in their life as well as hope for a better future. The side effects require parents to give special attention to the children on medication. They have to be carefully monitored.

Ritalin is used to confine 'Hyperactive' children to the norms of society.

This hypothesis can be linked to section 3.1.2. Society as we know it is made up of a set of rules. There are norms to follow. As such, society has quite a lot of expectations from an individual be it a child or an adult. They have to fit certain criteria. If not, these persons will be treated as 'abnormal'. It has long been a subject of controversy as to who we are to define 'normal'. Nevertheless, we have to agree that society would be dysfunctional without these sets of rules.

It is possible that the turbulence displayed by ADHD children is normal for them, since 'normal' is simply a concept. To some extent, we can say that we are trying to confine these children to the norms of society since Ritalin is not a cure for ADHD. Ritalin simply helps to control the symptoms of ADHD and assist the child to concentrate long enough on his studies to be able to learn.

Hyperactivity in Mauritian children has not been recognized and diagnosed as ADHD or treated as such as compared to America.

The third research question can be linked to this section. ADHD is recognised in Mauritius. Though, it is recognised by health professionals only. Parents are virtually ignorant on the subject. ADHD is common knowledge in the US. The related individuals are trained to identify these cases and bring these children to attention. Not all cases identified by teachers and parents are ADHD. Most of the time it is some other disorder sharing similar symptoms to ADHD. But the important point here is that because of training, even if not ADHD, disorders are being identified and treated. Had teachers not been trained, these cases would have gone unnoticed in the US at least. Mauritian teachers are yet to be trained.

Chapter 4: Limitations & Recommendation

Limitations

The limitations of this study were that ADHD is not an explored subject in the context of Mauritius. Data on the subject is practically inexistent and we have to rely on primary means of collecting data. Most of the requests for interviews yielded no response due to a busy schedule, which is quite understandable. It is also a sensitive subject about which everyone is not willing to talk about. However, we can note a willingness to learn and inform other people about ADHD on behalf of the persons who gave their opinion on the subject.

Recommendations

Train teachers to recognize the symptoms

As portrayed by Kypriotaki and Manolitsis (2010) in their study, teachers are usually the first to identify the symptoms of a child with a behaviour problem. Children are very easily considered as turbulent by parents at home but this form of behaviour takes on another form at school. The child is not simply playing. He cannot focus on one thing at a time and disturbs the whole class by his actions. He becomes difficult to be controlled by the teachers. Since he cannot focus, his grades fall and this becomes a cause for worry as it will affect the child's future. The study was carried out in a Greek island. The teachers, if not trained, were aware of ADHD as well as the symptoms of ADHD and were able to point them out so that they could be diagnosed and treated. The study showed that the teachers were more often than not, right about the children. They tended to identify more boys as ADHD than girls but were more accurate about girls than boys.

Teachers should be trained to identify the major symptoms and risk factors of the most common disorders which affect children and their learning process. They should get access to workshops and seminars on the subject where they can meet colleagues from all over the country and share information and their experiences. It is highly probable that many children are actually failing their CPE exams as the teachers and parents have not been able to identify the symptoms on time. The teachers should also be trained to work with these children as they have a right to equal rights. They have special needs and have a right to those special needs being fulfilled by the school. Instead of jumping to the final resort, medication, teachers should put in additional efforts to provide the child with an environment adapted to his condition.

Sensitisation Campaigns

According to Dr. Joomye, parents are literally clueless about ADHD and the likes. Mental health is still a taboo in the island. People still hold the wrong belief that seeing a psychologist or a psychiatrist means that the person is mad. They are not aware that there is no such concept as 'mad' or 'crazy'. People from the general population need to be educated through sensitisation campaigns. As Dr. Joomye states in his interview, parents react negatively to the suggestion of being referred to a psychiatrist. They refuse to admit that their child might have a psychological problem. Refusal to appropriate treatment will only worsen the condition of a child.

Therefore, the Ministry of Health and Quality of Life could launch a sensitisation campaign by displaying posters in strategic places such as Children's ward in hospitals and waiting rooms. The parents could also be presented with leaflets by the child's doctor along with a brief explanation. Sensitisation should start early in schools where children learn to accept children with difficulties as equals. Changing the mindset of a whole population is a lot to ask for. It's difficult but possible if appropriate measures are taken.

More Psychologists made available in schools.

There are way too few psychologists per school zone in Mauritius. There are 4 education zones in Mauritius and a total of 5 zones counting Rodrigues and the outer islands. One or two education psychologist cannot cater for the needs of all the students of the zone. It amounts to more than 1000 students per psychologist which makes it virtually impossible for the psychologist to give personal attention to each of them. School rectors have to contact the zone directorate to request the services of the educational psychologist. The process of the request itself is time consuming and the psychologist also has a busy schedule. The child has to wait ages before being finally seen by the psychologists. Very often there is no follow up of the cases. Things would be much better if each school had a permanent psychologist who would be able to follow the case of the students and be present at all time to intervene during appropriate situations.

Proper medical check-up and follow up in hospitals

It is great to have free access to health services in Mauritius. However, more often than not, patient folders are misplaced lost, and appointments are not taken seriously. Instead of finding a patient's file when the latter goes to the hospital, each time a new case is filed. Therefore, the patient does not have a coherent medical record. It makes it more and more difficult for early detection to take place and preventive measures to be taken in case of some illness. If children were properly followed and had a full medical record file, it would be easier for doctors to identify the risk factors as well as the symptoms and take preventive measures against ADHD. There should be follow ups to know how the children are responding to medication and treatment.

Special provision for ADHD children in the law and schools

ADHD children should be attending mainstream schools. America provides a special framework for ADHD children and adjustments are done to the school environment to help the children to adapt and learn effectively. ADHD children are also protected by laws and benefit from aids from the government. This is unheard of in Mauritius. The government should aim to help these children by adapting schools to their needs and including ADHD in the list as a Special Education Needs.

5. Conclusion