I do not know at what point in man’s evolution between when I left school (admittedly a long time ago but on an evolutionary scale, an immeasurably insignificant period) and when my kids started school, it became accepted by teachers and an alarming number of paediatricians and other therapists that children between the ages of 5 and 14 were capable of sitting for extended periods of time, captivated by what is being taught to them on any given school day. That they are capable of tuning out the chatter of their friends, thoughts of the weekend, after school activities, the intricacies and pitfalls of developing friendships, the drone of nearby teachings or the irritating hum of the lawnmower outside.
More importantly, our children are expected to present themselves in Grade R, probably trained in no more than the art of baking and writing their own name by rote, but armed with concentration skills most adults I know have yet to master.
I have been an advocate for 14 years and an attorney for 4 and spend my days having to concentrate on evidence being given while simultaneously having to tune out the natter of those in the gallery, my client tugging at my gown to tell me how outrageous the witness’s evidence is, plus keep a trained eye on the judge’s pen and face for any visual cues of his perception of the case as it unfolds. Despite my and other colleagues’ extensive practice fine tuning the aforesaid skills, in almost every court case there is a dispute between legal representatives, oft times the judge, and a witness as to what was said and the record has to be replayed to resolve the dispute. These are people who may not have been trained in the art of listening and concentrating (although we know these two things often do not co-incide), but who certainly have had enough practice at it.
I am not a medical expert, but one thing I do know is that my training has given me the skills to make an attempt at least, at understanding or making sense of the evidence (if any) and argument in support of any given position.
This article is not to tell you what to think, but to ask only one thing of you– to think. To think about what is being asked of us as parents, hearts exposed and vulnerable.
I, like many parents whom I know, have been asked “to see the paediatrician” about my child’s apparent distractibility, coupled with the assurance that the speaker / institution’s stated stance is never to tell you your child needs Ritalin or to force you to put your child on Ritalin. At least not in so many words
From discussions with friends and colleagues in the same position (and there are many) there is little variation on the theme when it comes to the communal experience of how it all starts, and only ever four (4) outcomes.
It all starts with only a very brief period of joy and delight as your child starts Grade R, all grown up in their big-school-clothes as they embark upon what should be an exciting journey of meeting new friends and learning the alphabet and counting from 1 to 10. Then one day the teacher in a not-so-quiet stage whisper catches you off guard while you are inappropriately still unpacking your child’s school bag in the classroom long after little Connie should have become independent enough to identify the Rhino symbol in her locker as belonging to her and unpack her bag herself, and raises her inability to focus. No-one dares mention Ritalin right away, even though in time it will become clear they all had this in mind from the get-go.
No, instead and with no discernible effort having yet been made to teach our children the skills it takes to concentrate / compartmentalise their thoughts about work and play, or to have work time and time out to dream in a school day (just a suggestion), you find yourself making appointments for at least 4 assessments (OT, Speech, Educational Psychologist and Audiologist) all of which, together with the report back sessions, will cost you at least R12 000 on top of the school fees you so studiously paid in advance, in the hope of finding some identifiable failing on your part in their development which can be remedied by additional lessons, so that you can avoid what you now suspect is coming.
Inevitably, and despite all the assessments (all of which will most definitely recommend further therapy), and without any real attempt to allow the said therapies to yield any improvement in your child’s performance, you find yourself being called in to yet another meeting, this time with no doubt more in number of the “professional” academic team. And so the pressure begins to mount. Some, if not all, of the team will regale you with success stories involving Ritalin and their assurance that they have become so skilled over time given the number of children on Ritalin, should Connie’s personality change more than expected, should she loose her spark, they will be sure to advise you to take her back to the paediatrician for a re-assessment of the dosage.
Depending on your view of medicating your children, one of four outcomes will result. They are in short, give in, get out, dig in (with or without recourse to continued therapies and natural alternatives, hoping to ride out the sustained pressure which will be brought to bear on you), or tell the teachers and relevant heads concerned that you pay good money for your children to attend the school (applicable to both private and public schools alike) and they should simply do their job and teach your child and stop complaining.
I can find no evidence to suggest that children ought to be better equipped to concentrate at school then when we were at school when our inattention was punished with corporal punishment and later detention coupled usually with having to write a nauseating number of lines, but I do know the following.
The law has always and still does recognise that children between the ages of 0-7 are doli and culpa incapax. This means, in layman’s terms, that they are unable to appreciate the difference between right and wrong and /or unable to act in accordance with such appreciation. Between the ages of 7 and 14 the law recognises that there is a rebuttable presumption that children are doli and culpa incapax. This means that is there is a presumption in law that children between 7 and 14 are unable to appreciate the difference between right and wrong and/or act in accordance with that appreciation, but that the State or Plaintiff as the case may be, can try and rebut this presumption with evidence to the contrary. Sound familiar?
We did, back in the day, as do our children today, know objectively that we were required to pay attention when the teacher talks, do our work neatly within the allocated time, and rush home to complete our homework with equal fervour, but could we? Can they?
There are no movements afoot to alter these age appropriate markers, so what happened within education? I offer you no medical advice or medical opinion, other than to persuade you to read and consider for yourself the Ritalin package insert and Medication Guide published online by the manufacturer, Novartis (updated April 2015 appearing at https://www.pharma.us.novartis.com/product/pi/pdf/ritalin_ritalin-sr.pdf). I offer you no more than my observations based on the above.
My own personal theory is that the ability to concentrate is a matter of skill and practice and accordingly, improves with maturity. The law recognises that legal culpability commences at 14. Is it any co-incidence then that the Ritalin package insert states the following “Drug treatment should not and need not be indefinite and usually may be discontinued after puberty”.
Now I ask you to consider the following before you decide to take option 1 above, namely to give in. (I will not blame you if you do, as oft times the pressure is unbearable especially as you are made to feel your children are falling behind, you are responsible for your child battling to stay on task, and that you would be met with the same problems if you move schools):
1. When, if ever, did you, or those around you, manage to make it through a prize giving, parent information meeting, gala, school play or sports day without sending or receiving an sms or email, only too thankful for the pretence of making a note on your phone or taking a pic? I confess I have not managed.
2. How many times have your children had to call your name more than once to get your attention, or complain that you never listen to them, or how many times have you told them that you just need to finish sending this text or email then will give them your undivided attention? How many of you text or make a call while driving?
3. How many times have you heard that Ritalin has been around for years and is one of the most “researched drugs” to date? Would it surprise you then that despite all this research, the manufacturer discloses the following under “Clinical Pharmacology” in the insert:
“The mode of action in man is not completely understood, but Ritalin presumably activates the brain stem arousal system and cortex to produce its stimulant effect. There is neither specific evidence which clearly establishes the mechanism whereby Ritalin produces its mental and behavioural effects in children, nor conclusive evidence regarding how these effects relate to the condition of the central nervous system.”
4. If there is no actual evidence of how or why it works on the brain, how reliable is any assurance that there will be no long term adverse effects on the brain or its functioning?
5. Given the time taken for the drug to reach its peak efficacy after ingestion, how useful is it going to actually be?
6. Why does the manufacturer stipulate that the drug must form part of a “total treatment program (sic) which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in children with a behavioural syndrome characterised by the following group of developmentally inappropriate symptoms:
Moderate to severe distractibility;
Short attention span
Emotional lability (which for the rest of you, like me, who had to look it up, means the tendency to laugh or cry unexpectedly at what may be the wrong moment);
How many of you know adults with one or more of these symptoms? These are the people for whom many colourful epithets have been created. I have at least four of them.
7. The manufacturer warns that recent onset of any of these symptoms is usually not an indicator of the syndrome. More importantly, soft neurological signs (in other words – atypical motor or sensory performance not related to mental retardation or brain damage), learning disability, abnormal EEG or central nervous dysfunction may not be present, but a diagnosis can still be made! It is apparently for this reason that the manufacturer states the origin of the “syndrome” is not known and there is no single diagnostic test. Diagnosis is made by special “psychological, educational and social resources”.
8. Over and above a litany of serious side effects (the most alarming of which the manufacturer admits as having occurred “sometimes” in both adult and paediatric male patients, is sustained or frequent and painful erections) the manufacturer can reliably predict that common side effects, which occur frequently, will include loss of appetite, abdominal pain, weight loss during prolonged therapy, insomnia and tachycardia. In addition to the foregoing, children between the ages of 7 and 10 who are consistently medicated (7 days a week throughout the year) will experience a slowing in growth height and weight. On average 2 cm and 2.7 kgs over a three year period. It also concedes there is no evidence that this growth will be recovered once treatment stops. Significantly what is missing is what the manufacturer considers will constitute something other than “consistently medicated”, is it 5 days a week for school terms only or less? Nowhere in the insert will it tell you what the adverse effects, if any, will be of what it euphemistically refers to as a “drug holiday”. The only thing it does warn is that the extended painful penile erections may still occur during the drug holiday. Not the type of holiday I would want for my prepubescent child.
9. Drug or alcohol abuse can be exacerbated. I don’t know about you, but I certainly haven’t taken my child to happy hour at the local to figure out whether he has a drinking problem which could become worse with Ritalin use.
10. Why has the increase in Ritalin use coincided with a decline of conventional lawful methods of punishment at school? My child doesn’t know what detention is!
11. Why, when our children live in the same over-stimulated environment with the same increased demands on our attention, is the phenomenon of the ever decreasing adult attention span not applicable to them?
In short, we are being asked to give our children a drug which is designed to affect the functioning of their central nervous system (the brain stem and/or cortex), in a manner which is not known, for a syndrome, the specific cause of which is no known, which may generally not even be physically detectable, and hence not capable of verifiable medical diagnosis alone (contrary to most other forms of medical ailments), and accordingly, which is diagnosed with the assistance of people with in fact no medical training at all (such as psychologists, teachers and counsellors), based only on the display of one or more symptoms, at least one of which is laughing or crying at inopportune times or being mildly or severely distracted. We are also told, that the only guarantees in this process is that given the mechanism of action of the drug is unknown, there can similarly be no conclusive evidential link to any of the adverse side effects, barring the frequent common side effects and slowed growth which they know for sure will result. Common side effects that on any ordinary day would have persuaded us to keep our children at home.
In my 18 years of practice as both an advocate and attorney, I have never heard of a more evidentially bereft case on which to base any action. But that is just my opinion.
All I ask of you, is that you apply the same consideration to the decision to medicate your children as you do to the many other decisions in your life and theirs. Don’t abrogate your responsibility to the paediatricians, teachers or psychologists. If you are going to make the decision, let it be an informed one, for which you are happy to take responsibility, not one you have been pressurised into after little more than an hour or two of assessments, most of which usually involve no recognised medical testing. I, for one, will resist allowing my child to be prescribed a medication which was designed to boost Rita’s stamina so that she could play tennis with her privileged country club gals
For now, I will stay in the trenches along with many of you until one day, the madness stops.