Paying attention to an attention deficit

Although no data exists on the number of people affected by Attention Deficit Hyperactivity Disorder, there are currently 168 children in Maltese schools being administered methylphenidate hydrochloride during school hours. Should we be concerned?

Lazy. Stubborn. Disruptive. Stupid. Bad. These are a few of the words which come hand in hand with an uneducated perception of attention deficit hyperactivity disorder, a developmental disorder which leaves people unable to concentrate for sustained periods of time and makes them hyperactive and edgy.

True, when untreated, parents and teachers find it remarkably tough to deal with an attention deficit hyperactivity disorder child, but a little awareness goes a long way, and treatment for this disorder is available and highly effective.

Through treatment and therapy, and a strong support network, there is no reason why a child with ADHD should not be successful both socially and at school, nor why he or she should not perform as well as his or her peers, according to the ADHD Family Support Group.

Unfortunately, there are no statistics available about how many people in Malta are affected by ADHD. But a recent parliamentary question put to Education Minister Evarist Bartolo by Opposition MP Charlo Bonnici revealed that there are currently 168 children in Maltese schools to whom  MMNDA nurses, during school hours, are administering the drug methylphenidate hydrochloride, used to treat ADHD.

"There needs to be an outcome study; we need more local research," says psychotherapist Mariella Dimech. "The study should include the treatment and monitoring of patients over a number of years."

People with ADHD may display a variety of symptoms, but the most common ones include a short attention span, impulsivity, stubbornness and forgetfulness. They may also be socially inept and misread nonverbal cues, but are also sensitive and often very intelligent.

"Some people may find out they have ADHD when they get their children diagnosed. The condition is genetic and therefore hereditary," says Pamela Muscat, president of the ADHD Family Support Group.

Muscat says it is often especially hard for a parent with ADHD to raise an ADHD child. "However, in some cases, having an ADHD parent helps the child feel more understood."

She says many people with ADHD, if undiagnosed, go through life feeling 'different,' sometimes turning to delinquency, but not having an explanation for their behaviour. "Being diagnosed with ADHD and knowing that treatment options are available can also be very liberating."

ADHD is a psychiatric condition attributable to a chemical imbalance. However, according to consultant psychiatrist and psychotherapist Dr Peter Muscat, "We must remember the brain is an extremely complex structure, and it is erroneous to think of it as a series of closed rooms. Rather, it is an open-plan, with the kitchen spilling over into the living room, close to the bedroom, and so on. This means we cannot localise the imbalance to just one area of the brain."

However, he says, with the right treatment, attention span, behaviour and concentration do improve, which often leads to a noticeable improvement in a patient's performance at school.

Muscat says that in order to diagnose ADHD, one must consider reports by parents, relatives and teachers, administer standardised tests and questionnaires and have a psychiatrist carry out an examination of the patient's behaviour and mental state.

It is also important to consider the patient's background and early upbringing and the mother's state during pregnancy. Anton Grech, head of psychiatry at Mount Carmel Hospital, agrees, saying diagnosis must be done through a combination of clinical assessment and standardised questionnaires.

"It is often the teachers who are first to notice the difference in behaviour in children when compared with peers, and they, in turn, address the issue with the child's parents," says Ms Muscat, emphasising the importance of parents being open to the teacher's point of view. "The earlier one deals with the condition, the better the support network one can build for the child as he or she grows."

Parents usually take the child to a GP, who is able to refer them to the Child Development Assessment Unit, or to a psychiatrist in private practice for a complete assessment. Often, when the child is older than nine, they are referred to the Child Guidance Unit to cut down on long referral times.

"It is worth mentioning here that ADHD children do not receive a special allowance, like children with autism do," says Muscat.

Dimech says therapy and support are just as important as medication. "Parents need to educate themselves and their families to provide the best support for their children."

Dimech raises another salient point: "We live in a society still where fathers often leave a lot of the child-raising to the mothers. We may talk about gender equality, but the truth is that it is often the women who are left with the responsibility of caring for the child."

She says this is a grave mistake, since children desperately need the support of both parents.

Both Muscat and Grech disagree with the assumption that ADHD is 'overdiagnosed' in Malta. "If anything, I think we tolerate a lot from children here before we seek advice," says Dr Muscat, adding parents are sometimes reluctant to medicate their child.

Grech says diagnosis differs from country to country, but he does not believe it is overdiagnosed in Malta.

Ms Muscat believes when referrals are made they are legitimate, but expresses concerns that in older girls, ADHD is often assessed as anxiety or depression. "In fact, these are secondary symptoms derived from many years of dealing with undiagnosed ADHD," she says.

When asked about concerns that medication turns children into 'zombies,' Dr Muscat says, "I've never seen a patient on methylphenidate hydrochloride looking like a zombie."

He adds that one must ensure the dose is correct. "They will be quieter and will be more like their non-ADHD classmates in terms of concentration and behaviour, but calling them 'zombies' is an overreaction," he says.

Similarly, Grech says methylphenidate hydrochloride increases concentration and decreases impulsivity, but does not cause sedation. "It is interesting to know that, contrary to popular belief, methylphenidate is a stimulant, not a sedative."

Only methylphenidate hydrochloride is given freely on the Schedule V register of free medicines dispensed on the NHS. "We are still waiting for atomoxetine, another ADHD treatment, to be added to Schedule V following a promise by former health minister Joe Cassar," he says.

"Meanwhile, patients who need this medication are either facing financial struggles (though the Community Chest Fund sometimes supports them) or end up not taking any medication at all."

Muscat says other treatments may also include preparations containing natural supplements like Omega 3, 6 and 9, which also help with concentration and memory. He clarifies that there are two versions of methylphenidate: the short-acting (administered three or four times a day) and the long-acting (taken just once or twice a day).

This is why, according to Ms Muscat, the ADHD support group president, there needs to be somebody to administer the medication in schools. The long-action treatment, she says, is expensive, and many families are unable to afford it. She also recommends supplements and exercise regimens, including martial arts, yoga and other sports, and exposure to arts like drama, painting, dance and music. She indicates that people with ADHD often have creative tendencies.

"There is no reason for people to feel ashamed or to try and hide their ADHD. Many manage to turn it into a positive trait with the right support," says Muscat.

She encourages carers of ADHD children to join the support group in order to be able to seek advice and ideas, and to learn from the experience of others. "Many often simply need a shoulder to lean on, and they will find it here," she says.

The ADHD Family Support Group is presently setting up Camp Phoenix - a summer camp especially for children with ADHD. For more information, visit, find the group on Facebook or call 7970 6364

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